Position Statement: On Infection Control Protocols and the Shortage of Respirators and Personal Protective Equipment for Health Care Personnel and First Responders During the COVID-19 Pandemic

In the face of the declaration of a global pandemic and the declaration of a state of emergency in the U.S. and New York to fight the current COVID-19 outbreak, it is imperative that we maintain and expand the health care infrastructure necessary to diagnose and treat the millions of Americans who are likely to be infected and the hundreds of thousands who will require hospitalization and other treatment.

At this point there are concerns about the level of bed capacity, particularly of intensive care units for the small percentage of infected patients who will require critical care (seniors, people with underlying conditions, the normal volume of trauma, cardiac, stroke and other serious health issues) and about the level of staffing that will be needed to staff our hospitals and other health care facilities (nurses, physicians, first responders, etc.).

Of more critical immediate importance in the fight against COVID-19, however, is the need to provide personal protective equipment (PPE) that will allow our front-line health care workers to continue to work and care for the expected surges in volumes of patients that are imminent.

It is imperative, in this context, to protect our nurses and other front-line workers from reckless or avoidable exposure to the virus.  If health care workers are exposed unnecessarily, they will have to be isolated or quarantined or will themselves become ill.

If the health care system and our hospitals are to continue to operate at the levels that we need, urgent emergency action must be taken now to protect nurses and other direct care staff from exposure and infection.

In recent days, however, the CDC and federal authorities have announced new infection control protocols and guidances that substantially roll-back the standards for protecting health workers that were established following previous novel influenza and corona outbreaks (SARS, MERS, H1N1, etc.).

The CDC, for example, has repeatedly updated its infection control protocols (which are non-binding guidances for hospitals and other providers.  With each update, the protocols have been loosened to lower the degree of protective measures for health workers, including reducing the range of workers who are to use N95 or other respirators when treating patients, calling for laxer rules for the reuse and extended use of disposable respirators, and suggesting the substitution of masks instead of respirators.  Local and state authorities are following the CDC’s lead and issuing local rules with less protection of health care workers. [1]

These changes in guidance and protocols by the CDC are a direct indication that there are not sufficient supplies of N95 respirators available to safely operate our hospitals and other health care facilities in the face of the COVID-19 pandemic.

It further appears that the Federal government failed to maintain adequate stocks of respirators in the national reserves and further failed to take action when the outbreak first arose in November-December to secure additional supplies of N95 respirators. 

Now, rather than taking urgent and immediate measures to secure and distribute an adequate number of respirators to front line health care staff, the CDC has instead opted to reduce protective standards and to make things worse by exposing nurses and other worker to increased risk of exposure and infection.  This will undermine the capacity to sustain operation of the health care systems that our people will rely on as the virus spreads in coming weeks.  If our nurses are in isolation or sick, they will not be there to provide patient care.

According to a 2015 study by the CDC, it was found that in a pandemic flu-like outbreak, our national health care system would need anywhere from about 1.5 billion to 6.7 billion N95 respirators, depending upon the infection rate among the general population and the severity of the illnesses caused by of the outbreak. [2]

Based on our analysis of the CDC modeling in that study, and considering the recent decision by the CDC to downgrade infection control standards and limit the use of N95 respirators, we have come to the conclusion that the standards have been rolled back not because they are the scientifically or medically indicated best practices but rather because we do not (nationally or locally) have the supply of N95 respirators available that will be necessary to address a prolonged outbreak.

We have further concluded, based on the estimated rate of usage of N95 respirators and the various respirator conservation strategies analyzed by the CDC in the study, that the recent reduction of the standards for the distribution of respirators and their use is consistent with a conservation strategy that implies we may have only 40 million to 195 million respirators available (rather than the 2-3 billion or more that a stricter infection control standard would require).

The answer to the shortage of respirators cannot and must not be to reduce safety standards, expose nurses, doctors, first responders and other vital health workers to infection, and undermine the effective operations of our hospitals.

RECOMMENDATIONS

NYSNA calls on the federal authorities and their local counterparts to restore the previously established infection control protocols and standards for the use and distribution of respirators and other PPE. This is vital to enable health care workers to continue to work through this crisis.

Accordingly, NYSNA calls on the CDC and other authorities to immediately issue universal, standardized, and mandatory protocols to be used by all local hospitals and health care providers to protect front line health care workers and first responders from exposure to COVID-19. 

In addition, to the Federal government and local authorities must take immediate coordinated emergency steps to expand the production, procurement and organized distribution of respirators and other PPE. This must be the top priority of the Federal government, which has the resources and powers to take immediate compulsory action to provide stocks of PPE.

These emergency measures must include the following:

1. All nurses and other staff caring for or coming into contact with suspected or confirmed COVID-19 cases must wear a minimum of N95 Respiratory protection, or with Powered Air Purifying Respirators (PAPRs) or other reusable respirators.  Staff caring for suspected or confirmed COVID-19 cases must also be provided with a suit of protective equipment, including impermeable gowns, booties, and face shields or goggles.
2. The standards for the use of respirators and other PPE must apply to staff who are directly caring for confirmed cases, but also for other staff having regular contact or encounters with possible COVID-19 cases, including, staff assigned as the initial points of contact or screeners of incoming patients in EDs and other acute care and outpatient settings, and for first responders.
3. The guidance to employers and providers must be mandatory and not subject to interpretation or being rolled back or ignored at the facility level.  These minimum mandatory standards should not be decreased or diminished in the pursuit of expediency or cost containment.
4. Finally, Federal, State and Local authorities must take immediate emergency action to secure and distribute stocks of N95 or higher-rated respirators and other PPE to our hospitals and other health care institutions in quantities necessary to protect staff from exposure and illness.

We note on this score that recently passed House legislation to address the outbreak includes authority for the CDC and FDA to allow the use of industrial N95 respirators and waives liability for the use of these respirators in medical settings.

We expect these necessary emergency steps to include (a) the use of Federal existing emergency powers to direct manufacturers to prioritize and maximize production of N95 respirators, including the direct appropriation of raw materials and machinery necessary to carry out this vital task; (b) to secure all existing stocks of both medical and industrial N95 or higher grade respirators of all kinds; and, (c) to directly undertake the orderly and efficient distribution of this vital equipment to local authorities and to our hospitals and other health care facilities.

We cannot ask our hospitals to fend for themselves in securing necessary PPE and respirators, or to implement ever looser protective standards because respirators and other PPE are in low supply.  It is the responsibility of the Federal government to correct its prior failings and do everything that is necessary to provide the necessary quantities of vital PPE on an emergency basis.

The responsible authorities need to take all necessary measures to ensure that our health care system and the nurses and other workers who staff it are able to continue to function during this crisis.  Our nurses and other health care workers are our front line troops in this battle, and they are armed with the knowledge and dedication to protect our communities.  They cannot be asked to go into this fight and win, however, if they don’t have the PPE ammunition they need to win this fight.

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