The Chester County Health Department, supporting the COVID-19 response in both Chester County and Delaware County, is issuing the following health alert for healthcare providers regarding: Conservation of Personal Protective Equipment.

Personal Protective Equipment (PPE) is a critical infection control measure to protect healthcare personnel (HCP), along with minimizing chance for exposures, engineering controls, and appropriate environmental cleaning. Additional guidance may be found at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.

COVID-19 is transmitted by respiratory droplets, which means for routine care, HCP should use contact and droplet precautions, including a regular face mask, eye protection, gown, and gloves. N-95 respirators are not needed for routine care of patients with suspected or confirmed COVID-19. However, certain procedures may generate aerosols, including tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary respiration, manual ventilation before intubation, and bronchoscopy. For these procedures, airborne precautions, including N95 respirators or the equivalent, are advised. It is unclear whether specimen collection via nasopharyngeal or oropharyngeal swabs may generate aerosols, so we have recommended airborne precautions for this. Details may be found at https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf

Shortages of PPE are widespread across the world and we anticipate continued difficulty obtaining supplies. We are aware of many jurisdictions in the US running out of PPE already. Use of PPE can be described in three strategies:

• Conventional Capacity - During routine operations, we operate under conventional capacity use, which means no change in daily practices.
• Contingency Capacity - Practices which change daily practice to conserve PPE, but do not impact the safety of HCP or the care delivered to the patient.
• Crisis Capacity - During shortages, measures taken which may not meet standards of care.

At this time in Chester County and Delaware County, we are not aware of any hospitals in crisis capacity mode. However, ALL hospitals and healthcare providers must immediately use contingency capacity measures if they are not already, in order to maintain our ability to protect HCP. The more PPE we conserve now, the more we can delay, and perhaps avoid, crisis strategies. Contingency measures include:

1. Use physical barriers - glass or plastic windows between patients and HCP at intake desks, triage stations, pharmacy pick-up, etc., can eliminate the need for this staff to use PPE.
2. Cohort - grouping patients with COVID-19 together, and designating teams of HCP who interact with them, can minimize the number of people needing PPE.
3. Use expired N95 respirators - many models have been tested and met NIOSH performance standards long past expected shelf life. See https://www.cdc.gov/coronavirus/2019-ncov/release-stockpiled-N95.html for details.
4. Use alternatives to face masks for source control - Placing a mask on a symptomatic patient can help keep their respiratory droplets from traveling towards HCP. However, any kind of fabric or tissue may be used as source control, which can preserve surgical masks for the protection of HCP. This includes covering the mouth and nose of a patient with their own shirt, hand- or machine-sewn masks, bandanas, etc. Use of these fabric alternatives by HCP has been shown to be less protective than the use of certified/tested surgical face masks, and would only be recommended during crisis capacity.
5. Encourage extended use of N-95 respirators and face masks - This means keeping the same mask/respirator on while caring for different patients, instead of removing and discarding after each encounter. Evidence from prior public health emergencies shows that respirators maintain their protection when used for extended periods. Use of a face shield over the mask/respirator can help reduce surface contamination. HCP must avoid touching the mask/respirator and must perform hand hygiene each time they do. Masks/respirators should be inspected and discarded if soiled or damaged.
6. Reuse eye protection - Clean and disinfect goggles or face shields between uses. Eye protection should be inspected and discarded if damaged.
7. Use cloth gowns which may be safely laundered and reused, or consider extended use of disposable gowns. Disposable gowns which become soiled or soaked should be discarded immediately.

Consider protocols now for re-use of face masks and N-95 respirators now, before it is needed. Explore whether ultraviolet germicidal irradiation is an option to safely implement re-use, such as this protocol: https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf Consider whether you are interested in receiving donations, such as through GetUsPPE.org.

For Hospitals

If you have an unmet a need for resources, and you have exhausted your internal resource acquisition process, you may submit a resource request through your local emergency management agency. This process of for critical needs, meaning that the PPE is required for continued operations and you anticipate running out of supplies in the next 5 days, Please do not make requests for future planning initiatives

For Chester County Facilities:

Contact your local Municipal Emergency Management Coordinator who will provide you with information to submit your request. Link to list of Chester County Local Emergency Management Coordinators: https://www.chesco.org/2508/Municipal-EMCs

For Delaware County Facilities:

Contact Delaware County Emergency Management Coordinator at delcologistics@co.delaware.pa.us

Please share this message widely with other healthcare providers in your networks. If you were forwarded this message, please click here to sign up for our health alerts directly: https://chesterco.az1.qualtrics.com/jfe/form/SV_9BwMAtMeyzmoILj

The Chester County Health Department (CCHD) is sharing the following information to healthcare providers regarding: Specimen Collection and COVID-19 Testing Guidance

Surveillance

For surveillance purposes, we continue to request that all patients who may have been exposed (whether or not testing is performed) self-report using the link at chesco.org/coronavirus and click the “Think You’ve Been Exposed?” button.  For patients without internet access, you may report on their behalf.

Testing

We are still facing some limitation on our COVID-19 testing.  Things are changing very rapidly, but at the moment, we are trying to prioritize testing for those in whom a test would make a difference in management.

Considerations for prioritization of testing include:

• Patient resides in a congregate setting
• Patient is a healthcare worker or first responder
• Patient is at risk for severe disease (age >60 years, chronic medical conditions)
• Patient requires hospitalization for symptoms

We are also still using epidemiologic information, such as exposure to a case, or travel to an impacted area (either here or abroad).  When possible, rule out other common respiratory illnesses since co-infection appears to be rare and since many other viruses are still circulating.

LabCorp and Quest are now running tests and no permission/contact with the health department is needed if you determine that a patient needs the test.  No PUI number needs to be assigned for commercial testing, including ARUP laboratories if you are a healthcare facility contracted with them.  This should be the preferred method of routing your tests.  A PUI number must be assigned only for testing through the Pennsylvania Bureau of Laboratories.  Call 610-344-6452 to connect with Disease Investigation and Surveillance at CCHD.  Commercial laboratories DO NOT perform specimen collection. 

Specimen Collection 

CCHD is not collecting specimens at this time.  Commercial laboratories are not collecting specimens at this time.  Certain medical practices, urgent care centers, and emergency departments are collecting specimens but this changes hourly and CCHD is not maintaining a list of locations at this time.  Please reserve referrals to emergency departments for patients who need emergent care or hospitalization.

New guidance from laboratories requires only a nasopharyngeal swab for testing.  This includes LabCorp, Quest, ARUP, and BOL.  You may submit in 1ml viral media vials or 2-3 ml viral media vials.  Use a sterile Dacron or rayon swab; do not use calcium alginate swabs or wooden-shaft swabs.

You may continue to submit oropharyngeal swabs, nasopharyngeal or oropharyngeal aspirates, or bronchoalveolar lavage or bronchial washings as needed.

Updated CDC guidance states that when no N-95 respirators are available, the collection of diagnostic specimens using contact and droplet precautions (and not airborne) is acceptable.  Their guidance is:

Collection of Diagnostic Respiratory Specimens

When collecting diagnostic respiratory specimens (e.g., nasopharyngeal swab) from a possible COVID-19 patient, the following should occur:

• HCP in the room should wear an N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown.
• The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.
• Specimen collection should be performed in a normal examination room with the door closed.
• Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.

The full document is available here:

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html           

We are mandating that all county employees involved in specimen collection continue to use airborne precautions.  [Note this is not specimen collection from the public at this time.] While each practice may decide for themselves whether they wish to collect specimens using surgical masks rather than respirators, we are highly recommending N-95 respirators while the supply is not exhausted.  We need to prioritize the protection of healthcare workers over the need for data.

Please share widely with your healthcare contact lists.