Reusable Health Care Textiles for Use in Personal Protective Equipment: Proceedings of a Workshop (2024)
Chapter: 9 Closing and Possible Paths Forward
9
Closing and Possible Paths Forward
The workshop closed with remarks from Jayaraman and from a leader of the sponsoring organization.
CONSIDERING PATHS FORWARD IN EXPLORING REUSABLE HCTS
Jayaraman highlighted key points from the workshop, including potential approaches to increase the adoption of reusable personal protective equipment (PPE) (see Box 9-1), and discussed possible paths forward in exploring reusable health care textiles (HCTs). He described the need to strike a balance in accounting for numerous factors when considering greater use of reusable HCTs. These factors include economics, environmental effects, and the safety of patients and health care workers (HCWs), which is of paramount concern and entails equitable protection. The One Health paradigm that considers the interconnected health of humans, animals, and the environment is relevant to achieving this balance, Jayaraman noted.
Jayaraman described ensuring the safety of HCWs and patients as paramount within a health care setting, with all other considerations being secondary. He remarked that a systems approach is essential when considering implementation of reusable HCTs. Therefore, efforts to increase the adoption of reusable HCTs should engage HCWs, procurement personnel, executives, and manufacturers and suppliers. A risk-based decision-support framework facilitates the exploration of
BOX 9-1
Potential Approaches to Increase the Adoption of Reusable Personal Protective Equipment Identified by Individual Speakersa
Innovation
- By updating manufacturing processes and implementing innovative tracking technology, the reusable health care textile (HCT) industry could increase reusable personal protective equipment (PPE) functionality and improve the tracking accuracy for HCT use life. (Merrow)
- Innovation in reusable HCTs could enable recyclable gowns made from recycled materials, thereby achieving a sustainable circular supply chain. (Merrow, Wintz)
- Increased automation and robotics in the reusable HCT industry could increase manufacturing efficiency and scalability, and decrease prices for reusable products. (Merrow, Wintz)
- Design features that could improve HCW safety and comfort in wearing reusable HCTs include: ease in donning and doffing; ability to fold flat; thermal comfort through passive ventilation or active cooling mineral finishes; integrated antimicrobial properties; electrostatic charge to trap particulates; and detection of leaks, wear, and pathogens. (Thurston, McQuerry, Dunne, Skivington, Morgan)
End-User Engagement
- Soliciting and incorporating end-user feedback into an iterative design process improves the user experience and could decrease resistance to adopting reusable HCTs. (Merrow)
- Soliciting and responding to input from a wide range of health care workers (HCWs) and engaging them in opportunities to sample various reusable PPE designs and participate in the selection process could foster enthusiasm in reusable HCT programs. (Marvel, DeBaun, Holmberg, Townsend)
- Physicians hold influence with hospital leaders, and collective requests for reusable HCT programs from groups of physicians have been successful in some cases. (Overcash)
- The Office of the U.S. Trade Representative is currently conducting engagement efforts with stakeholders to better understand how to support the domestic textile manufacturing base. (Agama)
- Engaging labor unions early in the process of adopting reusable HCTs reinforces a commitment to frontline workers and lowers potential for resistance. (Skivington)
- Champions of reusable HCT programs within health care systems are instrumental in generating openness to program adoption. (Thurston, King)
Cost Reduction
- Reducing the cost of biodegradable materials for PPE and demonstrating the performance of polymers made from renewable sources could drive demand for sustainable products. (Bhat)
- Investment in greater automation in HCT laundering and tracking reduces servicing costs and ensures that PPE retains its protective properties. (Thurston)
- Incentives are needed to encourage health care systems to purchase reusable HCTs. (Merrow, King)
- Underresourced health systems offer lessons in providing safe, effective services while generating less waste; data from such systems are instrumental in demonstrating efficacy of reusable HCT programs. (Thiel, King)
Education
- Product evaluation committees in hospitals and long-term care facilities are a mechanism for educating HCWs about reusable HCTs and generating buy-in for reusable PPE programs. (Falk)
- Canada has a higher rate of reusable HCT adoption than that in the United States; the successful efforts of Canadian commercial laundry facilities to highlight the merits of reusable HCT programs to customers could serve as an example to follow. (Petrovskis)
- National organizations could raise awareness of the economic and environmental benefits of reusable HCTs. (Thurston)
- Consumer education efforts within health care settings about the availability, safety, and benefits of reusable HCTs could increase adoption rates. (Agama, McQuerry, Schenk, Holmberg)
- Raising awareness that reusable gowns increase supply resilience during major health crises could encourage adoption of reusable HCTs. (Thiel)
- The development of best-practice standards could raise awareness of the safety and effectiveness of reusable HCTs. (Thurston)
- Comparing reusable HCTs to the use of reprocessed surgical instruments may facilitate HCW understanding that reusable medical supplies can be safe. (Holmberg)
- Infection evaluation of reusable HCT programs and laundering facility PPE performance testing provides reassurance to HCWs of the safety of these programs. (Holmberg, DeBaun, McCauley)
- Many HCWs and organizations are concerned about environmental sustainability; efforts to raise awareness about the environmental benefits of reusable HCTs could generate enthusiasm for these products. (Schenk, Thiel, King)
Reducing Logistical Barriers
- Addressing the barrier of group purchasing organizations’ support for single-use products could increase purchasing of reusable HCTs. (Overcash)
- Addressing access and availability of appropriate laundering services could encourage widespread reusable HCT programs. (Shirley)
- The availability of disposable gowns alongside reusable HCTs may increase HCW comfort with—and thus, confidence in—a reusable HCT program. (Holmberg)
- An incremental approach to reusable HCT program rollout—which solicits and responds to feedback at each stage of scaling—facilitates problem solving and decreases resistance. (Holmberg)
- Integrating reusable HCTs into the established workflow increases HCW convenience in adhering to HCT protocols. (Morgan)
- Providing gowns in sizes appropriate for current staff members can improve fit and encourage end-user acceptance of the product. (Morgan)
- Federal and state organizations could lead by example by purchasing products that are better for the environment and support U.S. manufacturing. (Merrow)
- Governmental efforts to foster PPE supply chain resilience for future crises and pandemics could bolster adoption of reusable HCTs. (Merrow)
- Legislated incentives for environmentally sustainable practices could foster adoption of reusable PPE. (King)
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a This list is the rapporteurs’ summary of points made by the individual speakers identified, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.
technical, economic, environmental, logistical, regulatory, and education facets of implementing a reusable PPE program. He stated his optimism that adoption of reusable HCTs will increase—particularly given the higher levels of environmental awareness present in the new generation of HCWs—and this effort will contribute toward protecting the safety of people, animals, and the environment.
CLOSING REFLECTIONS
Maryann D’Alessandro, director of the National Personal Protective Technology Laboratory (NPPTL), offered final reflections and outlined next steps. Sponsored by the National Institute for Occupational Safety and Health (NIOSH), the workshop was designed to examine the feasibility and potential benefits of increased use of reusable PPE. The workshop will serve as input for a NIOSH report exploring the increased use of reusable PPE in health care while ensuring the safety and health of HCWs and patients. The NIOSH report will emphasize health care delivery that (1) is conducted in an environmentally sustainable manner, (2) is provided at a potential cost savings, and (3) catalyzes action in the space of reusable PPE. Outlining NPPTL responsibilities, she described conformity assessment goals to address PPE workplace needs. NPPTL is addressing the goal of reducing inhalation hazards through leadership in research, federal standards development, and respirator approval activities. Efforts toward the goals of reducing dermal hazards and reducing injury hazards are less extensive. Although NPPTL has established a robust research
portfolio and participates in consensus standards regarding these goals, the research center does not own the standards and does not certify PPE related to dermal and injury hazard reduction.
D’Alessandro remarked that this workshop catalyzed conversations to identify potential actions in several areas:
- Research in innovative approaches toward understanding PPE performance, such as sensors and improved design for emotional fit;
- Standards development activities to address important standards gaps, such as cleaning efficacy for hospital soils on gowns, procedures for reusable facepieces, and differentiation for the minimum performance properties between reusable and disposable gowns;
- Identification of conformity assessment enhancements to ensure that products continue to conform to the requirements they claim by expanding postmarket activities and quality considerations; and
- Efforts to develop and disseminate communications tools to support health care systems and individuals.
She stated that communication tools should be used before the purchase of reusable gowns, respirators, or other forms of reusable PPE. These tools could facilitate understanding of the exposures being addressed and the options available with possible consideration of a control banding approach based on risk. Recalling the example of respirator stockpiling performed without first determining whether the respirators would fit the intended population, D’Alessandro emphasized that steps should be taken to ensure that reusable PPE is acceptable to end users before purchasing. This workshop identified numerous factors to consider in these determinations.
Benefits and drawbacks are both associated with the use of disposable or reusable gowns in health care, said D’Alessandro (see Box 9-2). Increased use of reusable gowns presents opportunities for enhanced pandemic preparedness, reduced environmental impacts, and potential cost savings in terms of cost per use. However, gowns must provide appropriate barrier resistance and address end-user concerns regarding design and comfort; appropriate laundry services must also be available. D’Alessandro outlined that increasing the use of reusable isolation and surgical gowns in the U.S. health care system will require a multifaceted approach involving research and development, regulatory support, standardization and guidance, investment in education and awareness, and investment in infrastructure through incentives, legislation, and other approaches.
D’Alessandro explained that NIOSH will consider the information presented in the workshop and work to identify (1) actions that can be taken
BOX 9-2
Balancing Benefits and Drawbacks for Both Disposable and Reusable Personal Protective Equipment Identified by Individual Speakersa
Manufacturing
- Manufacturing reusable health care textiles (HCTs) is more labor-intensive—and therefore more expensive—than disposable personal protective equipment (PPE). (Merrow)
- Reusable HCT manufacturers contend with substantial compliance expenses related to performance testing and U.S. Food and Drug Administration fees. (Stull)
- Manufacturing of disposable PPE requires less workforce training than reusable HCTs and can therefore be scaled more quickly. However, reusable HCT manufacturers demonstrated scaling ability and the capacity to manufacture one million reusable gowns per week during the COVID-19 pandemic. (Merrow)
- Reusable HCTs are more labor-intensive to manufacture than disposable PPE, and the per-unit price and durability of reusable HCTs are higher than those of single-use products. These factors lend themselves to an iterative design process and the incorporation of user-desired design and technology features in reusable HCTs that is not feasible for disposable products. (Merrow, Dunne, King)
- Innovation could enable reusable gowns that feature electrostatic charge to trap particulates, monitor risk of heat stress, include fans or passive ventilation, and detect leaks, wear, and pathogens; such features are cost-prohibitive for disposable products. (Dunne)
- Domestic reusable HCT manufacturing provides economic support to U.S. communities and labor protections to workers that overseas disposable PPE manufacturing does not. (Merrow, Thiel, King)
- The disposable PPE supply chain is more vulnerable to disruption than the more circular reusable PPE supply chain. (Thurston, Agama)
Purchasing
- The range of sizes, shapes, and styles of disposable gowns is currently wider than for reusables. (Falk)
- Compared with disposable HCTs, reusable HCTs require larger upfront investment but yield accrued cost savings over time. (Merrow, Overcash, Agama, Holmberg)
Storage and Use
- Packaged disposable gowns are more compact than their reusable counterparts, requiring less space for storage. (Falk, Merrow, Morgan, Thurston, Thiel, McCauley)
- Reusable HCT wash cycles must be accurately tracked to ensure that PPE continues to offer adequate protection. (Falk, Shirley)
- Advancements in laundering technology have decreased the water, electricity, and gas required to appropriately process reusable HCTs. (Remillong)
- The risk of hospital-acquired infections (HAIs) associated with reusable HCTs is low, and transitioning from disposable to reusable HCTs does not increase HAIs. (Overcash, Holmberg)
- Reusable HCT programs enable recovery of inadvertently discarded medical equipment and personal items. (Overcash)
- The environmental benefits of reusable HCTs over disposable HCTs include decreases in greenhouse gas emissions, solid waste, and water and energy consumption. (Overcash, Marvel, Bhat, Holmberg)
- Disposable PPE entails a linear supply chain that depletes natural resources more quickly than reusable HCTs. (Bhat)
- The concern that reusable gowns are more uncomfortable to wear is not always based on experience; research suggests that HCWs prefer the comfort of reusable gowns to disposable ones. (Overcash, Holmberg)
- The term “reusable” may foster a misconception that gowns can safely be reused without first being processed. (Morgan)
- Laundering services for reusable HCTs are not available in all parts of the United States. (Shirley)
- Reusable gowns outperform disposable gowns for liquid barrier protection and crosswise tensile strength. (McQuerry, Holmberg)
- Reusable gowns can be more challenging to don and doff than disposable gowns. (Holmberg)
- Reusable gowns featuring tie closures at the neck are more difficult to doff than disposable gowns with breakaway closures, potentially heightening contamination risk. (Morgan)
- A common misconception that plastic always provides better barrier protection than reusable products can make HCWs vulnerable to risk exposure while wearing disposable PPE that does not perform as well as reusable PPE. (Wintz, Daley, Skivington, DeBaun, Holmberg)
End of Life
- The U.S. health care system generates 15,000 tons of waste from disposable PPE each day. (Agama)
- Radio-frequency identification tracking of reusable HCT wash cycles increases accuracy of use life monitoring, decreases labor requirements, and enables location tracking. (Remillong, Thurston)
- Disposable gowns are often unnecessarily treated as biohazardous waste, which involves greater cost and resource expenditures for transportation and disposal than general waste. (Marvel, Gibbs, Wright)
- Biodegradable, plant-based polymers are being developed that would enable a cradle-to-cradle reusable HCT supply chain in which medical gowns at the end of life cycle would be returned to raw material and re-manufactured into PPE. (Bhat, Dawson)
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a This list is the rapporteurs’ summary of points made by the individual speakers identified, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.
now, (2) actions that require a 1- to 3-year time frame, and (3) long-term actions requiring more than 3 years. Long-term actions include research to address gaps identified in this workshop, such as gaps in standards and communication tools to address hazards confronting health care practitioners. By addressing such factors and implementing comprehensive strategies, increased use of reusable isolation and surgical gowns and reusable respirators could lead to benefits for health care providers and the environment. D’Alessandro stated that NIOSH will consider potential partners in this endeavor and seek to leverage the Allegheny Health Network elastomeric respirator case study and the Providence Health System isolation gown case study. She remarked that given that the term “reusable” could potentially generate confusion regarding the requirement that gowns should be appropriately processed between uses, terms such as “environmentally friendly,” “green,” or other descriptors should be considered.
Recalling that 1980s child passenger safety laws requiring children to wear seatbelts spurred change in seatbelt behaviors, D’Alessandro underscored that improved child safety might not have been realized in the absence of legislation. Similarly, the realization of the potential benefits of reusable PPE—such as reduced waste, decreased overall costs, and lowered environmental impact—is unlikely without legislation. NIOSH will work to identify partners to engage in advancing the effort to increase the use of reusable PPE. D’Alessandro closed by extending gratitude to the National Academies of Sciences, Engineering, and Medicine staff, the workshop planning committee, Jayaraman for his leadership in chairing the committee, and all speakers and panelists for their contributions to this effort.
