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One letter and two numbers have never meant so much to so many, in so short a time. That’s because the letter and numbers are N95. Why is this item of personal protection equipment (PPE) so essential? What is the story behind PPE supplies? Learn about the complexities of the supply chain; how Kaiser Permanente is sourcing and managing PPE during this critical time; and what KPSC is doing to ensure that our future PPE needs are met. This interesting article take a deep dive into this important topic ^[2].

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One letter and two numbers have never meant so much to so many, in so short a time. That’s because the letter and numbers are N95.

An N95 respirator is a personal protective device that covers the nose and mouth and filters out at least 95% of particles in the air, including large and small particles and droplets. When properly fitted and worn, almost all of the air is directed through the filter media.

“These N-95 respirators, along with gloves, isolation gowns, and goggles or face shields, compose the Personal Protection Equipment set that health care professionals must wear when interacting with patients suspected or confirmed to have COVID-19, “ said Annie Russell, RN, chief operating officer, Southern California Permanente Medical Group.

Under “normal” health care circumstances, Kaiser Permanente’s supply of this PPE would be fine; however, given the impact of the COVID-19 pandemic, we’re working in a whole new operating environment.

What happened to the supplies?
The United States supply of PPE are primarily produced in China, where the coronavirus outbreak first occurred. China manufacturing was severely impacted by the outbreak which reduced exports to the U.S. during its epidemic. And, our nation’s Strategic National Stockpile, which is supposed to provide masks and other PPE during the times that we’re currently in, reportedly disbursed some 85 million N95 respirators during the 2009 swine flu pandemic, along with other masks – and never adequately restocked that inventory. At the beginning of the coronavirus spread, the Stockpile had only about 12 million of the estimated 3.5 billion N95 masks the federal government assessed the nation’s health care system would need.

With the coronavirus advancing from an epidemic to a worldwide pandemic, there’s been an unprecedented increase in worldwide demand for N95s and other PPE. Vendors have placed client supply requests on allocation. This means instead of receiving 100% of what is ordered, KP may only receive 40% of its request. This scarcity of supply is the main reason for urgent calls for PPE conservation.

“It’s due to our current supply constraints that Kaiser Permanente has to carefully use its PPE to ensure the safety of its members, patients, and the KP people who care for them, while strictly managing the allocation and use of these supplies,” said Lesley Wille, RN, SVP and COO, Kaiser Permanente Southern California, Health Plan and Hospitals.

This scarcity of supply is also the reason that the average retail price of an N95 mask which was between $0.50 to $1.50, is now running between from $5.00 to $7.50 each. Buying in bulk – millions at a time – drastically reduces this cost. But it doesn’t reduce the scarcity of the items we need.

That brings us to how we’re acquiring the PPE supplies we need.

Sourcing our PPE
Kaiser Permanente’s Buy to Pay team is responsible for finding and purchasing the PPE and other supplies used to treat COVID-19 and other patients who come to KP for care. “We have pulled out all stops to replenish our inventory of equipment and supplies through our regular suppliers,” said Motz Feinberg, vice president, Supply Chain. “But, supplies, including N95 masks, surgical/isolation masks, surgical/isolation gowns, exam gloves, PAPR’s/CAPR’s, goggles, and face shields, continue to be in high demand, resulting in a global shortage of these items,” he added.

Buy to Pay, along with other resources within the KP enterprise, has made non-traditional efforts to improve our supply reserves. For example, we:

• Engaged Gap, Inc.to create masks, scrubs, and gowns.
• Arranged with Virgin Group founder Richard Branson for the loan of a 747 to bring supplies from China.
• Partnered with Gallo Wineries to produce hand sanitizer.
• Worked with Target, Staples and Costco for PPE purchases.
• Made supply store runs to purchase masks and other supplies from individual retail stores to bolster our inventories.
• Sourced a manufacturer of isolation gowns who will deliver them at a rate of 1,000 to 2,000 gowns daily.
• Provided surgical draping to a local L.A. garment district manufacturer to produce 400,000 gowns and 500,000 masks.

We also received and welcomed large and small donations of PPE:

• The West Covina Unified School District donated 21,600 masks to Kaiser Permanente Baldwin Park Medical Center from the district’s emergency stockpiles.
• de Toledo High School donated thousands of much-needed N95 masks to Kaiser Permanente Woodland Hills Medical Center from an unused supply procured for wildfire smoke protection in 2019.

PPE Management
In early April, the region instituted PPE patrols in our medical centers to help secure PPE supplies and to educate and coach people on appropriate PPE use. Medical centers are also using PPE calculators to ensure appropriate utilization of PPE by unit.

Mask and PPE guidelines based on droplet precautions developed by public agencies were recently updated. “KP uses these evidence-based safety protocols to ensure the health and well-being of our patients and care teams’ members, while ensuring the right mask is used for the right task,” said Wille. “But, over time, it was recognized that in addition to physical safety, our people wanted greater psychological safety gained through the broader distribution of masks,” she continued.

The KP mask guideline changes resulted in more people receiving masks, including N95 masks, where appropriate. To counterbalance this greater mask usage, KP instituted a mask reprocessing program that would decontaminate used N95s and return them for reuse. The Sterrad system was used. It tripled the life of N95 masks – from one use to three. KP is now moving over to the Battelle system, a more effective N95 reprocessing program that decontaminate up to 20,000 masks at a time. It also increases the life of each masks from 3 uses (under the Sterrad process) to up to 20 uses.

This greatly increases the life of these respirators and reduces impact on the N95 mask inventory.

Next Steps
The good news is that the expected surge we prepared for did not reach expected levels of demand and the surge curve has flattened. The not so good news is that unlike seasonal flu, we are far from the end of this pandemic. We don’t know how long COVID-19 will be with us or what eventual form it will take.

Our preparations for this pandemic have been and will continue to be broad, thorough, and flexible. As we move from surge implementation to re-entry and reactivation of care services, N95 usage is expected to increase.

“We will drive to get the utmost from the ingenuity and commitment of our people, our integrated care delivery system, and our technology to accomplish two objectives. The first is to meet the coronavirus’ challenge. The second, is to deliver high-quality, affordable health care for our members and our communities, while always focused on keeping our people safe,” said Wille.

The continued effective and efficient use of masks and other PPE will play an immensely important role in meeting our mission of delivering high-quality affordable health care. To get the most out of our supply inventory, we must all adhere to our guidelines for prudent, safe mask and PPE management. We have seen a reduction in infection rates because established protocols such as washing hands, social distancing, and wearing masks in public are working. And, we must remain vigilant in these practices.