Covid-19 PPE: Indications, Procurement & Conservation in - - PowerPoint PPT Presentation

Covid-19 PPE:

Indications, Procurement & Conservation in Northern Ontario

Dr Bhanu Nalla MBBS, FRCA(UK), FRCPC Staff in Critical Care & Anesthesia, HSN, Sudbury 12th June 2020

NOSM Weekly Covid-19 Clinical Rounds

Disclosures

• No expert knowledge on Personal Protective Equipment (PPE) prior to

the Covid-19 pandemic

• Evidence related to PPE use in the pandemic is constantly evolving

and may change following this talk

• No financial ties to any PPE manufacturer or dubious distributor!

Objectives

• 1. Identify type of PPE and define their role during the COVID-19

pandemic

• 2. Appraise levels of risk to healthcare personnel providing care to

suspected or confirmed COVID-19 patients and associated PPE recommendations.

• 3. Describe rational for healthcare PPE working groups including

planning challenges for the procurement, conservation and reuse of PPE.

Introduction

• PPE is a hot topic!
• Appropriate use related to minimizing transmission
• f coronavirus between patient and health care

worker (HCW)

• Emotive subject globally
• Main issues
• Lack of supply
• Massive increase in demand
• Inappropriate use

Chain of hazard controls in healthcare setting

Elimination & Substitution Engineering & Systems Controls Administrative Controls PPE

Types of PPE

1. Facemasks

• Non-fluid resistant vs non-fluid resistant
• Respirators

2. Eye/face protection

• Goggles, protective glasses, face-shields

3. Isolation Gowns

• Disposable, non-disposable, coveralls

4. Gloves 5. Head protection – bonnets, caps

Mask Terminology…confusing!

Procedure Mask Surgical Mask Non-fluid resistant (paper) Fluid resistant (surgical)

Types of Respirators

Isolations Gowns – protection & risk exposure

• Ideal gown:
• AAMI 2-3
• Extends below knee
• Back covered
• Full cuffs on arm
• Covers neck
• Quick to don, Easy to doff
• Disposable?

AAMI = Assoc for the Advancement of Medical Instrumentation

Transmission of Covid-19

Factors affecting exposure risk of HCWs to Covid-19 patient

Proximity to patient Duration of exposure to patient PPE

Appropriate choice Donning/doffing technique

Room ventilation

• Negative vs positive

pressure

• Air changes per hr

(ACH)

High risk Aerosol Generating Medical Procedures (AGMPs)

List of AGMPs

Laryngoscopy, endotracheal intubation & extubation, bag mask ventilation Bronchoscopy & BAL Tracheostomy procedures Non-invasive ventilation (BIPAP & CPAP) High flow nasal cannula (HFNC)? Sputum induction, open deep suctioning via ETT or tracheostomy Surgical procedures – laparascopy, ENT, Thoracic procedures Dental procedures – high speed drilling, ultrasonic scalers CPR – chest compression & defibrillation?

PPE for different risk levels

Moderate High Highest Name

Droplet + Contact Enhanced Airborne Enhanced NRI or AGMP

Situations

Generalized contact with Covid-19 presumed or positive patients HCW in the room with AGMPs performed, chest compression, defibrillation, circulating OR staff during AGMPs. Directly performing AGMP (Anesthesia/Surgery) or assisting (RT)

PPE required

Goggles or face-shield Fluid-resistant mask Procedure or surgical mask AAMI level 2 gown Gloves Eye protection + face- shield N95 or similar mask AAMI level 2 gown Gloves Head protection Eye protection + face- shield N95 or similar mask AAMI level 2 gown + Double gloves Head & neck protection

Lockhart, SL et al. Can J Anesth, April 2020: 1-11

Why is there a PPE shortage?

• Unprecedented demand
• Healthcare adopting a ”just in

time” policy to ordering supplies

• Majority of supplies from China
• own needs vs limited capacity to

supply

• Local, provincial and national

expired stockpile

• Dependent on provincially

approved supply sources

Preparing for PPE during the Pandemic

Planning Procurement & Preservation Education

• Dr Michael J Ryan,

Chief Executive Director, WHO Emergencies Program

Mission: optimizing PPE availability for HCWs

Optimize PPE availability

Co-ordinate PPE supply chain Minimize wastage Use appropriately Conservation & re-use strategies

Planning at HSN: PPE Working Group

Players:

• Operational & Clinical Lead
• Supplies staff & Processing
• Infection Prevention & Control

(IPAC)

• Nursing Clinical Managers
• Physicians
• Occupational Health
• HSN Foundation representative

Responsibilities:

• Purchasing
• Inventory / Burn Rate
• Storage – security
• Quality control
• Conservation and reprocessing

planning

• Contigency algorithms
• Regular update to IC

Inventory

• Requirement by MOH to update

daily

• Existing, expired & donated

stock

• Changes in stock over 1 week
• Historic vs projected usage
• Days on hand – important to

ramp up operations

Procurement of PPE

• Exponential global demand has led to significant challenges for PPE

supply in the North

• Supplies from standard sources, donations, alternative sources
• Traditional supply chain:
• limited supply available to facilities based on historical usage
• healthcare facilities dependent on provincially approved sources
• questionable stability
• Federal attempts at bulk orders have not come to fruition
• Global competition and political hierarchy have strained regular supply

Industrial Suppliers & Donations

Northern region has access to mining/industry suppliers Most stocks critically low by mid March – competition with mining companies and Toronto customers buying up stock Multiple donations:

• Industry
• Small businesses
• Physicians

Challenges to take stock and centralize receiving process

Alternative sources of PPE

• Less strictly regulated private supply

chain

• Multiple new suppliers, importers and

distributors offering services

• Challenges:
• Most distributors want cash up front
• Numerous reports of counterfeit

items or substandard quality

• Most products from China – timeline
• n delivery increasing from days to

weeks

• Cost of products rising with time

How can we tell the good from the bad?

Conservation and Re-use Strategies

PPE can be used over an extended period of time and over the course of many patients (eg cohort or ward of suspected or confirmed COVID-19 patients) Applies to N95, surgical/procedure masks, all isolation gowns, eye/face protection

Extended Use

Limited reuse refers to the practice of using the same PPE for multiple encounters with patients but carefully removing it (‘doffing’) after each encounter, storing it safely, and then putting it back on (‘donning’) without sterilization. Applies to N95, masks, cloth isolation gowns, eye/face protection

Limited re- use

Sterilization Methods for Reprocessing

• f PPE

Methods approved by Health Ontario:

Vapourized Hydrogen Peroxide (VHP) Ultraviolet Germicidal Irradiation (UVGI)

Issues:

Ability to remove and/or inactivate viral particulate safely Ability to preserve structural integrity of the mask

System required to collect used masks safely (brown paper bags) Strategy to disinfect, clean, sanitize and decontaminate disposable PPE for future use – applies specifically to N95 respirators

Limited re-use between cases Conservation of N95s for future reprocessing

Our N95 Planning Algorithm

Conventional

Existing medical grade N95s, disposable - fit tested <5yrs

Contingency

Medical grade N95s > 5yrs old, disposable Limit fit testing to HCWs who perform AGMPs

Crisis

Limited re-use and extended use of medical grade N95s Industrial grade respirators (NIOSH or CE approved) Reprocessed medical grade N95s Re-usable half and full-face respirators, PAPR units

No PPE

Non-NIOSH or CE approved masks (KN95) Fluid-resistant surgical masks Home-made masks

Education

Planning algorithms apply to all aspects of PPE Regular updates on current stock and usage Effective communication on conservation strategies vital Close co-ordination with IPAC and clinical staff Walkarounds addressing PPE needs in different departments and

• ffering solutions

Consistent messaging

• n best available

evidence and practice

Summary

• Despite our low Covid-19 cases, PPE usage remains high and is expected to

do so for the foreseeable future

• Inadequate PPE for HCWs associated with increased rates of transmission
• Overuse or misuse of PPE has unintended consequences:
• Impending shortages
• Compromised quality of patient care
• Risk of HCW contamination from doffing
• Strategies to preserve PPE include:
• Optimizing supply from all sources
• Initiate and adopt conservation strategies
• Effective communication and education to staff

References

1. IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID‐19 (https://www.publichealthontario.ca/- /media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en) 2. CDC Strategies to Optimize the Supply of PPE and Equipment, 2020 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html) 3. Ontario Health Recommendations on the Use and Conservation of PPE (https://www.ontariohealth.ca/sites/ontariohealth/files/2020- 05/Ontario%20Health%20Personal%20Protective%20Equipment%20Use%20During%20th e%20COVID-19%20Pandemic_rev10May20%20PDF_v2.pdf) 4. Chu, D.K et al (2020). Physical distancing, face masks, and eye protection to prevent person- to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-

• analysis. The Lancet (online print); 1st June: 1-14.

Questions?