Seek best practice for protection

Respirator use still a problem after H1N1

Two years after the emergence of the H1N1 pandemic, hospitals are still learning lessons that may help avert serious problems in a future outbreak. Respiratory protection in particular became a contentious issue during the pandemic, and it remains an area of concern.

Even in California, where hospitals had a clear set of requirements to follow under the state's new Aerosol Transmissible Diseases standard, there were gaps in respiratory protection plans, according to recent research sponsored by the National Institute for Occupational Safety and Health (NIOSH). Researchers are now comparing respiratory protection in California to other regions of the country.

"The vast majorities of hospitals had a written program, but it didn't necessarily cover all of the [required] elements," says Barbara Materna, PhD, CIH, chief of the Occupational Health Branch of the California Department of Public Health.

Written policies at 15 of the 16 hospitals in the study called for health care workers to use N95s when in close contact with patients with suspected or confirmed H1N1 pandemic influenza, "but they didn't necessarily have everything in place to ensure that the respiratory program was effective," Materna says.

Only 29% of unit managers surveyed said they audited the proper use of respirators by employees on their units.

To help hospitals improve their respiratory protection, the REACH project (Respirator use Evaluation in Acute Care Hospitals) has produced a toolkit, including a checklist that can be used to evaluate a respiratory protection program.

Respirator Program Evaluation Checklist

1

Y

N

Is there a written policy which acknowledges employer responsibility for providing a safe and healthful workplace?

2

Y

N

Has an individual been designated as the respiratory protection program administrator (RPA) with overall responsibility for development and implementation of the respiratory protection program?

Does the written respiratory protection program include the following required elements?

3

Y

N

written designation of a program administrator;

4

Y

N

an evaluation of hazards and identification of appropriate respirators for specific job classifications and/or tasks;

5

Y

N

procedures for medical evaluations of employees required to use respirators;

6

Y

N

fit testing procedures for tight-fitting respirators;

7

Y

N

procedures for proper use of respirators;

8

Y

N

procedures and schedules for storage, inspection, and maintenance of respirators;

9

Y

N

procedures for training employees regarding the respiratory protection program;

10

Y

N

a description of the training curriculum;

11

Y

N

procedures for voluntary use of respirators;

12

Y

N

procedures for regular evaluation of the program;

13

Y

N

Is the written program readily available to any employee included in the program?

14

Y

N

Is there a record of medical clearance for each employee required to wear a respirators?

15

Y

N

Is there a record of a fit test or fit test screening for each respirator user from within the last year?

16

Y

N

Have users been trained in the proper use, maintenance, and inspection of respirators?

17

Y

N

Are workers prohibited from wearing respirators with a tight-fitting facepiece if they have facial hair or other characteristics which may cause face seal leakage?

18

Y

N

Are respirators stored appropriately so as to prevent them from becoming damaged or deformed?

20

Y

N

Are the users wearing the respirator for which they have passed a fit test?

21

Y

N

Are N95, or more protective, respirators always worn by employees in areas occupied by a suspected or confirmed case of airborne infectious disease?

22

Y

N

Are PAPRs always worn by employees in areas where a high hazard procedure is being performed on a suspected or confirmed case of airborne infectious disease?

23

Y

N

Are respirators inspected by the users before each use?

24

Y

N

Are respirators being donned and doffed correctly?

25

Y

N

Are PAPRs cleaned and disinfected after each use?

26

Y

N

Is there a mechanism for users to report problems with respirator use?

27

Y

N

Is there a mechanism for users to provide feedback about the effectiveness of the program?

Source: Occupational Health Branch, California Department of Public Health, California REACH Project

NIOSH is working with the Joint Commission accrediting body to publish a best-practices monograph by the end of 2012, says Maryann M. D'Alessandro, PhD, associate director for science at NIOSH's National Personal Protective Technology Lab (NPPTL) in Pittsburgh.

For example, one measure that helps improve proper use of respirators is placing a sign outside of airborne infection isolation rooms reminding employees to don a respirator, she says. Best practices strategies revealed in the REACH project will be included in the monograph. NIOSH and the U.S. Occupational Safety and Health Administration also have developed a training video that can be used to educate health care workers. (www.cdc.gov/niosh/npptl/).

The lessons learned during the H1N1 pandemic "helped us focus our activities to inform the workers and hospital administrators," says D'Alessandro.

HCWs need respirator training

Respiratory protection in health care has been fraught with both controversy and confusion. During the H1N1 pandemic, guidance from the Centers for Disease Control and Prevention and local and state health departments sometimes conflicted.

Although N95s are not used with seasonal influenza, the CDC advised that they should be used when caring for patients with suspected or confirmed pandemic influenza. Some infection control professionals felt N95s were only necessary with aerosolizing procedures, but the U.S. Occupational Safety and Health Administration vowed to enforce the CDC guidelines.

Currently, CDC recommends using a facemask when caring for a patient with seasonal influenza but wearing an N95 respirator when performing aerosol-generating procedures.1

"My hope is that people will start to get past this [prior conflict] and gain an understanding of how respirators work to protect employees," says Materna.

That protection relies on a proper fit and training of employees. Too often, they don't understand when to use respirators, which device to select and how to don it and doff it properly to avoid contaminating themselves, says Materna.

In REACH, researchers observed health care workers using respirators or asked the employees to demonstrate how to wear them. Some risked contaminating their hands or face by failing to remove their personal protective equipment in the correct order, she says.

Hospitals also need to evaluate their respiratory protection program, to make sure employees know when and how to use the equipment, she says. "Respiratory protection is an important tool to protect workers" that should be used in conjunction with other infection control measures, says Materna.

"Healthcare workers are a valuable resource and we want them to be able to work when other people are sick and need care," she says.

No new national stockpile

In the post-pandemic analysis, respirator supply remains a major issue. The national stockpile has not been replenished, says Roland Berry Ann, deputy director of NPPTL. "Therefore, it may be better to have local and regional stockpiles rather than depending on a CDC strategic national stockpile," he says.

Hospitals need to determine how they would supply respirators during a pandemic or outbreak of an emerging airborne infectious disease, he says. For example, hospitals could turn to reusable respirators, such as powered air-purifying respirators (PAPRs) or elastomerics. Or they could arrange for a local stockpile, such as through distributors, a consortium of users of the same respirator products or by storing extra respirators onsite, he says.

In the REACH study, 50% of unit managers reported that there were shortages of N95 respirators during the H1N1 pandemic.

One bright spot: Respirator manufacturers developed new production sites during the surge of demand and may have greater capacity to respond to a future event, Berry Ann says.

Reference

1. Centers for Disease Control and Prevention. Prevention strategies for seasonal influenza in healthcare settings. September 20, 2010. Available at http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm. Accessed on October 17, 2011.