areas of inconsistency, especially in relation to reuse of respirators (with or without reprocessing) during and after aerosol generating procedures.

3 The reprocessing of surgical masks is not recommended.

4 Reprocessing of respirators under controlled and standardised conditions is recommended, but there is inconsistency regarding how or when this should take place and further research is needed in this area.

5 Where extended use or reuse is being practised, healthcare facilities and institutions should ensure that policies and systems are in place to enable these practices to be carried out in the safest way possible in line with available guidance.

The CDC also produced a guidance document, in October 2020, on implementing filtering facepiece respirator (FFR) reuse, including reuse after decontamination, when there are known shortages of N95 respirators. The CDC guidance states that, when the availability of N95 FFRs becomes limited due to an expected shortage, supplies first should be conserved using the following contingency strategies: l With extended use, N95 FFRs may be worn for a prolonged period, for multiple patient contacts, before being removed and discarded (unlike conventional strategies in which an N95 FFR is used for one patient contact then discarded). This will slow the N95 FFR ‘burn rate’ to help alleviate supply concerns.

l N95 FFRs may be used beyond the manufacturer designated shelf-life for fit testing and training.

After attempting the above ‘contingency strategies’, if there is still a known shortage of N95 FFRs and available supplies cannot meet needs based on the current burn rate,

‘crisis capacity strategies’ can be used. These include: l Respirators (including N95 FFRs and other types of respirators) may be used beyond the manufacturer-designated shelf life for healthcare delivery.

l Respirators may be used that are similar to NIOSH-approved respirators but are not NIOSH approved and are approved according to standards used in other countries.

l Respirators may be used that have reached the manufacturer-designated shelf life but have not been evaluated by NIOSH.

l With limited reuse, an N95 FFRs may be donned for one patient contact, then doffed and stored before being used for another patient contact for a limited number of donnings.

l The use of N95 FFRs and facemasks may be prioritised by healthcare activity type.

The guidance provides information on how to determine if, and when, a healthcare facility should be operating under N95 FFR crisis capacity situations during the COVID-19 pandemic and how to appropriately implement limited reuse of N95 FFRs, including their reuse after decontamination.2 The WHO’s advice on ‘Critical shortage or lack of PPE in the context of COVID-19’, also adheres to similar principles. “There has been a progression of thinking around this. Lots of people, internationally, have come up with similar ideas. The evidence base is still relatively limited and based on expert opinion, so I look forward to seeing more trials in this area in the future,” commented Brown.

NHS England and NHS Improvement (NHSEI) also produced a statement on PPE, that it wanted to “move away from disposable by default and assess new types of PPE that are designed for reuse from the outset, particularly through UK manufacturing.”

It further announced that it was piloting the use of reusable gowns with 20 providers (and many more waiting to join the pilot), to understand the challenges and potential barriers to increase sustainability in PPE. NHSEI’s review identified a number of challenges for the uptake of PPE innovations, including: l A complicated stakeholder landscape; l A need for improved demand signalling and engagement between innovators and frontline staff;

l Difficulty navigating the regulatory process for new entrants;

l Financial and procurement frameworks that incentivise single-use PPE with low purchase prices but potentially higher overall lifecycle costs.

In conclusion, Brown highlighted the need to rationalise the many online sources of IP&C and PPE guidance with a one-stop-shop for all advice. In the absence of an evidence base, there needs to be rapid development of guidance – including regular literature review, benchmarking and engagement with international colleagues, co-development with key stakeholders and cross-government involvement.

Reprocessing of single-use PPE Karen Tweed, deputy operations director at Sheffield teaching Hospitals, provided a personal insight into the difficulties around the management of PPE during the pandemic. Having dealt with decontamination of medical devices for many years, PPE presented a completely different challenge – no UK regulatory body had issued an exemption to the regulations for single-use medical devices or PPE to be reprocessed. “The Sheffield Teaching hospital, along with the other University hospitals, had infectious diseases centres and started admitting the first patients. It was a very difficult time. We did not know what to expect – we’d had MERS and SARS, and also looked at Ebola; there had been preparations, but this was still an ‘unknown’. We used our past learning and emergency planning…but people were not used to seeing the full hazmat PPE around the Trust and there was a lot of fear,” Tweed commented.

By mid-March there were concerns around FFP3 stock levels and availability, so a decontamination division group was established – comprising the decontamination lead, microbiologists, DIPC, deputy lead nurse and the risk manager – to review any necessary decontamination practices for single-use PPE, as well as single-use medical devices such as CPAP hoods and ventilator equipment, which experienced high usage due to the increase in COVID cases.


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