Since the pandemic began to wreak havoc in the U.S., my first question to bedside nurses has been, “Do you have enough PPE?” To my amazement, even as hospital admissions surged, many nurses told me that yes, they had a good supply of N95s. I quickly learned to be more specific: “How often do you receive a new N95?” Sometimes, the answer was “every shift.” More often, nurses told me “every week,” sometimes adding, “but I cover it with a new surgical mask every day.”

Redefining the PPE norm.

And so, barely a month into the pandemic, nurses had quickly adapted to a new normal. These days, it seems that N95 supplies are “good” when we have any at all. Certainly, nurses continue to protest our lack of PPE. But how did we arrive at this place where we are glad to have any protection at all?

“The lack of essential personal protective equipment (PPE) has been a defining characteristic of the coronavirus pandemic. From the beginning, respiratory protection guidance was driven by shortages of N95 respirators and surgical masks rather than by the well-established standards of infection prevention and control.”

In this month’s AJN Reports, we look at why PPE supplies are still suboptimal and likely to remain so at least until the fall. To this day, the U.S. Defense Production Act (DPA) has not been used to force production of N95 or other masks. Early in the pandemic, several other countries ramped up their own production of N95s and surgical masks, and banned their export to other countries. The U.S. did neither. The president did, however, invoke the DPA to force meat processing plants to remain open.

Recent developments.

Since this AJN Reports went to press, new research reports, policies, and legal actions offer a few hopeful signs that PPE issues have not been forgotten.

  • On April 20, the New York State Nurses Association filed lawsuits against the New York State Department of Health and two New York City-area hospitals for failing to protect the health and safety of nurses treating patients with COVID.
  • In a study published last month, researchers in Wuhan, China, demonstrated the protective effect of appropriate PPE: 304 nurses and 116 doctors deployed to Wuhan who worked directly with COVID-19 patients and wore protective gear that included an N95 respirator covered with a surgical mask tested negative for SARS-CoV-2 after their deployment ended. They were tested both for active infection and for antibodies (via an antibody test validated for accuracy) in case any had been infected without exhibiting symptoms.
  • On June 3, the ANA released the results of a late May survey of more than 14,000 nurses who worked in urban and rural hospitals and other health care settings across the country. Seventy-nine percent of these nurses reported that they were still “required or encouraged” to reuse N95s.
  • On June 9, Pennsylvania secretary of health Rachel Levine, MD, ordered hospitals to “develop, implement, and adhere to” (by June 15) several longstanding infection control measures that have been widely disregarded since early in the pandemic. These include
    • notifying staff within 24 hours if they were exposed to a probable or confirmed case of COVID-19.
    • ensuring the work exclusion and quarantine of exposed staff.
    • providing testing for both asymptomatic and symptomatic exposed staff upon request.
    • and providing staff with NIOSH-approved respirators (or if unavailable, respirators approved by the FDA under Emergency Use Authorization) at the start of each shift and when respirators have been soiled, damaged, or otherwise rendered ineffective.
  • On June 10, four ED nurses from the Sinai-Grace division of Detroit Medical Center sued both the medical center and its for-profit, Texas-based parent company, Tenet. The lawsuit contends that the nurses were fired for speaking out about conditions that they saw as unsafe for both patients and staff, and that they were traumatized by the substandard working conditions.
  • On June 16, National Nurses United and the Massachusetts Nurses Association called for a halt to “decontamination” of single-use masks, citing a lack of rigorous testing for safety and effectiveness.
  • HR 6139, introduced on March 9, remains in the House Subcommittee on Health. It directs the secretary of labor to issue an OSHA “emergency temporary standard” to protect health care and other designated essential workers from exposure to SARS-CoV-2. If passed, it would require that employers develop and implement an infectious disease exposure control plan based on the precautions for severe acute respiratory syndrome (SARS) as described in the CDC’s 2007 Guidelines for Isolation Precautions.

To read more about efforts thus far in the pandemic to procure adequate PPE for health care workers, read “Where Are the Masks?” in the June issue of AJN.