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Perhaps now is the time that innovation begins to rely more heavily on infection preventionists and our valuable insight into the world of healthcare PPE. The changes we help guide now, can help make healthcare safer and infection prevention easier.
Infection preventionists (IPs) know personal protective equipment (PPE) better than anyone and now is the time that their knowledge and skills should partner with efforts to bring PPE into the future so that we can avoid supply chain interruptions, while also addressing new challenges and requirements brought about by the coronavirus disease 2019 (COVID-19). Sustainable, reusable, and safe are all strategies that need to be a part of the infection prevention and PPE future. Unfortunately, until there is a more significant push for this, innovation may not occur. Innovation seems to be occurring in community-based measures addressing the public’s need for wanting to venture outside in rather fascinating ways. For example, the Micrashell, which was created to allow people to attend music concerts.1 Looking at some of the more ridiculous aspects of this suit, it does reinforce the notion that if people want to return to a more normal state in the face of a pandemic, innovators will try to find a way. Why can’t this be said for healthcare PPE?
Use of gowns, gloves, and masks have stayed mostly the same while the public has adapted a whole new approach to masks and PPE. This is a stark reminder of why the healthcare sector often struggles with innovation in areas that might not provide profit. Unlike a new robotic surgical tool, PPE doesn’t quite have the same pizzazz or the potential for new profit, which means selling the importance of independence and staff safety is something we must all collectively work on.
Perhaps now is the time for healthcare, infection prevention, and the tech geniuses of Silicon Valley to partner and develop a new approach to PPE. Consider face shields. There is considerable knowledge about their ability to protect the wearer, but what about source control?2 There is a desperate need to understand not only the efficacy of various non-traditional PPE, but also push for innovation in the name of sustainability and in the face of a pandemic.
Up until COVID-19, the term PPE was most commonly thrown around in healthcare and industrial environments, but it has quickly become a common phrase across the globe. From bandanas to half-face respirators, our daily lives are now integrated with respiratory protection. For some, this means finding the most comfortable or stylish approaches to face protection out in the community. For those of us in infection prevention and healthcare, it’s been an uphill battle that will likely evolve with the ebb and flow of COVID-19, but also the evolution of PPE.
Currently, recommendations focus on N95 respirators being ideal but surgical masks are acceptable if no aerosol-generating procedures are being performed on the patient. Part of the challenge though, as we saw with supply chain issues, was in how we approach extended use and re-use. These are phrases that were never considered in US infection prevention efforts—we’re a “single-use” sort of culture and frankly, never did we think we’d be facing a pandemic in which we had to deal with supply chain issues so early on in that pandemic. But that’s what happened, as IPs know all too well.
As a result of this, we’ve seen a few things happen—first, the allowance of KN95s, which meant a review of respirator safety and efficacy to allow for these to be used in emergencies.3 KN95 respirators are manufactured in China and, as a result of shortages in N95s, the National Institute for Occupational Safety and Health (NIOSH) approved specific types of KN95 respirators for use in the United States. As time went on though, concerns grew about KN95 variances or efficacy in ability to filter out small particulates. They have been worn more by the public than by the healthcare system, however. What this pandemic has really shown us is that we ultimately need to approach the PPE problem in innovative ways and not focus solely on respiratory protection.
That focus on respiratory protection emphasizes a lot of innovations and revisions to guidelines from the US Centers for Disease Control and Prevention (CDC) and NIOSH. First, the use of masks with exhaust valves. This has not been something we’ve traditionally seen or utilized much, but ultimately required significant review. Upon deeper analysis, masks with exhaust valves were discouraged by the CDC due to the lack of filtration from the valve, which could potentially be spreading infectious droplets/aerosols if the wearer was infectious every time he or she exhaled. This change impacted both healthcare and the community, as those healthcare workers in non-patient-facing roles were wearing cloth or personal masks in certain settings. This awareness reinforced the role of evaluating novel masks and those that increasingly become popular for perceived enhancements. Moreover, the recent review of various cloth masks has shed light on a further need to truly assess and test the efficacy and limitations of community masks. This especially comes into play as infection preventionists have to determine whether fabric masks are acceptable for those employees who are not in patient-facing roles.
A secondary piece to respiratory protection, though, has emphasized the need to re-use and extend use.4 This in particular is one that weighs heavy on the healthcare industry and we are inherently wasteful. Medical waste and pollution are increasingly topics of concern. The healthcare system struggles to move to more sustainable options for supplies. Consider PPE— as a result of the pandemic, many of us are moving toward half-face respirators that can be reprocessed, or even the reprocessing of N95 masks to extend use and re-use. Really, what this means is that in terms of PPE innovation, the direction we need to move toward is one of sustainability and reduced waste.
Ultimately, this would drive not only a reduction in having to haphazardly fit test people when we run out of one type of mask but reduce the dependence on a fragile international supply chain. COVID-19 has shed light on the utter dependence hospitals and healthcare facilities have on temperamental supply chain systems. Moving toward a model that would allow for reprocessing, like the half-face respirators, would of course create a new workflow and impact infection prevention efforts. Determination of how to store masks, which disinfectants to use, and general movements of masks between staff or units are all things that need to be considered. Determining a process for reprocessing, collection and returning of the masks, ensuring that people are aware of the need to have them reprocessed, and ability to train on cleaning/disinfecting after use and throughout a shift are all things the infection preventionist would need to consider. Despite these barriers, it seems that creating this process could help ultimately prevent a situation where our respiratory protection is intrinsically linked to vulnerable suppliers.
Masks and respiratory protection aren’t the only PPE we worry about though—gowns have increasingly become a hot topic. Reuse and extended use quickly became the topic of conversation after masks were no longer at the forefront of public discourse. Many have turned to gowns that can be laundered. In fact, the CDC put together crisis capacity strategies that include extended use of isolation gowns, reuse of cloth isolation gowns, and methods for prioritizing gowns, which included the recommendation: “During care activities where splashes and sprays are anticipated, which typically includes aerosol-generating procedures, during the following high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers, such as: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care.”5
Re-useable and Safe
These recommendations point to a growing realization that we simply must establish a new approach to PPE in healthcare. Truly, IPs know the nuances of PPE better than most. We know how to train and educate on them, evaluate them, but we also know the challenges that occur with a novel production or process. This points to a critical need for infection preventionists to be part of this product evaluation and innovation moving forward in not only the COVID-19 response, but also larger pandemic preparedness.
For IPs, this also means we should be refining our evaluation process for PPE—not just in terms of if it works and protects staff, but how well it’s functioning in the work environment. Is it challenging to disinfect? Uncomfortable and prone to misuse? Pulling on this knowledge and the role of infection prevention in educating, perhaps now is the time that innovation begins to rely more heavily on infection preventionists and our valuable insight into the world of healthcare PPE. The changes we help guide now can help make healthcare safer and infection prevention easier.
SASKIA V. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.