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Are you one of the haves or the have-nots?

July 2020
PPE masks

BY EARLY MAY, Edward Ma, MD—a hospitalist in a community hospital in the Philadelphia suburbs—had been treating covid patients for several weeks. While his hospital had ample personal protective equipment (PPE), most staff wanted to use it judiciously.

The PPE protocol Dr. Ma followed had him donning an N95 covered by a surgical mask and face shield, as well as a gown and gloves. (He also wears a bouffant.) Between patients, Dr. Ma changed gloves, but he kept on the same gown as he went from room to room, seeing between five and 12 patients. The rationale: removing gowns between rooms might release virus into the air, and doffing frequency might increase transmission risk.

He rethought that strategy, however, after three of the doctors, nurses, and NPs/PAs on his unit tested positive for coronavirus—and he was one of them. (He stayed home for 10 days and has recovered fully. Click here to see his Father’s Day card.) “Is something about this protocol putting people at risk?” he asks. “If I walk out wearing the same gown, could it inadvertently contact commonly touched surfaces? Or are some viral particles on the gown becoming airborne?”

“It’s very important for everybody to be on the same page.”

Edward Ma, MD

~ Edward Ma, MD

After many discussions, he and his colleagues decided to keep the protocol they were using. And re-visiting whether to change gowns between patient rooms is only one of the PPE challenges Dr. Ma says his hospital has had to face. Some clinicians have gone beyond their internal PPE guidance, adding goggles under their face shields, for instance, for increased protection. But every additional layer or item some of them don causes other staff to worry that they aren’t wearing enough.

“It creates a huge level of anxiety,” Dr. Ma points out. “It’s very important for everybody to be on the same page.”

Getting “on the same page” in terms of PPE in the U.S. has turned out to be maddeningly complicated and, ultimately, impossible. Given the lack of national strategy and distribution, individual hospitals and health systems have improvised their own protocols, sometimes changing those daily.

Many hospitals have also had to compete with other facilities and governments in a PPE bidding war that has been likened to “The Hunger Games.” That conflict and the mixed messaging around what PPE health care workers need to be safe has, during a deadly spring and summer, pushed stress levels even higher.

Conflicting guidance and messaging
In the pandemic’s early days, some doctors were told to stop wearing masks in the hospital because they were scaring the nurses. And in some hospitals, nurses were told to not wear a mask or they’d scare the patients. Most facilities have since moved to universal masking.

“We still don’t know enough about this disease to know if we’re really protecting people.”

Carol Nwelue, MD

~ Carol Nwelue, MD
Christian Hospital

But nurses have staged boycotts to protest what they say are unsafe PPE standards, while clinicians have been disciplined—even fired—for complaining about inadequate protection. Some hospital leaders have set up controversial pecking orders: While clinicians treating covid in ICUs, for instance, can wear N95s, their counterparts on non-critical covid units may not.

And some administrators have bungled their messaging, not being transparent about supply levels or provider-infection rates or insisting that surgical masks confer the same level of protection as N95s. While such communication may be well-intentioned, designed to not cause panic among staff, those missteps have eroded local trust at a time when everyone needs to pull together. (See “Procurement chaos and unintended consequences.” )

Differing guidance from national and international agencies hasn’t helped. The WHO believes the virus is spread by droplets and advises providers to use N95s only during aerosolizing procedures like intubations. Otherwise, it recommends that clinicians use surgical masks, not N95s, when treating covid patients.

Not so, says the CDC, which recommends using airborne precautions and wearing N95s for all positive or suspected covid—unless supplies are limited. The CDC has issued three separate mask strategies pegged to whether hospitals have conventional, contingency or crisis supply capacity. Its contingency strategy is the same as the WHO guidance, and both its contingency and crisis strategies include the extended use or re-use of face masks.

Local variance
Physicians know they need to adjust to supply constraints, says Kendall Rogers, MD, division chief of hospital medicine at the University of New Mexico in Albuquerque. “It’s absolutely appropriate to have varying levels of standards, depending on conditions,” he points out, speaking to the CDC’s three-tier strategies. “That’s normal crisis management.”

“We really used N95s until they didn’t function well anymore.”

Joshua Case, MD

~ Joshua Case, MD
Northwell Health

What is less appropriate, Dr. Rogers adds, is having variance be such a local phenomenon. Hospitalists around the country know they are all using different PPE standards—and that some are “haves” while others are definite “have-nots.” Hospitals within the same city can have drastically different PPE policies. Even in health systems, one site may provide all its clinicians treating covid patients N95s, while another site in the same system just miles away permits only surgical masks.

That stress comes on top of bucking traditional practice. “People have been told for years that you cannot re-use your mask or gown,” says Carol Nwelue, MD, who was medical director of hospitalist services at Christian Hospital in St. Louis, part of BJC HealthCare, until earlier this month. “All of a sudden, all that has changed.”

Then there’s the question of evidence. “We still don’t know enough about this disease to know if we’re really protecting people,” says Dr. Nwelue, whose hospital was the hardest hit with covid in her state. “As we learn more, we may realize that we can decrease the kind of PPE we need, but we’re not there yet.”

Most hospitalists in her group, she adds, believe the virus droplets are airborne. When additional resources become available, group members hope N95 use will be “expanded to all caregivers taking care of covid patients.”

The protocol at Dr. Nwelue’s hospital calls for using N95s only for aerosolizing procedures.

“We still haven’t addressed the two key components since the beginning: testing and PPE. We haven’t gotten a real handle on either of those.”

Kendall Rogers, MD

~ Kendall Rogers, MD
University of New Mexico

However, the hospitalists—and other front-line physicians—are using N95s for all direct covid care. That decision can in part be traced back to when covid testing was reserved solely for patients who had traveled to China or Italy, so there was no way to know who was positive.

Another concern: “We don’t know if the patient is going to cough or sneeze on us when we’re in the room,” she points out. “At any moment, we could be at risk of the virus being aerosolized.” Several physicians, including those in her group, have purchased N95s and KN95s and given them to nurses and other nonphysician front-line staff.

Reuse as a strategy
With 16 acute care hospitals throughout the greater New York metropolitan area, Northwell Health was treating more than 3,400 confirmed covid cases on the one day it considers its apex, April 7. Joshua Case, MD, is hospitalist medical director across those facilities.

Northwell’s protocol: Everyone in the hospital wears surgical masks, including patients with confirmed or suspected covid, while everyone providing direct covid care wears N95s covered by a surgical mask as well as goggles.

As part of the health system’s initial guidance, Dr. Case says physicians changed surgical masks between patients. But “as we got further in, we started leaving the surgical masks on until we were truly doffing our N95.”

Very early on, Northwell Health decided to follow longstanding CDC pandemic guidance and extend clinicians’ use of N95s as long as possible. According to manufacturer instructions, Dr. Case explains, even N95s sold for single use can be utilized for up to 100 hours.

“We really used N95s until they didn’t function well anymore, until a strap broke or they became soiled or you really couldn’t breathe through one,” he says. “We’ve reused N95s for days and days.” Covering them with surgical masks helped extend that use, Dr. Case points out. At the end of their shifts, the hospitalists store their N95s in paper or breathable plastic bags to dry them out.

In the midst of the crisis, the New York state government mandated that hospitals had to give a new N95 every day to any health care worker who requested one. “But the vast majority of our hospitalists didn’t feel they needed that,” Dr. Case notes. Instead, the storage-and-reuse strategy “allowed everyone who needed an N95 to have one. And it let those doing true aerosolizing procedures to discard their N95s after single use.”

So did that tactic adequately protect staff? After the peak of the outbreak, Northwell Health offered free antibody testing to all of its more than 70,000 staff members. The percentage of positives uncovered “was consistent with total community numbers and far lower than we expected,” Dr. Case points out. That, he believes, is “good evidence that extended use and re-use of N95s was safe and effective.”

Driving innovation
Extended use and re-use has become another big PPE controversy, particularly as decontamination systems have come to the fore. The FDA last month issued a list of respirators it says should be not decontaminated or reused; that list includes any N95s manufactured in China, as well as those with exhalation tubes.

But extended use and re-use have also driven creativity. Some hospitals have gotten creative in ways that aren’t safe, like resorting to cloth masks in the hospital, says hospitalist Gerard Kiernan, MD, quality manager of hospital medicine at Cheshire Medical Center, a member of Dartmouth-Hitchcock Health in Keene, N.H.

Others, however, “have looked at re-use and gone about it in a way that’s scientifically rigorous,” Dr. Kiernan says. He cites his own hospital’s decontamination strategy for N95s as one example.

Clinicians turn in their respirators at the end of the day. “Each N95 is bar-coded with our name so only I use that mask.” It’s then put into a strawberry container—used for only that respirator—and sterilized with hydrogen peroxide vapor, he explains. The hospital tracks how often each mask is sterilized, and “after 20 cycles, it’s taken out of service.”

Such a system, Dr. Kiernan says, “is totally reasonable” because it’s backed by science. That helps clinicians maintain trust in their hospital leadership.

“It’s reassuring,” he says. “I feel my facility has a scientifically-supportable process that’s safe.”

The need for transparency
Maintaining trust with hospital leaders around PPE can become another sore point. At her hospital, Dr. Nwelue says a daily 10 a.m. phone call among the physician operations group helps staff maintain confidence in PPE supplies. “We talk about how many swabs we have, how many gowns, gloves, N95s and PAPRs,” she says. “Every day, we make sure we’re keeping up with demands, and we look every week at the run rates for any deviations.”

In Albuquerque, Dr. Rogers says his medical center formed an institution-wide PPE committee, “which was a very smart move.” Every day, that committee updates an electronic dashboard that shows red, yellow or green based on supplies on hand and what’s anticipated. “The committee has stakeholders from many departments who can all be spokespeople for the institution,” Dr. Rogers says. “They’re making sure the medical center maintains the level of transparency that it should.”

In New York, Dr. Case says that Northwell Health opted for what he calls “over-communicating and over-explaining” in terms of PPE. Daily meetings between physician and nursing leadership hammered out “where the supply chain was constrained, why any change was being made, and what were the reasons some people received some equipment and others did not.”

Those discussions, he adds, “were repeated in conversational videos” that everyone in the health system could access. “People may have agreed or disagreed with a policy, but there was very clear messaging,” Dr. Case says. “That takes a lot of hard work, and there are no shortcuts.”

Stockpiling and conservation
Dr. Rogers wishes he could point to more progress in terms of guaranteed access to PPE. But “we still haven’t addressed the two key components since the beginning: testing and PPE. We haven’t gotten a real handle on either of those.”

Cheshire Medical Center’s Dr. Kiernan is more optimistic, pointing out that facilities at least have a better idea of what best practices look like. “We know a lot more now about how to conserve resources but still keep people safe.” He also takes heart in the fact that U.S. industry has ramped up production.

In New York, Dr. Case says he and his colleagues are trying to balance the growing numbers of non-covid patients with covid care. “Appropriate PPE is a big part of figuring out how to do that safely,” he notes.

In the meantime, his health system is stockpiling equipment for “what none of us hopes happens but what may be possible,” he says. “We are planning for actually something worse than what we experienced in April.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist

Procurement chaos and unintended consequences

LOOKING BACK at this spring’s national chaos around PPE procurement, Kendall Rogers, MD, hospital medicine division chief at Albuquerque’s University of New Mexico, is clear on what he thinks should have taken place.

“The CDC or some other federal agency should have immediately taken control of PPE manufacturing and distribution to ensure that those who needed PPE had it,” Dr. Rogers says. A centralized federal approach could have targeted PPE supplies to rolling hotspots shifting month by month around the country.

“How is it that we have all watched New York City suffer greatly while other places sit on gear, ‘just in case’ “?

Gerard Kiernan, MD

~ Gerard Kiernan, MD Cheshire Medical Center

And a central authority could set one national PPE standard “that would affect everyone,” based on needs and the PPE pipeline. If one city or region had to adopt a contingency strategy because of constrained supplies, “that strategy should apply throughout the rest of the country.”

Instead, health care workers in epicenters have struggled with inadequate supplies. Other “unfortunate side effects” of not having a national strategy “have been local distrust and conflict,” Dr. Rogers points out. When people realize that other institutions can maintain different PPE standards, “they begin to feel their individual institutions aren’t doing all they should to try to protect them.”

Such local mistrust “is the last thing we need right now,” Dr. Rogers adds, noting that the amount of variance between institutions “is making our jobs more difficult. Individual organizations keep having to make these terribly complicated decisions—PPE burn rates, anticipated surge capacity, transmission risk—without national standards or guidance.”

It hasn’t helped, says hospitalist Gerard Kiernan, MD, quality manager of hospital medicine at Cheshire Medical Center, a member of Dartmouth-Hitchcock Health in Keene, N.H., to turn on the news and “see our colleagues overseas in Europe and in Asia decked out head-to-toe in very aggressive PPE ensembles. You think, ‘Wait a minute, if they’re able to get this organized, where’s our government?’ ”

It has also been sobering to see how geographic variability has played out in terms of disease burden and PPE-supply problems.

“How is it,” Dr. Kiernan asks, “that we have all watched New York City suffer greatly while other places sit on gear, ‘just in case’? How have we not managed to distribute materials to the areas of greatest need?”

For him, problems procuring PPE have highlighted gaps in ethics and fairness. “If we approached this as one people who had each other’s backs, we could give freely, knowing that in our time of need, we’d have support.” Instead, hospitals in areas that haven’t—or haven’t yet—been hard-hit “are reasonably saying, ‘Why should I give my stuff up? We might get hit in the future.’ And they might.”

A better stethoscope

WHEN TREATING covid patients, hospitalist Edward Ma, MD, who works in a community hospital outside Philadelphia, kept struggling with how to remove his standard stethoscope from his ears after examining covid patients.

“No matter how I gripped the stethoscope,” Dr. Ma says, “I couldn’t remove it without touching my ears or neck or face shield.” That all seemed to increase his potential risk for transmission.

His solution: Buying a $250 EKO digital stethoscope that connects via Bluetooth to his iPhone. He keeps the iPhone in one of his back pants pockets, and listens to it via an AirPod in one ear.

He typically covers the digital stethoscope with a glove, turns it on and listens to the patient, then turns it off and throws the glove away when he leaves that room. “Sometimes, I don’t have a glove, and I just wipe it down between patients.”

He keeps the sound volume at the maximum level; otherwise, it’s tough to hear. But “using it gives you an extra foot or two of separation, and it works beautifully,” Dr. Ma says. “It’s a much safer way to auscultate patients.”

ma with stethoscope
Edward Ma, MD, believes using a digital stethoscope can reduce the potential risk of transmission.
Published in the July 2020 issue of Today’s Hospitalist
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Will Bobbitt MD SFHM FACP
Will Bobbitt MD SFHM FACP
July 2020 11:31 am

Great idea, but I find that listening through a glove with my ears sacrifices all of the low frequency sounds when using the bell. I know most folks have given up on the bell, but it’s a very useful tool in its own right.