Overcoming the Issue of Personal Protective Equipment Shortage in the Operating Theatre

As of 30^th April, 2020, which marks the 4^th phase of lockdown period in Malaysia, the total number of recovered patients is 4087 out of 5945¹ confirmed COVID-19 cases, indicating 69% recovery rate. Furthermore, the number of new cases has reduced. The Malaysian government, particularly the Ministry of Health, has taken active and serious measures from the moment World Health Organisation declared COVID-19 as global pandemic. The aim is to flatten the curve of this new infection and hence reduce the burden of healthcare system.

The health care personnel play a vital role in a pandemic crisis. Thus, it is undeniably fundamental for the government and authorities to ensure that these frontliners are protected. The sad reality of inadequate personal protective equipment (PPE) such as masks, face shields, gloves and gowns has led to unwanted results where transmission of infection has occurred among patients, healthcare personnel and family. Inadequate PPE is a global issue, and United States, the country with the highest infection rate, declared shortage of PPE and ventilators to handle their critically ill patients.²

The Centres for Disease Control and Prevention’s (CDC) recommends the use of PPE with additional powered air-purifying respirator (PAPR) or N95 respirator plus face shield when treating COVID-19 patients or patients with high risk of viral exposure. COVID-19 is not an airborne virus and is spread via droplets and contact.³ The transmission of COVID-19 is not limited to symptomatic individuals. The danger of not recognising the potential harm caused by transmission by asymptomatic individuals has been reported.⁴ In China, for instance, 22 out of 3000 estimated confirmed positive cases among healthcare personnel died.⁴ Whereby in Italy, a high incidence of infection and death among healthcare personnel has been reported.⁵ The shortage of PPE was blamed for the high mortality and infection rate.⁵

In the place where airway manoeuvres are widely performed, particularly during tracheal intubation in emergency or even in elective cases, PPE is a must and protection from spread of infection and contact precautions are vital. Aerosol generating procedures are encouraged to be done in a negative pressure room where the facility is available. The number of attending staff should be minimised. Rooms with rapid air turnover are preferred over rooms with low rate of air exchange. ⁶        

Realising the importance of cross-infection prevention in the operation theatres and intensive care unit, Department of Anaesthesia and Intensive Care Unit, Hospital Universiti Sains Malaysia, led by Head of the Department and Operation Theatre Coordinator initiated a workforce task with a combination of ideas from the nurses, supporting staff, students and lecturers. Temporary working place in the recovery area was created for a small PPE project just enough to cater to the need of the department. The nurses volunteered themselves to sew the PPE materials and willingly loan their sewing machines for the project.These consisted of hood covers, face shields, shoe covers and coverall suits. However due to the global shortage of supply we are still lacking coverall suits, N95 masks and PAPR. It was unfortunate that in this dire situation some suppliers took the advantage of increasing the PARP price up to almost 4-5 times normal.         

 Besides the volunteer work amongst the operation theatre staff, the students (Mmed Anaesthesiology candidates) also assisted in making the face shields. Furthermore, we do received donations from several NGOs on various items especially on N95 masks, face shields and also coverall suits. Infectious Disease Control Unit played their part by distributing the PPE to many units including the operation theatres and ICU. Pertaining to the global shortage of N95 masks, we tried to approach few pharmaceutical companies to help us to get the supply and managed to ensure all students and lecturers were equipped with the masks. The PPE project is a success as we managed to overcome the PPE issue without compromising patients’ care and safety of the health care personnel. On the hindsight, the number of infected cases is comparably low compared with other developing countries as well as the South East Asia region.

 In conclusion, specific training and encouragement of adherence to the guidelines, hygiene and barrier precautions may promote the feeling of trust and security among healthcare personnel. These will eventually create a calm and safe environment for the staff to overcome the pandemic efficiently.

References

1. COVID-19 (Maklumat Terkini)- KKM www.moh.gov.my (30^th April 2020)

2. Ranney, M. L., Griffeth, V., & Jha, A. K. (2020). Critical supply shortages—the need for ventilators and personal protective equipment during the Covid-19 pandemic. New England Journal of Medicine, 382(18), e41.

3. Furukawa, N., Bell, M., & Delaney, L. (2020). Coronavirus Disease 2019 (COVID-19): update and infection prevention and control recommendations.

4. Bai, Y., Yao, L., Wei, T., Tian, F., Jin, D. Y., Chen, L., & Wang, M. (2020). Presumed asymp tomatic carrier transmission of COVID-19. Jama, 323(14), 1406-1407.

5. Balmer, C., & Pollina, E. (2020). Italy’s Lombardy asks retired health workers to join coronavirus fight. In World Economic Forum, Reuters.

6. Cook, T. M. (2020). Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic–a narrative review. Anaesthesia.

FIGURE 1: OPERATION THEATRE COORDINATOR AND STAFF WITH THEIR PROJECT

FIGURE 2: A LECTURER AND NURSES SEWING THE PPE AT THE RECOVERY AREA

TABLE 1: HUSM PPE GUIDELINES