Smallest health providers face biggest problem finding protective gear

Most U.S. hospitals and health systems have, over the pandemic's nine months, stitched together systems and improvisations to acquire masks, gowns, gloves and other personal protective equipment (PPE). Yet many small health-care and social-service settings continue to suffer from shortages they expect to grow worse.

A New Orleans mission for the homeless and addicted finally gave up searching for masks after an offer from a local sports team fizzled, so its staff members rely on disinfecting throughout the day. To conserve gowns, a Boston health center requires nurses to stand without them on the opposite side of plexiglass barriers from most patients who come for coronavirus tests, instructing people how to swab their own noses. And a pediatrician near Fredericksburg, Va., was thrilled when her husband spotted N95 masks at a nearby Lowe's, because her office manager was unable to get more than a list of where to look for supplies from the state.

The scrounging and adapting to scarcity attest to a two-tier reality that has emerged in health workers' ability to obtain the equipment that provides a physical barrier against the virus that has sickened more than 12 million people in the United States and killed at least 255,000.

"No one is talking about this huge inequity of availability," said Megan Ranney, a Providence, R.I., emergency room doctor and Brown University researcher who in March co-founded with several other worried physicians Get Us PPE, a group that collects and distributes donated supplies.

Since it started, Get Us PPE has fulfilled 12% of the requests it has received - a percentage dropping lately as the pandemic intensifies and the eagerness for protective equipment increasingly outstrips donations. Yet requests from hospitals have declined from the thousands in April to fewer than 100 per month more recently, the group's information shows.

This disparity - with small facilities facing PPE shortages to a greater extent than larger ones - has not been recognized in federal officials' recent statements about masks, gloves, goggles and gowns to protect workers especially vulnerable to infection.

In a statement on the pandemic this month, President-elect Joe Biden said the government must provide "frontline health-care workers" with resources "including personal protective equipment that is again in short supply." Nor did Senate Minority Leader Chuck Schumer, D-N.Y., and two other Senate Democrats draw the distinction among facilities last week when they announced a bill that would devote $10 billion to the federal Strategic National Stockpile to increase purchases of N95 masks and other protective supplies.

And in a briefing Thursday by the White House's coronavirus task force, David Sanford, on loan from the Defense Department to the Federal Emergency Management Agency to oversee supplies, said: "Since the late summer, we have grown our personal protective equipment capability 10 times to 15 times" in the stockpile and at FEMA over levels before the pandemic, with four months' worth of N95 masks likely to be needed in the current surge of cases. Sanford did not mention that some places still have trouble getting them.

According to hospital CEOs, state officials, procurement specialists and nonprofits such as Get Us PPE, shortages linger in some small hospitals, especially those in rural areas and the most intense virus hot spots.

Exam gloves are in a global shortage now, and some distributors of other supplies are rationing orders as the pandemic worsens and hospitalizations rise, according to David Gillan, senior vice president for sourcing at Vizient, a company that works with 60% of the nation's hospitals on group purchasing and other performance improvements.

And many hospitals are getting by, using new government-approved protocols for cleaning and reusing N95 masks that were meant to be worn once and discarded.

At York General Hospital, with 25 beds in a small Nebraska town of that name, the hospital board voted to spend nearly $80,000 from its strained budget to buy a robot that disinfects with ultraviolet light to allow N95 masks to be used five times. The cleaning process meets guidelines issued this year by the Centers for Disease Control and Prevention. But Jennifer Uffelman, York General's environmental health safety and security coordinator, said the hospital would "absolutely not" be reusing masks if it had an adequate supply.

"It just makes people feel better when they know they can go to the cupboard and get a new one," Uffelman said. "It just makes people feel better to know we have the stock, we are not worried about shortages. But they know we are doing everything we can. . . . The science has said this is safe."

Still, unlike in the pandemic's early days, York now has a "burn rate calculator" the state handed out to track the use of PPE. And Doug Carlson, Nebraska's chief procurement officer, said that, in late April, he and others created a model in which hospitals and other facilities fill out a form to submit to the state's regional health districts and, once a week, supplies are distributed from a central warehouse.

Such systems were not common at the pandemic's outset, and many hospitals - especially small ones - began relying on folkways they developed.

The Texas Organization of Rural and Community Hospitals had never bought members any type of supplies until its president, John Henderson, started getting frantic daily calls about PPE from many of the state's 157 rural hospitals. "We were at the end of the supply chain, and the supply chain was broken," he said.

TORCH, as the group is known, began developing relationships with vendors and buying and collecting donations of masks, hand sanitizer and other gear. It crammed boxes into its Austin offices and created chains of volunteers to drive, relay-style, across Texas's expanse for deliveries.

Now, as the pandemic surges in West Texas, stressors are reemerging, and gloves are a particular trouble spot, Henderson said. But most of the state's rural hospitals are far closer to having what they need, according to Henderson and several hospital chief executives.

In some corners of the nation, the scrounging has been even more homespun. At Mat-Su Regional Medical Center in Palmer, Alaska, nearly 40 miles north of Anchorage, Thomas Quimby, the emergency department's medical director, became the leader of the hospital's coronavirus task force in March.

"We were short on everything," Quimby recalled. "We went around and bought up all the industrial respirators" the hospital could find and turned to a local distillery to start making hand sanitizer. But it could not find disposable gowns, so the task force came up with the idea of asking a local sewing club to make cloth versions.

One April day, Quimby reached for a gown among several hanging from an IV pole in the emergency department's hallway - and realized that the cream-colored fabric printed with cowboys had been his favorite sheets as a boy. He had known that his mother, Sandy Quimby, a half-hour away in Eagle River, was a pack rat. He had not known that she was part of the Mat-Su Valley Makers, the sewing club.

Over several months, the hospital has phased out community-made gowns because it found a commercial supplier.

"I feel much better about PPE than when the first wave hit," said Anne Zink, Alaska's chief medical officer. Even though Alaska's small population and great distance are hindrances to purchasing, she said, the state has been able to stockpile most of the equipment it needs for the hospitals it supplies.

Gillan, of Vizient, said hospitals in general have become less reliant on federal and state supplies because they have found ways to buy their own.

Despite the current glove shortage, Gillan said, "it's remarkable to see how all of these hospitals are working with the manufacturers and the distributors." And as a backup, he said, Vizient has built up its disaster response so that, when its client hospitals run low on certain PPE, "we address them when we're made aware of those, one hospital at a time."

Such buying power and reserve sources are far different than in the world that Steven Chies inhabits as president of North Cities Health Care, a family-owned company outside Minneapolis that runs two nursing homes and an assisted-living facility.

Large nursing facilities are faring better. But the most recent figures the American Health Care Association, a trade group, submitted to federal health officials on behalf of about 14,000 nursing homes, show that more than 600 were out of N95 masks and that an additional 900 or so had less than a one-week supply. Few are completely without gloves or gowns, the data indicates.

Yet as a small company without much buying clout, Chies said, "it's week-to-week. It's more of a gut punch when you don't get what you ordered, and you're concerned our staff won't have the right equipment. It's just scary at that point." This month, all of the suppliers he relies on have cut back on what they are willing to send, and Chies fears scarcity will grow as coronavirus cases keep setting records.

At the moment, his workers have enough gloves and surgical masks, but supplies of disposable gowns are low, and N95 masks are so scarce that workers use them only when entering the rooms of patients with nebulizers for asthma or other equipment that increases the spread of aerosols.

That sense of relative scarcity is familiar to Genevieve Daftary, director of pediatric medicine at Codman Square Health Center in Boston, in the shadow of the city's large, well-heeled academic medical centers. Protective equipment "is not a budget item for an organization always operating on the margin," she said. "What we've realized is there is no cavalry coming," despite an intense effort by the development staff to raise money for such supplies and find donations.

"We've learned to triage, not just the patients, but triage the PPE," Daftary said.

Of 2,900 face shields on hand, fewer than one-third have padding at the forehead and comfortable elastic at the back. The rest, less expensive, "are the ones giving you a headache" by the end of the day, she said.

Over the months, the health center has altered protocols so that fewer workers need to wear the scarce gowns and masks. Patients arriving for a test with the worst symptoms typical of covid-19, the illness caused by the novel coronavirus, are ushered into an exam room in the clinic's urgent-care section. Just outside the room, a nurse practitioner, physician assistant or doctor - not suited up in protective gear - calls the patient, who picks up a phone on the room's desk, and the medical worker takes the patient history. Only after getting filled in does another staff member wearing protective gear duck inside to see the patient, limiting exposure, while wearing the same gown all day.

People without symptoms, or with mild ones, are directed for tests to an auditorium down the street, where they are seated before tables with laminated instructions, tissues, a swab and a vial. A three-sided plexiglass wall separates them from a clinic staff member, stationed at least six feet away - using a face shield but no mask - to talk them through the test.

In Spotsylvania, Va., Suzanne Richman, a pediatrician in solo practice, began trying to order gowns last winter from McKesson, a major health-care supplier. It was August before a box of 50 arrived, she said.

At one point in the spring, Richman asked her office manager to check with the regional arm of the Virginia Department of Emergency Management, which helps provide PPE. What arrived at Richman's office was a list of companies to check with about supplies - including McKesson, which wasn't sending her any.

But, she said, "we were lucky." One spring day, her husband happened to be at a Lowe's home improvement center and called to say the store had a couple of boxes of N95 masks. "Buy them all," she told him.

The New Orleans Mission has stopped looking for masks. It has three sites and provides shelter. It offers addiction treatment and job training to about 300 people at a time.

"We can't get it, and we can't afford it," David Bottner, the mission's chief executive, said of PPE. New Orleans was an early pandemic hot spot, and Bottner's staff searched hard for protective gear, looking for donors or help from city government. Finally, as the season's first hurricane threatened, the city sent a box of masks. It contained 50, enough to last the staff less than two days.

Now, the mission gives out a mask only when people ask. But cleaning five times a day, with a strict rule about temperature checks before anyone enters, has held coronavirus cases over the months to 17 among clients and two among workers.

In September, a representative of a sports team called, Bottner said. "They had a coach that was setting up a fund to buy PPE to help facilities like ours," Bottner said he was told.

"We said, 'Oh my God, yes, we could use it.' "

He never heard back, he said.