Will surgeries tax Minnesota's supplies to protect caregivers from COVID-19?

Nurses already were nervous about limited supplies of masks and gowns — and the conservation policies to stretch reserves of protective equipment for COVID-19.

That was before hospitals started planning to resume elective surgeries that nurses fear might strain those supplies even more.

"My kids know by this point that when Mom's off of work, they stay completely away from me until I shower and scrub myself down — before they can even come close to me," said Brittany Livaccari, an emergency room nurse at United Hospital in St. Paul. "I feel so much concern for my co-workers who have very young children and who are really afraid of bringing this home to them, or have immunocompromised family members. It's horrifying."

With hospitals resuming elective surgeries as early as Monday, tensions have arisen between nurses and their hospitals over the use of personal protective equipment amid the COVID-19 pandemic.

Hospitals say they're carefully monitoring the situation and prioritizing worker safety but need to resume the elective surgeries and procedures that were postponed as of March 23.

The governor's order calls on facilities that use personal protective equipment (PPE) and ventilators to develop and implement plans that ensure safety for workers and patients and prioritize which surgeries should come back first. In recent weeks, the state has built up its stockpile of masks, gloves and face shields, including smaller increases of gowns and N95 respirators.

The state's critical care supply warehouse can be drawn on by hospitals when their own reserves run low. Previously, hospitals couldn't tap the supply warehouse until they had only zero to three days' worth of equipment. Now, hospitals can tap the warehouse if they have four to seven days' worth of a supply, said Alice Roberts-Davis, commissioner of the state Department of Administration.

"We have gained a tiny bit of breathing room," Roberts-Davis said during a Wednesday call with reporters.

At M Health Fairview Southdale, nurse Ericka Larson Helling looks at messages from administrators and still sees plenty of supplies shaded red. She's not precisely sure what the color means in terms of supply counts but sees problems with access to gowns and N95 masks, which filter out 95% of airborne particles.

Before COVID-19, caregivers would put on a disposable gown when entering the room of an infectious disease patient and throw it away when leaving, she said. Now, nurses are issued a cloth gown at the beginning of each shift and return it at day's end for laundering. Replacements are available if the gown gets soiled.

N95 respirator masks used to be single-use devices. Now, nurses wear their mask for an eight-hour shift and then place it in a paper bag until it's used again five days later.

"Current facility policies on the use of PPE, including its reuse, are endangering nurses, other health care providers and patients," Mary Turner, president of the Minnesota Nurses Association, wrote in a letter to state officials this week.

M Health Fairview says its approach to masks and gowns fits with contingency recommendations from the federal Centers for Disease Control and Prevention as well as practices adopted by other hospitals.

Hennepin Healthcare was similarly following federal guidance when it ran short of N95 masks and used a backup supply that was technically beyond its shelf life. Some received new elastic, prompting a complaint by nurses to the U.S. Occupational Safety and Health Administration that they were being required to wear expired masks that didn't fit properly.

Expanded coronavirus testing is helping hospitals conserve supplies by knowing when and where to use the most protective equipment, said Dr. Peter Kelly, executive medical director of surgery and vice president of perioperative services for M Health Fairview. Reuse strategies are being developed in conjunction with manufacturers and infection control experts, he said, and include U-V technology for N95 masks.

Kelly said he understood the concern of nurses and front-line caregivers. But about 5,000 surgeries were postponed over a six-week period, and some of those patients will suffer if they don't get treatment soon.

"There's a lot of patients out there that have cancer and have other diseases that really need to be taken care of, and that we have basically put on the shelf," Kelly said in an interview. He added by e-mail: "All decisions about elective surgeries will be made after ensuring we have the proper PPE necessary to treat all the patients in our system."

It's a similar approach at Allina Health, where officials will dial up or down the volume of elective surgeries depending on PPE supplies, said Lisa Shannon, the chief operating officer.

Allina has had better luck procuring supplies in recent weeks, Shannon said, so with most things there's no risk of an immediate shortage. There's a 30-day supply of almost everything, she said, and N95 mask reserves are growing. Allina is working to give caregivers better information about equipment totals.

"We will continue to work on ways that we can communicate so that our staff knows, we will turn the dial down [on elective surgeries] if our PPE supplies become less available," Shannon said.

Information can't come soon enough for Livaccari, the ER nurse at United, which is one of Allina's largest hospitals. For weeks, Livaccari has said that she and colleagues haven't received complete information about supply counts.

They also reuse N95 masks, Livaccari said, and are stapling together elastic bands on respirators when they become loose. Trouble is, the masks haven't been fit-tested, she said, for use after an eight-hour shift or repair with a stapler.

At United, nurses haven't had trouble finding gowns, Livaccari said, but say the garments don't completely cover their scrubs. So nurses for weeks have been pushing for access to scrubs that are issued and laundered by the hospital.

Technically, scrubs aren't considered protective in the same way as masks, said Sara Criger, United Hospital president.

Believing they offer protection could create a false sense of security, she added. The hospital instead gives workers pillowcases in which they can place their workday clothes and put them immediately in the wash back home.

N95 masks with broken straps are taken out of use, Allina says, but aren't being discarded "out of an abundance of caution on preserving supplies." United Hospital is piloting a training program in which peers train, coach and mentor other peers about correct and safe mask and PPE use, reuse and conservation.

Criger said she is concerned about keeping nurses feeling safe and protected: "They need to feel comfortable and confident with what they have so they can be the best for patients, who are also scared and anxious when they come to the hospital."