STUFF

The recent COVID-19 pandemic revealed the vulnerability of healthcare systems and how they can rapidly be overloaded in terms of available material capacity. In the setting of a pandemic surge, many forms of supplies are essential to provide lifesaving care to critically ill patients. According to the consulted guidelines, key equipment and supplies in light of the COVID-19 pandemic include mainly – but are not limited to – mechanical ventilators and personal protective equipment (PPE). We will, therefore, mainly focus on these two supplies, but will also highlight some general options to, for example, improve stock management. This section is structured using the following strategies:

1. Optimise the utilisation of stuff (see 8.4.1) 2. Increase the supply of stuff (see 8.4.2) 3. Improve the stock management (see 8.4.3) 8.4.1 Optimise the utilisation of stuff 8.4.1.1 Ventilators

The large surge of COVID-19 patients with respiratory failure has led to shortages of mechanical ventilators in some countries. Without access to appropriate mechanical ventilation, many of the infected patients suffering from acute hypoxemic respiratory failure will not survive.⁶³

The first option to optimise the utilisation of stuff, is to avoid intubation and mechanical ventilation when medically appropriate alternatives exist. For instance, there are good results of treating patients with acute hypoxemic respiratory failure due to COVID-19 by high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), or continuous positive airway pressure (CPAP).^zz83-85 Protocols for intubation should, therefore, be developed and

zz Despite the merit of avoiding intubation, these treatments are also accompanied with some side effects. For example, NIV and HFNO are potentially associated with an increased risk of viral spread and nosocomial

implemented, as well as the use of HFNO and NIV.⁶³ In addition, when standard full-featured ventilators are limited, repurposed devices and alternative techniques could be considered. This could entail the use of long-term ventilators, emergency transport ventilators, anaesthesia gas machines, MRI compatible ventilators, or even prolonged manual ventilation, NIV for invasive ventilation, or veterinary ventilations.⁶³

Another option to optimise the utilisation of ventilators could be to incorporate a TLT period.⁶³ However, as discussed above in 8.3.2, this option is subjected to ethical considerations and the conditions have to be clearly stipulated in a legal framework.

Some guidelines and publications suggest the use of a single mechanical ventilator to support multiple patients during surge of patients with hypoxemic respiratory failure (i.e. “ventilator splitting”).^{71, 86, 87} However, lung compliance and resistance are likely to vary among patients (and even in the same patient over time), which could lead to large variations in tidal volumes. The Columbia University College of Physicians and Surgeons proposed a ventilator sharing protocol (requiring careful patient selection with similar mechanical support need, use of neuromuscular blockades, and especially the transfer of patients to a single ventilator for weaning).⁸⁸ Nevertheless, several professional groups, such as the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anestesiologists (ASA), American College of Chest Physicians (CHEST), issued a consensus statement in which ventilator splitting is not recommended, because it cannot be done safely with current equipment.⁸⁹

Last, a mechanism for the prompt maintenance and repair of essential equipment has to be in place (and non-essential maintenance and repair should be postponed).⁶⁸ This will also require sufficient and qualified technical staff.

transmission of the infection due to aerosol generation. Also, the failure of non-invasive respiratory support and delayed intubation could be associated with worse outcomes.⁶³

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8.4.1.2 Personal protective equipment (PPE)

Many of the consulted guidelines formulate recommendations on the procurement/utilisation of PPE. This is primarily because, during the first wave of the COVID-19 pandemic, many countries were caught by the rapid spread of the virus, leading to acute deficits in PPE availability. We assume that this acute deficits will be less pronounced in latter stages of the pandemic, due to large efforts of all public authorities to procure and distribute PPE. Nevertheless, for the completeness of this chapter, we describe the cited recommended strategies targeted to PPE.

Protection of healthcare professionals from COVID-19 requires airborne precautions through adequate respiratory protection. When the supply of PPE (almost) is exhausted, several conservation and re-use techniques may be recommended. First, a plan for optimising the use of PPE in case of shortages should be in place. For instance, most protective eyewear/gowns/respiratory protection can be reserved for those performing high-risk interventions (e.g. intubations, monitoring patients on BiPAP), FFP2/3 masks can be reserved for airborne generating procedures and surgical masks can be used for other procedures. As cohorting becomes necessary and the volume of cases increases, a shift to continuous use in designated units or even through the entire hospital may be required (rather than intermittent use).69, 72, 90, 91 The European Centre for Disease Prevention and Control⁹⁰ recommends to keep using the same FFP2/3 mask up to four hours (if not damaged), when performing the same activity or when managing care for multiple COVID-19 patients. Also, in times of pressing shortage of PPE for healthcare personnel, public authorities can decide to discourage the general population from wearing masks.^{69, 91} However, this can only be recommended in times of acute shortage.

In times of shortage of PPE, single-use supplies can also be recycled or reused.62, 69, 91 For instance, elastomeric half-face masks in high-risk environments could be used and reused after appropriate disinfection procedures. Aziz et al.⁶³ recommend not to use time as a decontamination method of PPE, mainly because the virus remains in the mask for more than seven days. Instead of disinfecting N95/FFP3 masks with ethylene oxide, they should rather be reprocessed with ultraviolet germicidal irradiation

(UVGI) or vaporized hydrogen peroxide (VHP) to extend usage time of these masks. Also, the use of surgical masks across multiple days for patients is not recommended.⁶³

Last, in order to limit the loss of PPE, healthcare professionals should be trained in putting on (“donning”) and taking off (”doffing”) PPE.^{61, 62} This is best propagated by local “champions” or “superusers” that take ownership over PPE training and adherence in their unit.⁶²

Table 23 – Options to optimise the utilisation of stuff

Recommendations References

Ventilators

Avoid intubation by developing and implementing clear protocols for intubation, as well as the use of HFNO and NIV

Aziz et al. (2020)⁶³

In a setting with a shortage of full-featured ventilators, alternative devices that provide invasive mechanical ventilation or alternative techniques should be considered

Aziz et al. (2020)⁶³

Time-limited ventilation trial period Aziz et al. (2020)⁶³ Ventilator splitting: not recommended with

current equipment Abir et al. (2020)⁷¹, Aziz et al.

(2020)⁶³ Ensure a mechanism for the prompt maintenance

and repair of the equipment required for the essential services. Postpone non-essential maintenance and repair.

World Health Organization (2020a)⁶⁸

PPE

Plan for optimising the use of PPE in case of

shortages Bader et al. (2020)⁷²,

European Centre for Disease Prevention and Control (2020)⁹⁰, Harris et al.

(2020)⁹¹, Hick et al. (2020)⁶⁹

192 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335

Recycle/reuse single-use supplies Anesi et al. (2020)⁶², Aziz et al. (2020)⁶³, Harris et al.

(2020)⁹¹, Hick et al. (2020)⁶⁹ Training in putting on (“donning”) and taking off

(“doffing”) PPE European Centre for Disease

Prevention and Control (2020)⁶¹

8.4.2 Increase the supply of stuff 8.4.2.1 General

Many of the general recommendations targeted to the supply of stuff are related to sufficient and adequate policy or legislation issued by public authorities. We describe this macro-component more elaborately in section 8.6.2. Below, we focus on recommendations addressed to individual healthcare facilities. Facilities should ensure the adequate availability of supplies through facility-based storage, with vendor agreements and understanding of supply chain resources and limitations.⁷⁴ For instance, supply chain bottlenecks can be resolved through the government, which can help to ensure the continuous provision of essential supplies (e.g.

institutional and central stockpiles, emergency agreements with local suppliers, donations).^{7, 68}

Einav et al.⁷⁴ provided some mass critical care target lists for the ancillary equipment for surge in positive pressure ventilation, medical equipment for critical surge and pharmaceuticals. These target lists can be used by hospitals to plan and acquire the relevant and essential resources for current pandemic response.

8.4.2.2 Ventilators

In addition to the recommendations to optimise the utilisation of ventilators (see 8.4.1.1), hospitals can increase the number of available ventilators by purchasing domestically available ventilators, or borrow ventilators from other hospitals in their network or region.^{62, 63, 71} Hospitals can potentially also acquire additional ventilators from their stockpiles. Related to this,

hospitals should partner up to safeguard the supply, flow capacity, and quality assurance of oxygen.⁹²

8.4.2.3 Personal protective equipment (PPE)

Anesi et al.⁶² recommend a mechanism in which PPE are efficiently redistributed across hospitals. Hospitals with lower stocks or more infected patients should receive more PPE compared to less affected hospitals.

Alternative suppliers have to be identified if the main suppliers are running out of stock (especially for PPE).⁶¹

Table 24 – Options to increase the supply of stuff

Recommendations References

General

Facilities should ensure adequate availability of disaster supplies through facility-based caches, with vendor agreements and understanding of supply chain resources and limitations

Einav et al. (2014)⁷⁴

Identify and resolve supply chain bottlenecks World Health Organization (2020)⁷

Consult with authorities to ensure the continuous provision of essential medications and supplies (e.g. institutional and central stockpiles, emergency agreements with local suppliers, donations).

World Health Organization (2020a)⁶⁸

Assess the quality of contingency items prior to

purchase World Health Organization

(2020a)⁶⁸ Use the mass critical care hospital target lists for

basic equipment, supplies, and pharmaceuticals Einav et al. (2014)⁷⁴ Ventilators

Acquire additional ventilators:

• Purchase domestically available ventilators

• Procurement and donations of ventilators

Abir et al. (2020)⁷¹, Anesi et al. (2020)⁶², Aziz et al.

(2020)⁶³

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• Borrow ventilators from other hospitals in the network or region

• Acquire ventilators from stockpiles

Partner up to safeguard the supply, flow

capacity, and quality assurance of oxygen Adelaja et al. (2020)⁹² PPE

Efficient redistribution of PPE across hospitals Anesi et al. (2020)⁶² Identify alternative suppliers if main suppliers

should run out of stock (especially for PPE) European Centre for Disease Prevention and Control (2020)⁶¹

8.4.3 Improve stock management

Physical space for the stockpiling of additional supplies needed during a pandemic or crisis has to be designated by hospitals.⁶⁸ Essential supplies and pharmaceuticals should be stockpiled according to recommended guidelines. A comprehensive list has been developed in the context of the influenza pandemics. However, it is likely that this list can also be applied to the COVID-19 population.^{74, 93} Hospitals have to develop an inventory of supplies and equipment necessary to provide care to critically ill patients during a pandemic and identify potential shortages based upon projected ICU need in the most likely outbreak scenario.^{61, 63, 68} In addition, methods to monitor, maintain, and accurately report equipment and stock levels are recommended to be in place.^{61, 63, 92} For example, a list of available sizes and expiry dates of the stockpiled PPE must be compiled and be up to date and escalation procedures for supply shortages within the organisation should be clearly communicated.^{61, 92} Also, hospitals can anticipate these critical shortages by creating a strategic buffer of key supplies (e.g. for hand and respiratory hygiene, PPE, isolation, ICU supplies, mechanical respirators, etc.).⁶¹

A plan should be in place to keep track and custody of key supplies (e.g.

PPE, ventilators, cleaning and disinfection material, alcohol solution, etc.) to avoid misuse, overuse or theft.^{61, 92} We refer the reader for planning tools and models targeted to supplies in Section 8.7.

Table 25 – Options to improve stock management

Recommendations References

Identify physical space within the hospital for the

storage and stockpiling of additional supplies World Health Organization (2020a)⁶⁸

Methods should be in place to monitor, maintain, and accurately report equipment and stock levels in each clinical area

Adelaja et al. (2020)⁹², Aziz et al. (2020)⁶³, European Centre for Disease Prevention and Control (2020)⁶¹

Buffer stock of key supplies (e.g. for hand and respiratory hygiene, PPE, isolation, ICU supplies, mechanical respirators) should be acquired

European Centre for Disease Prevention and Control (2020)⁶¹

Estimate the consumption of essential equipment, supplies, and pharmaceuticals (e.g., amount used per week) based on most likely outbreak scenario

World Health Organization (2020a)⁶⁸

Keep track and custody of key supplies (e.g.

PPE, ventilators, cleaning and disinfection material, alcohol solution, etc.) to avoid misuse, overuse or theft

Adelaja et al. (2020)⁹², European Centre for Disease Prevention and Control (2020)⁶¹

194 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335