Personal Protective Equipment (PPE)

An important point for surgeons is the use of PPEs in the operating room. Because there seems to be a variable understanding of the recommendations, we have provided some basic recommendations. The CDC has the following information and recommendations for PPE use for COVID-19 patients, or persons under investigation (PUI).

While in the operating room (OR), N95 respirators are recommended, particularly when operating on confirmed or suspected COVID-19 patients; however, the American College of Surgeons recognizes that many health care facilities have limited access to N95s at this time. Recent recommendations have been developed by the ASA and others for projected shortages of N95 masks. These include: implementing leadership controls to minimize who needs respiratory protection, use of alternatives to N95 masks, practices allowing extended use and or limited reuse of N95 masks, prioritization of N95 masks for health care personnel at highest risk of COVID-19 and consider use of masks approved by the National Institute of Occupational Safety and Health typically used in manufacturing and construction. For individuals at highest risk of exposure at institutions that are unable to provide N95 masks to all members of the OR team, we recommend that all surgeons and other personnel who are not wearing N95s evacuate the OR during intubation, extubation, and other procedures that may generate aerosolized small particles. The Centers for Disease Control and Prevention and the American Society of Anesthesiologists have recommendations to help prioritize.

Ensuring a proper fit of the N95 mask is paramount, so FIT TESTING is needed. The CDC also has delineated some key factors for using the N95 mask effectively, as well as checking for an appropriate mask “seal”.

Finally, shortages of masks increasingly are being reported, so strategies for optimizing facemasks/PPEs from the CDC are provided in this link.

A similar donning and doffing technique can be used as the Centers for Disease Control and Prevention (CDC) recommended for physicians on the front lines during the Ebola crisis. Informational materials are available that demonstrate the procedures described in CDC guidance for putting on and removing PPE.

The same recommendations made for hospital care should be applied to outpatient office visits. The safety of patients and health care professionals is best served by allowing patients to stay home whenever possible to avoid bringing together large numbers of people. Although much of the focus has been on surgery and procedure areas, outpatient office areas experience a much higher volume of traffic with more providers in a smaller area without routine PPE during patient interactions. In addition to trying to discourage social interaction in these settings, additional preservation of PPE is a priority, which is undermined by continuing to see patients without urgent problems in outpatient offices. Thus, whenever possible outpatient evaluation should be by permissible remote connectivity. Patients who the provider deems in need of urgent personal evaluation may still be offered in-person office visits.

Oregon has initiated a policy whereby surplus PPE must be arranged to be delivered to the state by March 27 for redistribution. The language excludes certain life- and limb-threatening diagnoses, and the stipulation to arrange for delivery of excess supplies is vague.

To conserve PPE during this time, Billings Clinic, MT, has mass produced and distributed 3D-printed surgical masks with reusable filters. The source file is available on the clinic’s network for any health system that would like to use the instructions. The U.S. Food and Drug Administration has granted the clinic temporary approval of the masks.

The U.S. Food and Drug Administration recognizes that the need for PPE, such as medical gloves, may outpace the supply available to health care facilities during the COVID-19 outbreak. Consequently, the agency has issued a letter to health care providers that refers specifically to potential shortages relating to surgeons’ gloves and patient examination gloves.

The conservation strategies are categorized for a range of needs and supply levels and are intended to assist health care organizations as they determine procedures during the COVID-19 pandemic. The conservation strategies described are intended to augment specific controls and procedures developed by health care facilities, the Centers for Disease Control and Prevention (CDC), or the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) to aid in infection prevention and control. These strategies are not limited to use in the care of patients infected with COVID-19. Health care facilities may find additional useful information in guidelines on modifications to medical standards of care during a crisis.

Surgical Innovation Fellowship, Boston Children’s Hospital

Making Your Own Reusable Elastomeric Respirator for Use During COVID-19 Viral Pandemic N95 Shortage