Box 2.

Critical Questions and Ethics Vignette

The University of Nebraska Medical Center and its clinical partner Nebraska Medicine established a Critical Questions and Ethics committee immediately before experiencing its first COVID-19 patients. This allowed decision-makers and implementers alike a space in which to air concerns based on unanswered questions or perceived operational or organizational risks. The committee was advisory in nature. One such question asked how best to prioritize N95 respirators that were anticipated to be in short supply. The conversation revolved around fit-testing requirements. At a center like UNMC/NM, several hundred respirators are consumed each year in quantitative fit testing for staff who have newly arrived, or for required periodic testing. Logistical, ethical, legal, and operational considerations included finding the right balance between the need for appropriate fit—especially if at high risk of SARS-CoV-2 exposure, differences in regulatory intent for fit testing and a more rigorous standard applied by the university, and preconceived notions of need, practice, and requirements. Several small program adjustments were thought to have promise. These were reevaluating nondestructive or qualitative fit testing, using a survey to enable a longer interval before retesting, and prioritizing new employees and areas with higher risk for encounters with ill patients. Important research avenues emerged, and this process highlighted the need for interdisciplinary approaches. Environmental hygiene, logistics, and implementation science aims all arose from the conversation in ways that might not otherwise have emerged. Decision-related knowledge needs relevant to the prospective, observational cohort study described in this article have included viral shedding dynamics, clinical course relevant to resource demand, and the horizon of available medical countermeasures and their development.