Considerations for U.S Healthcare Facilities to Ensure Adequate Supplies of Personal Protective Equipment (PPE) for Ebola Preparedness

Key Points

• Facilities ordering PPE recommended in PPE guidance issued by CDC may have longer than normal delivery times.
• Hospitals should review the guidance on the Framework for a Tiered Approach before determining how much PPE they need.
• Hospitals should have the minimum amount of PPE on hand to match their role.
• Hospitals can contact their state and local health departments for help getting the PPE they need.

Current Supply Situation

On October 20, 2014, CDC issued revised interim guidance for use of PPE when caring for patients with Ebola virus disease (EVD). The Department of Health and Human Services (HHS) and CDC have been working closely with PPE manufacturers and distributors to better understand the demand and supply for products mentioned in this guidance. As of December 2015, manufacturers and distributors have reported that they are able to fill most orders placed for PPE products. However, some products may be available in smaller quantities than requested or with a later delivery date than requested. HHS and CDC continue to keep close contact with manufacturers and distributors of medical equipment and supplies to maintain situational awareness about availability of PPE and any shortages.

Do all hospitals need the same amount of PPE to prepare or care for patients with EVD?

No, all hospitals do not need the same amount of PPE. The amount of PPE a facility has depends on the facility’s role. To create a coordinated, comprehensive, and networked approach among healthcare facilities, state and local public health authorities, in collaboration with healthcare officials, are identifying acute healthcare facilities in their jurisdictions to serve in various roles as outlined in CDC’s Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach. In some cases, a hospital may be prepared to serve in more than one role. As described in the guidance, the role a facility plays in preparing to identify, isolate, evaluate, and in some facilities, treat patients under investigation (PUIs) for EVD will determine the amount of PPE needed.

Based on this framework, sufficient amounts of PPE needed for the care of one person under investigation or with confirmed Ebola infection are as follows.

Role: Frontline facilities – Ebola PPE sufficient for 12 to 24 hours of care

Most U.S. acute care facilities equipped for emergency care (acute care hospitals and other emergency care settings including urgent care clinics and critical access hospitals) are in this tier. State and local public health departments are actively monitoring persons with a recognized EVD exposure risk within the last 21 days (per CDC’s Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure). Therefore, these persons will be directed to designated facilities for evaluation if they become ill, making it unlikely that patients with unrecognized EVD will seek treatment at a frontline healthcare facility without warning. However, if a patient was to seek treatment without warning, he or she would likely have mild symptoms such as isolated fever. It is unlikely that frontline healthcare facilities will be required to provide prolonged care (>12 to 24 hours) for a severely ill patient at high risk for EVD. Accordingly, most patients can be cared for in these facilities using PPE (face shield and surgical face mask, gown, and 2 pairs of gloves) as described in CDC’s Emergency Department Evaluation and Management of Patients with Possible Ebola Virus Disease.

Plans for PPE supplies in frontline facilities should focus on ensuring an adequate stock of gloves, gowns, surgical facemasks, and face shields and ensuring that all staff are regularly trained on its use. In the unlikely event that PPE recommended for care of hospitalized patients with confirmed EVD is needed, frontline healthcare facilities may want to have access to Ebola PPE sufficient for 12 to 24 hours of care. They should also ensure that healthcare workers who may be required to use Ebola PPE are trained for their roles in Ebola patient care and have demonstrated proficiency in use of Ebola PPE, including donning and doffing. Additionally, frontline facilities will discuss with public health authorities the possibility of immediately transferring these patients to an Ebola assessment hospital or to an Ebola treatment center.

Role: Ebola Assessment Hospitals – Ebola PPE for at least 4 to 5 days of patient care

These facilities are prepared to receive and isolate a PUI and care for the patient until a diagnosis of EVD can be confirmed or ruled out and until discharge or transfer is completed. Initial isolation and evaluation of minimally symptomatic patients can be performed using PPE according to CDC’s Guidance for Emergency Department Evaluation and Management for Patients Who Present with Possible Ebola Virus Disease. These facilities should also be prepared to care for patients with more severe symptoms. Because it may take 72 hours or longer after symptom onset to definitively confirm or rule out a diagnosis of EVD (with an additional 12–24 hours for specimen transport, testing, and identification of another facility for transfer, if needed), assessment hospitals should be prepared to provide care for patients with possible EVD for up to 96 hours and should have sufficient Ebola PPE for at least 4 to 5 days of patient care.

Role: Ebola Treatment Hospitals – Ebola PPE for at least 7 days of patient care

These hospitals are prepared to care for patients with confirmed EVD throughout the course of their illness. Given current PPE shortages, hospitals may not be able to procure in advance the amount of PPE needed for the entire time to care for a patient with EVD. Therefore, to be ready to accept and care for patients with EVD, hospitals will need, at a minimum, sufficient Ebola PPE for at least 7 days of patient care. If hospitalization is anticipated to exceed 7 days, state and local health authorities, in collaboration with CDC, may provide or facilitate the procurement of additional PPE supplies.

How should my hospital increase the PPE in our facility as part of Ebola preparedness?

Once you determine your facility’s role and what amount of Ebola PPE is needed, determine a phased approach to increase PPE preparedness.

Coordinate with state/local public health officials

• As part of hospital preparedness, and optimally before a patient with EVD exposure and signs/symptoms seeks care, hospitals should ask their local and state health departments if centralized or shared inventories of product are available that they may access if needed. Some health departments may be aware of regional, state, or local stockpiles of Ebola PPE that may be available if additional supply is needed.
• Discuss the state Ebola plan with public health officials to understand how PPE shortages will be addressed; some states have recently purchased supplies of PPE to backfill shortages within the hospital networks. Communicate regularly with state and local public health officials as they may have plans to supplement hospital inventories.

Purchase PPE to meet minimum recommendations based on your hospital’s role

• The amount of PPE needed for each day of patient care will depend on various factors including: the number of patients, the acuity of patients, projected number of staff and healthcare team configuration, length of shifts, number of required breaks for staff wearing PPE, isolation unit location and staff support strategies, waste management strategy, lab location, lab testing demand, and hospital protocols for products.
• The initial goal should be focused on having supplies to care for at least one patient.
• If the brand and type of PPE you plan to order is unavailable, consider ordering substitutions or identify similar products from other brands outside of your hospital’s normal product list. Because different brands or products might require slight changes in the procedure of use, ensure that staff is trained on and demonstrates proficiency in use of the new product.

Consider a plan to share PPE

• Hospitals are encouraged to partner with neighboring hospitals, in-network facilities, and/or healthcare coalitions to share inventory for any product that may be in limited supply. It may also help if other facilities who can share PPE use the same products (for example, the same model PAPR systems) to decrease the need for just-in-time training on different models.

Procure PPE supplies needed for training

• If supplies are limited, hospitals may want to consider limiting hands-on training with PPE to only the critical staff who are most likely to care for Ebola patients. If hospitals do not have sufficient PPE for training and are having issues attaining product through normal channels, they should contact their local and state health departments to determine if other inventories of product are available for this purpose.
• Hospitals may want to issue a set of PPE to critical staff, especially those items that are durable and hard to obtain, to use for training. Reusing this equipment for training would help alleviate the need to expend PPE for training.
• Hospitals may also want to contact manufacturers to see if products specific for training or in-services are available.

Is Ebola PPE available from CDC’s Strategic National Stockpile (SNS)?

CDC has increased Ebola PPE quantities in the SNS to assist U.S. hospital healthcare teams in caring for Ebola patients in the event supplies are not immediately available at the facility. The supplies in the SNS are intended to provide a stop-gap measure until other product can be procured or identified for the facility through sharing with other local/state partners or provided via commercial supply.

What if my facility has a patient and we need PPE?

If a facility is treating a patient with confirmed EVD and needs more PPE products and cannot attain products through their normal supply channels, the facility should immediately contact its state and local health department. State health departments may be able to identify additional PPE supplies locally to supplement hospital inventory, or they may request federal assistance to obtain additional PPE from the SNS.

If federal assistance is requested, the first step is for CDC personnel to work with manufacturers and distributors to help direct product to that treatment facility. If additional federal assistance from the SNS is needed, state health departments may use the regular, established process for submitting a request to the CDC Emergency Operations Center. Once a request for SNS assets is approved, CDC will rapidly deploy PPE from the SNS to meet the hospital’s needs until other product sources are identified.