By Andreas Voss, Jan Kluytmans and Alexander Friedrich

As the surge of COVID-19 cases is hitting some of the Dutch hospitals hard, healthcare, in the areas being overwhelmed with cases, experience a shortage of PPEs and especially masks. In other Dutch regions with no or only a few cases, colleagues still believe that life is normal and PPEs can be ordered with a click on the computer. They look with awe at what colleagues in the midst of battling COVID-19 and shortages are facing. In addition, all healthcare-settings that do not usually use a lot of PPE’s (e.g. nursing homes and GPs), will be heavily understocked.

Still, infection control advice seems to be based on standard, safety-maximized procedures, thereby wasting valuable resources. As a consequence, HCWs in the Netherlands are still following these recommendations, by using FFP masks routinely, in low risk situations, while they should be saved for the high-risk procedures.

We believe that it is time to rethink our protocols, based on the fact that we still assume that COVID-19, in general, is based on droplet and contact transmission.

1. Restricted and risk-based use of FFP masks
2. Use of surgical masks for normal care of COVID patients
3. Efficient and extended use of FFP masks and other PPEs
4. Re-use of FFP masks

1. Restricted and risk-based use of FFP masks

FFP masks should be reserved for aerosol-generating tasks such as tracheal intubation, bronchoscopy, CPR, use of nebulizers (which actually should not be used in COVID patients), non-invasive ventilation (NIV), CPAP, NRM, optiflow, and so on.  Most of these tasks will be in critical units such as (N)ICUs and CCUs, but some, such as use of optiflow in internal and pulmonology units, or NRM on acute GP posts. Consequently, even in high-risk units, short visits to the patient room, with sufficient distance to the patient, and no aerosol-forming can and should be done using surgical masks, to save FFPs.

2. Use of surgical masks

In all cases and settings, where no aerosols are to be expected, surgical masks should be sufficient, as transmission of SARS-CoV-19 will be based on droplets and contact.  Consequently, GPs, nursing home, elderly care and home-care personnel, and other healthcare professionals not involved in acute care should use surgical masks (with the above mentioned exceptions)

3. Efficient and extended use of FFP masks and other PPEs

COVID-19 patients in healthcare settings should be cohorted as much as possible, not only to use rooms efficiently, but most importantly to allow extended duration of the use of PPE. In times of shortage, within a COVID-19 cohort, HCWs may continue to use the PPE they wear for several hours (isolation gowns, caps, protective googles, and mask) only changing gloves and perform hand hygiene between patients. In addition, at this time we recommend using a plastic apron over the gown, which is changed between patients. It is unclear for how long FFP masks can be worn, but many suggest a maximum of 3-4 hours or increased breathing resistance.
Workflows should be designed to allow a minimum of donned HCWs to combine needed tasks over multiple patients.

4. Re-use of masks

Re-use of masks is heavily discussed.  Re-use could be achieved by HCWs donning and doffing a “personal” mask during their shift, versus cleaning and sterilizing a used mask.

The risk of contaminating hands and/or coming in contact with mucous membranes during re-donning of a used mask, is a reason for many to disagree with this strategy.

Cleaning and sterilization also include many uncertainties and draw-backs.  Next to the basic principle of sterilization “you can’t sterilize what you can’t clean, the best method is unknow presently.  Recently the Dutch RIVM suggested plasma sterilization as the method of choice, based on a pilot study. The advice is based on a limited number of experiments, on a single type/brand of unused FFP2 masks, with a main outcome parameter of a fitting test and the particle penetration related to the fit of the mask. No test with regard to toxic residues or the functionality of the mask’s membrane were done. While believing in the principle of re-use and re-sterilization of a disposable at a time of scarcity and need, a national advice based on such limited outcome parameters is unnerving. This is especially true because hydrogen-peroxide is still present in the mask immediately following plasm sterilization, as well as the fact that masks, in our experience, have lost part of their droplet resistance.  Different methods of sterilization (e.g. gamma, UV, steam) are presently under evaluation, and while individual institutions might have success with their type of mask and sterilization process, we should keep collecting FFP masks until reliable methods are established.

We are faced with an unprecedented emergency in society and even more in healthcare. This forces us to reconsider our current practices. The principles of current quality systems with maximum safety as a starting point, which are based on unlimited resources, cannot cope with the present reality. We need to find an optimal balance between safety for patients and health care workers which urges us to reconsider the existing guidelines while realizing there is hardly time to take all aspects into consideration.