Audience: These considerations are intended for use by federal, state, and local public health officials; leaders in occupational health services and infection prevention and control programs; and other leaders in healthcare settings who are responsible for developing and implementing policies and procedures for preventing pathogen transmission in healthcare settings.
Purpose: This document offers a series of strategies or options to optimize supplies of facemasks in healthcare settings when there is limited supply. It does not address other aspects of pandemic planning; for those, healthcare facilities can refer to COVID-19 preparedness plans.
Surge capacity refers to the ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the present capacity of a facility. While there are no commonly accepted measurements or triggers to distinguish surge capacity from daily patient care capacity, surge capacity is a useful framework to approach a decreased supply of facemasks during the COVID-19 response. Three general strata have been used to describe surge capacity and can be used to prioritize measures to conserve facemask supplies along the continuum of care.
- Conventional capacity: measures consist of providing patient care without any change in daily contemporary practices. This set of measures, consisting of engineering, administrative, and personal protective equipment (PPE) controls should already be implemented in general infection prevention and control plans in healthcare settings.
- Contingency capacity: measures may change daily standard practices but may not have any significant impact on the care delivered to the patient or the safety of healthcare personnel (HCP). These practices may be used temporarily during periods of expected facemask shortages.
- Crisis capacity: strategies that are not commensurate with U.S. standards of care. These measures, or a combination of these measures, may need to be considered during periods of known facemask shortages.
The following contingency and crisis strategies are based upon these assumptions:
- Facilities understand their facemask inventory and supply chain
- Facilities understand their facemask utilization rate
- Facilities are in communication with local healthcare coalitions, federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) regarding identification of additional supplies.
- Facilities have already implemented other engineering and administrative control measures including:
- Reducing the number of patients going to the hospital or outpatient settings
- Excluding HCP not essential for patient care from entering their care area
- Reducing face-to-face HCP encounters with patients
- Excluding visitors to patients with confirmed or suspected COVID-19
- Cohorting patients and HCP
- Maximizing use of telemedicine
- Facilities have provided HCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care
Use facemasks according to product labeling and local, state, and federal requirements.
- FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures.
- Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.
Selectively cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.
Remove facemasks for visitors in public areas.
Healthcare facilities can consider removing all facemasks from public areas. Facemasks can be available to provide to symptomatic patients upon check in at entry points. All facemasks should be placed in a secure and monitored site. This is especially important in high-traffic areas like emergency departments.
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.
- HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene.
- HCP should leave the patient care area if they need to remove the facemask.
Restrict facemasks to use by HCP, rather than patients for source control.
Have patients with symptoms of respiratory infection use tissues or other barriers to cover their mouth and nose.
Cancel all elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.
Use facemasks beyond the manufacturer-designated shelf life during patient care activities.
If there is no date available on the facemask label or packaging, facilities should contact the manufacturer. The user should visually inspect the product prior to use and, if there are concerns (such as degraded materials or visible tears), discard the product.
Implement limited re-use of facemasks.
Limited re-use of facemasks is the practice of using the same facemask by one HCP for multiple encounters with different patients but removing it after each encounter. As it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that HCP 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.
- HCP should leave 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:
- For 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
- For performing aerosol generating procedures, if respirators are no longer available
When No Facemasks Are Available, Options Include
Exclude HCP at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients.
During severe resource limitations, consider excluding HCP who may be at higher risk for severe illness from COVID-19, such as those of older age, those with chronic medical conditions, or those who may be pregnant, from caring for patients with confirmed or suspected COVID-19 infection.
Designate convalescent HCP for provision of care to known or suspected COVID-19 patients.
It may be possible to designate HCP who have clinically recovered from COVID-19 to preferentially provide care for additional patients with COVID-19. Individuals who have recovered from COVID-19 infection may have developed some protective immunity, but this has not yet been confirmed.
Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask.
Consider use of expedient patient isolation rooms for risk reduction.
Portable fan devices with high-efficiency particulate air (HEPA) filtration that are carefully placed can increase the effective air changes per hour of clean air to the patient room, reducing risk to individuals entering the room without respiratory protection. NIOSH has developed guidance for using portable HEPA filtration systems to create expedient patient isolation rooms. The expedient patient isolation room approach involves establishing a high-ventilation-rate, negative pressure, inner isolation zone that sits within a “clean” larger ventilated zone.
Consider use of ventilated headboards
NIOSH has developed the ventilated headboard that draws exhaled air from a patient in bed into a HEPA filter, decreasing risk of HCP exposure to patient-generated aerosol. This technology consists of lightweight, sturdy, and adjustable aluminum framing with a retractable plastic canopy. The ventilated headboard can be deployed in combination with HEPA fan/filter units to provide surge isolation capacity within a variety of environments, from traditional patient rooms to triage stations, and emergency medical shelters.
HCP use of homemade masks:
In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.