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March 27, 2020

When desperation breeds creativity: How US hospitals are approaching a PPE shortage

Daily Briefing

    A national shortage of personal protective equipment (PPE) is forcing U.S. health systems to deploy creative strategies to conserve and improvise alternatives to face masks, respirators, eye protection, and gowns, though their efficacy is unproven.  

    Cheat sheet: Overview of CDC’s new guidelines following PPE shortages due to COVID-19

    Even with the CDC's recently relaxed PPE guidance, many health systems have reached a tipping point that requires them to reuse or create their own PPE. Although the CDC recognizes that alternatives like bandanas or lab coats aren't considered true PPE, many organizations are turning to them as a last resort—as evidenced by a JAMA call for ideas that surfaced solutions from using scuba masks to making 3D-printed face shields.

    Below we've compiled a list of early examples from U.S. health systems deploying creative strategies to reuse—or replace—protective gear.

    Reusing face masks and respirators

    In line with CDC guidelines that recommend respirator reuse no more than five times, some health systems are instructing providers to extend the use of face masks and respirators to conserve supplies.

    • The George Washington Hospital in Washington, D.C. has instructed providers to reuse respirator masks before discarding them, and placed their supply of PPE under lock and key after their CMO reported theft of face masks.

    • Providence Health in Washington State now allows providers to wear masks for longer than normal in accordance with CDC's relaxed guidelines, and moves stores of surplus PPE between hospitals in Seattle and Spokane during the night to adjust to fluctuating supply needs at each location.

    PPE disinfection with UV

    Though CDC guidelines on PPE don't give guidance on UV disinfection, a literature review by Nebraska Medical Center showed that ultraviolet germicidal irradiation (UVGI) inactivates human respiratory viruses, including coronaviruses, on a wide range of N95 models without adversely affecting their fit and filtration.

    • University of Nebraska Medical Center in Omaha, Nebraska, is sterilizing formerly-one-time respirators to last a week or longer using UV light. Staff place groups of N95 respirators in paper bags and take them to a room with two ultraviolet light towers, where they hang the masks on wires that run across the room. The UV lights decontaminate the masks within three to five minutes. After decontamination, staff return the masks to their original owners for reuse.

    Homemade PPE alternatives

    As a last resort, some health systems are creating PPE from household materials. Efficacy of homemade alternatives is not proven, but one study by the University of Cambridge found that homemade masks made from t-shirts blocked approximately 50% of 0.02-1 micron particles—compared with 80% blocked by standard surgical masks.

    The CDC currently does not recommend providers use homemade products. If they must be used, the agency recommends they take additional precaution by also using a face shield.

    • Boston Children's in Massachusetts conducted a small pilot study in their Surgical Innovation Fellowship for a DIY, low-cost respirator mask alternative. The respirator, made from an anesthesia mask, ventilator inline bacterial or viral filter, and elastic straps, can be made for under three dollars. Providers can disassemble and reuse the mask until it shows visible signs of wear or contamination. The respirator is not approved for use at Boston Children's at this time, though researchers say they will use the device should the need arise.

    • Providence Health's infection and control quality experts created homemade face-shields using supplies from Home Depot, including military-grade vinyl, industrial tape, foam, and elastic. Last week, the team and administrative staff assembled 500 face shields to send to their Seattle hospital, and are currently testing a prototype facemask made from surgical wrap material. Providence also launched the "100 Million Mask Challenge"—a campaign in which they distributed sewing kits and an instructional video to members of the community. They received so many hand-sewn masks that they halted the challenge for now.

    • Henry Ford Health System staff in Detroit have turned to everyday items to fashion homemade face masks and shields as short-term PPE replacements as part of their Innovation Institute's challenge campaign. Staff created their prototyped mask with moisture wicking fabric, elastic bands, and air filter material, and they can wash the mask with a bleach cleaning solution for reuse. They made homemade face shields from materials including plastic sheets, elastic bands, and tongue depressors. Staff and volunteers plan to ramp up production of the homemade masks to 500-1,000 pieces per day to bridge the gap between their dwindling supply and their next shipment of standard supplies.

    • Deaconess Health System in Indiana posted a PDF template and video instructions for homemade fabric masks on their website along with directions for donating masks to hospitals in need. The system recognizes that providers should not use fabric masks to care for COVID-19 patients outside of a crisis situation, but says their orders for standard masks are on long back order. Providers can sterilize and reuse the masks as needed.

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