IOM cites 'urgent' need for action to ensure HCW safety in flu pandemic

The weakest link in pandemic preparedness?

Not enough is known about how to protect health care workers in an influenza pandemic, and that lack of knowledge critically weakens the nation's preparedness, an Institute of Medicine panel has concluded.

The IOM experts determined that there is "an urgent need" for more research and better technologies for personal protective equipment and to raise the "employer and employee commitment to worker safety and appropriate use of PPE [personal protective equipment]." Hospitals need to develop a culture of safety, they said.

"Health care worker safety is essential for patient safety and patient care. Being prepared for an influenza pandemic places a priority on protecting the health care work force," the IOM experts stated.

Despite the urgent tone of the report, it garnered little attention when it was released in September. The IOM didn't issue a press release or hold a press conference, as it has with prior patient safety or nursing work force reports. Yet in an October meeting, the IOM Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic sought to move forward by bringing together representatives from The Joint Commission accrediting body, labor unions, and federal agencies.

"The urgency really [leads to] the doorstep of the policy-makers, [who should] read this report and allocate resources to get the work done to protect the work force and the nation," says Bonnie Rogers, DrPH, RN, COHN-S, LNCC, a professor at the University of North Carolina School of Public Health in Chapel Hill and a member of the panel.

IOM panel members were "shocked" by the lack of scientific evidence regarding the transmission of influenza, says Rogers, who also is director of the North Carolina Occupational Safety and Health Education Research Center. But with a commitment of resources, many preparedness gaps could be filled as quickly as within one to three years, said panel chair Lewis Goldfrank, MD, chair of emergency medicine at the New York University School of Medicine and director of emergency medicine at Bellevue Hospital, NYU Hospitals and the VA Medical Center in New York City, in the report's preface.

"It is our belief that health care workers will feel secure only when the PPE that they are asked to wear is as safe and effective as the vaccines and medications they are asked to take," he said.

Many hospitals have stockpiled masks, respirators, and gloves for use during a pandemic. But a hospital's responsibility for ensuring the safety of workers goes far beyond that, the IOM panel said.

"The institution needs to provide the equipment and the training and needs to make sure people are compliant," Rogers explains. Using safety equipment, including respirators when appropriate, should be as natural as buckling a seat belt when you get into a car, she says.

Employees' perception of the safety culture — how much the institution values worker safety — influences work practices, injury rates, employee satisfaction and even patient safety, says Robyn Gershon, MHS, DrPH, professor in the Department of Sociomedical Sciences at the Mailman School of Public Health at Columbia University in New York City. Gershon, an expert on safety climate, presented study findings to the IOM panel and is a member of the broader IOM Committee on Personal Protective Equipment for Workplace Safety and Health.

Health care workers will be more likely to report for work during a pandemic or other emergency if they feel adequately protected, she says.

Hospitals should make sure that employees have a personal emergency plan so they know who will care for their children if they are called into work during a health emergency, she says. They should beef up their education and training and make sure that health care workers are fit-tested for respirators, she says.

"Fit-testing should be a priority now. You can't do it when everything is chaotic," Gershon says.

There are other barriers to respirator use. The N95 filtering facepiece respirators are uncomfortable and make it difficult to communicate with patients — or even to breathe.

"Health care workers are not really sure that these things really work. That's problematic because when you weigh that against all these barriers it's understandable why some people won't wear them in all instances," she says.

If health care workers understand how the respirators work, why they are necessary, and how to don and doff them properly, they will be more likely to be compliant, she says.

The panel also recommended that The Joint Commission enforce standards that "ensure the proper use of PPE is a priority."

The Joint Commission will respond to the report after its final release in January, says Louise Kuhny, RN, MPH, MBA, CIC, associate director for standards interpretation. But she noted that The Joint Commission has several standards that apply to worker protections and pandemic preparedness.

For example, surveyors may ask employees about the hospital's plan for handling "an influx of infectious patients" — including the use of protective gear, she says. "Employee health issues are definitely addressed [by the standards]," she says. "We do write 'requirements for improvement' related to employee health."

Not enough known about transmission

Meanwhile hospitals need more guidance. What is the best personal protective equipment to protect against the spread of pandemic influenza? This basic question can't be answered without more information on the transmission of influenza, the panel concluded.

The National Institute for Occupational Safety and Health (NIOSH) and other agencies need increased funding to study influenza transmission and appropriate PPE, the panel said. "The basic research really needs to come first," says Rogers.

The IOM panel recommended the creation of an Influenza Study Network and collaboration between the U.S. Department of Health and Human Services and the World Health Organiza-tion to mount a global study of influenza transmission and prevention. Without that information, it's not possible to know the most likely route of transmission — contact, droplet, or airborne — or how best to protect workers, the panel said.

The panel also stressed that procedure or surgical masks are not personal protective equipment and cannot be used in place of respirators.

Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union in Washington, DC, lauded the panel for targeting the lack of scientific information about effective respiratory protection against infectious diseases. "For too long, we've relied on so-called expert opinion and qualitative judgments," he says. "The emphasis on evidence-based science is what's revolutionary."

The panel also called for better design and testing of PPE for health care workers.

The report could have far-reaching impact in shaping regulatory and research priorities, says Les Boord, director of the National Personal Protective Technology Laboratory at the National Institute for Occupational Safety and Health, which requested the report.

"It identifies a lot of issues and concepts for advancing the state of the art of personal protective technologies for the health care worker," he says. "I think it's a very important and significant report."

(Editor's note: A pre-publication copy of the IOM report, Preparing for an Influenza Pandemic: Personal Protective Equipment for Health Care Workers, is available at