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Effect of extended use N95 respirators and eye protection on personal protective equipment (PPE) utilization during SARS-CoV-2 outbreak in Singapore.
Antimicrobial Resistance & Infection Control ( IF 5.5 ) Pub Date : 2020-06-15 , DOI: 10.1186/s13756-020-00753-2
Glorijoy Shi En Tan 1, 2 , Kyaw Zaw Linn 1 , Margaret Mei Ling Soon 1, 2 , Shawn Vasoo 1, 2 , Monica Chan 1, 2 , Bee Fong Poh 2 , Oon-Tek Ng 1, 2, 3 , Brenda Sze-Peng Ang 1, 2 , Yee-Sin Leo 1, 2, 3, 4 , Kalisvar Marimuthu 1, 2, 4
Affiliation  

Dear Editor

The ongoing Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) pandemic has resulted in shortage of personal protective equipment (PPE) worldwide [1]. The first positive case in Singapore was reported on 23 January 2020 when the outbreak began [2]. As the numbers of suspect and confirmed SARS-CoV-2 cases in Singapore rose, the largest proportion of them were cared for at the National Centre for Infectious Diseases (NCID), a purpose-built facility designed to strengthen Singapore’s capabilities in infectious disease management. We describe rates of PPE utilization during the outbreak and the impact of practicing extended use N95 respirators [3] and eye protection on their usage in outbreak wards.

We conducted the study between 1 February and 2 March 2020. All suspect and confirmed cases of SARS-CoV-2 were admitted to a single isolation room (12 air exchanges per hour). We included all patients admitted to both the general ward and intensive care unit. Healthcare workers (HCW) involved in their care were required to don full PPE comprising N95 respirator, eye protection, full sleeve gown and surgical gloves. HCW were advised to cluster clinical activities (for example blood taking, physical examination), and use ViSi Mobile (ViSi®), a wearable remote vital signs monitor, for routine monitoring to minimize entry into patient rooms.

Prior to 4 February 2020, N95 respirators and eye protection were single-patient use. On 4 February, reusable goggles were issued to each HCW. On 8 February, a directive was issued recommending extended use of N95 respirators and eye protection for repeated encounters with different patients, without changing between patients unless visibly contaminated or dislodged (Supplementary Appendix Floor Plan). Gowns and gloves remained as single-patient use.

During study period, a daily ward-level stocktake calculating the difference in balance PPE compared to preceding day, accounting for supplies replenished, was defined as utilization rate per day. A daily ward census was recorded. We applied linear regression using STATA 15.0 to compare change in PPE utilization per 100 patient-days (β) before and after extended use.

A total of 77 confirmed and 725 suspect cases were admitted during study period. Intensive care unit (ICU) admissions contributed to 199 (8.1%) patient-days (Fig. 1). The average utilization rate of single-use eye and N95 respirators per 100 patient-days reduced as a result of extended use policy. The average utilization rate of single-use eye protection and N95 respirators reduced from 1950 to 250 and 2490 to 1710 respectively after implementation.

Fig. 1
figure1

Utilization of PPE per 100 inpatient days during SARS-CoV-2 Outbreak in NCID

Full size image

Before extended usage, the N95 respirator utilization per 100 patient-days steadily increased from 400 on 1 February to 5428.6 on 8 February (β = 521.22) (Supplementary Appendix Fig. A). After implementation, the N95 utilization rate dropped to 388.1 on 2 March (β = 11.04). Single–use eye protection utilization rate per 100 patient-days was 2076.3 on 1 February and had decreased to 1411.4 on 3 February (β = − 332.45) (Supplementary Appendix Fig. B). By 2 March, it decreased sharply to 32.84 (β = 4.84).

We describe the relative reduction in PPE utilization with extended eye protection and N95 respirator use. As of 23 March 2020, no HCW in our institution has been confirmed to have nosocomially acquired SARS-CoV-2 through staff surveillance and testing of symptomatic staff, reaffirming safety. In a preliminary analysis, N95 respirators and goggles of HCW were found not to be contaminated after patient contact [4, 5].

There are some limitations in our analysis. Data pertaining to PPE utilization were based on crude estimation of balance ward supplies counted on a daily basis and may not reflect exact utilization rate. Secondly, the implementation of extended N95 respirator use was recommended as of 8 February but not strictly enforced and cannot be assumed to be at 100% compliance. HCW were at liberty to change their N95 respirators when clinically indicated, if adjustments were required or if PPE was visibly soiled. Evaluation of compliance to PPE use are being planned for. Lastly, as this was a purely descriptive study, there may have been other factors confounding factors affecting PPE utilization rate that were not analysed.

As the SARS-CoV-2 pandemic continues to develop with cases anticipated to increase globally, there is ongoing need to review PPE stockpiles and rationalize PPE use. Intervening measures such as extended use of N95 respirators can safely help to reduce rapid consumption of limited supplies. Further modelling data on the utilization of PPE using different hospital admission strategies and PPE use are required in order to determine whether stockpiles of PPE will be sufficient in the medium to long term.

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    WHO. Shortage of personal protective equipment endangering health workers worldwide. 2020. https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide (Accessed 10 Mar 2020).

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    Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. Jama. 2020;323(15):1488–94. https://doi.org/10.1001/jama.2020.3204.

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    Ong SWX, Tan YK, Sutjipto S, Chia PY, Young BE, Gum M, et al. Absence of contamination of personal protective equipment (PPE) by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Infection Control Hospital Epidemiol. 2020;41(5):614–6.

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The authors would like to acknowledge the following people for their contributions to this study - Albert Tan and NCID Operations, Poh Lian Lim, Cheng Chuan Lee, David Chien Boon Lye, Li Min Ling, Lawrence Soon-U Lee, Barnaby Edward Young, Sapna Sadarangani, Chen Seong Wong, Tau Hong Lee, Ray Junhao Lin, Po Ying Chia, Mucheli Sharavan Sadasiv, Deborah Hee Ling Ng, Chiaw Yee Choy, Tsin Wen Yeo, Frederico Capulong Dimatatac, Isais Florante Santos, Go Chi Jong, Yu Kit Chan, Jun Yang Tay, Stephanie Sutjipto, Pei Hua Lee, Sean Wei Xiang Ong.

Affiliations

  1. National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, Singapore, 308442, Singapore

    Glorijoy Shi En Tan, Kyaw Zaw Linn, Margaret Mei Ling Soon, Shawn Vasoo, Monica Chan, Oon-Tek Ng, Brenda Sze-Peng Ang, Yee-Sin Leo & Kalisvar Marimuthu

  2. Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore

    Glorijoy Shi En Tan, Margaret Mei Ling Soon, Shawn Vasoo, Monica Chan, Bee Fong Poh, Oon-Tek Ng, Brenda Sze-Peng Ang, Yee-Sin Leo & Kalisvar Marimuthu

  3. Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore

    Oon-Tek Ng & Yee-Sin Leo

  4. Yong Loo Lin School of Medicine, 10 Medical Drive, Singapore, 117597, Singapore

    Yee-Sin Leo & Kalisvar Marimuthu

Authors
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Contributions

GSET, KZL and KM wrote the manuscript. All authors contributed to the critical revision of the manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Glorijoy Shi En Tan.

Competing interests

None. No funding was required for this study.

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Additional file 1: Utilization rates of N95 respirator and single-use eye protection per 100 patient-days before and after extended use; Floor plan of isolation room.

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Tan, G.S.E., Linn, K.Z., Soon, M.M.L. et al. Effect of extended use N95 respirators and eye protection on personal protective equipment (PPE) utilization during SARS-CoV-2 outbreak in Singapore. Antimicrob Resist Infect Control 9, 86 (2020). https://doi.org/10.1186/s13756-020-00753-2

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Keywords

  • SARS-CoV-2
  • Personal protective equipment
  • Extended use N95 respirator

中文翻译：
在新加坡SARS-CoV-2爆发期间，长时间使用N95呼吸器和眼睛防护对个人防护设备（PPE）的使用。

亲爱的编辑

持续的严重急性呼吸系统综合症冠状病毒（SARS-CoV-2）大流行导致全球个人防护设备（PPE）短缺[1]。爆发于2020年1月23日，报告了新加坡首例阳性病例[2]。随着新加坡疑似和确诊SARS-CoV-2病例数量的增加，其中最大比例的疾病被国家传染病中心（NCID）照料，该中心旨在加强新加坡在传染病管理方面的能力。我们描述了暴发期间PPE的利用率以及长时间使用N95呼吸器的影响[3​​]以及在暴发病房中使用护目镜对其的使用。

我们在2020年2月1日至3月2日期间进行了研究。所有可疑和确诊的SARS-CoV-2病例均被送往一个隔离室（每小时进行12次换气）。我们包括所有同时进入普通病房和重症监护病房的患者。参与护理的医护人员（HCW）必须穿戴全套PPE，包括N95防毒面具，护目镜，全袖长袍和手术手套。建议HCW集中临床活动（例如抽血，身体检查），并使用可穿戴式远程生命体征监测仪ViSi Mobile（ViSi®）进行常规监测，以最大程度地减少进入患者病房。

2020年2月4日之前，N95呼吸器和眼睛防护设备仅供单人使用。2月4日，向每个医护人员发放了可重复使用的护目镜。2月8日，发布了一项指令，建议在与不同患者反复接触时应继续使用N95呼吸器并提供眼部保护，除非明显地被污染或移位，否则患者之间不得更改（补充附录平面图）。手术服和手套仍为单人使用。

在研究期间，将计算补充物资的每日病房水平库存量计算为每天的利用率，计算出当日PPE与前一天的差额。记录了每日病房普查。我们使用STATA 15.0进行了线性回归，以比较长期使用前后每100个患者日（β）的PPE利用率变化。

在研究期间共确认了77例确诊病例和725例可疑病例。重症监护病房（ICU）的住院天数为199（8.1％）个患者日（图1）。由于延长使用政策，单眼和N95呼吸器的平均利用率每100个病人日降低。实施后，一次性眼罩和N95口罩的平均利用率分别从1950年降低到250和2490降低到1710。

图。1
图1

NCID SARS-CoV-2爆发期间每100住院日的PPE使用率

全尺寸图片

在延长使用之前，每100个患者日的N95呼吸器使用率从2月1日的400稳定增加到2月8日的5428.6（β= 521.22）（补充附录图A）。实施后，N95利用率在3月2日降至388.1（β= 11.04）。2月1日，每100个患者日使用一次眼防护的利用率为2076.3，2月3日已降至1411.4（β= − 332.45）（补充附录图B）。到3月2日，它急剧下降到32.84（β= 4.84）。

我们描述了通过扩大眼睛防护范围和使用N95防毒面具，PPE使用率的相对降低。截至2020年3月23日，我们机构中没有通过医护人员监督和对有症状人员进行测试来确认医院内的医务工作者已从医院获得SARS-CoV-2的确认，从而重申了安全性。在初步分析中，发现与患者接触后N95呼吸器和HCW护目镜未受到污染[4，5]。

我们的分析存在一些局限性。与个人防护设备利用率有关的数据是基于每日计算的平衡病房供应量的粗略估算，可能无法反映确切的利用率。其次，从2月8日开始建议延长使用N95防毒面具，但并未严格执行，不能认为100％符合规定。如果需要进行临床调整，需要进行调整或明显弄脏了个人防护装备，医护人员可自由更换其N95型呼吸器。计划对PPE使用的符合性进行评估。最后，由于这仅是描述性研究，可能还有其他因素尚未影响影响PPE利用率的混杂因素。

随着SARS-CoV-2大流行的继续发展，全球病例预计将增加，持续需要审查PPE库存并合理使用PPE。采取干预措施，例如延长使用N95防毒面具，可以安全地帮助减少有限物品的快速消耗。需要使用不同的医院入院策略和PPE使用情况的PPE利用率的进一步建模数据，以确定PPE的库存在中长期内是否足够。

  1. 1。

    WHO。个人防护设备的短缺危及全世界的卫生工作者。2020年。https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide（于2020年3月10日访问）。

  2. 2。

    Young BE，Ong SWX，Kalimuddin S等。新加坡SARS-CoV-2感染患者的流行病学特征和临床病程。贾玛 2020; 323（15）：1488-94。https://doi.org/10.1001/jama.2020.3204。

  3. 3。

    Fisher EM，Shaffer RE。建议在卫生保健场所中延长使用过滤式口罩呼吸器并限制其重复使用的注意事项。J占领环境Hyg。2014; 11（8）：D115–28。

    文章Google学术搜索

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    Ong SWX，Tan YK，Chia PY等。有症状患者的严重急性呼吸综合症冠状病毒2（SARS-CoV-2）污染了空气，地面环境和个人防护设备。贾玛 2020; 323（16）：1610-12。https://doi.org/10.1001/jama.2020.3227。

  5. 5，

    Ong SWX，Tan YK，Sutjipto S，Chia PY，Young BE，Gum M等。严重急性呼吸系统综合症冠状病毒2（SARS-CoV-2）没有污染个人防护设备（PPE）。感染控制医院流行病学。2020; 41（5）：614-6。

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作者要感谢以下人员对这项研究的贡献-谭伟杰和NCID运营，Poh Lian Lim，Cheng Chuan Lee，David Chien Boon Lye，Li Min Ling，Lawrence Soon-U Lee，Barnaby Edward Young，Sapna萨达兰加尼（Sadarangani），陈成皇（Cheng Seong Wong），李涛宏（Tun Hong Lee），林俊浩（Po Jun Chia），宝盈嘉（Mucheli Sharavan Sadasiv），黛博拉（Deborah Hee Ng Ng），邱义才（Chaw Yee Choy），岑文耀（Yen Wen Yeo），弗雷德里科·卡普隆（Frederico Capulong Dimatatac），伊萨斯·弗洛朗特·桑托斯（Isais Florante Santos），高志钟（Go Chi Jong），余洁Chan（Yu Kit Chan） ，Jun Yang Tay，Stephanie Sutjipto，Pei Hua Lee，Sean Wei Xiang Ong。

隶属关系

  1. 国家传染病中心，新加坡惹兰陈笃生16号，308442，新加坡

    Glorijoy Shi En Tan，Kyaw Zaw Linn，Margaret Mei Ling Soon，Shawn Vasoo，Monica Chan，Oon-Tek Ng，Brenda Sze-Peng Ang，Yee-Sin Leo和Kalisvar Marimuthu

  2. 谭笃成医院，惹兰陈笃成，新加坡，308433，新加坡

    Glorijoy Shi En Tan，Margaret Mei Ling Soon，Shawn Vasoo，Monica Chan，Bee Fong Poh，Oon-Tek Ng，Brenda Sze-Peng Ang，Yee-Sin Leo和Kalisvar Marimuthu

  3. 李光前医学院，新加坡曼德勒路11号，308232，新加坡

    吴文泰＆李怡善

  4. 新加坡新加坡10 Medical Drive的Yong Loo Lin医学院，117597，新加坡

    Yee-Sin Leo和Kalisvar Marimuthu

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GSET，KZL和KM撰写了手稿。所有作者都对稿件进行了严格的修订。作者阅读并批准了最终手稿。

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对于已发布地图和机构隶属关系中的管辖权主张，Springer Nature保持中立。

附加文件1：长期使用之前和之后，每100个病人日的N95呼吸器和一次性使用眼部防护装置的使用率；隔离室的平面图。

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Tan，GSE，Linn，KZ，不久，MML等。在新加坡SARS-CoV-2爆发期间，长时间使用N95呼吸器和眼睛防护对个人防护设备（PPE）的利用。Antimicrob抗蚀传染控制 9， 86（2020）。https://doi.org/10.1186/s13756-020-00753-2

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关键词

  • SARS-CoV-2
  • 个人保护设备
  • 长时间使用N95防毒面具
更新日期：2020-06-15
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