IMPORTANT NOTE ➡️ This article was written in 2020 and was accurate at the time. There were many references to various CDC and WHO sources that were accurate at the time of publication. However, many of those have changed since.
The current recommendation in personal protective equipment (PPE) for front line health care providers (nurses, doctors, respiratory therapists, and so forth) is to wear the following for suspected or confirmed COVID-19 patients:
- Gowns
- Gloves
- Eye protection
- Surgical masks – except for aerosol-generating procedures
- N95 or better – for aerosol-generating procedures
(CDC source, OSHA source, WHO source, ANA source)
Once the supply chain is restored and we’re not grappling with a critical worldwide shortage of respirators, the goal is to get back to using a new N95 or better for all patient encounters for suspected or confirmed COVID-19 patients, as that level of precaution provides an abundance of caution.
In the meantime, we need to prioritize N95s or better to be used for those healthcare workers at highest risk for coming into contact with aerosols (nurses, doctors, RTs during procedures that create them).
In terms of understanding the current isolation precaution level, here is an outstanding article from the NY Times, which fleshes out the rationale with diagrams. (This article may be particularly helpful to share with your family members and loved ones who may be concerned about healthcare exposure risk.)
If you’d like to learn more about why we’re so short as a nation, here’s a great article.
The short version of why we don’t have enough masks: China produces about 80% of PPE worldwide, so to deal with their own outbreak they’ve subsequently significantly reduced export. We don’t have nearly enough domestic production to keep up with our demand. We should have a government stockpile, but after H1N1 in 2001 we depleted 100 million masks from the stockpile and they were never replaced.
A really helpful resource to clear the air (no pun intended)
The American Nurses Association has a free webinar available for nurses on COVID-19 that is phenomenal.
(This is NOT a sponsored post or plug for the ANA. I watched it on Friday and was blown away at the value of the content and the expertise of the speaker. Please watch it if you want to know more about PPE!)
It featured Terri Rebmann, Ph.D. RN CIC FAPIC who is part of the Association for Professionals in Infection Control and Epidemiology, a professor for the Department of Epidemiology and Biostatistics at Saint Louis University, and the Director of the Institute for Biosecurity.
Needless to say, she knows what she’s talking about. Her explanation of the change from Airborne Precautions to Droplet Precautions (except for aerosol-generating procedures) is astute and offers reassurance for those who understandably feel concerned downgrading.
You can listen to her 60-min talk on COVID-19 for free here.
(Again, the webinar was produced by the American Nurses Association. While You do have to register to get access, you do not need to be an ANA member to watch.)
While there were a lot of major take-home points, I wanted to share with you the one that hit me the hardest.
How healthcare workers can inadvertently infect themselves
Dr. Rebmann discussed the SARS outbreak back in 2003. Depending on the source you’re looking at, anywhere from 20-30% of infections were from healthcare workers (the WHO says 30%), which is pretty alarming and concerning. However, she outlined that a lot of healthcare workers were actually inadvertently infecting themselves while removing their PPE.
So, how was this happening?
The front of the respirators and face masks carry the highest bioburden of contaminants. An observational study was completed and they noticed that many healthcare workers were touching the front of the mask while removing it. Because their finger(s) were near their face or mouth, they would inadvertently touch their face or mouth, thus subsequently inoculating themselves.
Once the staff was educated on proper removal of PPE, staff infection plummeted.
(She references this study in the webinar but I am still working on finding a citation of the actual study itself.)
While it is our employer’s responsibility to provide us with the PPE to keep us as safe as possible, it is our responsibility to use it correctly.
So let’s do this!
How to properly remove an N95 face mask
Because there are various manufacturers, I highly recommend asking your Infection Prevention team about which one(s) you use to make sure you’re doing it right. It is imperative that you’re doing this correctly.
If you’re a manager, consider having the Infection Prevention team coming by for demos, if they haven’t already. Please make sure to explain the WHY, not just the HOW.
It’s not enough to say, “Don’t touch the facepiece”. We’re constantly being told hundreds of things to do and not do, with varying levels of severity. There are a lot of places healthcare providers take shortcuts in real-life practice because, like a lot of life, sometimes good enough is better than not at all.
The “perfect world” of healthcare doesn’t exist, where we always have the resources and time we need to do things perfectly or the way the textbook says you should. Sadly, a lot of education revolves around this non-existent theoretical world. When you highlight every page of the book or say every single thing is important – it makes it so none of it is, and we don’t know where to focus our constantly-stretched efforts. This leaves healthcare providers who are short on resources or time to make the call at the moment on what they’re going to devote their limited time or resources to – to decide what really is important and what is good enough.
And to be honest, right now, we’re dealing with a lot of “good enough” because we’re dealing with less-than-ideal situations and a massive lack of resources worldwide. We’re constantly trying to read between the lines of what REALLY matters and what can be less than perfect and still acceptable.
Therefore, I urge you to communicate the specifics on why we can’t touch the facepiece.
(Because that’s where the contaminants are and if you touch that, then anything else before washing your hands – you can easily infect yourself.)
Because 3M is a popular manufacturer, I grabbed their instructional video on respirator use and removal to give you an example. If you want to skip straight to the removal demo, it’s at the 3:34 mark.
https://youtu.be/05wyH1-mLGk?t=214
The biggest thing is to not touch the facepiece. Make sure you’re only touching the straps!
Also, dispose of it or store it appropriate for the next use if you’re doing limited-reuse, and wash hands immediately.
Storing your N95 with limited re-use
If your hospital is having you do the CDC’s practice of limited re-use, they have specific recommendations for how you should store the N95 in between uses. (Dr. Rebmann goes over this practice in the webinar and explains it very well.)
Let’s back up a touch first… before you put the N95 on for the first time, you should label it so that you’re not mixing up masks with colleagues.
The CDC doesn’t want you to put it in a plastic sealed container because contaminants will get on the container, this would require you to clean the container thus creating another task, and possibility for infection due to a lack of airflow.
They prefer you to store it in a clean, breathable, and disposable bag. You don’t have to clean it because you can just toss it after each use and get a new one, you can label it and keep it separate from others, and it’s breathable.
Their suggestion is to use a brown bag, which is what many hospitals are doing. Alternatively, you can hang it near a patient room. However, it must be in a location where it’s not going to easily fall and multiple masks are not hung together.
It’s not all garbage bags and bandannas
I know it’s really tough to get on social media and other forms of media right now and see disturbing posts after disturbing posts of nurses on the front lines.
If you’re in that situation, I hear you and see you. It is not right or fair to be put in a position where you have to choose between your personal safety and your job/livelihood. Many of us never dreamed we would be in a situation like this, so finding ourselves here is really frustrating and upsetting – especially when you feel you already give too much of yourself.
My hope is that you have the autonomy to make that decision of what’s best for you out of a place of confidence and peace, not fear.
However, in talking to nurses across the country, I have heard that not every organization is at the crisis level – even though it may feel like it. There are many who have a sufficient PPE and ventilator stock… many who have dedicated COVID-19 units… who have canceled all elective non-essential surgeries, thus freeing up staff and other resources to devote to the impending surge… who are cross-training nurses so they can help in other units… who are having chaplains, counselors, and EAP staff rounding on front line providers … who are doing everything they can to support their staff elbow-to-elbow.
I say this not to detract focus from the need for PPE, but to also bring the balance that there are many organizations doing well despite these seemingly insurmountable odds. I believe that this large-scale stressor on the healthcare system is bringing organizational leadership deficits to light – and making apparent which organizations have the right leaders in place.
It is through adversity and crisis in which good leaders emerge… and how a leader responds to adversity is often more important than the adversity itself. Humanity will continue to have outbreaks of infectious diseases, events will happen that create mass surges at hospitals … but it is how leaders prepare, allocate resources, educate, respond, encourage, and extend compassion and support to their staff is what will determine the level of success and safety of staff and public alike.
This is showing which organizations are scrambling and which ones are calmly and systematically enacting the existing processes designed to deal with this very issue.
If you are a leader who is working tirelessly to do your best to get your staff what they need, educate, and encourage them – I want to extend my deepest gratitude to you. It is not an easy position to be in, let alone flourish in the way your staff needs you to.
As a community, we desperately need selfless, wise, and sound leadership and structure at this pivotal moment. It’s challenging to lead a workforce of healthcare providers who are in survival mode themselves, who are responsible for keeping the sickest members of our society alive right now. It feels like we are digging our heels in to brace for the hit, and stand our ground to shield, protect, and physically care for our patients, while we simultaneously absorb the brunt force of the storm.
We are thankful to those who are showing up, leaning in, and weathering the storm right alongside us – encouraging, elevating, and equipping us to soldier on until the clouds finally part.
Resources
A lot of organizations are putting out COVID-19 specific educational resources, as well as education for those being asked to step into roles they’re not very familiar with (like ICU).
Unveiling the Mysteries of Mechanical Ventilation – An online course from Nicole Kupchik to help get people up to speed on vents if you are cross-training, it is currently marked down significantly (normally $159, it’s now at $49) to help support our community as we prepare for a large influx of patients. Nicole has also done some educational videos on her Instagram channel. Follow here at @nicolekupchik and check out her IGTV videos.
Healthy Simulation Coronavirus COVID-19 Medical Simulation Resources List – This list is incredibly comprehensive of various simulation resources.
Nursing.com – They have a ton of great resources in general for nursing school, but they are offering some great resources for students and educators. For nursing student resources, click here. For nurse educator resources, click here.
American Association of Critical Care Nurses – This resource is AMAZING. It’s also FREE. You do NOT need to be a member of the AACN to take it. It’s an online course on COVID-19 patient management, including the following topics:
- Analyzing ABGs and managing patients’ oxygen delivery including oxygenation and ventilation
- Caring for patients with acute respiratory failure and acute respiratory distress syndrome (ARDS)
- Administering care for patients requiring endotracheal intubation or invasive mechanical ventilation, and troubleshooting ventilators
- Managing patients on mechanical ventilation, including spontaneous awakening trials, neuromuscular blockade, prevention of complications, weaning from ventilation and extubation.
American Nurses Association – This is a link to the COVID-19 webinar I mentioned earlier in the article.
References
- Center for Disease Control and Prevention. (2020, March 10). Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings. In Coronavirus Disease 2019 (COVID-19). Retrieved March 19, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
- Center for Disease Control and Prevention. (n.d.). Recommended guidance for extended use and limited reuse of N95 filtering facepiece respirators in healthcare settings. In The National Institute for Occupational Safety and Health (NIOSH). Retrieved March 26, 2020, from https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
- Fisher, E. M., & Shaffer, R. E. (2014). Considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings. Journal of occupational and environmental hygiene, 11(8), D115–D128. https://doi.org/10.1080/15459624.2014.902954
- Manjoo, F. (2020, March 25). How the world’s richest country ran out of a 75-cent face mask. In the New York Times. Retrieved March 30, 2020, from https://www.nytimes.com/2020/03/25/opinion/coronavirus-face-mask.html
- Popovich, N., & Parshina-Kottas, Y. (2020, March 11). What U.S. health care workers need to fight coronavirus. In The New York Times. Retrieved March 26, 2020, from https://www.nytimes.com/interactive/2020/03/11/us/virus-health-workers.html
- United States Department of Labor. (n.d.). Know Your Rights. In the Occupational Safety and Health Administration. Retrieved from https://www.osha.gov/workers/
- United States Department of Labor. (2020). COVID-19 control and prevention. In the Occupational Safety and Health Administration. Retrieved March 26, 2020, from https://www.osha.gov/SLTC/covid-19/controlprevention.html
- World Health Organization. (2003, May). Consensus document on the epidemiology of severe acute respiratory syndrome (SARS). In Epidemic Alert & Response. Retrieved March 30, 2020, from https://apps.who.int/iris/handle/10665/70863
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