24 Mar AVMA Guidelines for use of PPE
Survey – We are working with Veterinary Medical Association Executives (VMAE) to determine the supply of personal protective equipment (PPE) in the veterinary community.
Our goal is to determine how long veterinary hospitals can practice under current conditions based on the PPE supplies on hand in hospitals. We also wish to inform how veterinary medical associations advocate for veterinary medicine in governmental discussions about PPE distribution. The survey closes at midnight on Wednesday, March 25. Please submit only one response per practice HERE.
AVMA Guidelines for use of personal protective equipment (PPE) during the COVID-19 pandemic when demand exceeds supply
Published at 2:30 p.m. on March 20, 2020
With some medical products in short supply requests have emerged that all medical professionals, including veterinarians, conserve personal protective equipment (PPE) until supplies become more readily available.
Postponing elective procedures that require the use of PPE is one way of conserving. Conservation strategies can also include safely extending the use of disposable PPE, re-using disposable PPE, or increased use of washable PPE.
Guidance has been developed to control personnel exposure to occupational hazards utilizing a hierarchy to achieve feasible and effective controls. Multiple control strategies may be implemented concurrently, sequentially, or both to minimize exposure. This hierarchy is frequently represented as: (adapted from CDC)
- Engineering controls
- Administrative controls
- Personal protective equipment (PPE)
Elimination (physically removing the hazard) and substitution (replacing the hazard) are not typically options in the healthcare setting to prevent infectious disease transmission. However, engineering and administrative controls, and PPE can often be used to reduce or avoid exposures to transmissible pathogens in healthcare facilities. Prompt detection, effective triage, and isolation of potentially infectious patients are essential control measures to prevent unnecessary pathogen exposure of patients, healthcare personnel (HCP), and visitors in a given facility.
The best way to prevent disease transmission is to use a combination of interventions from across the hierarchy of controls. This results in a greater degree of protection than a single method and provides backup in the event one control intervention fails, becomes less effective, or even unavailable.
Veterinarians should increase focus on engineering and administrative controls and consider how they can safely extend the life of disposable PPE during times of a national shortage.
The FDA has issued guidance in a letter to healthcare providers regarding surgical mask and gown conservation strategies. Three levels of capacity strategies are described:
- Conventional Capacity Strategies: supply levels are adequate to provide patient care without any change in routine practice
- Contingency Capacity Strategies: limited supply levels may change patient care, but may not have a significant impact on patient care and healthcare provider safety
- Crisis or Alternate Strategies: may need to be considered if surgical mask or gown demand exceeds the supply
For detailed information on the first two strategies listed above, please refer to the FDA guidance. The third strategy, when demand exceeds supply, will be the focus of the following section.
The following Q&As are based on the information from this FDA document and sources from CDC. The use of PPE in veterinary medicine for protection of the wearer (eg, infectious disease) is much less common than the use of PPE to protect the patient (eg, surgery).
Q1. May disposable, single use PPE be re-used when supply levels are adequate (conventional capacity strategies)?
A1. Generally, no. Most PPE is designed to be used only once by a single person prior to disposal. However, there are exceptions in limited situations identified by FDA, CDC, and OSHA which include gowns, surgical masks, N95 respirators, reusable face shields or goggles. Details for each are briefly mentioned below.
Q2. Can we use expired gowns and surgical masks? Do they offer the protection needed?
A2. These products were designed to serve as protective barriers and thus FDA believes they may still offer some protection even when they are used beyond the manufacturer’s designated shelf life or expiration date. The user should visibly inspect the product prior to use and if there are concerns (such as degraded materials or visible tears) the product should be discarded.
Q3. Can we use surgical masks and gowns on more than one procedure?
A3. Gowns may be worn to see multiple patients with the same infectious disease diagnosis or exposure when they are maintained in a common area.
Gowns may be worn for multiple surgeries where the surgical procedure has a low risk of contamination.
In all cases, if the gown becomes contaminated, replace it.
Surgical masks may be worn for extended periods (re-used) during care for multiple patients where they are used to protect the patient from droplets from the surgeon. If the mask becomes wet or contaminated, replace it.
Q4. Can reusable cloth gowns be used in a shortage?
A4. FDA cleared or approved reusable cloth gowns can be used. Adequate laundering, or sterilization if available, can reduce the level of pathogen contamination to a negligible level, thus lowering the overall risk of disease.
Q5. What is an N95 respirator and what do I need to know to use one properly?
A5. An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles.
The ‘N95’ designation means that when subjected to careful testing, the respirator blocks at least 95 percent of very small (0.3 micron) test particles. If properly fitted, the filtration capabilities of N95 respirators exceed those of face masks. However, even a properly fitted N95 respirator does not completely eliminate the risk of illness or death.
N95 respirators are rarely used in veterinary medicine and most veterinarians are unfamiliar with how they are to be used. AVMA is not recommending the routine use of N95 respirators however there may be specific situations where it may be considered (e.g. house call veterinarian under extreme circumstances needing to enter the home of a positive COVID-19 patient). If you find yourself in a situation where an N95 mask is needed, please refer to the additional information section below for further information on proper use.
Q6. What does reuse mean?
A6. CDC defines reuse as:1 the practice of using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient. When N95 respirator reuse is practiced or recommended, restrictions are in place which limit the number of times the same respirator is reused, this is “limited reuse”. Limited reuse has been recommended and widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.(2, 3, 10-12)
Q7. How do I minimize the need to reuse N95 respirators?
A7. CDC recommends the following steps to minimize use of N95 respirators:
- Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
- Use alternatives to N95 respirators (eg, other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
- Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
- Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.
Q8. How may I reuse N95 respirators?
A8. If reuse of N95 respirators is permitted in the locality, healthcare facilities should provide staff with clearly written procedures to:
- Follow the manufacturer’s user instructions
- Conduct a user seal check
- Only reuse for up to five donnings (unless the manufacturers label recommendation explicitly states another number)
- Follow recommended inspection procedures
- Discard any respirator that is obviously damaged or becomes difficult to breathe through
- Pack or store respirators between uses so that they do not become damaged or deformed.
Q9. What if N95 respirators are not available at all?
A9. If no respirators are left
- Postpone elective and non-emergency procedures until seeing the animal in person does not expose the veterinary staff to known or suspected COVD-19 patients prior to release from quarantine.
- Consider taking extra precautions regarding veterinarians and staff who are themselves at higher risk for severe illness from COVID-19. According to the CDC, this may include older adults and those with chronic medical conditions.
- Use a patient isolation room that limits the exposure of other personnel and patients for risk-reduction.
PERSONAL PROTECTIVE EQUIPMENT AND RESPIRATORY PROTECTION
Use masks not evaluated or approved by NIOSH or homemade masks as a last resort.
REUSABLE FACEMASK SHIELD, GOGGLES
- Protective eyewear, such as goggles, may be reused if the user follows decontamination methods in the product labeling.
- A reusable face shield that can be decontaminated may be an acceptable method of protecting against droplet transmission.
*The use of PPE in veterinary medicine for protection of the wearer (eg, infectious disease) is much less common than the use of PPE to protect the patient (eg, surgery). Some interpretation of FDAs guidance is needed for most veterinary practices.
AGENCY COVID-19 WEBSITES:
- OSHA: https://www.osha.gov/SLTC/covid-19/
- CDC: Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings
- Healthcare-associated Infections
- Strategies for Optimizing the Supply of N95 Respirators – Updated February 29, 2020
- FDA: N95 Respirators and Surgical Masks (Face Masks)