BEFORE THE IOWA DEPARTMENT OF PUBLIC HEALTH
PPE SHORTAGE ORDER
Pursuant to the authority contained in Iowa Code sections 135.142 and 135.144(3), the Iowa Department of Public Health (Department) hereby issues the following Personal Protective Equipment (PPE) Shortage Order (Order):
Definitions: The following definitions shall apply in the interpretation and enforcement of this Order:
“Health care provider” means a person who is licensed, certified, or otherwise authorized or permitted by the laws of the state of Iowa or Gubernatorial Proclamations of Disaster Emergency issued on or after March 9, 2020, to administer health care services or treatment.
“Hospital” means a facility as defined in Iowa Code section 135B.1(3).
“Health care facility” means a facility as defined in Iowa Code section 135C.1(7)
“Personal protective equipment” or “PPE” includes protective clothing, gloves, face shields, goggles, facemasks, respirators, gowns, aprons, coveralls, or other equipment designed to protect the wearer from injury or the spread of infection or illness.
Public Health Disaster Declared: The Governor of the State of Iowa issued a proclamation of public health disaster emergency on March 17, 2020, in response to the COVID-19 global pandemic. The pandemic has resulted in a statewide, regional, and national shortage of PPE. The Centers for Disease Control and Prevention has issued guidance for optimizing PPE supply on the grounds that “PPE shortages are currently posing a tremendous challenge to the U.S. healthcare system because of the COVID-19 pandemic.” The Department is therefore authorized to control, restrict, and regulate by rationing and using quotas, prohibitions of shipments, allocation, or other means the use, sale, dispensing, distribution, or transportation of PPE.
Individuals, Facilities, and other Entities Covered by this Order: All Iowa health care providers, hospitals, health care facilities, clinics, local public health agencies, medical and response organizations, and any other person or facility utilizing PPE in the care or treatment of a patient or resident are covered by this Order.
Conditions of Order:
You shall cooperate with the Iowa Department of Public Health and local boards of health or health departments to assess and monitor the supply of PPE and to ensure the utilization of PPE in accordance with this Order.
You shall immediately inform all staff of the conditions of this Order and you shall prominently post this Order in locations where PPE is utilized.
Due to the current shortage of PPE in the State of Iowa, you are hereby ordered to immediately comply with the following directives:
- Decrease Demand. You shall immediately decrease demand for PPE by taking each of the following steps:
- Maximize use of engineering controls, such as barriers and maintained ventilation systems, and administrative controls, such as altering work practices to minimize patient contacts.
- Comply with the ban on nonessential medical and dental services issued in the Proclamation of Disaster Emergency on March 26, 2020, and all subsequent extensions.
- Cancel all other elective and non-urgent procedures and appointments which utilize PPE.
- Reserve PPE for health care providers and replace PPE normally used for source control with other barrier precautions.
- Maximize the use of telemedicine.
- Implement Contingency Capacity Strategies. If, following completion of all steps in paragraph 1, the demand for PPE at your facility continues to exceed the supply, you shall comply with the following directives:
Implement extended use of facemasks. Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters.
- The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
- Health care providers must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene.
- Health care providers should leave the patient care area if they need to remove the facemask.
Restrict facemasks to use by health care providers, rather than patients for source control.
Shift gown use towards washable cloth isolation gowns. Consider the use of coveralls.
Use expired gowns beyond the manufacturer-designated shelf life for training. Use gown or coveralls conforming to international standards.
Shift eye protection supplies from disposable to re-useable devices, including goggles and reusable face shields.
Implement extended use of eye protection. Extended use of eye protection is the practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters.
Extended use of eye protection can be applied to disposable and reusable devices.
- Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through.
- Eye protection should be discarded if damaged.
- HCP must take care not to touch their eye protection. If they touch or adjust their eye protection they must immediately perform hand hygiene.
- HCP should leave the patient care area if they need to remove the eye protection.
Decrease length of stay for medically stable patients with COVID-19. Temporarily suspend annual fit testing.
Use N95 respirators beyond the manufacturer-designated shelf life for training and fit testing.
Extend use of N95 respirators. Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.
- Implement Crisis Capacity Strategies. If, following completion of all steps in paragraphs 1 and 2, the demand for PPE at your facility continues to exceed the supply, you shall comply with the following directives:
Use facemasks beyond the manufacturer-designated shelf life during patient care activities.
Implement limited re-use of facemasks. Limited re-use of facemasks is the practice of using the same facemask by one health care provider for multiple encounters with different patients by removing it after each encounter. As it is unknown what the potential contribution of contact transmission is for COVID-19, care should be taken to ensure that health care providers do not touch outer surfaces of the mask during care, and that mask removal and replacement be done in a careful and deliberate manner.
- The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
- Not all facemasks can be re-used.
- Facemasks that fasten to the provider via ties may not be able to be undone without tearing and should be considered only for extended use, rather than re-use.
- Facemasks with elastic ear hooks may be more suitable for re-use.
- The health care provider should leave the patient care area if they need to remove the facemask. Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container.
Prioritize facemasks for selected activities such as the provision of essential surgeries and procedures; during care activities where splashes and sprays are anticipated; during activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable; and for performing aerosol generating procedures, if respirators are no longer available.
If no commercially manufactured facemask is available and no other facemasks are available, consider if alternative approaches such as homemade facemasks used in combination with a face shield that covers the entire front (extending to the chin or below) and sides of the face will reduce the risk of health care provider exposure and are safe for patient care. These homemade cloth face masks are not considered PPE since their ability to protect against COVID-19 has not yet been studied.
Extended use of isolation gowns, including the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same health care provider when interacting with more than one patient known to be infected with the same infectious disease when these patients are housed in the same location. If the gown becomes visibly soiled, it must be removed and discarded.
Re-use of cloth isolation gowns.
Prioritize gowns for selected activities such as during care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures, and during high-contact patient care activities that provide opportunities for the transfer of pathogens to the hands and clothing of healthcare providers.
If no commercially manufactured gown is available, consider if alternative approaches such as homemade gowns will reduce the risk of health care provider exposure and are safe for patient care. If utilizing a homemade gown for patient care, you shall comply with the following guidelines of the Department: “Use of Homemade Gowns for Patient Care when Commercially-produced Personal Protective Equipment (PPE) is Unavailable.”
Use eye protection devices beyond the manufacturer-designated shelf life during patient care activities.
Prioritize eye protection for selected activities such as during care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures, and during activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable.
Consider using safety glasses such as trauma glasses that have extensions to cover the sides of the eyes.
Consider excluding health care providers at higher risk for severe illness from COVID- 19 from contact with known or suspected COVID-19 patients.
Consider designating convalescent health care providers for provision of care to known or suspected COVID-19 patients.
Use respirators beyond the manufacturer-designated shelf life for healthcare delivery.
Use respirators approved under standards used in other countries that are similar to NIOSH-approved respirators.
Limited re-use of N95 respirators. Re-use refers to the practice of using the same N95 respirator by one health care provider for multiple encounters with different patients but removing it after each encounter.
Use of additional respirators beyond the manufacturer-designated shelf life for healthcare delivery that have not been evaluated by NIOSH.
Prioritize the use of N95 respirators by activity type.
Extend the use of N95 respirators by decontaminating. According to the CDC, vaporous hydrogen peroxide, ultraviolet germicidal irradiation, and moist heat are the most promising decontamination methods. If N-95 decontamination is considered, these methods do not appear to break down filtration or compromise the mask; however, many of these methods can only be used for limited times.
Healthcare providers should take the following measures prior to using a decontaminated N-95:
- Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the N-95.
- Avoid touching the inside of the N-95.
- Use a pair of clean (non-sterile) gloves when donning and performing a user seal check.
- Visually inspect the N-95 to determine if its integrity has been compromised.
- Check that components such as the straps, nose bridge, and nose foam material did not degrade, which can affect the quality of the fit, and seal.
- If the integrity of any part of the N-95 is compromised, or if a successful user seal check cannot be performed, discard the N-95 and try another N-95.
- Users should perform a user seal check immediately after they don each N-95 and should not use an N-95 on which they cannot perform a successful user seal check.
Immunities. Iowa law contains immunity provisions protecting persons, corporations, and other legal entities, and employees and agents of such persons, corporations, and other legal entities who provide medical care or assistance in good faith under the direction of the Department of Public Health during a public health disaster. Iowa Code § 135.147.
A health care provider, hospital, health care facility, and any other person, corporation, or other legal entity or employee of all such entities acting in compliance with this Order, or other guidance issued by the Iowa Department of Public Health or the Centers for Disease Control and Prevention related to optimizing PPE supply, in good faith is acting at the request of and under the direction of the Iowa Department of Public Health for purposes of the immunity provisions of Iowa Code section 135.147.
Violation of Order: This Order may be enforced pursuant to Iowa Code section 135.38 and by professional licensing boards.
Effective date: This order shall be effective immediately on April 9, 2020, and shall continue so long as the state of public health disaster emergency remains in effect unless sooner terminated or modified by subsequent order of the Department or proclamation of the Governor.
Executed by Gerd Claybaugh, Director, Iowa Department of Public Health
On April 9, 2020