The Latest Pandemic PPE Shortage: Gowns

Sheila Mulrooney Eldred

June 25, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

When Daniel DelCastillo, DMD, takes his disposable gown off after a day of work at his dental office in Miami, he sprays it down with a mixture of water and Pinesol, then carefully wipes it down with a towel. Only after a week or so will he throw it out.

DelCastillo uses an expletive to describe the difficulties getting any type of personal protective equipment (PPE), but some things are harder to come by than others. These days, he can find masks if he's willing to pay inflated prices. Gowns, however? "Gowns are impossible." The best he can do, he says, is stretch out his remaining supply.

Both disposable and reusable isolation gowns are in short supply right now, leading some healthcare workers to wear disposable gowns several times or to opt for white coats, graduation gowns, even trash bags as protection. Organizations that procure PPE for healthcare workers have seen a surge in demand for gowns as the pandemic stretches on and elective surgeries resume in some places.

"When we first started out, we very much knew we'd have issues with masks and respirators," said Val Griffith, MD, an emergency medicine physician and cofounder of GetUsPPE. "It was luck of the draw for a healthcare provider whether or not their hospital had stockpiled them."

Requests for gowns from rose to 255,569 the week of June 8–14, almost double any previous week. "We expected to see these increased numbers," Griffith said, "and we expected there to be a delay." ProjectN95, another organization that popped up to respond to healthcare workers' need for PPE, reports current requests for 333,453 gowns.

At Premier, a healthcare supply-chain company, demand for PPE has surged, according to company president Mike Alkire. In particular, requests for isolation gowns, which Alkire called "essential both for treating COVID-19 patients and resuming elective surgeries," have increased by 500% over historic levels during the pandemic.

Premier estimated that as of June 10, it had met only about 70% of the pandemic-level demand for gowns. It may have been a case of robbing Peter to pay Paul: Increased production of face masks and respirators may have had the unintended consequence of reducing the number of available gowns, inasmuch as the manufacturing process requires some of the same supplies, Alkire said.

The demand for masks likely surfaced first because supplies of N95s were limited even before the pandemic, Griffith said, since respirator masks typically are used much less frequently. Most hospitals, however, keep large backup supplies of gowns and gloves, since they're the most-used types of PPE.

"The concern is we're now eating through the backup supplies of gowns," she said. "Hospital surpluses have been diminished, and now we have an uptick in requests" ― especially now that some nonurgent and elective surgeries are back on the schedule.

"We're not the usual pathway to get gowns and gloves," Griffith said. GetUsPPE "only exists because the supply chain is broken. We only exist because hospitals and healthcare providers cannot get equipment on the normal basis."

Outside of hospitals, some practitioners have struggled with the gown shortage from the beginning.

"It's been a need all along," said Mary Hastings, MD, in St. Louis, Missouri, who has volunteered her time organizing PPE for nursing homes. "For whatever reason, there was a huge emphasis on masks and N95s at first. But in the meantime, the employees [at nursing homes] were getting sick. So gowns are huge."

How Gowns Help

In normal times, isolation gowns are used for interacting with patients who have contact-driven infections, such as C difficile, antibiotic-resistant infections, and some respiratory infections, Griffith said. That accounted for maybe 10% of patients in the ICU and approximately 5% in the emergency department, she said.

COVID-19 spreads via droplets that people touch and then transfer to mucous membranes. Gowns can reduce transmission by keeping those droplets off clothing that healthcare workers then touch, according to the Centers for Disease Control and Prevention (CDC). Gowns are particularly important during aerosol-generating procedures, delivery of high-contact care, and anywhere where splashes and sprays are likely, CDC guidelines state.

The CDC also recommends that providers use respiratory protection, eye protection, gown, and gloves when approaching any patient suspected of having COVID-19. "The best approach to containing the virus' spread is to approach every single patient with universal precautions," Griffith said.

It all adds up to healthcare workers wearing more gowns than ever before.

Alternatives and Work-Arounds

For facilities facing PPE shortages, the CDC recommends reusing disposable gowns ― either by the same healthcare provider with multiple COVID-19 patients or different healthcare providers for the same patient ― before resorting to gown substitutes. But neither the CDC nor any other public health authority has issued guidance on how to decontaminate gowns, as they have for masks, Hastings said. She notes that clinicians at one nursing home were reusing gowns by turning them inside out until she advised them not to.

Cloth isolation gowns meant to be laundered and reused are not common in the United States, but hospitals with these gowns may have an advantage if they have laundry facilities big enough to meet the demand.

At most hospitals, however, gown alternatives have proliferated. They run the gamut from rarely used white coats to the trash bags that desperate nurses at Mount Sinai West in New York City donned in March.

Commencement gowns, worn backwards, have a high neckline that helps protect the critical zones of chest, torso, waist, and forearms, said Nathaniel Moore, CPA and founder of the nonprofit Gowns4Good. This also makes donning and doffing simple: With the zipper in back, it's easy to invert and roll up without contaminating yourself, he says. The organization is seeking donations from recent graduates. It has collected and redistributed 13,000 donated graduation gowns nationwide and has received almost 100,000 requests.

Hastings has connected the hardest-hit nursing homes in her area with DIY donations of face masks, shields, and hand sanitizer. But gowns, she says, are harder to fashion at home.

Until the gown shortage has been addressed, Griffith says, practitioners can employ other work-arounds. None are ideal.

"There are ways you can get around [needing to use PPE], but it's not optimal patient care," she said. For example, a healthcare worker who just needed to talk to a patient could stand 6 to 10 feet away in the doorway to their room and not touch anything, or they could call the patient on the phone instead of standing next to their bed.

The situation presents an ethical challenge for healthcare workers: "If I don't have optimal PPE, it becomes a question of how much risk am I willing to take," Griffith said. "It's so frustrating and upsetting as an emergency medicine provider to feel that way. We should not have to question our own safety and whether to prioritize that over our patients."

Sheila Eldred is a freelance health journalist in Minneapolis. Find her on Twitter @MilepostMedia.

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