Jan Dyer

During the Middle Ages, people tried to escape the plague by sequestering themselves-not an easy task (then or now). Dealing with infectious diseases still comes down to containing the spread. 

Modern hospitals have isolation down to a science, literally. Nowadays, it means having a room or unit in which the infected air is rerouted, away from other patients and hospital staff. One way to do this is with a negative pressure room, in which a lower air pressure allows outside air into the room; any air that flows out of the room has to pass through a filter. By contrast, a positive pressure room maintains a higher pressure inside the treated area than that outside it. Clean filtered air is pumped in; if there’s a leak, the air is forced out of the room. Positive pressure rooms are usually used for patients with compromised immune systems; negative pressure rooms are common in infection control, to ensure infectious germs don’t spread via the heating, ventilation, and air conditioning (HVAC) system. 

A negative pressure room is particularly crucial when something like coronavirus disease 2019 (COVID-19) strikes-this new virulent killer is too much of an unknown quantity to take even the smallest chances of spreading. But the need for such rooms can put extreme stress on hospitals, which are not always ready to handle influxes of infected patients-let alone in the massive numbers of the COVID-19 pandemic. In New York, the current epicenter of the pandemic, total cases crested to 75,000 in early April-and the peak hadn’t even been reached yet.

In the case of a pandemic, says Nick Clements, PhD, an investigator at the University of Colorado, Boulder, wrote in a 2014 blog post, hospitals should be prepared for at least a 300% to 500% increase in ICU and isolation room capacity.

 But despite the increasing need for negative pressure rooms, Saskia Popescu, PhD, MPH, MA, CIC, and a member of 

’s Editorial Advisory Board, says most hospitals are not equipped to handle the high volumes of patients requiring them. Popescu, a hospital epidemiologist and infection preventionist, has researched the role of infection prevention in facilitating global health security efforts. 

“Hospital ventilation systems are designed and engineered to handle a handful of these rooms per unit,” she wrote in a 2017 article, “and so response plans often include moving these patients to designated areas like gymnasiums or tented-care areas built in parking lots.” 

Most hospitals, small and large, have some form of negative pressure space. But a pandemic with a fast-spreading mystery virus has meant many facilities are having to come up-quickly-with more places to keep the COVID patients safely isolated. Some, like Humber River Hospital, in Toronto, built in 2015 with “SARS foremost in our mind,” according to president and CEO Barbara Collins, are purpose-built to be “pandemic safe.” She told Toronto’s 

  that her hospital is capable of isolating entire departments under negative pressure. Moreover, the ambulance bay and an adjoining “hazmat room” are tailored for “seamless transformation” into a pandemic-ready area.

In an interview with WCMH-TV, Jo Henman, director of infection prevention at OhioHealth, in Columbus, said her facility has 85 inpatient negative-pressure rooms and, thanks to portable high-efficiency particulate air (HEPA) filters, the ability to create more if needed.

At Westchester Medical Center, an 895-bed regional system in the New York metropolitan catchment area, every ICU is negative pressure, and can swap out as needed (except with oncology and other high-risk patients, of course). Minnesota-based Alomere Health, which estimates its surge volume at 20 COVID-19 patients at full capacity, plans to use its negative pressure medical/surgical rooms if the ICUs overflow.

The 1500-bed Cleveland Clinic has converted a 4-story health education building into a surge hospital, with 327 beds for low-acuity patients who don’t need ventilators and accommodating up to 1000 hospital beds if needed.

 California spent $30 million to lease short-term space.

 In late March, Detroit and Chicago were both planning to turn convention centers into temporary COVID-19 hospitals.

Or, a hospital might, like Brigham & Women’s Faulkner Hospital in Boston, just decide to do a large-scale conversion-in double-quick time.

 Faulkner rapidly transformed 2 negative pressure wards for COVID-19 patients. The initial plan went from concept to development within just a few days, with a project that included converting the existing HVAC systems to 100% outside air to eliminate the risk of recirculated air, revising the system controls by rewriting its code, and rebalancing the air distribution components.

Older hospitals, or those with budgets that won’t support major conversions, can still prepare quickly. The American Society for Health Care Engineers says that standard patient rooms can be retrofitted as negative pressure isolation rooms.

 The American Society of Heating, Refrigerating and Air-Conditioning Engineers’ Standard allows for using recirculated room air, provided the air first passes through a HEPA filter. This can be accomplished with a recirculating HEPA filter unit, the association says. 

In a real time-crunch, a temporary isolation area can be set up surprisingly fast. Investigators from University of Colorado, Boulder and the VA’s National Center for Occupational Health and Infection Control got a temporary 30-bed negative pressure ward up and running in less than an hour.

They tested it in a fully functioning hospital in the San Francisco Bay Area. The existing ward had its own dedicated air-handling unit, dedicated bathroom exhaust system, a separate dedicated exhaust system for return registers in the isolation rooms, and a firewall separating the ward from the rest of the hospital. 

The research team used 2 heating, ventilation, air conditioning HEPA-filtered negative-air machines to establish the pressure. Performing pressure measurements at 22 locations, they found they maintained negative pressure that was actually higher than recommendations by the US Centers for Disease Control and Prevention (CDC), and there was no pressure reversal when medical staff entered or exited. They did find that some rooms became neutrally or slightly positively pressured, so they advise staff to use personal protective equipment at all times.

The infection prevention and control team “was heavily involved and present at every meeting,” hospital administration was very supportive, and the nursing staff were especially interested and engaged, Shelly Miller, PhD, the team leader, says.

And the research team proved that it could all be done in approximately 40 minutes-including installation and troubleshooting of the anteroom. “We wanted to get it up fast, it was duct tape and plastic,” says Miller.

Their solution could be lifesaving for smaller or rural hospitals. Miller points out that according to the Institute of Medicine’s report on medical surge capacity, the cost of pandemic preparedness is important to consider-tents, temporary housing materials, disaster response trailers, and HEPA-filtered negative-air machines are expensive. In their study, choices such as plastic sheeting with zippered openings helped lower costs.

A portable anteroom can be used as an extra layer of protection between the isolation space and the rest of the hospital. A positively pressured anteroom, for instance, lets staff don PPE in a protected environment. A drawback is that because the anteroom is less pressurized than the isolation room, there’s a risk of infectious particles carrying from the movements of healthcare workers into the patient’s room.  

Further, because the pressure in these specialized rooms has to be so carefully nuanced, maintenance is important. Citing a 2001 long-term assessment of isolation room performance, Nick Clements notes in his blog post that isolation room operating conditions may “shift away from optimal” for a variety of reasons, and operating conditions are “somewhat temporally variable.”

 A loose air handling unit fan-belt or accidental changes made during maintenance could, he says, result in “sharp changes” in the room pressure.

There are few studies as yet testing the effectiveness of establishing temporary isolation wards during a surge, cautions Clements, who was on the team that established the Bay Area temporary ward. Before including a temporary isolation ward in a hospital surge capacity plan, he advises conducting a (successful) full-scale demonstration to uncover any logistical and engineering issues.

Caring for patients in negative pressure rooms can amplify the usual constraints and stresses for staff. Guangdong Second Provincial General Hospital, in China, came up with a way to help lessen some of the stress.

By February 2020, the hospital had admitted more than 30 confirmed cases of COVID-19 and more than 200 suspected cases. It’s not uncommon, clinicians from the hospital report in 

 that medical personnel in negative pressure wards are not fully aware of their exposure while caring for patients. So, the hospital set up an innovative infection-control system called the observing system. Cameras cover the entire ward except for the privacy area. Infection control observers, who are appointed by the hospital’s Department of Infection Control and Nursing and undergo intensive training to become familiar with the requirements for infection control in the negative pressure wards, monitor the wards via computers. 

Their responsibilities include maintaining the normal operation of the isolation wards, supervising the implementation of disinfection, ensuring a sufficient supply of protective materials, arranging specimens for inspection and-not least-they “relieve anxiety of the medical personnel while treating patients.” 

They also watch to make sure healthcare providers don’t omit or overlook steps in putting on or taking off PPE. In one case a patient’s zipper unexpectedly ripped a nurse’s glove. Discovering the situation, the observer “immediately soothed the nurse and sent another staff member into the ward to assist,” assessed the risk for the nurse, and arranged a quarantine room to ensure full safety before the nurse returned to the ward.

The frontline medical staff highly recommend the new system, the authors say. 

Whether caring for a few or thousands of infectious patients, healthcare facilities must be both proactive and flexible. Most recently, Miller and her team have been conducting another pop-up test, this one in a nursing home, depressurizing an entire wing. Given that nursing homes have all along been hotspots of COVID-19, fast, secure response is key. Until we know more about this deadly intruder, protection is the strongest weapon.

Janet Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, NY.

1.     Clements N. Temporary isolation rooms and their application to hospital surge capacity for infection control. microBEnet. 10-04-2014. 

https://microbe.net/2014/10/04/temporary-isolation-rooms-and-their-application-to-hospital-surge-capacity-for-infection-control/

2.     Popescu S. Building airborne isolation units during emergent times. ContagionLive. 08-25-17. 

https://www.contagionlive.com/contributor/saskia-v-popescu/2017/08/building-airborne-isolation-units-during-emergent-times

3.     Miller J. How ‘negative pressure rooms’ can help hospitals fight the coronavirus. 

https://www.thestar.com/news/gta/2020/01/30/inside-the-hospital-fight-against-the-coronavirus.html

4.     Hart T. Hospitals prepare ‘negative-pressure rooms’ for COVID-19 patients. WCMH. 03-09-20. 

https://www.nbc4i.com/community/health/coronavirus/hospitals-prepare-negative-pressure-rooms-for-covid-19-patients/

5.     Oliver E. Minnesota health system releases surge plan. 

https://www.beckersasc.com/new-asc-development/minnesota-health-system-releases-surge-plan.html?tmpl=component&print=1&layout=default

6.     Paavola A. Cleveland Clinic builds COVID-19 surge hospital. 

https://www.beckershospitalreview.com/facilities-management/cleveland-clinic-builds-covid-19-surge-hospital.html?tmpl=component&print=1&layout=default

7.     Paavola A. The race to boost hospital bed capacity: updates from 5 states. 

https://www.beckershospitalreview.com/facilities-management/the-race-to-boost-hospital-bed-capacity-updates-from-5-states.html?tmpl=component&print=1&layout=default

8.     Brigham & Women’s Faulkner Hospital: negative pressure wards for COVID-19 treatment. Fitzemeyer & Tocci. 04-07-20. 

https://www.f-t.com/post/brigham-women-s-faulkner-hospital-negative-pressure-wards-for-covid-19-treatment

9.     Herrick M. Retrofitting an existing room for negative isolation. 

https://www.hfmmagazine.com/articles/2672-retrofitting-an-existing-room-for-negative-isolation

10.  Miller SL, Clements N, Elliott SA, Subhash SS, Eagan A, Radonovich LJ. Implementing a negative-pressure isolation ward for a surge in airborne infectious patients. 

https://www.sciencedirect.com/science/article/pii/S0196655317300925

11.  Chen X, Tian J, Li G, Li G. Initiation of a new infection control system for the COVID-19 outbreak. 

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30110-9/fulltext

Articles

										A portable anteroom can be used as an extra layer of protection between the isolation space and the rest of the hospital. A positively pressured anteroom, for instance, lets staff don PPE in a protected environment.						 

COVID-19 Forced Hospitals to Build Negative Pressure Rooms Fast

Pam Koman-Podolak is immunocompromised, with multiple health conditions, including rheumatoid arthritis. She falls squarely into the category of people most at risk during the COVID-19 pandemic. When the state of New Jersey, where she lives, issued stay-at-home orders, she says, “I was so sad, thinking I had to cancel appointments. And I was scared to go in because my rheumatologist works in a big medical center and I’m on immunosuppressant meds. But I really needed to talk to him and see him.”

Koman-Podolak is lucky: Her rheumatologist is “really into technology,” so she was able to talk with him via computer. Although this was her first experience with telemedicine, it turned out to be a good one. “It was immediately obvious that he was comfortable using this technology,” Koman-Podolak says. “It felt very personal and professional. I was impressed that he noticed my knuckles were swollen by examining my hands through the app!” Her rheumatologist (she calls him a “rheumy rockstar!”) “saved the day for me by offering this wonderful solution.” 

But despite 20 years of real-life experience and growing popularity, telehealth and telemedicine (which is usually defined as clinical interactions) still aren’t as widely used as might be expected. According to 2019 data fromDefinitive Healthcare, an analytics firm, only one-third of inpatient hospitals and 45% of outpatient facilities provide telehealth solutions or services. Iowa, Utah, and South Dakota-which have large rural swaths-have the highest implementations, with 64% or more of the state’s hospitals reporting a service.

 Northeastern states reported the lowest level.

That’s changing, as the coronavirus disease 2019 (COVID-19) pandemic has wrought changes in everything from routine care to triage. Between erratic supplies of personal protective equipment for practitioners and patients who don’t want to risk their health, telemedicine is proving a boon. 

Last year, the Infectious Diseases Society of America (IDSA) updated its position statement to educate its membership on the use of telemedicine and telehealth technologies to provide “evidence-based, cost-effective, subspecialty care” (the list of established-use cases for infectious diseases includes infection prevention and control).

 Most acute care facilities have infection prevention (IP) specialists, but many community hospitals and long-term care facilities, now overwhelmed by the flood of pandemic-related cases, may not have had the time, money, or expertise to develop and manage IP programs. In those cases, IDSA encourages use of telehealth tools as a potential solution: Where an IP specialist isn’t available, the authors say, telehealth platforms can be used to connect infectious disease physicians and other experts with local providers.

The American Hospital Association (AHA) also thinks telehealth is particularly crucial now. On March 5, Richard Pollack, AHA’s president and CEO, wrote a letter to US Department of Health and Human Services Secretary Alex Azar headed “action needed to support hospitals’ ability to respond to COVID-19.”

 Ensuring safe care for patients, protecting healthcare professionals providing patient care, and supporting the health and safety of communities “are the main priorities for hospitals and health systems preparing for and responding to COVID-19,” the letter said. 

To that end, “We urge the administration to take the following regulatory actions to support these efforts…” Among them, to enable broader use of telehealth. “Hospitals want to enable individuals who are experiencing symptoms and may suspect they have COVID-19 to consult with a care provider without going to the hospital.…” That was followed on March 19 by a joint letter to Congress from the AHA, American Medical Association, and American Nurses Association, again detailing urgent needs to combat coronavirus, including training on telemedicine and telehealth capacities.

The Veterans Administration (VA), an early adopter of telehealth, is among those leading the way. It began offering telehealth services in 2003, and has experience based on nearly 3 million healthcare interactions with (as of 2019) more than 900,000 veterans. The VA has been beefing up its telehealth system and is getting more money to help fight COVID-19. Roughly $16 billion of the emergency funding passed last month in the Coronavirus Aid, Relief, and Economic Security (CARES) Act is going to the VA to expand its telehealth services.

 CARES also includes some expanded authorities for VA officials to respond to the coronavirus crisis, such as new agreements with broadband internet suppliers to increase telemedicine options for veterans. 

The Definitive Healthcare data reveal some possible reasons why providers have been slow to implement telehealth: Fear of fraud is one. In February, 2 telemedicine companies were charged with conducting a complex $56 million scheme to convince Medicare beneficiaries that they needed such items as back or knee braces regardless of medical necessity.

Another is federal policy. The US Centers for Medicare and Medicaid Services (CMS), according to Definitive Healthcare, only finalized expansion of provider reimbursement for telehealth and virtual care services in late 2018.

 CMS also issued a new ruling that, as of this year, Medicare Advantage members will have more access to virtual care visits. DH speculates that providers might have been waiting for the new ruling to go into effect before investing in new technologies. Cost, of course, is always a barrier. Virtual technologies may only apply to a small percentage of patients, making it an investment that some providers may feel outweighs the benefits. 

And, as AHA’s Pollack noted in his letter, hospitals have concerns that these technologies may not be compliant with Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements. Still, the AHA urged HHS to waive HIPAA privacy requirements and to loosen reimbursement rules to allow coverage of services for telehealth. In early April, the HHS eased HIPAA enforcement “during this public health emergency.”

Among other things, the updated rule allows healthcare providers to use FaceTime, Zoom, Skype, and other approved applications for the provision of care.

Finally, there’s a prevailing concern, Definitive Healthcare concludes, about whether providers can gather the “personal insight that comes with consistent treatment by the same caregiver over time.” 

That’s a worry that Koman-Podolak also had. “My doctor had me hold my hand up to the camera, make a fist, and rotate my fist so he could examine my joints. But I usually get a full physical exam of my shoulders, elbows, wrists, knees, ankles, hips, and back. It’s simply too much to accomplish in a telehealth visit.” And Michael Petrucelli, a New Jersey retiree who had his first telehealth visit with his regular doctor recently, says it was quick and to-the-point, which he enjoyed. But, he says, “I think it would be difficult for a medical professional to diagnose anything without meeting the patient in person.”

IDSA notes that a patient’s comfort level with their healthcare provider affects their health outcomes and quality of life. “The practice of medicine has a tradition of establishing a trusting, therapeutic relationship with patients,” the IDSA statement says. “There can be a perception amongst inexperienced providers and patients that technology lacks intimacy.”

There are ways around the lack of in-person interaction. Brook Calton, MD, MHS; Nauzley Abedini, MD, MSc; and Michael Fratkin, MD, of University of California, San Francisco, and ResolutionCare Network, offer some practical pointers on making the virtual visit more “lifelike.”

 Based on their experiences, they advise clinicians to, among other things:

·       Create “a therapeutic telemedicine environment,” with a quiet, private, well-lit space. When possible, choose a space with a professional, neutral, and uncluttered background. 

·       Use a laptop or desktop computer if possible, to avoid the distracting-or even nauseating-sensations of a moving handheld smartphone. 

·       Look at the camera to ensure good eye contact and foster rapport and trust.

·       Reassure the patient that the conversation is private by showing them the room, and asking the patient to do the same.

·       Pay close attention to subtle comments made by patients and caregivers and their body language.

The authors also suggest looking for “unique opportunities” to learn more about the patient via telemedicine. For instance, meet their pet virtually, or have them share family photographs. And, particularly relevant in the current pandemic, “A simple question early in the telemedicine visit like, ‘I know we are facing really scary, uncertain times right now. How are your spirits?’ can be effective.” Moreover, they add, clinicians can brainstorm what parts of the physical exam can be performed by video: “[I]t’s surprising to most clinicians how much is possible.” 

Patients could help drive the uptake of telehealth services. Published data and anecdotal evidence suggest patients like telemedicine, although as recently as last year a survey found only 10% of patients nationwide had tried it. 

 When they do, they give it high marks for saving them time, travel, and close contact with the germs rife in public and healthcare areas. Koman-Podolak’s rheumatologist visits mean a 3-hour round trip, for instance. She also says in-person visits are too dangerous right now; she feels “100% safer with a telehealth option.” 

Dan W., a veteran in rural Idaho who did not want to give his last name, has been using video appointments with his psychiatrist-who lives in Minnesota-for several years now. In fact, the VA telehealth program was started mainly as outreach to meet the needs of rural veterans, who make up more than half of the VA patient population. Dan considers the system a “tremendous service. I couldn’t be happier.” He’s not alone: In a 2016 survey, VA telehealth scored high in veteran satisfaction: 92% for clinical video telehealth and 88% for home telehealth.

Practitioners, too-even those who might have been anti-telehealth or on the fence-are acknowledging the benefits, particularly now. Haider Warraich, a Boston cardiologist, for instance, was a skeptic at first. But now he hopes that one thing that comes out of the pandemic will be an increased reliance on telemedicine, “something that should have happened long ago.” In an opinion piece in the 

, Warraich says, “Physical exams are the bedrock of how doctors and nurses assess patients…Physical contact, I’d always thought, was at the heart of how doctors and patients communicate.”

His mind has been changed, though, not only by experiences with telemedicine, but by practicality. “Hospitals have been notorious petri dishes for deadly bugs since long before COVID-19,” he notes, “and this pandemic has brought that risk into crystal-clear focus.”

Once tried, telehealth may change usual habits for the better. “When this pandemic has passed, I will probably keep a mix of in-person and telehealth visits,” Koman-Podolak says. “I plan to use it for endocrinology, primary care, and emergency medical (that is, virus or flu), if needed. I don’t think I would rule anything out.” 

Anything that helps keep patients safer and gives practitioners a chance to stay in touch without actually being in touch is a good thing. Could be that telehealth is a silver lining to the dark cloud of the COVID-19 crisis.

Janet Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

1.     Telehealth adoption in the US: 2019 trends. Definitive Healthcare. 04-29-20. 

https://blog.definitivehc.com/us-telehealth-adoption-2019

2.     Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases. 

https://academic.oup.com/cid/article/68/9/1437/5372646

3.     American Hospital Association. AHA urges HHS to take regulatory actions to help hospitals respond to COVID-19. Letter. 03-05-20. 

https://www.aha.org/lettercomment/2020-03-05-aha-urges-hhs-take-regulatory-actions-help-hospitals-respond-covid-19

4.     American Hospital Association. AHA, AMA and ANA send letter to Congress on COVID-19 funding. Letter. 03-19-20. 

https://www.aha.org/lettercomment/2020-03-19-aha-ama-and-ana-send-letter-congress-covid-19-funding

5.     CARES Act expands telehealth coverage for Medicare, FQHCs and the VA. mHealth Intelligence. 03-30-20. 

https://mhealthintelligence.com/news/cares-act-expands-telehealth-coverage-for-medicare-fqhcs-and-the-va

6.     Owners of telemedicine companies charged in $56M Medicare fraud scheme. Becker’s Hospital Review. 02-06-20. 

https://www.beckershospitalreview.com/legal-regulatory-issues/owners-of-telemedicine-companies-charged-in-56m-medicare-fraud-scheme.html

7.     US Department of Health and Human Services. HIPAA, civil rights, and COVID-19. 

https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html

8.     Calton B, Abedini N, Fratkin M, Telemedicine in the time of coronavirus. 

https://www.jpsmjournal.com/article/S0885-3924(20)30170-6/fulltext

. Accessed April 24, 2020. [note: don’t know how to style this, no vol or page info. It was published online]

9.     Telehealth: best consumer healthcare experience you’ve never tried, says J.D. Power study. JDPower. 10-28-19. 

https://www.jdpower.com/business/press-releases/2019-us-telehealth-satisfaction-study

10.  US Department of Veterans Affairs. VA telehealth services. 

https://www.newengland.va.gov/nhvision/VATelehealthServicesFactsheet.pdf

rraich HJ. Op-Ed: As a doctor, I use telemedicine. With the coronavirus threat, it could revolutionize healthcare. 

https://www.latimes.com/opinion/story/2020-03-17/op-ed-as-a-doctor-i-use-telemedicine-with-the-coronavirus-threat-it-could-revolutionize-healthcare

The Infectious Diseases Society of America updated its position statement to educate its membership on the use of telemedicine and telehealth technologies to provide “evidence-based, cost-effective, subspecialty care.”

Telehealth in the Time of COVID-19: A 20-Year Overnight Success

As the novel coronavirus COVID-19 continues its logarithmic leaps from person to people, across borders and oceans, trailing jokey and terrifying viral memes, it has triggered an odd assortment of hoarding behaviors in the panicky public: toilet paper, hand sanitizer, soap … and surgical face masks.

Early-and indeed, ongoing-lack of information about the virus’ etiology and pathology meant face masks have become a precious commodity. In early March, health authorities from Washington state (which by that time had announced the first COVID-19–related death in the US) sent an urgent request to the federal Strategic National Stockpile for 233,000 respirators and 200,000 surgical masks.  

They received an answer-but not the one they hoped for. They would get less than half the amount they requested: 93,600 N95 respirators and 100,200 surgical masks.

In late February, when US Department of Health and Human Services Secretary Alex Azar said the US needed at least 300 million N95 respirators for healthcare workers, the US had only 30 million.

As of March 5, Prestige Ameritech, one of the few manufacturers still making face masks and respirators in the US, had received requests for 1.5 billion masks.

As of March 10, the US had a national stockpile of 12 million N95 masks and 30 million surgical masks for a healthcare workforce of about 18 million, according to an article in 

, which notes “[i]f only 6 million of them are working on any given day (certainly an underestimate) they would burn through the national N95 stockpile in two days if each worker only got one mask per day, which is neither sanitary nor pragmatic.”

The US Centers for Disease Control and Prevention (CDC) in mid-March posted new guidelines, saying surgical masks are now an acceptable alternative for N95 respirators because “the supply chain of respirators cannot meet demand.”

The mismatch between demand and supply has opened questions about what actually is the best way to protect against infections like COVID-19, and who will benefit most from them. The World Health Organization (WHO) has said wearing masks may create a false sense of security among the general public.

US Surgeon General Jerome Adams, MD, tweeted in exasperation: “Seriously people-STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” 

Shortfalls in protective masks have put a spotlight on 2 concerns in particular: utility and compliance. Experts agree that not every situation requires a face mask, even in this world of drug-resistant bacteria-although it isn’t always definitively clear which situations do. 

In an interview with BBC News, David Carrington, MD, of the University of London, said although routine surgical masks could help lower the risk of contracting a virus via the “splash” from a sneeze or cough, and provide some protection against hand-to-mouth transmission, they aren’t effective against airborne viruses or bacteria because they’re too loose, have no air filter, and leave the eyes exposed.

Face masks have come a long way since the 1800s, when they were basically gauze strips placed over the mouth. Originally developed to minimize the risk of transmitting microorganisms from clinician to patient, they’re now intended to protect both patients and clinicians from drug-resistant pathogens transmitted by blood or other body fluids. 

Masks come in different shapes, with different features, intended for different purposes: flat-fold tie-on, duckbill with or without shield, cone shaped, flat-fold with shields…theoretically, there should be something for everyone. But they’re only effective when worn properly, and not everyone can-or does-wear them properly. Most guidelines suggest changing a surgical mask any time it becomes wet. A mask wet with exhaled moisture has increased resistance to airflow, is less efficient at filtering bacteria, and vents more.

It’s not uncommon, though, says Dianne Rawson, RN, MA, in 

, to see masks poorly fitted, placed below the nose, or wet with blood or body fluids.

Even the correct mask can put clinicians at risk if not worn correctly: with nose and mouth completely covered to create a seal and prevent gaps. But fit can be an issue for anyone whose face doesn’t follow the median contours, or someone who has a beard or mustache. A 2000 study found that bacterial shedding from people with beards was increased (although an analysis of that study called it “an example of contamination being extrapolated to infection without measuring the endpoint of infection”).

One National Health Service hospital in England has responded to the coronavirus pandemic by asking staff to “consider” shaving their beards. “I recognize,” Derek Sandeman, MD, the medical director, said, “for some this is a big ask, that beards are so popular at present. However, I do believe it is the right thing to do.” He added that alternative types of respiratory equipment are available for people who have a good reason to keep their beards, including for religious reasons.

The CDC has helpfully published a visual aid for the kinds of facial hair that work, or don’t work, with mask use.

Some styles, such as soul patches, pencil mustaches, and “the Zappa” made the cut. 

The current health emergency (like other pandemics) has also put a new spotlight on compliance, a complicated subject. Studies have demonstrated that healthcare workers are generally poorly compliant with respiratory guidelines.

But compliance studies often run into the Hawthorne effect: Knowing they’re being observed, staff tend to improve their adherence. 

Interestingly, a 2019 study found that following hospital protocol for using N95 respirators was a given-until it wasn’t. Discussions with focus groups of nurses and nursing assistants at 4 Veterans Administration and academic medical centers revealed that discomfort was not the main issue. People wanted to follow respiratory protective equipment (RPE) protocol, the investigators said, but RPE misuse was driven by “personal” protocols, such as when people did not trust the protocol and instead relied on their experience. Generally, the misuse amounted to overuse-staff didn’t trust the safety protocols and wanted to protect themselves and patients. The overuse, of course, is a factor in supply shortages.

Moreover, according to researchers who reviewed studies on facial protection, healthcare workers may view standard precautions as adversely affecting job performance and their relationships with patients: They cite insufficient time, interference with job duties, reduced dexterity, and discomfort.

But the investigators also found peer pressure and attitudes of family members who were afraid of contracting infection influenced the actions of the healthcare workers, making them more likely to adhere to safety procedures.

One health professional said, “I think the fear of contracting the disease was palpable, very real. Nobody was trying to cut corners.”

The CDC has issued interim recommendations, tempered with reality: When possible-given the current shortages-patients with confirmed or possible infection should wear surgical masks, and healthcare workers treating potentially infected patients should wear N95 respirator masks and goggles. N95 respirators are more protective, reducing exposure to small particles, filtering out at least 95% of airborne particles, and, because of the tight fit, allowing minimal leaking

(the National Institute for Occupational Safety and Health recommends fit assessment during the initial selection of a respirator and periodically as part of a respiratory protection program.)

But the tight fit that makes respirators safer than masks also makes them uncomfortable, especially when worn for long stretches. Julie Feuer, an oncology nurse practitioner in a large county hospital in Westchester County, New York, says she wears a mask for about half the day, depending on how many of her patients are on droplet isolation. Although she prefers the N95 for safety reasons, especially during this pandemic, “it’s pretty tight on my face, leaving marks-and it’s hot under there!” It’s a little claustrophobic, she says. “Regular surgical masks are easier to deal with and looser fitting.” 

Kathy Manelis, RN, agrees. Recently retired after 37 years, she worked with critically ill patients and usually wore a mask for 20 to 30 minutes at a time. She, too, found the masks claustrophobia-inducing-and they steamed up her glasses.

Alessia Bonari, a young nurse in Italy, posted a photo of the chafe marks from the respirator, saying, “I’m afraid because the mask might not stick properly to the face…I’m physically tired because the protective devices hurt…”

Respirators have also been associated with mild adverse effects, including acne, skin rashes, dehydration, and headaches. About one third of healthcare providers in one study reported headaches, which could be due to hypoxemia, hypercapnia, or stress, the researchers say.

It’s also possible, they note, that the pressure from the strap on the neck over the superficial nerves might aggravate neck strain. 

Researchers who surveyed healthcare workers about respirator use said the respondents were looking for respirators that are more comfortable, interfere less with breathing, diminish heat buildup, are disposable, and permit the user to have facial hair.

Healthcare workers have also said time constraints related to donning, doffing, and changing masks frequently are very real: “…In triage, you change your goggles, gloves, mask and gown between every patient and it’s 100% not feasible,” said one. “Patients would be dying waiting at the triage desk.”

The CDC offers alternatives to N95 respirators, such as other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air-purifying respirators (which can be repeatedly disinfected, cleaned, and reused), all of which provide equivalent or higher protection than N95 respirators (“when properly worn,” the CDC cautions).

Crisis strategies also include using respirators beyond the manufacturer-designated shelf life, and “limited” re-use.

Health authorities have a double-pronged problem to tackle: The pandemic-driven urgency for enough protection and the daily-use desire for more comfortable protection. The CDC has come under fire for not planning for a shortfall during the current crisis, and for not acting quickly and forcefully enough when the crisis began to expand. The result? Workers are not sure day to day whether they’ll have the supplies they need, leading to a breakdown in a crucial bond of trust. 

“…[I]f workers had more confidence in their employers’ commitment to worker health and safety,” Yassi notes, “employees would have more confidence in the messages and directives they received during a crisis.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, NY.

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One hospital has asked workers to consider shaving their beards.

Author | Jan Dyer

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