Rapidly Changing PPE Policies Sow Confusion

Sheila Mulrooney Eldred

April 18, 2020

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In the Ob/Gyn department at Main Line Health, a suburban Philadelphia hospital, rules surrounding personal protective equipment (PPE) have evolved — from minimal use to measured caution — over the past few weeks.

When COVID-19 first hit Pennsylvania, hospital administrators limited surgical mask use to providers treating patients with confirmed COVID-19. Then, the policy became masks in rooms but not hallways. Only when the Gov. Tom Wolf declared everyone should wear face masks in public did the hospital allow masks to be worn in hallways too.

Elsewhere, a neurosurgical unit at one hospital in Minnesota was converted to a COVID-19 floor mid-shift. The staff — who rarely wear PPE — had to scramble for guidance on what to use and how to wear it.

A different facility in Minnesota issued new rules and then withdrew the policy before it had even been made public…twice. (The hospitals have not been named so as to protect employees, all of whom asked to remain anonymous for fear of retribution.)

The specifics of PPE use have been controversial since the pandemic first hit US shores. But once the Centers for Disease Control and Prevention (CDC) issued the recommendation 2 weeks ago that everyone wear masks in public, hospital PPE policies began shifting rapidly. Many providers welcomed the change, and the number of healthcare workers being reprimanded for using their own PPE appears to have plummeted.

But rolling out new policies in the midst of a pandemic has created new problems: Frontline providers aren't always clear on current protocols. Institutional instructions on donning and doffing a wider variety of PPE sometimes lag behind or are completely lacking. And some medical organizations, including The American Association of Nurse Attorneys, have urged the CDC to reconsider its loosened standards, which allow for the use of bandanas in lieu of masks, saying they "will most likely result in the increased spread of the virus."

"Hospitals all over have greatly changed their practices around PPE use in response to existing shortages," said Eric Toner, MD, a senior scholar at the Johns Hopkins Center for Health Security who conducted a new analysis on how much PPE may be needed. "And these will continue to evolve in response to local supply and demand mismatches."  

The disparate medical system of the US means that each healthcare facility must set its own PPE policy based on a number of factors, including what types of conditions it treats and how much protective equipment it has available. Even a universal masking strategy means different things at different hospitals.

There are thousands of hospitals and outpatient facilities in the US, said Sylvia Garcia-Houchins, MBA, RN, Director of Infection Prevention and Control for the Joint Commission. "Every single one is different. Every one has a different level of PPE, and every one decides how to don and doff. There's not one way in the US right now."

Those differences, and the lack of a single, standard policy, has led to confusion — especially when hospitals change protocols faster than their staff can keep up.

Garcia-Houchins noted that complaints from healthcare workers have been flooding in, reflecting fear and confusion about constantly changing policies. When the Joint Commission funnels advice back to organizations that have received those complaints, she said, most of it focuses on improving communication of policy changes.

"Every day there's a change at some places, so getting that word out is so crucial," she said.

Hospitals need to communicate not only what types of PPE they mandate, but also how to correctly don and doff every single piece and every different style. Garcia-Houchins noted that a few are doing an exemplary job, using multiple modes of communication: how-to videos that every employee watches when starting a new shift, posters, and announcements, to name a few.

When PPE isn't used correctly, it's not nearly as effective. And each variant of each item requires different, precise methods to put them on and take them off safely. Hospital gowns are just one example of this: Most US hospitals shifted from cloth to disposable gowns long ago. During COVID-19, however, hospitals are using both, and the different styles have different methods of donning and doffing. Done incorrectly, contamination risk increases. (Some healthcare workers have reportedly been asked to reuse disposable gowns, posing additional risk.)

Beyond the policy changes, however, is a deeper problem: There's still simply not enough protection for many providers to feel safe.

"I feel emotionally devastated, because the burden of us needing to ensure adequate protection should never have fallen on me, and I should never have had to fight for the right to be protected," said one physician who asked to remain anonymous for fear of retribution from administration. "I should be able to trust that what is happening is the right thing, that my best interest is being taken care of...The hospital should never err on the side of underprotection, but on the side of overprotection, to show us that we are cared for by an institution that wants to keep us healthcare workers safe." The experience has been so distressing that the doctor considering leaving medicine altogether, once the COVID-19 pandemic is over.

Sheila Eldred is a freelance health journalist in Minneapolis. Find her on Twitter @MilepostMedia.

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