Sitting in a Washington state government warehouse are more than 30 million N95 masks — enough to provide every one of the state's health care workers nearly 100 masks each.
They're sitting there even though nearly all of the state's hospitals are reusing their N95s or otherwise conserving supply, as the nation faces a looming shortage and Washington's COVID-19 cases spike to the highest levels in the pandemic.
Does the stockpile represent careful planning by state officials for this surge, or a missed opportunity to provide about $90 million of needed masks?
Some in the industry support the state's reserves, but others suggest the stockpile has grown because the masks are too large for a mostly female health care workforce. And some providers have been unable to obtain them because the ordering process is a bureaucratic maze.
Nearly all of the state's N95s are a model unfamiliar to hospitals, developed during the pandemic by a Chinese auto manufacturer.
Since April, state officials have maintained strict qualifications on who can receive the free N95s, and have recently said they are intentionally maintaining an emergency supply.
Without N95s, providers struggle to follow workplace safety laws and employees risk their own health while caring for patients.
"I have referred to the stockpile multiple times as a unicorn," said John Ficker, executive director of the Adult Family Home Council, which represents more than 3,000 long-term care facilities. "I haven't talked to anybody who can show me how to actually get access to it."
Building a stockpile
In the spring, as the first coronavirus wave blazed through Washington, Gov. Jay Inslee's administration launched a frantic effort to find personal protective equipment, awarding no-bid contracts to some companies with little experience manufacturing health care supplies.
Hospitals' normal supply chains had run bare, especially for the N95 respirator mask, the most critical piece of protective equipment for front-line medical staff, and the Strategic National Stockpile failed to quickly fill the gaps.
So far the state has purchased more than $407 million of equipment — including gowns, gloves and sanitizer — and has received some donations and shipments from the national stockpile. About half of the equipment acquired by the state has already been distributed.
N95 masks make up the largest category of spending. Washington has distributed about 6 million N95s to county emergency managers, prisons, dentists, fruit farmers and other groups. More than 80% of the masks, though, remain in an undisclosed warehouse.
Reed Schuler, a senior adviser to Gov. Jay Inslee, said the state did not make a "determination to hold back a large level of inventory." Instead, he said, the mask stockpile reflected the small number of "qualified requests received" compared to the large number of respirators ordered. The state has viewed its supply as an "emergency backstop," he said.
State guidelines for distributing N95s prioritize organizations based on their level of interaction with COVID-19 patients and their remaining supplies. If a hospital has less than a two-week stock of masks, they may qualify for an emergency batch.
But not all facilities receive top priority. Long-term care homes, for instance, only qualify if they have active COVID cases and their PPE supplies are also nearly depleted.
Under these strict controls, the state has received so few orders that it has been able to supply 95% of the N95s requested by high-priority facilities like hospitals over the last three months, Schuler said.
Almost all of the state's hospitals are operating under a "contingency" status, in which they have to conserve N95 supplies, said Cassie Sauer, president of the Washington State Hospital Association. That could mean workers wearing the same mask for repeated close-contact encounters with several different patients.
Instead of leaning on the state, hospitals have scraped by ordering masks from their existing suppliers. The international supply of N95s has improved since the spring, but hospitals are warily watching the market, Sauer said.
If China or India experience a surge in cases, supply could be significantly constrained, she said, because those countries are home to a bulk of the mask manufacturers.
"We would love to partner with the state to figure out how to get the masks that the hospitals want, to get out to hospitals for the fall surge," Sauer said.
Others are cautioning against releasing the stockpile. Holding back some masks could prevent a repeat of the spring, when health care providers didn't have enough protective equipment to see patients, said Bracken Killpack, executive director at the Washington State Dental Association.
"It's not just hoarding for the sake of hoarding," said Killpack, who has attended discussions on the subject convened by the governor. "We don't want to necessarily dip into that unless things get really bad on the market."
This summer the state developed a "staging model" to determine how much personal protective equipment it should keep on hand, said Karina Shagren, spokesperson for the Military Department. It is based on the level of cases, how quickly providers are using equipment, and the status of the market.
In October Washington was prepared to provide about half the personal protective equipment needed by high-priority health care workers for roughly two months, she said. That equates to 28.4 million N95 masks on hand.
Even if the state opened the spigot, it's not clear if hospitals would take its N95s.
Washington's stockpile of N95s is almost entirely made up of masks made by BYD, a Chinese automotive conglomerate that converted some of its production lines from car interiors to medical supplies during the pandemic. Washington state agreed to pay BYD nearly $100 million.
But in recent months, the state sent samples of BYD's N95s to some hospitals and received mixed feedback, Shagren said. Some testers found samples didn't fit consistently, especially for smaller faces, which is an issue in a health care workforce made up primarily of women.
Whether or not the samples worked, a provider could be hesitant to adopt a new model, experts say. Hospitals — especially large ones — have established brands, and switching would require an investment in time-consuming training and fitting.
"If you've been fit to one respirator you're not necessarily enthused about switching to a different respirator," said Anne Miller, executive director at Project N95, a nonprofit that sources masks for health care providers. "It's like when you buy a shoe. All the different brands fit differently. It's the number one reason people return product to us."
Ideally, the state would have surveyed hospitals to learn their needs before ordering, Miller said, but that was impractical during the desperate buying in the spring, when the Department of Enterprise Services, the state agency in charge of procurement, placed most of the mask orders.
"I do give them grace," said Sauer, the hospital association president. "It was a crazy, hypercompetitive supply chain, and people were buying things sight-unseen."
Fitting an N95 mask properly is crucial to filtering out viral particles, and each brand of mask comes with specific instructions. The BYD masks are made of a pliable fabric and come out of the box folded in half, while many hospitals have long used masks made by U.S.-based 3M, which have molded, round facepieces.
Diane Whittick, a nurse in charge of infection prevention and employee health at Pullman Regional Hospital in southeast Washington, said she has learned through trial and error how to fit the BYD masks. Her hospital has about 20,000 from the state stockpile.
"I wear one myself and I like it," she said.
Pullman, a 25-bed hospital, didn't often use N95s before the pandemic, so most employees had never been fit to a particular brand. Whittick echoed what some other hospitals have found — that the BYD masks don't fit people with smaller faces as well as other models.
"They're very user-specific," she said about the fit of N95s. "It's also greatly dependent on the user's education on how to get them on properly."
The state hired an independent firm to conduct a fit-test on the BYD N95s, and found that out of 12 people tested, 10 were able to fit them properly.
"Bottom line, overall testing shows these fit at an acceptable rate," said Linda Kent, a state spokesperson.
BYD spokesperson Frank Girardot said training is key: "If there's a particular hospital that needs training, we're happy to set them up."
Dentists have had a positive response to the BYD masks, said Killpack from the dental association. This summer his group arranged for distribution of 340,000 of the state's masks to dental offices.
A new marketplace?
For other health care providers who have tried to get state supplies, the ordering process has proved clunky.
Instructions have been inconsistent, said Ficker from the Adult Family Home Council. Until two weeks ago his members had been told by state officials to place requests with their county health departments, but those orders weren't consistently being fulfilled, he said.
According to the Washington State Emergency Operations Center, health care providers are supposed to place orders with their local emergency management agencies, which then request and receive the equipment from the state. Usually, the state ships emergency orders within 12 hours, said Shagren, the Military Department spokesperson.
Hospitals are facing some of the same issues with the ordering process, and the hospital association has been advocating for the state to eliminate the middleman in the process, said Sauer.
"We would like for hospitals to be able to directly order from the state, and order the specific models they want, rather than going through the current steps," she said.
But state officials have resisted. Some counties buy their own protective equipment and may be able to fulfill orders without tapping the state stockpile. Also, the state "could not handle the volume of resource requests coming directly from statewide customers," Shagren said.
As the state's N95 stockpile continues to grow, officials are exploring ways to distribute more than just an emergency supply. In addition to the BYD masks, the state expects more than 1 million 3M masks in the coming months. One new option is under consideration, said Schuler, the governor's adviser: reselling the masks at cost to Washington providers.
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