On March 17, 2020, the Centers for Disease Control and Prevention (CDC) issued a series of strategies for optimizing the supply of personal protective equipment (PPE) to deal with the current shortage in connection with the COVID-19 pandemic.

This alert provides a high-level summary of the strategies for crisis situations, which should be reviewed carefully and integrated into efforts to develop and implement policies and procedures for preventing pathogen transmission in health care settings when the supply of PPE is limited.

The CDC guidance discusses four types of PPE:

• Eye protection
• Isolation gowns
• Facemasks
• N95 respirators

For each category, the guidance discusses strategies based on (1) conventional capacity, (2) contingency capacity, and (3) crisis capacity. Conventional capacity means operating under essentially normal circumstances. Contingency capacity practices are for expected temporary shortages of PPE. Crisis capacity practices are not consistent with the standards of care in this country but may become necessary.

The contingency and crisis capacity strategies are based on the assumptions that facilities:

• understand their current inventory and supply chain for the PPE resources
• understand their utilization rates of the PPE resources
• are in communication with local health care coalitions, public health partners, and others resources to identify additional supplies of PPE
• have already implemented other measures, including reducing the number of patients entering the setting, excluding nonessential health care personnel from the patient care areas reducing face-to-face encounters with patients, excluding patient visitors, cohorting COVID-19 patients and health care personnel, and maximizing the use of telemedicine
• have educated health care personnel about how best to use PPE

Facemasks

Crisis capacity strategies for facemasks include:

• canceling all elective and non-urgent procedures that would normally be done using PPE
• using facemasks that are beyond the manufacturer designated shelf life
• implementing limited reuse of facemasks during a shift until the facemasks become too soiled or damaged
• removing and storing disposable facemasks in a clean, sealable paper bag or breathable container for the same person to use again

When no facemasks are available, options include:

• excluding health care personnel at high risk for severe illness from providing patient care
• designating health care personnel who have clinically recovered from COVID-19 to provide care for patients being treated for COVID-19
• using a face shield that covers the entire front and side of the face
• using homemade facemasks

Eye Protection

Crisis capacity strategies for eye protection include:

• canceling all elective and non-urgent procedures that would normally be done using PPE
• prioritizing eye protection for activities that involve splashes and sprays and activities where prolonged face-to-face or close contact with the potentially infectious patient is unavoidable
• using safety glasses (e.g. trauma) that have extensions to cover the sides of the eyes
• cleaning and disinfecting eye protection, even single use disposable face shields, for re-use
• excluding health care personnel at high risk for severe illness from providing patient care
• designating health care personnel who have clinically recovered from COVID-19 to provide care for patients being treated for COVID-19

Isolation Gowns

Crisis capacity strategies for isolation gowns include:

• canceling all elective and non-urgent procedures that would normally be done using PPE
• extending the use of gowns (disposable or cloth) when interacting with multiple patients with COVID-19
• washing and reusing cloth gowns
• prioritizing gowns to situations in which splashes or sprays are anticipated and during high contact patient activities, such as dressing, bathing, changing linens, assisting with toileting, wound care, etc.  
• using alternatives when no gowns are available, including disposable lab coats, reusable patient gowns, reusable laboratory coats, disposable aprons, and combinations of clothing to create garments with long sleeves and open backs

When cloth gowns and other reusable alternatives are used, additional laundry operations and personnel may needed to handle additional washing loads and routine inspection and replacement of damaged gowns.

N95 Respirators

Crisis capacity strategies for N95 respirators include:

• using N95 respirators beyond their designated shelf life
• reusing N95 respirators throughout a shift when caring for patients with COVID-19
• prioritizing the use of N95 respirators by activity type
• using (as a last resort) respirators that are not evaluated or approved by NIOSH or homemade masks