Ebola. H1N1. MERS. SARS. The stakes are high when health care workers care for patients with an emerging infectious disease, and gaps in respiratory protection can have deadly consequences. Yet studies show those gaps persist.1
Three leading safety agencies have released comprehensive resources to address longstanding weaknesses in respiratory protection programs in hospitals. They provide a kind of primer, an effort to improve training, compliance, awareness, and coordination.
In May, the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) jointly issued a Hospital Respiratory Protection Program Toolkit that focuses on aerosol transmissible diseases. The Joint Commission produced a companion monograph with best-practice case studies called “Implementing Hospital Respiratory Protection Programs: Strategies from the Field.” Previously, the American Association of Occupational Health Nurses (AAOHN) released free educational modules on respiratory protection. (See editor’s note below for more information on accessing resources.)
The OSHA/NIOSH toolkit covers respirator use, existing public health guidance on respirator use during exposure to infectious diseases, hazard assessment, the development of a hospital respiratory protection program, and additional resources and references on hospital respiratory protection programs. The document also includes an editable respiratory tool that hospitals can customize to reflect their program.
“If you use your best practices every day, when there’s an outbreak you’re ready. The best preparedness is good day-to-day practice,” says Debra Novak, RN, DSN, senior service fellow with NIOSH’s National Personal Protective Technology Laboratory (NPPTL), who was the project officer for the toolkit and monograph.
Respiratory protection is often a responsibility of employee health professionals, yet many learned about it on the job rather than through formal education, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, manager of employee health services at Allegheny Health Network in western Pennsylvania and association community liaison for the Association of Occupational Health Professionals in Healthcare (AOHP). A 2012 survey by AOHP found that half of the members managed their hospital’s respiratory protection program.
“We want to make sure accurate information is out there for them to use to help build their program and protect their workers,” she says.
Respiratory protection has often been a source of confusion — and concern. When two Dallas nurses became infected with Ebola while caring for a patient, attention soon turned to their respiratory protection, or lack of it. The nurses reported that they initially wore surgical masks, per guidance from the Centers for Disease Control and Prevention. CDC later revised the guidance and recommended respirators.2
In Toronto, transmission of SARS to healthcare workers raised critical questions about the use of surgical masks versus respirators.3 And a recent survey by AAOHN found that one-quarter of occupational health nurses are uncomfortable describing the difference between surgical masks and respirators.4 To complicate matters further, a new meta-analysis from Canada concludes that when strictly looking at clinical studies, there is no discernable difference between respirators and masks in preventing healthcare worker respiratory infections. (See related story, page 94.)
The OSHA/NIOSH toolkit attempts to clarify that surgical masks are not respirators. Yet the guidance still reflects the conflict between the occupational safety and infection control perspectives. It defines “droplet precautions,” an infection control precaution in which healthcare workers wear a surgical mask to protect their mouth and nose from large droplets produced when a patient talks or coughs.
But the toolkit also notes that the mode of disease transmission is not always clear, and that symptoms of an airborne disease, such as tuberculosis, may be mistaken for other respiratory viruses.
“A prudent approach is to implement the use of respirators early on based on suspected diagnosis, for example in the emergency department, and discontinue it later if the patient is subsequently diagnosed with a disease that does not require respiratory protection,” the toolkit states.
Still, respiratory protection expert Lisa Brosseau is concerned about the implication that surgical masks are a form of personal protective equipment. She notes that they were created to prevent infection of wound sites during surgery.
“[The toolkit’s recommendations] continue to confuse people about what a surgical mask or respirator is,” says Brosseau, ScD, CIH, professor and director of the Industrial Hygiene Program at the University of Illinois at Chicago, and a member of the technical expert panel for the monograph. “They continue to indicate that surgical masks offer protection for inhalation and they do not. They were never meant to and they were not designed for that.”
She points to a chart that shows surgical mask use is appropriate for “viral hemorrhagic fevers.” Footnotes state, “A surgical mask is not a respirator but can be effective in blocking large particles” and “5 October 2014 CDC guidance for Ebola virus disease recommends at least an N95 respirator.”
Novak notes that the toolkit reflects current CDC guidance, and that surgical masks can be used as barrier protection from droplet spray. However, hospitals should conduct a hazard evaluation before making a decision about respirator use, and healthcare workers should be able to consult an infectious disease expert with any questions, she says.
“It depends upon the type of hazard that you’re trying to eliminate or minimize. The infection control paradigm really drives that,” she says.
In other respects, the toolkit and monograph offer a clearer pathway to better training and coordination of a respiratory protection program.
The Respirator Use Evaluation in Acute Care Hospitals (REACH) project, sponsored by NIOSH, revealed that healthcare workers often lack adequate training and fail to use respirators properly. For example, in a 2009-2010 survey, California nurses reported their instruction during annual fit-testing lasted from one minute to 15 minutes.1 A follow-up REACH study in six states in 2011 and 2012 found widespread lack of understanding among healthcare workers about when and how to wear respirators.
Too often, hospital respiratory protection programs existed on paper, but weren’t implemented in day-to-day use, Novak says.
“The toolkit takes the essential [OSHA-]mandated elements for a respiratory protection program and gives you a very organized, orderly, and comprehensive manual for how to develop the program properly,” she says. It was modeled after a similar toolkit published in 2012 by the California Department of Public Health.
Respiratory protection programs should have a single administrator with overall responsibility, even if duties are delegated, the toolkit advises. OSHA’s Respiratory Protection Standard also requires employers to conduct a hazard evaluation to determine which employees could be exposed. In hospitals, the hazards include infectious diseases, aerosolized hazardous drugs, disinfecting agents, surgical smoke and waste anesthetic gases. Aerosol-generating procedures may require a higher level of protection, the toolkit notes.
Each required aspect of a respiratory protection program is explained in the toolkit, from creating a written program and fit-testing to recordkeeping and evaluation. (For a list of training requirements, see box below.)
In a companion document, The Joint Commission solicited strategies for respiratory protection programs from hospitals around the country.
Even hospitals with established respiratory protection programs reported challenges in implementing and maintaining respiratory protection amid so many hospital priorities, says Barbara Braun, PhD, associate director of the Department of Health Services Research in The Joint Commission’s Division of Healthcare Quality Evaluation and principal investigator of the monograph project.
Hallmarks of good programs include the following:
• Leaders who value safety for workers as well as for patients.
• Collaborative efforts through multidisciplinary teams.
• A broad approach to respiratory hazards.
• Integration of respiratory protection with emergency preparedness.
• Measures to raise awareness about respiratory protection.
Education needs to be an ongoing process, says Braun. This is particularly important in healthcare, where staff might not necessarily use a respirator every day, Braun said.
Hospitals reported many ways to educate and remind staff when a respirator might be needed and how to use it properly. For example, some hospitals placed signs outside airborne isolation rooms reminding healthcare workers to don a respirator before entering. Some hospitals required employees to demonstrate competency with respirators prior to their use. Other hospitals tailored education strategies according to different staff needs, such as offering training in multiple languages.
“Anecdotally, hospitals reported better buy-in when staff understood why they were wearing a respirator,” Braun says.
Editor’s note: The Hospital Respiratory Protection Program Toolkit is available at www.osha.gov/Publications/OSHA3767.pdf, and “Implementing Hospital Respiratory Protection Programs: Strategies from the Field” is available at www.jointcommission.org/assets/1/18/Implementing_Hospital_RPP_2-19-15.pdf. The AAOHN educational modules are available at http://aaohnacademy.org/rpp/rpp-program.php.
- Beckman S, Materna B, Goldmacher S, et al. Evaluation of respiratory protection programs and practices in California hospitals during the 2009–2010 H1N1 influenza pandemic. Am J Infect Control 2013; 41:1024–1031.
- Centers for Disease Control and Prevention. “CDC tightened guidance for U.S. health care workers on guidance for personal protective equipment with Ebola.” October 20, 2014. Available at www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html.
- Campbell A. The SARS commission executive summary, volume 1, Spring of Fear. Toronto, Ontario, Canada: Commission to Investigate the Introduction and Spread of SARS in Ontario; 2006. Available at www.archives.gov.on.ca/en/e_records/sars/report/v1-pdf/Volume1.pdf.
- Burgel BJ, Novak D, Burns CM, et al. Perceived competence and comfort in respiratory protection: Results of a nationwide survey of occupational health nurses. Workplace Health & Safety 2013;61:103-115.