COVID-19: Personal Protective Equipment (PPE)

• The Wisconsin Department of Health Services (DHS) Medical Stockpile is a cache of state-owned medical surge supplies and personal protective equipment including gloves, gowns, coveralls, face masks, face shields and N95 respirators.
• The stockpile is available at no cost to hospitals, clinics and other healthcare providers in the event that an incident or situation outstrips existing inventory of such material.

The DHS Medical Stockpile may be accessed by facilities or agencies that meet the following criteria:

• An emergency event has occurred (such as a mass casualty accident, pandemic, etc.).
• Requested items do not exist in local stocks OR depletion of existing inventory is expected to occur and supplies cannot be obtained from other sources in the needed time frame.
• Your facility has exhausted all attempts to obtain PPE from other sources.
• Your facility is following the latest Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), and DHS or other applicable guidelines for the use of PPE.
• You are ordering what is needed, but not more than a two week’s supply. You may be able to reorder. Products are non-returnable.
• There may be other extenuating circumstances that meet the requesting criteria. Requesters are asked to indicate those as well.

1. Explore all options for PPE. This includes sourcing from local vendors or from other facilities in your area.
2. Download and complete the DHS Stockpile Request form.
3. Email the completed form to dhsstockpile@dhs.wisconsin.gov. 
4. Participate in a consultation call from WI DHS to discuss your request.

Yes, please submit your request as directed above. You will receive a call from a WI DHS staff who can discuss your request, and assist you with finding the resources you need.

If an employer mandates or requires the use of N95 respirators by employees, they must provide a respiratory protection program, medical surveillance and other regulatory requirements as provided by OSHA. These OSHA standards are specifically incorporated by reference in the State of Wisconsin for public sector employees within SPS 332. Public Sector Employee Safety Website Resources can be found on the DSPS website.

However, per the OSHA standard, if an employer provides an N95 respirator on a voluntary basis, they can do so without providing a respiratory protection program per the regulation as long as they provide the information noted in Appendix D of the OSHA standard. We also recommend providing to those who use the N95's further information about optimal mask effectiveness, per the CDC. 

Health care personnel should adhere to Standard and Transmission-based Precautions when caring for patients with SARS-CoV-2 infection. Recommended PPE is described in the CDC's infection control guidance.

DHS has published interim guidance regarding the use and decontamination of respirators. 

Health care facilities should review CDC’s guidance on PPE optimization and NIOSH’s guidance on extended use and limited reuse of N95 respirators for full information.

Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit).

Reuse refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. Extended use is favored over reuse because it is expected to involve less touching of the respirator and therefore less risk of contact transmission.

If extended use or reuse of N95 respirators is permitted, health care facilities should consider additional training and reminders (for example, posters) for staff to reinforce the need to minimize unnecessary contact with the respirator surface, strict adherence to hand hygiene practices, and proper donning and doffing technique.

For extended use or reuse of N95 respirators, health care facilities should advise staff to take the following steps to reduce contact transmission:

• Ensure respirators are only used by a single wearer.
• Ensure the respirator maintains its fit and function.
• Discard respirators following use during aerosol generating procedures.
• Discard respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
• Discard respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.
• Discard any respirator that is obviously damaged or becomes hard to breathe through.
• Consider use of a cleanable face shield (preferred) over the respirator and/or other steps (for example, masking patients, use of engineering controls) to reduce surface contamination.
• Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).

Additionally, for reuse of N95 respirators, health care facilities should advise staff to take the following steps:

• Follow the employer’s maximum number of donnings (or up to five if the manufacturer does not provide a recommendation).
• Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other. Storage containers should be disposed of or cleaned regularly. Pack or store respirators between uses so that they do not become damaged or deformed.
• Label containers used for storing respirators and/or label the respirator itself (for example, on the straps) between uses with the user’s name to reduce accidental usage of another person’s respirator.
• Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, perform hand hygiene.
• Use proper respirator donning techniques including inspection of the device for physical damage (for example, Are the straps stretched out so much that they no longer provide enough tension for the respirator to seal to the face? Is the nosepiece or other fit enhancements broken?)
• Use a pair of clean (non-sterile) gloves when donning a used respirator and performing a user seal check. Discard gloves after the respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal.
  More information can be found at: CDC COVID-19 for instructions in how to perform a seal check.

Decontamination of Filtering Facepiece Respirators (FFRs)

Among other strategies, decontamination of FFRs has been suggested as a crisis capacity strategy. Decontamination procedures are not considered standard use by any of the FFR manufacturers or CDC’s National Institute for Occupational Safety and Health (NIOSH); however, in light of the existing shortages, CDC published guidance on their website.
 
In addition, the Food and Drug Administration (FDA) has issued Emergency Use Authorizations (EUA) for several FFR decontaminated processes. These EUAs included a guidance document for the decontamination method manufacturer along with specific instructions for the health care facility and health care workers, including the number of decontamination cycles that can be utilized for each process.

Due to the inaugural nature and risks associated with these decontamination procedures, these procedures are meant to be implemented as in-house policies that require specialized equipment, a written program, and adequately trained staff. The respirator manufacturer(s) must be consulted to determine if the chosen method is compatible with the FFRs in use at each institution.

An alternative suggested strategy to decontamination of FFRs is to issue five respirators to each health care worker who may care for patients with suspected or confirmed COVID-19. The health care worker will wear one respirator each day and at the end of each shift store it in its own breathable paper bag. (Each bag should be placed in a second paper bag that is disposed after each use). The order of FFR use should be repeated, so that a minimum of five days passes between each FFR use. This will result in each worker requiring a minimum of five FFRs, providing that they put on, take off, care for them, and store them properly each day.

For additional information, and updated resources, please refer to current CDC website.

DHS expects that personal protective equipment (PPE) from the Strategic National Stockpile (SNS) will not fully meet the needs of the provider community operating at surge capacity. Because DHS expects continued PPE shortages, facilities should follow strategies to optimize the supply of PPE in accordance with guidance from the Centers for Disease Control and Prevention (CDC).

Optimizing Your PPE

• To optimize PPE, facilities should ensure that they have also implemented all possible engineering and administrative controls to reduce infectious disease transmission. Engineering controls may include isolation in airborne infection isolation rooms, use of physical barriers, properly maintaining ventilation systems, and other measures. Administrative controls may include limiting the number of patients going to hospital or outpatient settings, excluding all health care personnel (HCP) from patient care areas who are not directly involved in patient care, limiting face-to-face encounters of HCP with patients, restricting visitors, source control, cohorting patients and HCP, maximizing use of telemedicine, and other measures.
• Per the CDC guidance, facilities should understand their current PPE inventory, supply chain, utilization rate, and community PPE supply to know whether they are operating under conventional capacity, contingency capacity, or crisis capacity.

Conventional Capacity Measures

Under conventional capacity, facilities use measures for providing patient care without any change in daily contemporary practices. These measures, consisting of engineering, administrative, and PPE controls, should already be implemented in general infection prevention and control plans in health care settings.

Contingency Capacity Measures

Under contingency capacity, facilities use temporary measures during periods of expected PPE shortages that may change daily contemporary practices but may not have any significant impact on the care delivered to the patient or the safety of the HCP. Depending on the type of PPE, measures may include:

• Use of PPE beyond the manufacturer-designated shelf life for training and fit testing.
• Extended use of PPE, which refers to the practice of using the same PPE for repeated close contact encounters with several different patients, without removing the PPE between patient encounters.
• Limited re-use of PPE, which refers to the practice of using the same PPE by one HCP for multiple encounters with different patients but removing it after each encounter.
• Other measures.

Crisis Capacity Measures

Under crisis capacity, facilities use alternate strategies, or a combination of alternate strategies, during periods of expected or known PPE shortages that are not commensurate with contemporary U.S. standards of care. Depending on the type of PPE, measures may include:

• Extended use or limited re-use of PPE.
• Prioritization of PPE.
• Use of PPE beyond the manufacturer-designated shelf life for health care delivery. The FDA recommends that because expired PPE, such as gowns and surgical masks, still provide some protections, these PPE can be utilized by HCP as long as there are no visible damages, such as degraded materials or visible tears, and the PPE is not being used in surgical settings.
• Use of PPE approved under standards used in other countries that are similar to U.S. standards.
• Use of alternatives to PPE, such as supplies that have not been evaluated as effective.
• Other measures.

During severe resource limitations, facilities should consider excluding HCP who may be at higher risk for severe illness from COVID-19, such as those of older age, those with chronic medical conditions, or those who may be pregnant, from caring for patients with confirmed or suspected COVID-19 infection.

Resources

• CDC guidance on strategies to optimize the supply of PPE for details on appropriate optimization measures by specific type of PPE
• CDC checklist for optimizing the supply of N95 respirators

CDC Fact Sheets

• How to Put On and Take Off PPE
• Facemask Do's and Don'ts
• Respirator On/Respirator Off
• How to Properly Put on and Take off a Disposable Respirator 

DHS Fact Sheets

Law enforcement personnel use and conservation: PPE, P-02645
English

Home and Community Based Service Providers Use and Conservation of PPE, P-02665
English

Home and Community Based Service Providers: Use and Conservation of PPE, P-02665A
English

Recipients of Home and Community Based Services Use and Conservation of PPE, P-02665B
English

In-Home Visits for Social Workers Use and Conservation of PPE, P-02665C
English

Providers of Transportation Services Use and Conservation of PPE, P-02665D
English

Personal Protective Equipment (PPE) Fact Sheet for Assisted Living Facilities, P-02885
English

Personal Protective Equipment (PPE)
Optimization Fact Sheet For Assisted Living Facilities, P-02932
English

CDC Capacity Strategies for Optimizing Personal Protective Equipment (PPE), P-02987
English

CDC Resources:

• How to Properly Don, Use, and Doff PPE
• Strategies for Optimizing the Supply of PPE
• How to Perform a Respirator Seal Check
• Three Key Factors Required for a Respirator to be Effective
• Understanding the Difference (surgical masks, N95 FFRs, and Elastomerics) Infographic

OSHA Resources:

• Respiratory Standard
• COVID-19 webpage

Respirator Fit Testing:

• Pre-Fit Testing Checklist
• Fit Testing Training Videos

Other Resources:

• Nebraska Medicine COVID-19 PPE Guidance: Extended Use and Reuse of Facemasks, Respirators and Protective Eyewear For Healthcare Personnel
• Hand Hygiene and PPE Observation Form (PDF) 
• COVID-19 Infection Prevention and Control: Frequently Asked Questions (PDF)