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When Contingency Meets Crisis – Extending PPE
Gopi Patel, MD MS FIDSA
Hospital Epidemiologist, The Mount Sinai Hospital
Associate Professor, Division of Infectious Diseases
Icahn School of Medicine at Mount Sinai
Pandemic Planning
▶ Stockpile of pandemic supplies including N95-respirators
– Applied lessons learned from H1N1 and Ebola virus disease
– Measles outbreak in New York a year ago
▶ NYC is moderate-risk for Tuberculosis
– Use about 6000 N95-respirators a month (single use)
▶ Endemic for carbapenem-resistant Enterobacteriales and Candida
auris and historically had high rates of Clostridiodes difficile
– We use a lot of single use isolation gowns
2
MSH COVID-19 Timeline
3
Dec. 31, 2019
Outbreak identified
in Wuhan, China
Feb. 29, 2020
First Case
Identified in NYS
Jan. 7, 2020
MSHS EOC
Established
Jan. 21, 2020
First Case in US
Identified
Jan. 17, 2020
MSHS Screening
Tool Updated
Mar. 2, 2020
Community spread
recognized in NYS
Mar. 5, 2020
1st ICU converted
to COVID ICU
Mar. 7, 2020
First MSHS
COVID-19
Admission
Jan. 29, 2020
First internal drill
for COVID-19
Feb. 7, 2020
First COVID-19
Town Hall
Mar. 25, 2020
Established
double-bed ICU
occupancy
Mar. 13, 2020
Move to “Special
Droplet
Precautions”
Mar. 30, 2020
Visitor screening
for L&D,
Liberalized N95
distribution
Mar. 16, 2020
NYC Schools
Close
Mar. 17, 2020
In-house testing, visitor
restrictions, universal masking,
contingency standards for N95
respirators, halted elective
procedures
Mar. 22, 2020
NY Pause
Mar. 23, 2020
Pre-operative
screening
Mar. 26, 2020
Construction of
lobby space
Apr. 29, 2020
NYS issues
guidance regarding
elective surgeries
Apr. 1, 2020
Opening of Field
Tent, extended use
of gowns
Apr. 4, 2020
> 2000 patients in
MSHS
Apr. 8, 2020
COVID-19 palliative
care unit, first day of
census decline
Apr. 13, 2020
Crisis stage for
gowns
Apr. 26, 2020
> 4000 patients
discharged
Apr. 14, 2020
Opening of lobby,
re-opened first non-
COVID unit
Apr. 30, 2020
Governor’s orders
to expand
visitation
Crisis Standards
▶ Conventional Standards
– Provide care with no change in practice
▶ Contingency Standards
– Change in practice with no significant change in care delivery
or HCW safety
▶ Crisis Standards
– Outside of the standard
4https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html accessed 4May20
Engineering and Administrative Controls
▶ Converted 260 patient rooms to airborne
isolation rooms
▶ Doubled occupancy in ICU by placing
two patients in a single occupancy room
– 10 ICUs and 240 ICU-capable beds
▶ Incorporated remote patient monitoring
with cameras and point of care monitoring
▶ Expanded inpatient telehealth
capabilities
▶ Cohorting both patients and staff
5
Who Gets a Surgical Mask?
Everyone
6
JAMA. published February 21, 2020. doi:10.1001/jama.2020.2565
MMWR. published April 1, 2020 vol 69 DOI: http://dx.doi.org/10.15585/mmwr.mm6914e1
NEJM. Published Apr 1, 2020 DOI: 10.1056/NEJMp2006372
“Shift” to Droplet Precautions
▶ NYC DOHMH updated their
guidance to support droplet and
contact precautions
▶ Surgical Mask + Eye Protection
– N95-respirators reserved for
aerosol-generating procedures
7NYC DOHMH Alert # 6 - COVID-19 Updates for New York City published 15Mar20
Who Gets a N95-Respirator?
▶ Limited reuse
– Doff after each encounter
▶ Extended use
– Wear continuously for multiple
patients
8
NYC DOHMH Alert # 8 - COVID-19 Updates for New York City published 20Mar20. published 20Mar20
https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/contingency-capacity-strategies.html published 29Feb20
Contingency (or Crisis) Standards for Gowns
9
NYC DOHMH Alert # 8 - COVID-19 Updates for New York City published 20Mar20. published 20Mar20
NYC DOHMH Strategies for Reuse and Extended Use of Personal Protective Equipement During COVID-19 Outbreak
https://www1.nyc.gov/assets/doh/downloads/pdf/imm/strategies-for-the-conservation-of-respiratory-ppe.pdf published 6Apr20
Crisis Communications
▶ Daily briefings and daily huddles
▶ Broadcast messaging
– Leveraging social media
▶ Engage bargaining units
▶ Virtual town halls
▶ “Elbow bump” rounds
10
Charlene Henry, RN
MSHS Hospitalizations COVID-19
11
0
500
1000
1500
2000
2500
MSHS COVID-19 HospitalizationsCOVID-19 Positive PUI
