Alex LT Clos1,2, Ashley P Cohen, BSN1,2, Lindsay E Edwards1,2, Allison HH Martin, MSc1,2, Tazim S Merchant1,3, Tricia Rae Pendergrast1,3, Matthew A Siegel1,4, Roger S Smith1,3
1 Contributed equally to this manuscript
2 Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA
3 Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
4 University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA
Correspondence concerning this article and requests for reprints should be addressed to Allison HH Martin (allison.martin@my.rfums.org)
ABSTRACT
Purpose: COVID-19 created a critical shortage of medical supplies such as personal protective equipment (PPE). A group of medical students in Chicago formed GetMePPE Chicago to assist frontline healthcare workers overcome the PPE shortage locally. PPE was obtained through several avenues: solicitation of donations from local businesses, fundraising efforts to purchase, manufacture by local craftsmen and engineers, and partnerships with local and national groups. An allocation strategy was designed to ensure efficient, equitable distribution of PPE.
Methods: The allocation framework utilized to distribute PPE was developed with clinical bioethicists and intended to address inequity and inefficiency in PPE distribution between healthcare institutions across Chicago. This framework places institutions into tiers by acuity of care delivered. Each facility is then proactively contacted and needs for PPE are assessed to prioritize within tiers by COVID+ patient burden, facility resources, risk of patient population due to comorbidities, and inherent risk for community transmission. Statistical analysis was performed to better understand the trends in PPE distribution across Chicago.
Results: The distribution model led to the successful donation of over 100,000 units of PPE to areas of greatest need in Chicago. Spearmen correlations demonstrated that it prioritized non-white and/or low-income neighborhoods in Chicago. It was not successful in prioritization of Hispanic communities.
Conclusion: This framework is a scalable, efficient means of categorizing healthcare facilities for ethical and equitable distribution of PPE donations. It may be applied by similar organizations to address ongoing PPE shortages during this pandemic or adapted for use in other circumstances requiring the distribution of scarce resources in times of supply chain disruption.
BACKGROUND
SARS-COV2 is the virus responsible for COVID-19, a viral syndrome associated with fever, cough, and malaise. On March 11th, 2020, the WHO declared the viral outbreak a pandemic, with over 100,000 cases reported globally [1,2]. The first case of community spread in Illinois was documented March 8th, 2020 in Cook County; this region became a hotbed of community transmission over the following months [3].
N95 respirator mask consumption in hospitals rose dramatically, resulting in well-documented shortages [4,5]. Despite radical conservation protocols, the shortage of N95s worsened in Illinois throughout the spring of 2020. Supply chain deficiencies spread to other types of personal protective equipment (PPE) such as eye protection, hospital gowns, hand sanitizer and surface disinfectant.
While government agencies were primarily charged with supporting healthcare institutions with the growing COVID-19 patient burden, numerous nongovernmental and charity organizations also took up this cause on a regional, local, and national scale.
According to Emmanuel and colleagues, strategies for the distribution of scarce resources in pandemics are rooted in four specific values: (i) ensuring people are treated equally, (ii) prioritizing those who are worst off, (iii) creating the greatest benefit for society, and (iv) supporting instrumental value (e.g., physicians in a pandemic) [6]. Random distribution, waitlist creation, prioritizing those who will benefit most in the shortest period of time, and considering criteria such as prognosis and reciprocity (i.e., those who contributed most to society should be favored), among others, are all possible applications of these criteria [7-9]. Emerson and colleagues have readily applied the aforementioned values to the allocation of ventilators. They recommend prioritizing ventilatory interventions to save younger patients with more life-years (to maximize benefit), research participants, and physicians when other factors are equal, and to resort to random selection in patients with a similar prognosis. However, applying these principles to PPE resource allocation has not been well studied.
METHODS
On March 16, 2020, recognizing the danger that PPE shortages posed to healthcare workers, students from Chicago-area medical schools formed a joint venture named GetMePPE Chicago (GMPC, getmeppechicago.org). The mission of GMPC was to assist frontline healthcare workers overcome PPE shortages. GMPC initiated a crowdfunding effort and organized volunteers who called to solicit PPE donations from local businesses. As GMPC grew, efforts to source PPE diversified. Do-it-yourself (DIY) efforts manufactured PPE items unavailable for purchase, while partnerships with local and national organizations facilitated large scale distribution of additional items. PPE was warehoused and inventoried at a leadership team member’s residence.
Here, the authors elaborate the development of GMPC’s resource allocation strategy and evaluate how the system functioned to equitably meet PPE needs, effectively operationalizing the values guiding ethical distribution of scarce resources articulated by others [6].
Allocation Strategy
GMPC developed a framework for allocating scarce resources during a pandemic. It is designed to maximize benefits by providing resources to where they would do the greatest good. Other considerations included prioritizing institutions that were the worst off, and prioritizing care for individuals instrumental to the pandemic response or the maintenance of critical infrastructure. [6] In the context of PPE allocation, the value of prioritizing the worst off directly aligns with the maximization of benefits in essentially all cases, as supporting the facility with the highest COVID-19 burden maximally reduces transmission. These guiding values are detailed in Table 1.
Hospitals operating emergency departments, intensive care units, and dedicated COVID-19 units needed the greatest quantity of PPE, and were prioritized for support. Focusing on institutions heavily affected by COVID-19 maximizes the benefits that PPE donations provide by slowing community transmission, while also prioritizing healthcare workers instrumental to the pandemic response.
Identifying Needs and Establishing Contact
After developing an allocation strategy, the next task was prioritizing allocation among the more than 20 operational hospital facilities in the Chicago area [10]. GMPC targeted distribution to facilities with the fewest baseline resources and serving populations at highest risk for community transmission (Figures 1A and 1B). Accordingly, the allocation framework prioritizes communities that are historically underserved. This was driven by the assumption that the systemic inequities underlying past and present discrimination (poverty, race, immigration status, disability, substance use, age) would persist, and further restrict access to PPE. Individual facilities’ PPE use decisions, including stockpiling or reuse strategy, were uncontrollable. Likewise, GMPC could not control redundant or inefficient allocation strategies employed by similar PPE donation groups. As such, neither of these factored into allocation determinations. GMPC remained consistent in pursuing needs-based allocations per the established framework.
The supply and demand for various PPE items was dynamic, with shortages arising unpredictably across Chicago. The data needed to make appropriate allocation decisions was obtained from each facility daily using an online questionnaire (Figure 1C). The questionnaire, called the “PPE Needs Assessment,” stratified PPE supply as ‘Dire: <48 hours supply remaining’, ‘High: <1 week supply’, ‘Medium: 1-2 weeks supply’, or ‘Low: >2 weeks supply’. These values were determined independently for each type of PPE item in use at each facility (N95 respirators, isolation gowns, face shields, surgical masks, etc.).
Metrics such as number of licensed beds, number of staff, COVID-19 patients, and ICU capacity were considered to objectify the assessment of each facility’s COVID-19 burden. Ancillary information like PPE conservation, reuse, and re-sterilization procedures enabled GMPC to appreciate the epidemiologic impact of PPE donations to a given facility. For example, 100 N95 respirators might provide complete coverage in Facility A for one week, but provide complete coverage in Facility B for only two days. For facilities similarly impacted by COVID-19, GMPC would strive to cover one facility fully instead of two facilities incompletely. This increases the chance of slowing disease transmission and maximizes benefit [11-13].
All information in the questionnaire was gathered daily and shared via spreadsheet with leadership members. Once completed, team members responsible for each facility proposed a daily donation based on these metrics; proposals were shared and voted on via Slack, a web-based communication platform. Proposals were compared for volume and acuity, and decided based on PPE inventory. Donation allocation numbers were most closely related to the number of clinical staff and the number of licensed facility beds, when supply allowed. The proposed donations were posted to a dedicated Slack channel, where discussions were held and majority vote signified approval. Discrepancies triggered further discussion and re-vote. Once approved, donations were packaged and sent out the same day, utilizing a network of volunteer drivers. Operational logistics, strategy, and difficult donation proposals were discussed in daily virtual meetings.
Responsible Choices for Distribution
Incoming PPE was immediately allocated for distribution to hospitals, leaving little to no inventory held longer than 48 hours. As PPE supply chains were re-established and shortages slowed, GMPC leadership was faced with the decision of whether to stockpile excess PPE. The rapid distribution of the acquired PPE could be maintained only if new sources of demand were identified.
A unanimous vote affirmed that the most ethical approach was to expand scope beyond acute care hospitals in Cook County, and maintain rapid distribution to these newly identified facilities. The GMPC leadership team concluded that it is more ethical to maximize benefits today, rather than deferring potential benefits by stockpiling PPE for an uncertain future. Additionally, actions taken in the short term may mitigate the timing and intensity of future needs. Although the medical ethics literature was not consulted for this decision, the GMPC team felt that the most ethical approach was to provide PPE to presently high-need organizations. Doing so considers both the certainty of need and the degree of benefit, while potentially mitigating the timing and intensity of future needs.
Acuity Determinations
By summer, over 50% of Illinois’ total COVID-19 mortality was occurring in nursing homes and long-term care facilities [14]. Nursing homes were also unlikely to be able to compete financially with hospitals to purchase PPE. On the other hand, needs were simultaneously identified at acute care hospitals beyond Cook County. With the resolution to seek additional PPE recipients, GMPC needed to decide whether to expand outreach to acute care facilities beyond the county boundary or begin serving lower acuity types of healthcare facilities within Cook County. GMPC formalized “tiers” of healthcare facility acuity (Figure 1A), which like the allocation decision tree, might guide the efficient and equitable approach to expanding the scope of resource distribution.
Different types of facilities were assigned to one of five tiers based on their role in the pandemic response, epidemiologic risk, and potential impact on viral transmission. Each tier was stratified using factors similar to those considered for the allocation decision tree (Figures 1B and 1C), with additional variables specific to that setting: type of facility, staff and/or patient demographics, COVID-19 specific risk factors of the population served, and transmission risk posed to workers. Each variable could serve as a tiebreaker in allocation decisions, and all were considered to frame each facility’s epidemiologic importance to the cumulative COVID-19 burden in Chicago. Allocating resources to lower acuity facilities was a means of shielding higher acuity facilities from increased COVID-19 burden by preventing both intra-facility and community spread. Directly addressing community spread potentially avoided hospitalizations, a means of both maximizing benefits while rewarding healthcare workers instrumental to the pandemic response.
Using the acuity tier framework, GMPC implemented a stepwise approach to expansion. As Cook County was the base of operations and heavily affected by COVID-19, identification of new targets for proactive needs assessment began there. Outreach to facilities within each tier in Cook County would persist until all facilities were contacted. When the respective list of facilities was exhausted, operations were then expanded geographically to equal tiered facilities within neighboring counties. This preceded donations to lower acuity tier facilities within Cook County. Geographic expansion focused on neighboring areas, likely to have an epidemiological impact on Cook County, and on those with high COVID-19 burden according to data obtained from the Illinois Department of Public Health. [14]
Acutely Identified Needs and Breaking the Framework
Although the frameworks identified above (Figure 1) allowed for efficient allocation of donated PPE, GMPC received multiple requests that did not fit neatly into the allocation hierarchies. One example came in late May 2020, following the murder of George Floyd and the subsequent Black Lives Matter protests. Previously, GMPC focused on healthcare workers, apart from cloth mask donation to residents of long-term care facilities. GMPC received requests for PPE from protest organizers and affiliated medical and mutual aid efforts. Leadership met to discuss and vote regarding allocation. Concern over viral spread following Memorial Day Weekend social gatherings combined with incomplete needs assessments among Tier 2 facilities to make GMPC reluctant to immediately fulfill protest-related requests. GMPC waited for one week before donating to the protest efforts. During that week, leadership rapidly completed Tier 2 needs assessments and simultaneously gathered information from community organizations, activists, and mutual aid groups. At the end of that week, Tier 2 needs assessments were completed, and sufficient supplies were on hand. Following a unanimous vote, GMPC reached out to offer appropriate PPE to these community organizations. Their needs were prioritized above the established Tier 3 due to the size of the gatherings and implications of COVID-19 transmission, in line with the focus on maximizing benefit. Beyond modifying needs assessment approach, supplying PPE to this non-healthcare audience required in-depth conversations about education and training to ensure that allocation would maximize benefits (i.e., reduce transmission most greatly) and prioritize those worst off.
Purchasing PPE
As a non-healthcare entity, GMPC was cautious not to compete with hospitals and healthcare organizations for the limited PPE on the market. This was an increasing concern as the fundraising efforts came to fruition. As a small organization without contractual obligations to suppliers, GMPC’s purchasing efforts were more agile than larger healthcare facilities. The comprehensive needs assessment infrastructure gave GMPC up-to-date awareness of needs, enabling rapid distribution of purchased PPE.
Following the US Food & Drug Administration’s issuance of an Emergency Use Authorization (EUA), the U.S. market became saturated with KN95 respirators. The leadership team viewed purchasing these masks as a means of bolstering donation offerings while minimizing the effect such a purchase might have on competing organizations.
Items considered for purchase were evaluated for impact on viral transmission, EUA and supply chain implications, current demand, and anticipated future demand. Anticipated demand was based on predictive models and observed trends in other cities (e.g., New York, Los Angeles) where COVID-19 trajectories preceded Chicago. Anecdotally reported changes in supply and demand were analyzed with the help of a local business school, which evaluated PPE market trends in other cities and countries. Purchasing efforts focused predominantly on N95s, KN95s, isolation gowns, and face shields.
What was not available commercially was acquired through partnership with manufacturers. Manufacturers included volunteers sewing cloth masks or assembling plastic gowns, 3D printers and laser cutters making face shields, and industrial factories retooling to produce various items at scale. These manufacturers sought reliable distribution of their products and provided GMPC with a steady supply of some of the most desperately needed items when supply chains had almost completely shut down.
Statistical Analysis
Statistical analyses were performed to understand trends in PPE distribution across Chicago. Data were analyzed using R version 4.0.2. (R Project for Statistical Computing). Shapiro-Wilk tests of variance were used to determine if data were normally distributed [15]. Spearman's rank-order correlations were used to probe the relationship between total units of personal protective equipment donated (as of June 20, 2020) per Chicago zip code, and COVID19 case burden, demographics (% white, % Black, % Hispanic, % Asian) and community characteristics (average household size, mean household income) [16]. These data were defined and obtained from the American Community Household Survey [17]. Correlations were computed including zip codes where zero units of PPE were donated, as decisions both to donate and not to donate were made in line with the framework.
RESULTS
While the epidemiologic impact on viral transmission of GMPC’s resource distribution will be remarked upon elsewhere, the success of the allocation strategy to identify and serve the underserved was assessed retrospectively using publicly available data [17].
To date, GMPC independently raised over $30,000 for the purchase of PPE, and was supplemented by over $70,000 from parallel fundraising efforts. GMPC distributed over 100,000 units of personal protective equipment in Chicago, over 70 percent of which are respiratory protection items (N95, KN95, surgical mask, or cloth mask). Further, GMPC coordinated logistics for the donation of over 300,000 face shields from a national partner to sites across the Midwest, specifically community and rural healthcare institutions in dire need.
Community data from the Illinois Department of Public Health and US Census and American Community Household Survey, was used to evaluate relationships between risk factors for COVID-19 or markers of underserved communities disproportionately affected by COVID-19 and total units of PPE donated [17]. To better understand these trends, statistical analyses of PPE distributions and zip-code level demographic data were performed. With all areas included, total units of PPE donated was positively correlated with percentage Black (rs = 0.44, p = 0.0003) residents and service workers (rs = 0.48, p < 0.0001), average household size (rs = 0.39, p = 0.00127), and negatively correlated with mean household income (rs = -0.55, p <0.0001), percentage white (rs = -0.43, p = 0.0003) and Asian (rs = -0.26, p = 0.035) residents (Table 2).
DISCUSSION AND RECOMMENDATIONS:
The COVID-19 pandemic severely disrupted the global supply chain of personal protective equipment and precipitated shortages. Various grassroots and volunteer organizations responded by sourcing or creating PPE for healthcare workers. Although well intended, these disparate efforts led to inefficient and inequitable distribution that risked exacerbating existing healthcare disparities. GMPC recommends that these organizations perform proactive outreach to facilities to identify needs, and coordinate closely with local, regional, and national groups to form a united front to avoid redundancy and inequity in distribution.
GetMePPE Chicago worked to accomplish these goals by developing a decision-making framework to codify the efficient, equitable allocation of resources in the Chicago area. The framework stratifies PPE donation recipients by available resources, population served, COVID-19 burden, and urgency of need. Executing this framework in an effective and efficient manner required continuous data collection from stakeholders within healthcare facilities. These data were used to inform decisions and resolve conflicts arising from simultaneous PPE requests.
The decision-making framework successfully mitigated the complexity of PPE distribution during the pandemic. Results suggest it succeeded in prioritizing communities disproportionately affected by COVID-19, especially those consisting of a high non-white population, with lower than average household income and those working in service industries. These are communities and neighborhoods where unemployment, systemic racism, and longstanding socioeconomic disparities have affected access to healthcare, partially evidenced by the disproportionate impact of COVID-19 [18]. The framework did not succeed in prioritizing predominantly Hispanic communities, which may reflect a paucity of healthcare facilities operating within these zip codes. Such a lack of healthcare access may partially explain the particularly devastating toll suffered by the Hispanic community of Chicago [19]. As this is the initial analysis of GMPC’s application of the framework, future distribution strategy adjustments will consider the disparity in resources offered to the Hispanic community. GMPC leadership plans to engage community organizers within Chicago's Hispanic community in order to most effectively maximize benefits. Analyses will be repeated at two-month intervals to evaluate the impact of strategy adjustments on distribution data for all communities.
The GMPC framework and recommendations are based on the principles of maximizing benefit, supporting those who are instrumental to the pandemic response, and prioritizing the most vulnerable. It is a functional, scalable model for the equitable and ethical distribution of PPE in times of scarcity that requires only cursory knowledge of the healthcare system and guidance from publicly available information. The framework can be applied to subsequent waves of the COVID-19 pandemic, or to future infectious disease outbreaks that might disrupt medical equipment supply chains.
Data analysis was performed by TRP and RSS.
Disclosures: None.
Acknowledgements:
The authors would like to thank:
Dr. Joshua Hauser and Dr. Erin Talati Paquette, for assistance in developing the framework.
Dr. Graham McMahon and Dr. Mark Sheldon for edits and proofreading.
All the volunteers who work to make GMPC successful.
And GMPC’s partners: Illinois PPE Network, IMPACT4HC, Julian Baumgartner, Fashion Studies Department of Columbia College Chicago, Illinois Masks Now, Angels Wear Gowns, Dremel Illinois, Schlep, Boston Scientific, bKL Architecture, GetUsPPE, Medical Supply Drive, and importantly, the staff of the healthcare institutions served.
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