March 1, 2020 Policy Review of COVID-19 PPE Recommendations for Healthcare Problem: With the revised PUI guidance from the CDC, we are expecting a significant increase in patients seeking evaluation for COVID-19. Considering the current and ongoing supply chain issues and increasing surge in hospital demand, the CDC PPE recommendations for healthcare workers (HCWs) are not sustainable. The current CDC infection control guidance states that any suspect patient should only be evaluated with airborne (N95 respirator) and contact precautions with eye protection. This guidance makes no accommodation for evaluating patients when N95s are not available and/or when staff are not fit tested, which is the case in most outpatient settings. The implications for this include:    More outpatient settings are trying to purchase N95s and fit test staff which will continue to deplete supplies at a higher rate; The CDC guidance implies that facilities/providers without N95s and/or fit testing program should refer patients to the ED, even if they could otherwise have been seen and sent home from the outpatient setting; That could lead to additional avoidable healthcare exposures, including EMS and waste of additional PPE supplies. Recommendations: 1. Immediately change DOHMH guidance for outpatient settings (that are not performing high-risk procedures) from airborne to droplet. New guidance should include focus on rapid patient identification and source control, ensuring they are masked and isolated quickly. PPE for providers in close contact with the patient should include facemask, isolation gown, gloves and eye shield/goggles. Staff that are not in close contact with the patient but within 6 feet can wear a face mask only. 2. Immediately change guidance for EMS first responders as described above. N95s may still be appropriate for suspect patients with severe respiratory symptoms (e.g., dyspnea needing highflow oxygen). 3. Ensure that healthcare workers that manage confirmed COVID-19 cases using standard, contact, and droplet precautions with eye protection are classified as low risk and would not require active monitoring or furlough from work. 4. Immediately pivot our messaging to encourage those with mild illness to stay home throughout the duration of illness and, if moderate symptoms, call your doctor for further guidance. 5. Review guidance for emergency departments and inpatient settings with input from healthcare infection control SMEs. Consider recommending change to droplet precautions and placement in normal pressure rooms for ED and admitted patients without severe respiratory symptoms. An alternative would be to present clear de-escalation recommendations and endorse dedicated care teams for confirmed/suspected COVID-19 cases and the extended use of N95s. 6. Maintain guidance to use airborne precautions (N95s in negative pressure rooms) for severely ill patients in ICUs and for high-risk aerosol generating procedures. Rationale:   The WHO Infection Control Guidance for COVID-19 endorses droplet precautions over airborne. According to the new Report on the WHO-China Joint Missions on Coronavirus Disease 2019: “COVID-19 is transmitted via droplets and fomites during close unprotected contact between an March 1, 2020    infector and infectee. Airborne spread has not been reported for COVID-19 and it is not believed to be a major driver of transmission based on available evidence; however, it can be envisaged if certain aerosol-generating procedures are conducted in health care facilities.” According to the CDC guidance on assessing HCW exposure risk, the recommended change would still be considered a ‘low-risk’ exposure and would not require HCW furlough (provided the patient is wearing a face mask). Several studies, including a recent large RCT showed no benefit to the use of N95s vs. face masks in preventing influenza and other viral respiratory infections in HCWs (Radonovich, 2019) Changes must be implemented now to help reduce anticipated hospital surge and preserve scarce PPE stocks for the HCWs caring for severely ill patients and performing high risk procedures. Additional Considerations:    Implementation of this recommendation in NYC contradicts current CDC guidance and will likely result in opposition from some healthcare workers and Unions; this would be mitigated by making the recommendation jointly with NYSDOH and leaders from within the healthcare community (hospital epidemiologists, infection prevention and control organizations, and unions). o We will discuss with SDOH with the goal of aligning our guidance o The NYC Hospital Epi council will meet this week and can review these recommendation o GNYHA is supportive of the proposed change Multiple other jurisdictions are supportive of implementing similar measures Several large urban hospitals systems throughout the country are requesting review of the CDC’s airborne recommendations. o At least one NYC health system has already implemented the outpatient approach described above. Pending Questions:  Would we want to recommend patient wears mask (for source control) during inpatient interactions?