How U.S. Hospitals Are Preparing for the Coronavirus Outbreak

As new coronavirus infections accumulate across America, hospitals want to make sure they have everything they need to keep staff safe.

In China, where the virus was first discovered, protecting health care workers was a serious challenge. More than 3,300 nurses, doctors and other hospital staff members across the country were infected, many because of insufficient protective equipment.

In the United States, some hospitals are already struggling with limited supplies, as health officials figure out the best way to protect workers. More than 1,000 cases of Covid-19, the disease caused by the new coronavirus, have been reported across America so far, with the largest outbreak in Washington State.

“We need to think about what the right thing is for patients, but also for our caregivers to make sure they’re not exposed,” said Amy Compton-Phillips, chief clinical officer at the Providence St. Joseph Health, a hospital network that has treated more than a dozen patients in Washington State.

That means making sure there’s an adequate supply of protective equipment for staff members and enough space to isolate patients, while also navigating a flurry of regulations and recommendations that could change at any moment.

Protective equipment: Gowns, gloves, goggles and respirators






Current C.D.C. recommendations for health care workers

Eye protection

Goggles or face shield

Respirator or medical mask

N95 respirator, if available

Gown

Closed securely

at the back

Gloves

Pulled up over

gown sleeves

Current C.D.C. recommendations for health care workers

Eye protection

Goggles or face shield

Respirator or medical mask

N95 respirator, if available

Gloves

Pulled up over

gown sleeves

Gown

Closed securely

at the back

Current C.D.C. recommendations for health care workers

Eye protection

Goggles or face shield

Respirator or medical mask

N95 respirator, if available

Gloves

Pulled up over

gown sleeves

Gown

Closed securely

at the back


There is still some uncertainty about how the new coronavirus spreads, but experts agree it is most likely passed through close contact with people who are infected, and specifically the viral droplets they expel when they cough or sneeze.

The Centers for Disease Control and Prevention has advised health care workers to treat potential and confirmed cases of Covid-19 with the level of precaution usually reserved for high-risk illnesses that spread easily through the air, like tuberculosis or measles.

Workers are required to wear gowns, gloves, goggles and special masks, like N95 respirators, that fit tightly over the nose and mouth to filter out virus particles before they are inhaled. (They can also wear devices known as PAPRs, or powered air-purifying respirators, which cover the entire head.)

With respirator masks in short supply across the country, the C.D.C. recently updated its recommendations for health care workers. If respirators are not available, the agency says standard medical masks can be used instead for most coronavirus patient care. These looser-fitting masks protect against droplet transmission from coughs and sneezes, but do not filter out airborne pathogens.

The change puts the C.D.C. in closer alignment with World Health Organization guidelines, which only require respirator masks during special procedures that may result in the spray of tiny viral particles. Health departments in two of the hardest hit states, Washington and Oregon, have already adopted standards in line with W.H.O.

As the coronavirus continues to spread across the country and more is learned about the disease, these safety guidelines could evolve.






N95 respirator

Surgical mask

Tight fit; must be specially fitted. Filters out 95% of small particles.

Loose fit around edges. Provides protection from large droplets.

Surgical mask

N95 respirator

Loose fit around edges. Provides protection from large droplets.

Tight fit; must be specially fitted. Filters out 95% of small particles.

N95 respirator

Tight fit; must be specially fitted. Filters out 95% of small particles.

Surgical mask

Loose fit around edges. Provides protection from large droplets.


Hospitals across the country are currently facing protective equipment shortages because of increased global demand, as well as supply chain disruptions.

“At the moment, we have significant limitations on our high-level N95 masks, and even surgical masks are in short supply,” said Dr. Compton-Phillips of Providence St. Joseph Health.

Experts say surgical masks and respirators are not effective for protecting the general public from Covid-19 but are crucial for health care workers who are in close contact with infected patients.

And because respirators and other medical supplies are single-use, hospitals need a large stock for doctors, nurses and other staff members. Representatives from hospitals across the country said they were taking steps to preserve the supply of protective equipment, including limiting the number of people who enter a patient’s room to essential personnel only.

Some larger hospitals and hospital networks maintain their own stockpiles of respirator masks and other equipment. The Department of Health and Human Services also maintains the Strategic National Stockpile of emergency preparedness supplies, which currently contains 13 million N95 respirator masks and 30 million surgical masks, according to a spokeswoman for the agency.

But Alex Azar, the secretary of Health and Human Services, told Congress that as many as 300 million N95 respirator masks could be needed by United States health care workers to fight the spread of the virus. The agency has said it will buy millions more masks over the coming months.

Isolating patients with Covid-19

Under new protocols, the C.D.C. recommends coronavirus patients be isolated in single rooms, behind closed doors, away from other patients. But more severe cases may require the use of a special room with negative pressure, which allows air to move inward but not escape back into general circulation.






HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.

HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.

HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.

HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.

HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.

HEPA filter

Area of lower air pressure

Negative pressure allows air to flow inwards, but not out of the room.


Note: This is one possible layout for a negative pressure isolation room; an anteroom is optional, and air flow systems may vary.

Negative pressure isolation rooms are recommended for special procedures that may result in the spray of tiny viral particles, like intubation for patients who need help breathing, or bronchoscopy, a procedure that allows doctors to examine a patient’s lungs. Respirator masks are required during these procedures, too.

But most coronavirus cases will quite likely not require hospitalization, said Dr. Compton-Phillips of Providence St. Joseph Health.

“If you are healthy — even if you have Covid but are not ill enough to be in a hospital — we don’t want to treat you in the hospital,” she said. Instead, patients with mild coronavirus infections and no underlying medical conditions may be asked to quarantine at home.

According to the W.H.O., 80 percent of Covid-19 patients in China experienced a mild form of the illness, 14 percent had a severe form, and 5 percent became critically ill. Older people and those with prior health conditions were at the highest risk.

“We don’t know how big this epidemic will be,” said Dr. Gabor D. Kelen, the director of the Johns Hopkins Office of Critical Event Preparedness and Response and the emergency medicine department. “Hopefully most of the people who are sick can be cared for at home and only those with serious respiratory conditions and the elderly who need I.C.U. care are the ones who get admitted to a hospital.”

Determining the proper precautions

The gear health care workers need to protect themselves and how they isolate patients depends largely on how an illness is transmitted.






Airborne spread up to 100 ft

Measles, tuberculosis

Smaller, lighter aerosol droplets can linger in the air.

Influenza, whooping cough, and most likely Covid-19, per W.H.O.

Larger, heavier viral droplets fall to the ground after being expelled.

DROPLET SPREAD

Up to 6 feet

Influenza, whooping cough, and most likely Covid-19, per W.H.O.

Larger, heavier viral droplets fall to the ground after being expelled.

AIRBORNE SPREAD

Up to 100 feet

Measles, tuberculosis

Smaller, lighter aerosol droplets can linger in the air.

Airborne spread up to 100 ft

Measles, tuberculosis

Smaller, lighter aerosol droplets can linger in the air.

Influenza, whooping cough, and most likely Covid-19, per W.H.O.

Larger, heavier viral droplets fall to the ground after being expelled.

DROPLET SPREAD

Up to 6 feet

Influenza, whooping cough, and most likely Covid-19, per W.H.O.

Larger, heavier viral droplets fall to the ground after being expelled.

AIRBORNE SPREAD

Up to 100 feet

Measles, tuberculosis

Smaller, lighter aerosol droplets can linger in the air.


Some illnesses, like measles and tuberculosis, can spread far and wide through the air. Their ability to linger in the air for hours and travel long distances after a sneeze or cough makes them highly contagious.

But experts think that other respiratory illnesses, like the flu, do not stay airborne for long. Instead, the viral droplets that leave a person’s mouth or nose end up falling to the ground within six feet or less. Think of it more like a sprinkle of rain than a cloud of mist.

The W.H.O. has said Covid-19 is most likely spread through this droplet route.

Such illnesses are usually spread through close contact, within family groups or during large gatherings, and can also be transferred by touching infected surfaces. (Reminder: wash your hands and stop touching your face!)

Health care workers routinely treat droplet-borne illnesses at a lower level of precaution than fully airborne ones, using medical masks rather than respirators. But for new diseases, like Covid-19 or H1N1 swine flu, health authorities may recommend higher-level protections while the transmissibility question remains unsettled.

“During the outbreak, you’re going to see changing guidance for hospital workers,” said Amesh Adalja, an infectious disease physician at the Johns Hopkins Center for Health Security. Where the new coronavirus falls in terms of mortality and risk perception “will change as we start to get more data within the United States,” he said.

The updated C.D.C. guidelines, which allow the use of medical masks instead of respirators for health care workers treating coronavirus patients, were met with a mixed response.

“If nurses and health care workers aren’t protected, that means patients and the public are not protected,” said Bonnie Castillo, a registered nurse and executive director of National Nurses United, a union that represents about 150,000 nurses across the country.

“Now is not the time to be weakening our standards and protections, or cutting corners,” she said.

Other medical experts said the new recommendations did not go far enough to clarify how health care workers dealing with the outbreak should be protected.

“We want health care workers to be confident they are being kept safe,” Dr. Adalja said.

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