Discussion

Current COVID-19 PPE requirements increased burdens to WIC workflows including added time, high resource utilization, and excess environmental waste. Sentiments by frontline HCP reinforced these results during the pilot (results from an accompanying voluntary survey by these researchers), indicating a majority strong agreement that PPE increased the time required, burden to HCP, and waste during patient encounters. ^{Reference Stern, Bashaw and Talbot6} These challenges reduce the likelihood of HCP wearing PPE in ambulatory settings when encountering communicable diseases, as seen with frontline HCP at Colorado primary and urgent care clinics where only 4% of HCP exposed to Mpox cases adhered to all recommended PPE. ^{Reference Marshall, Barton and Nichols7}

Notably, the pilot occurred during a period of relatively low community incidence of COVID-19 and influenza, meaning that projections for workflow effects, capacity reductions, PPE waste, and cost would be substantially higher during expected peak periods of illness. These data likely underestimate the true amount of time added, as the mean number of 1.8 donning and doffing cases per patient appears lower than expected for a typical WIC encounter. Process mapping of clinic capacity and logistics are essential to understand how current PPE requirement impacts factor into each touchpoint of clinic, including triage/intake and provider examination.

Transmission-based precautions for suspected or confirmed COVID-19 in the ambulatory setting should be modified to remove the contact requirement of isolation (gown and gloves) given a paucity of data to support its use, limited risk of transmission by non-airborne routes, ability to promptly identify suspected patients and apply source control measures such as recommending patients to wear a mask if symptomatic, and environmental harms. ^{Reference Rabin, Marr and Blumberg8–Reference Rodriguez-Nava, Diekema and Salinas10} This underscores the importance of screening for highly transmissible pathogens and optimizing proper respiratory PPE use rather than inefficient use of resources. In addition, the risk to HCP in ambulatory clinic settings is deemed very low given the short duration of clinic encounters (which would markedly limit environmental contamination with SARS-CoV-2 virus, along with cleaning high touch surfaces between patient encounters) and lack of performance of aerosol-generating procedures in most areas. Some healthcare systems have de-escalated the contact component of COVID-19 PPE guidelines without a noted signal of harm for HCP or patient safety and have benefited from reduced environmental waste and cost. ^{Reference Sutjipto, Aung and Soon11}

These proposed PPE modifications may improve clinic efficiency and decrease burdens to HCP. Successful transitions in healthcare systems would benefit from making PPE easily available to all HCP for voluntary use if desired, though gown and gloves would not be required. Emphasis on patient and HCP masking and the use of standard precautions should continue.

Potential limitations of this study include the assumption that time to don and doff PPE would remain static over time when extrapolating data, though practically HCP would be anticipated to become more adept and faster with experience. A small subset of observations noted improper donning and doffing techniques, such as keeping masks on after leaving the room, which likely shortened the time recorded for PPE. The IP team provided real-time education to correct those gaps. Noncompliance with PPE by a smaller subset of HCP was noted though not formally tracked for this pilot. Possible implementation generalizability limitations of these data involve resource availability at WICs outside this pilot, including underserved areas, which are not uniform and may pose barriers to compliance with current national guidance.

De-escalation of PPE requirements for ambulatory care of patients with suspected or confirmed COVID-19 is worthwhile to pursue to promote safe, efficient, and durable practices. Challenges of scale and practicality must be balanced with risk and resiliency, particularly as the ambulatory care footprint expands. Current COVID-19 PPE guidance merits a change to the contact component given limited benefit both scientifically and operationally, harms of isolation gowns, and opportunity to safely transition to a new standard.