N95 shortage puts hospitals in a bind

Surgical masks are a reluctant backup

A shortage of N95 respirators has forced hospitals to scramble for supplies as they seek to expand their respiratory protection program in response to severe acute respiratory syndrome (SARS).

Faced with an unprecedented worldwide demand for the respirators, 3M Corp., a major manufacturer, stepped up production and focussed its supply on the most acutely affected areas. "Based on discussions with health authorities worldwide, 3M has decided our first priorities are health care workers and families directly in contact with SARS patients," the company reported.

Yet some U.S. hospitals were having difficulty filling new orders for the respirators, which are available from a number of manufacturers. Some hospitals are asking employees to reuse the N95s with TB patients if the masks are not damaged or obviously soiled — a procedure that is mentioned as acceptable in TB Respiratory Protection Program in Health Care Facilities Administrator’s Guide from the National Institute for Occupational Safety and Health.

However, the Centers for Disease Control and Prevention (CDC) has advised hospitals not to reuse disposable respirators with SARS, and to thoroughly disinfect reusable respirators, such as powered air-purifying respirators (PAPRs). Yet CDC acknowledged that hospitals may need to modify their practices if they run out of respirators.

Baystate Health System in Springfield, MA, which has treated two probable cases of SARS and another suspected case, was hoping to get additional supplies of N95s from the same manufacturer. Otherwise, the employees would all need to be fit-tested again — a daunting task, says James R. Garb, MD, director of occupational health and safety.

"We may have to use a standard surgical mask as a backup if we run out of the N95s," he says. "The surgical masks were never designed to protect the wearer. They were designed to protect the patient from the surgeon."

At Marshfield (WI) Clinic, Bruce Cunha, RN, MS, manager of employee health and safety, also found that the hospital’s brand of N95 respirators was out of stock. Out of 6,700 employees, about 200 have been fit-tested for N95s — and all would need to be fit-tested again if the clinic changes manufacturers. "You can see the problems this is going to bring up," he says. "This is just going to be a nightmare."

If hospital transmission were to emerge in the United States, the protective efforts — and fit-testing — would intensify. In Ontario hospitals, all employees in the emergency department, intensive care, neonatal intensive care, and other high-risk areas wear masks. The Ontario Nurses Association (ONA) raised questions about nurses on medical floors who were not given masks.

"We did initially have concerns around supply of masks," says Barb Wahl, RN, president of the ONA. "Then we had concerns around distribution of masks. Today, my concern is around who’s wearing them — employer policies around who should and who shouldn’t be wearing N95 masks."

The province of Ontario ordered more than 4 million N95s, Wahl says. "The task of protecting an entire population of health care workers is mind-boggling," she says.

If N95s are in short supply, Wahl advises hospitals to be upfront about the problem and include frontline health care workers in the solution. "Don’t leave the nurses out of the loop," she says. "Don’t make decisions for them. They are the ones who will be on the front line. They have every right to be part of the decision making. If there is a limited number of masks, say so. Let them be involved in the decision about who gets the mask."

At the same time, you don’t want to discourage appropriate use of the masks, says Garb. After all, the masks will protect health care workers, and ultimately the entire hospital population, from secondary transmission of SARS.

"We tell people in the emergency department to be liberal about when they decide to put on an N95 mask," he says. "If someone comes in with a cough and fever, until you know whether they have TB, you should put on a mask."

SARS simply underscores that basic advice.