Supply chain issues are a larger, more systemic aspect of healthcare and national preparedness. Although IPs may not be able to fix them individually, there are ways we can ensure the safety of our hospitals.
The supply (or lack thereof) and utilization of personal protective equipment (PPE) has been one of the most frustrating aspects of dealing with coronavirus disease 2019 (COVID-19) for infection preventionists (IPs). Enacting emergency re-use and extended-use policies and protocols is not only a novel situation, but something that goes against our natural tendencies.
The COVID-19 pandemic shed light on the dependency we in healthcare and in the United States have on international suppliers and manufacturers of critical items, like PPE.
As Maryn McKenna noted in February, “According to data compiled by the US Department of Health and Human Services, 95% of the surgical masks used in the US and 70% of the respirators—thicker, tight-fitting masks that offer better protection against viruses—are made overseas. That leaves the mask supply vulnerable to labor disruption if a pandemic sickens manufacturing workers, as well as to flat-out diversion if a government decides to keep its own stock at home.”1 As the COVID-19 pandemic fluctuates and might be more severe in some countries, supply chains will likely be impacted.
Shortages extend beyond masks and gowns, but also into tubing, Foley catheter kits, disinfecting wipes, hand hygiene products, disposable laryngoscope blades, and much more. COVID-19 is a marathon, not a sprint, and ultimately represents the bigger issue of hospital preparedness and how we integrate critical aspects, like supply chain and surveillance. It is important to note that the battle to reduce and even prevent COVID-19 must continue as healthcare experts keep a lookout for a second wave. Instead of a stop-go-stop-go approach, it’s important we approach this from the perspective of perseverance and resolve.
One of the first ways we can work toward more sustainable efforts is to first focus on daily PPE counts. This is something most likely to do with larger international and national supply chains from manufacturers and distributers but, overall, this is a good measure to establish as a standard infection prevention and control (IPC) practice.
Moreover, are IPs simply evaluating what’s available day to day or are they also considering what will be needed in a surge? In many cases, the relationship between IP and the supply chain department is passive and fluctuates with emergencies or new products. What if, though, we worked to have a more proactive relationship that involved weekly meetings regarding the level of supplies, like PPE? Right now, many of us are getting daily reports on the number of supplies we have and how many usage days that translates to.
Working with the supply chain department to set up more continuous, proactive check-ins that are measured by days of supplies on hand and how that would fluctuate with varying surges can be immensely helpful. This also involves scaling or descaling PPE-focused efforts. For many, guidance from the US Centers for Disease Control and Prevention (CDC) is what actions are based on. When the CDC declares something an emergency, that is often the trigger point for most hospitals and healthcare facilities.
Perhaps, though, a more proactive approach is needed: indicators for scaling up PPE conservation efforts and then triggers for descaling. Continued monitoring of outbreaks locally and internationally can go a long way. Travel-based screening and education about existing outbreaks, like the current Ebolavirus outbreak in the Democratic Republic of the Congo, requires us to keep tabs on what’s going on in the world.
An outbreak anywhere is an outbreak everywhere and although some countries might have enhanced surveillance measures, COVID-19 has taught us that we are all uniquely vulnerable. While it might not change the outcome for millions, monitoring and helping guide preparedness efforts earlier could change the outcome for thousands of employees and patients. This requires support and a collaboration between infection prevention, administrative leaders, and key stakeholders like supply chain, laboratory services, and others.
In addition, IPs can possibly utilize more sustainable PPE. Full-face respirators have become more common with the COVID-19 pandemic. These offer an alternative to N95 respirators and, in some cases, combine eye protection. A benefit to these devices is that they are re-usable and able to be cleaned and disinfected between use. Like powered air purifying respirators (PAPRs), they offer a long-term alternative for extended use that is often more comfortable for staff. More importantly, they allow staff to re-use them with disinfection protocols that change the traditional disposable notion of PPE. Although IPs have traditionally thought of PAPRs for only emergency preparedness situations, perhaps full-face respirators offer a middle ground that can change pandemic preparedness in healthcare.
Face shields are another piece to this puzzle. More research is being conducted on the feasibility of using face shields in several environments—for all triage staff as protective measures, but also as a potential alternative for community mask use.2 While these offer protection for eyes, respiratory protection will still be required for those in isolation requiring a mask (eg, surgical or N95). The use of face shields in the community as an alternative to face masks is an increasing topic of conversation. Changes cannot be made to current PPE protocols at the moment, but it will be interesting to see where this research leads.
Supply chain issues are a larger, more systemic aspect of healthcare and national preparedness. Although we may not be able to fix them individually, there are ways we can account for them and ensure the safety of our hospitals and healthcare facilities. Those aforementioned efforts shouldn’t focus solely on PPE, though.
A big piece to this is also about the collective efforts of IPs and hospitals. IPs are often under-represented when it comes to hospital preparedness and, often, many healthcare colleagues don’t even realize IPs exist, let alone the work IPs do. Now is the time for IPs to use their voice. Work with the Association for Professionals in Infection Control and Epidemiology’s Policy Group to help drive legislation and accountability locally and nationally. Engage with local leadership, hospital consortiums, and policy makers. Infection prevention voices and representation are critical to help not only drive change, but also spread awareness of the very real issues we see and manage daily. Moreover, work with local public health officials and departments.
Our public health personnel are some of our greatest allies. We often interact with them regarding reporting of communicable diseases, and they often offer committee feedback and training, and serve as a wealth of knowledge to understand how we all work together. IP representation on public health steering groups and committees is immensely helpful and not only gives us a voice, but also ensures that there is awareness for the intricacies of how healthcare operates. Moreover, continued engagement with public health agencies enhances the relationship that we are fundamentally reliant on.
Combatting COVID-19 will require a considerable amount of dedication, resources, and coordination. It will take time and there will be setbacks as IPs navigate through a pandemic. Infection prevention efforts, though, are so critical and extend beyond hospital and healthcare walls. We often act as the intersection between healthcare, public health, and emergency preparedness. Utilizing our knowledge and incorporating some of the lessons learned, especially about PPE and response, will be critical for not only COVID-19, but also future infectious disease outbreaks and events.
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.
1 Maryn McKenna. “Amid Coronavirus Fears, a Mask Shortage Could Spread Globally”. WIRED. February 4, 2020. Available at https://www.wired.com/story/amid-coronavirus-fears-a-mask-shortage-could-spread-globally/
2 Perencevich EN, Diekema DJ, Edmond MB. Moving Personal Protective Equipment Into the Community: Face Shields and Containment of COVID-19. JAMA. Published online April 29, 2020. doi:10.1001/jama.2020.7477