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MARCH 26, 2020 -- Innovative workarounds by hospitals and clinicians are evolving amid the race to stay ahead of dwindling supplies as resource demands soar in the COVID-19 crisis.
In a JAMA interview reported on by Medscape Medical News, Kaiser Permanente's COVID-19 response chief, Stephen Parodi, MD, said baby monitors are being used in rooms with COVID-19 patients to reduce coming and going by healthcare providers and to preserve personal protective equipment (PPE). A physician can virtually examine a patient with another practitioner in the room.
In Italy, Cristian Fracassi, founder of the engineering firm Isinnova, heard about the shortage of valves that connect oxygen masks to ventilators and his start-up, with 14 employees, quickly replicated 100 valves with 3D printing, as reported by Medscape Medical News.
"[T]he hospital tested them and told us they worked," Fracassi said, and they delivered 100 of them at no cost to the hospital.
In a post in a private Facebook group, an advanced practice nurse at a hospital in Washington state (name withheld) who kept suiting up to tend to intravenous pumps, tossing goggles and masks each time, writes that she suggested moving the pumps into the hallway and running tubing extensions to the patient.
"The hospital implemented this and it will save thousands of valuable PPE sets," she writes.
A Warning Against Multiple People on One Ventilator
Some have proposed sharing one ventilator for more than one patient, but Lewis Kaplan, MD, president of the Society of Critical Care Medicine (SCCM), told Medscape Medical News, "There are a host of problems and they are not minor."
Charlene Babcock, MD, an emergency medicine physician in Detroit, Michigan demonstrates in a YouTube video how to adapt one ventilator for multiple patients and the video has been widely shared.
She emphasizes that the patients need to be paralyzed for this to work.
The idea was previously detailed in a study she coauthored in 2006 on using one ventilator for four people simultaneously.
Questions followed in response to the video about potential transmission of bacteria, how this could be done when settings are personalized for patient characteristics, and whether the ventilator can cope with the carbon dioxide eliminated from multiple patients at the same time.
She responded that a filter is placed before the expiration port connection with the T-piece and it's a 1-way circuit. She noted that the tubing is 5 feet from the endotracheal tube.
An anesthetist in eastern Ontario, Alain Gauthier, inspired by Babcock, reports using a similar process for putting more than one person on one ventilator.
Gauthier, who has a PhD in respiratory physiology, believes the system will work, but only with patients who are about the same size, with similar health status and similar lung mechanics, the Ottawa Citizen reports.
Kaplan said one of the dangers with sharing ventilators is that if the gas comes out of the ventilator and gets split, it also must come back to the ventilator and get rejoined.
"Whatever is coming back aerosolized from the lung of one patient will end up mixing in some way. You're talking about very tiny particles," he said.
Kaplan noted that COVID-19 patients could potentially be on ventilators for a long time.
"Therefore, they have the nonzero risk that accrues with each day of developing ventilator-associated infections or ventilator-associated pneumonia and the potential to share from patient to patient on the same ventilator is significant," he said.
Another major problem is that ventilators are calibrated and monitored for individual lungs and to alert providers when something is amiss.
"Once you put multiple people on the same circuit, you lose that. You have no idea. You won't know just by chest wall rise whether one person's lung is getting far too much gas or not enough," Kaplan said.
"Right now, this is not a recommended approach for direct clinical care," he said. "But I think it is a highly recommended area of intense investigation."
Solutions Born of Dire Need
Physicians stress these ideas are born in unprecedented times and are by no means ideal.
An example from the New York Times showed the severity of the PPE shortage.
Faezah A. Bux, MD, an anesthesiologist in Danville, Kentucky, in recent days had to intubate several elderly patients in respiratory distress without the masks or eye gear recommended by the Centers for Disease Control and Prevention.
"There's absolutely no way to protect myself. Not only can I not protect myself, I can't protect my patients," she said.
Masks Locked Up
Workers in Washington state are looking to office supplies to make face shields, according to a report in Bloomberg News.
"We are very close to being out of face shields," Becca Bartles, RN, executive director of infection prevention at Providence St. Joseph Health, told the publication last week.
She said that the 51-hospital system is "probably a couple of days away" from running out.
Providence infection control and quality experts designed a prototype with "marine-grade vinyl, industrial tape, foam and elastic," Bloomberg reports. At Providence headquarters, staff and volunteers put together 500 face shields that were going to a Seattle hospital that night.
National Public Radio reports that some hospitals in Washington state have locked up masks and respirators to protect supply. In a Seattle emergency room, a charge nurse is required to ask a series of questions about need before she can release a mask or piece of equipment.
SCCM's Kaplan acknowledged that "something is better than no mask," noting that is the thought behind the Centers for Disease Control and Prevention's suggestion to use a bandana or scarf as a last resort.
But while bandanas and scarves can be washed, some of the material being fashioned into homemade masks, such as vacuum cleaner bags, can't be — and repetitive use is concerning because of the biologically active material that gathers, he said.
The seal between rigid and nonrigid parts is also very concerning, Kaplan said.
"That can certainly make you feel secure when you are not really secure," he said.
He said finding safe materials for do-it-yourself masks must be done in parallel with seeking out other industries, such as oil businesses, where masks protect from oil droplets, or home and auto stores that sell masks that protect from spray paint. Some of those companies are already donating supplies, he noted, but the demand is unprecedented.
"The rate that these masks are being used is eight- to 10-fold higher than what we ever used before," he said.
Distilleries Making Hand Sanitizer
Distilleries all over the country are using their alcohol to create their own hand sanitizer solutions. Some are packaging it in small bottles, others are asking people to bring their own containers. Many are giving it away for free.
Last week, distilleries got the go-ahead from the the acting administrator of the Alcohol and Tobacco Tax and Trade Bureau to make ethanol-based sanitizer through June 30, bypassing the usual approval process.
The CDC states that effective hand sanitizer must have at least 60% alcohol.
As to the shortage of approved hand sanitizers, the US Food and Drug Administration said, "We will continue to work with manufacturers, compounders, state boards of pharmacy, and the public to increase the supply of alcohol-based hand sanitizer available to Americans."
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