Finding the Value in Personal Protective Equipment for Hospitalized Patients During a Pandemic and Beyond

While all hospitalized patients are admitted using standard precautions, decisions surrounding PPE can be nuanced for even experienced clinicians. Although the CDC does provide guidance for PPE use based on symptoms that correlate with potential for transmission (eg, patients with cough should be placed in at least droplet precautions),¹ guidelines must rely on provider evaluation and interpretation. For instance, three etiologies of cough—pneumococcal pneumonia, RSV bronchiolitis, and pulmonary tuberculosis—would all require different PPE. The clinician must weigh the probabilities of each pathogen and assess the harm of not protecting against certain pathogens in his or her decision.

Amidst the stress and cognitive burdens placed on clinicians, accuracy in PPE decisions is easily deprioritized. Clinicians may not completely consider patient-specific indications for PPE, implications for patients and staff, and supply shortages. Although the CDC and many hospitals have PPE initiation and discontinuation criteria, clinicians may favor educated guesswork and reliance on past experience when guidelines are poorly accessible or poorly searchable. Such individual, nonstandardized decisions likely lead to variability in practice patterns, inaccuracies in PPE decisions, and ultimately waste of PPE resources.

At our institution, the inconveniences, cognitive burden, and perceived benefit of routine PPE interventions have created a system in which PPE is regularly overused. On our hospital medicine wards, we found that PPE was both over-ordered upon admission (eg, contact/droplet precautions ordered for influenza when droplet precautions only would have sufficed) and unnecessarily continued even after children met discontinuation criteria.

On discharge review from our general pediatric ward in 2019, 18% of children discharged with PPE orders no longer met criteria for PPE. Two conditions—community-acquired bacterial pneumonia and skin and soft-tissue infections—accounted for 47% of discharges with unnecessary PPE orders. At an estimated cost of $0.13-$0.53 for droplet precautions per use, $0.69 for contact precautions, and $0.82-$1.22 for both, the absolute cost of continuing PPE without indication could be as high as $61/day per patient when estimating 50 uses per day. This direct cost represents healthcare spending without added value when PPE are not necessary. Furthermore, the additional emotional cost to the patient and family in their hospitalization experience, the cost of clinician time donning and doffing, the environmental cost of PPE waste, and the cost to the limited PPE supply are not considered in these calculations.

During a pandemic characterized by PPE shortages nationwide, allowing missed opportunities for PPE discontinuation to persist is not only wasteful, but inattentive to public health.

For individual clinicians, opportunities exist to improve PPE usage in daily patient care. Clinicians should not overlook PPE decisions; instead they should make it a practice to review PPE orders daily during rounds as they would lab orders. Clinicians and nursing staff should work together to identify PPE discontinuation opportunities, leveraging the electronic medical record when possible. For the benefit of patients and families, clinicians and bedside staff should recognize and assist in managing patient expectations of PPE.