key: cord-1034798-a3dsk2os
authors: Rajamani, Arvind; SUBRAMANIAM, Ashwin; SHEKAR, Kiran; HAJI, Jumana; LUO, Jinghang; BIHARI, Shailesh; WONG, Wai Tat; GULLAPALLI, Navya; RENNER, Markus; Alcancia, Claudia Maria; Ramanathan, Kollengode
title: Personal Protective Equipment Preparedness in Asia-Pacific Intensive Care Units during the COVID-19 Pandemic: A Multinational Survey
date: 2020-09-29
journal: Aust Crit Care
DOI: 10.1016/j.aucc.2020.09.006
sha: 7ea47022738fe353810beff179657f5083e27689
doc_id: 1034798
cord_uid: a3dsk2os

BACKGROUND: There has been a surge in COVID-19 admissions to Intensive Care Units (ICUs) in Asia-Pacific countries. Since ICU healthcare workers (HCWs) are exposed to aerosol-generating procedures (AGPs), ensuring optimal personal-protective equipment (PPE) preparedness is important. OBJECTIVE: To evaluate PPE-preparedness across intensive care units (ICUs) in six Asia-Pacific countries during the initial phase of COVID-19 pandemic, defined as World Health Organization (WHO) guideline-adherence, training healthcare workers (HCWs), procuring stocks and responding appropriately to suspected cases. METHODS: A cross-sectional web-based survey was circulated to ICUs from Australia, New Zealand (NZ), Singapore, Hong Kong (HK), India and Philippines in 633 Level II/III ICUs. FINDINGS: 263 intensivists responded, representing 231 individual ICUs eligible for analysis. Response rates were 68%-100% in all countries except India, where it was 24%. 97% either conformed to or exceeded WHO recommendations for PPE-practice. 59% employed airborne precautions irrespective of aerosol-generation-procedures. There were variations in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE stock-awareness (best in HK/Singapore/NZ). High-flow-nasal-oxygenation and non-invasive ventilation were not options in most HK (66.7%, 83.3% respectively) and Singapore ICUs (50%, 80% respectively), but were considered in other countries to a greater extent. 38% reported not having specialized airway teams. Showering and “buddy-systems” were underutilized. Clinical waste disposal training was suboptimal (38%). CONCLUSIONS: Many ICUs in the Asian-Pacific reported suboptimal PPE-preparedness in several domains, particularly related to PPE-training, practice and stock-awareness, which requires remediation. Adoption of low-cost approaches such as buddy-systems should be encouraged. The complete avoidance of high-flow nasal oxygenation reported by several intensivists needs reconsideration. Consideration must be given to standardise PPE guidelines to minimize practice variations. Urgent research to evaluate PPE-preparedness and SARS-CoV-2 transmission is required.

Background: There has been a surge in COVID-19 admissions to Intensive Care Units (ICUs) 6

in Asia-Pacific countries. Since ICU healthcare workers (HCWs) are exposed to aerosol-7 generating procedures (AGPs), ensuring optimal personal-protective equipment (PPE) 8 preparedness is important. 9

Objective: To evaluate PPE-preparedness across intensive care units (ICUs) in six Asia-Pacific 10 countries during the initial phase of COVID-19 pandemic, defined as World Health 11

Organization (WHO) guideline-adherence, training healthcare workers (HCWs), procuring 12 stocks and responding appropriately to suspected cases. Response rates were 68%-100% in all countries except India, where it was 24%. 97% either 17 conformed to or exceeded WHO recommendations for PPE-practice. 59% employed 18 airborne precautions irrespective of aerosol-generation-procedures. There were variations 19 in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE 20 stock-awareness (best in HK/Singapore/NZ). High-flow-nasal-oxygenation and non-invasive 21 ventilation were not options in most HK (66.7%, 83.3% respectively) and Singapore ICUs 22 (50%, 80% respectively), but were considered in other countries to a greater extent. 38% 23 reported not having specialized airway teams. Showering and "buddy-systems" were 24 underutilized. Clinical waste disposal training was suboptimal (38%). 25

Conclusions: Many ICUs in the Asian-Pacific reported suboptimal PPE-preparedness in 26 several domains, particularly related to PPE-training, practice and stock-awareness, which 27 requires remediation. Adoption of low-cost approaches such as buddy-systems should be 28 encouraged. The complete avoidance of high-flow nasal oxygenation reported by several 29 intensivists needs reconsideration. Consideration must be given to standardise PPE 30 guidelines to minimize practice variations. Urgent research to evaluate PPE-preparedness 31 and SARS-CoV-2 transmission is required. 32

Introduction 35

The COVID-19 pandemic has seen an unprecedented surge of intensive care unit (ICU) 36 admissions in many countries. 1 Personal-protective equipment (PPE) preparedness -defined as adherence to 45 guidelines, HCW-training, procuring PPE stocks and responding appropriately to suspected 46 cases -is crucial to prevent HCW-infections. 7-9 The ability to minimize hospital acquired 47 COVID-19 with adequate PPE availability is considered one of the performance indicators to 48 assess the national performance to COVID-19. 10 Concerns have been raised about 49 suboptimal PPE-preparedness and PPE stocks. 2, 11-14 Moreover, there are conflicting 50 recommendations from international, national, and regional organisations. 2, 11 For example, 51 the World Health Organization (WHO) Guidelines recommend a tiered approach based on 52 the risk of aerosol-generation (airborne precautions for aerosol-generating procedures 53 (AGPs) and droplet precautions for non-AGPs). 2, 12 However, the Australia-New Zealand This issue has assumed more relevance in the setting of controversies of SARS-CoV-2 57 being transmitted as aerosols. 15 Observers to monitor/checking colleagues for donning/doffing PPE ("buddy-system") 24 COVID-19 patients" by 14% (32), 26% (60) and 45% (104) respondents respectively. The 125 complete avoidance of HFNO was high in Singapore (50%, 3/6) and HK (67%, 8/12). NIV was avoided by 80% intensivists in these countries (Figure 3 ). Other countries were prepared to 127 use low-flow oxygen (39%), HFNO (45%) and NIV (34%) for patients in negative-pressure 128 The most important and immediately remediable concern was suboptimal ICU-HCW 152 training in many ICUs. Although regular donning/doffing training was reasonably common, 153 training for AGPs was inconsistent overall, with NZ being better than others. Despite the fact 154 that there is little or no evidence that adherence to infection-control recommendations 155 results in fewer HCW infection, HCW-training is a commonly recommended strategy for 156 pandemic-preparedness in influenza and Ebola. 7, 25 Also, ANZICS has recommended that 157 only staff trained in PPE-usage should care for patients with COVID-19. 11 Training, coupled 158 with low-cost strategies like buddy-systems, promote safety, team-bonding and staff 159 mental-health. 9, 24, 26 In our survey, more intensivists from NZ, Singapore and HK (which had 160 more consistent training practices and/or overall resources) reported feeling safe compared 161 to intensivists from the other countries with inconsistent training or resources. Since the 162 morale, security and mental health of HCWs are intricately related to the perception of 163 safety, it is important for ICU/hospital administrators to evaluate this among their staff, and 164 to also conduct comprehensive training sessions. 165

Resource-management is another area that needs to be addressed, especially in the 166 context of many countries building ad-hoc / makeshift field hospitals for COVID-19 167 patients, 27 with a relative paucity of negative-pressure rooms and shortages of ventilators 168 and/or skilled personnel. 28, 29 To mitigate this risk, it may be advisable for ICU HCWs to 169 employ routine airborne-PPE, 11, 30 until urgent high-quality research is done to elucidate the 170 relative importance of different transmission routes, as recommended by the WHO. 171

The multitude of international, national, regional, local/institutional and even 172 departmental PPE guidelines, sometimes making contradictory recommendations is concerning. While we need to acknowledge the fact that information on viral transmission is 174 still emerging, the lack of uniformity is guidelines is likely attributed to the availability of 175 resources and the pattern of pandemic spread. None of the recommendations are evidence-176 based (such as by identifying contamination using UV light for luminescent particles) or 177 based on robust simulation work, as shown by a systematic review appraising PPE guidelines 178 worldwide that our group has just completed. 31 Multiple guidelines may contribute to 179 variations in respiratory PPE-usage across ICUs. For instance, one-third of respondents 180 followed the WHO recommendations of reserving N95/P2 masks exclusively for AGPs, while 181 60% (especially in HK and Singapore) followed the practice of routinely using N95/P2 masks, 182 irrespective of AGPs, which is advocated by ANZICS. Although limited evidence suggests that 183 routine airborne-precautions are no better than targeted airborne-precautions, the optimal 184 balance between conserving PPE and ensuring ICU-HCW safety is unclear. 12 Table   Legend Main Manuscript Table 1 Design and Development of the Questionnaire Table 2 Summary of Management and Training Strategies Figure 1 CONSORT diagram demonstrating 42% response rate. After exclusion, 231 ICUs were included for final analysis. Overall response rate was very good, except in India, which reduced the overall response rate. Key: ICU -intensive care unit 

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The authors thank Dr Adam Howard, Intensivist, Royal Perth Hospital, Western Australia, Dr Ross Acknowledgements 242