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It took three weeks for Virginia to receive its first shipment of personal protective equipment from Northfield Medical Manufacturing after signing a roughly $27 million contract with the Norfolk-based company on March 31.

The lengthy lead time was just one of the unusual features of the procurement agreement, said Virginia’s Secretary of Finance, Aubrey Layne. Operating amid a chaotic global supply chain, it took state officials weeks to parse through a list of more than 100 potential vendors. Northfield was one of the only companies willing to break up orders and accept smaller upfront payments, rather than demanding the whole $27 million allotment, Layne said.

“Paying a contractor upfront is unusual in and of itself,” he added. “But that’s the environment we’re in. And when you’ve got to pay money upfront, you want someone that’s going to deliver.”

Northfield did, Layne said. Details from the state’s contract, released to the Mercury on Thursday through a Freedom of Information Act request, show that the order — scheduled to be delivered in periodic shipments, based on availability, “through June 30, 2020, or until the emergency PPE equipment is no longer needed in support of COVID-19” — includes 2.5 million N95 respirators and the same number of KN95 masks, a similar model regulated under different standards. 

The contract includes six other categories of equipment, including 5 million surgical masks, 8 million nitrile exam gloves, and 500,000 medical face shields. The state is requesting a total of 2 million yellow isolation gowns with knitted or elastic cuffs.

Under the terms of the agreement, Northfield is required to provide the state with a weekly availability report listing the products it can procure from its manufacturers, the delivery time and any changes in price. This, too, is unusual, but Layne said it’s become increasingly necessary as the supply chain for medical gear continues to fluctuate.

“We’ve heard of states who put up money and never saw supplies come in,” he said. Staggering the shipments allows Virginia officials to cancel orders or seek out other suppliers if there’s a change in price or availability. 

So far, that hasn’t been necessary, Layne added. The state is expecting its second shipment from Northfield about two weeks from now. 

The terms of the contract underscores continuing anxiety over the supply of personal protective equipment and other supplies, even as calls amplify for Gov. Ralph Northam to relax some of the emergency restrictions put in place during the COVID-19 pandemic. One of those was a ban on elective surgeries, defined by the administration as any procedure “which if delayed, are not anticipated to cause harm to the patient” through adverse health outcomes, disability or death. 

Northam issued the order at a time when COVID-19 cases were just beginning to spike and state officials were still struggling to procure a reliable supply of protective equipment. State and federal documents show that Virginia, like many other states, was receiving a fraction of the supplies it ordered from the Federal Emergency Management Agency.

As health officials learn more about the virus and its anticipated impact on the state, a major player in Virginia’s health care industry is calling for an end to the ban. On Thursday, the Virginia Hospital and Healthcare Association released an April 18 letter sent to Northam by CEO Sean Connaughton, asking the governor to end the elective procedure ban on April 24 as originally planned. 

Hours later, Northam announced that he would extend the order until May 1 as the state continued to assess its supply of protective equipment.

Gov. Ralph Northam speaks at a media briefing on the coronavirus outbreak earlier this month. (Ned Oliver/ Virginia Mercury)

“We have increased our supply of PPE, but before we allow elective surgeries to resume, we must first be assured that the doctors, nurses and medical staff who are fighting this virus or conducting emergency surgeries have the necessary supplies,” Northam said in a news release. 

The divide between VHHA and the administration reflects wider disagreements across the industry, said Dr. Clifford Deal, president of the Medical Society of Virginia. Over the last two weeks, MSV and officials with the Virginia Department of Health have hosted a series of conversations with physicians of all specialties, Deal added. 

The main takeaway has been a wide range of opinions on the availability of protective equipment and continued restrictions on many medical professionals.

“One thing is clear,” Deal said. “We’re not in the same situation we were three weeks ago when we thought the sky was falling on our heads.” While COVID-19 cases in Virginia are still on the rise (with nearly 11,000 as of Thursday), the state has seen far fewer hospitalizations and deaths than areas such as New York City and Detroit.

In his letter to the governor, Connaughton pointed out that the ban on elective surgeries — which many hospitals voluntarily halted even before the executive order — “has led to a tremendous availability of beds at our hospitals.”

“There are almost 6,000 open beds at our hospitals along with 2,200 unused ventilators,” he continued, statistics that remain largely unchanged based on VHHA data. Over the past several weeks, the number of hospitals reporting shortages of personal protective equipment has also been reduced from nearly a dozen to three.

Deal emphasized that MSV has not taken a position on resuming elected surgeries. But physicians across the state have reported a significant decline in emergency room use as patients avoid what they fear are unnecessary procedures.

“Most emergency rooms are safe places to get emergency care, but they’re being underutilized because people are afraid,” he added. Some patients may be concerned about contracting COVID-19 — though most areas of the state are reporting few hospitalized cases of the virus — but there’s also broad misunderstanding over the definition of “elective procedure” by both doctors and patients.

“There’s a wide degree of latitude in the governor’s order,” Deal said. Some procedures, such as colonoscopies, carry the risk of complications and can generally be safely deferred. But he added that the mantra of “do no harm” still applies during the COVID-19 pandemic if a patient would suffer without the operation.

“I’ve heard from my orthopedic colleagues that narcotics use has exploded over the past few months,” Deal added. “We’re creating addicts out of people because they can’t get these elective things done. And I would argue that if a patient is in that much pain, you’ve got the latitude to help them.”

Hospitals across the country have worried that ongoing bans on profitable elective procedures could hurt their bottom line and put smaller facilities out of business. But while most in Virginia appear to have stabilized their supply chains, other frontline medical facilities are still reporting major shortages of personal protective equipment. 

The most recent data from LeadingAge Virginia, an association of nonprofit senior living centers, shows that at least 62 facilities across the state are reporting shortages of gloves, respirator masks, gowns and other essential supplies. Funeral homes — which describe themselves as the “last responders” to the COVID-19 pandemic — have received little to no supplies from the state.

Northam cited the ongoing uncertainty — and the flexibility of his executive order — in his decision to extend the ban on elective surgeries for another week. Deal also pointed out that there’s still uncertainty over how long COVID-19 cases will continue to rise.

On Thursday, Virginia recorded 731 new cases — the largest single-day increase to date, according to Health Secretary Dr. Daniel Carey. Prisons and long-term care facilities are also reporting an increasing number of outbreaks.

“We just don’t know the impact that’s going to have,” Deal said. “If those cases continue to rise, all of a sudden, you might see a lot more hospitalizations.”