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Respiratory Protection: Compliance, Research are Key Issues for the Future


By Kelly M. Pyrek

Ensuring healthcare worker compliance with the proper use of respiratory protection when it is warranted remains a challenge for infection preventionists and is a continued area of study by researchers in the public and private sectors. One such agency pursuing this knowledge is the National Institute for Occupational Safety and Health (NIOSH), the federal agency specifically dedicated to generating new knowledge in the field of occupational safety and health and to transferring that knowledge into practice.

The National Personal Protective Technology Laboratory (NPPTL) is the NIOSH division that is responsible for generating scientific research and developing guidance that can help to better inform the agenda that prevents disease, injury and death for U.S. workers relying on personal protective equipment (PPE). The NPPTL, established in 2001 at the request of Congress, was created in response to a recognized need for improved PPE and focused research into personal protective technologies (PPT).

Respiratory protection is the cornerstone of NPPTL’s efforts, and in 2008, as a recommendation from the National Academies, it was advised that increased research on the use and usability of PPE be conducted. At the same time, it was recommended that the NPPTL continue its research in priority areas such as new-materials technology (including “no-fit test” respirators); comfort, ergonomics, and human factors which determine whether or not the PPE is worn by the worker; and enhancing the culture of workplace safety through worker education, training and understanding of hazardous exposure risk to health.

Debra Novak, DSN, RN, a senior service fellow with NIOSH and the NPPTL, explains that a renewed focus on PPE and respiratory protection specifically was triggered by what she calls a "symphony of events" that included not only the IOM reports but the H1N1 influenza pandemic in 2009.

"These events synergistically came together to a point where we at the NPPTL started to recognize that there seemed to be a compliance problem with proper usage of respiratory protection," Novak explains. "Out of that came a series of funded studies that we were able to initiate, with the first being the Respiratory Evaluation for Acute Care Hospitals (REACH) study, or REACH I, which started in California. We then expanded to a REACH II study that looked at respiratory protection usage in five regions in the U.S.

In the REACH I study, the goal was to assess the usage of respiratory protection for influenza exposure among healthcare workers in 16 participating healthcare organizations. Onsite surveys and observational data collection methods were employed in each facility and 204 healthcare workers participated in the study from a variety of clinical specialties. Several trends emerged, including respirator re-donning.  In answer to the survey question, "Have you ever re-used an N95 respirator when in close contact with patients who have confirmed or suspected H1N1?" 57.7 percent of participating healthcare workers said "no," while 42.3 percent said "yes." If the answer was "yes," healthcare workers indicated they reused a respirator because of a shortage or respirators, or that it was standard practice, or they simply didn't know why they reused a respirator.

Common problems with N95 respirators as cited by the healthcare workers surveyed included:  uncomfortably warm (39 percent); interferes with other PPE (21 percent); difficulty in speaking or being understood (20 percent); difficulty breathing (16 percent); moisture build-up (13 percent); claustrophobic (10 percent); other (8 percent) and interferes with glasses (4 percent). Thirty-five percent of the surveyed healthcare workers reported no problems.

In answer to the question, "How do you know that you need to wear a respirator?" Healthcare workers reported that there was a sign on the door of the patient's room (194); they were told during a shift report (165); they conducted a patient assessment that indicated respirator use (156); co-workers informed them (155); respirators were located near a patient's room (118); a supervisor informed them (68); or another method was used (35).

In terms of what healthcare workers believe about PPE usage, 65 percent of surveyed healthcare workers said they thought they were at high risk of becoming ill with influenza due to their work (35 percent disagreed); 96 percent said that wearing an N95 or better respirator can help protect them from exposure to influenza (3 percent disagreed); and 94 percent said respirators are more effective at protecting them from influenza than surgical masks (3 percent disagreed and 2 percent weren't sure).

Other findings from the REACH I study included:
- 50 percent of the hospital managers reported that their facility had experienced a shortage of respirators between April 2009 and the survey period (Jan. 20-Feb. 23, 2010).
- The observational data indicates improper use of respiratory protective equipment as evidenced by donning and doffing practices, including not performing a seal check, improper strap placement and touching the facepiece upon doffing.

The REACH I study found that the most deficient areas of the written program were designation of a respirator program administrator; recordkeeping; fit-testing protocol; training; and program evaluation. Areas of implementation with the greatest need for improvement included selection of appropriate respirator for task and suspected/confirmed infectious disease risk; donning/doffing N95 respirators; regular evaluation of program; and employee use of the specific respirator for which they were fit-tested.

In March of this year, NIOSH and the NPPTL held a personal protective technologies stakeholder meeting during which participants received an overview of recent efforts to identify innovative, effective strategies and practices to strengthen healthcare respiratory protection programs, and to identify challenges associated with the implementation of these programs. The meeting also included an update on the REACH II study; while the results are still being processed, preliminary findings indicate that:
- Respiratory protection program plans exist on paper
- Response differences between HCWs and hospital managers regarding operations of the respiratory protection program.
- Most healthcare workers recall fit-test at hire with minimal updates.
- Fit-testing is the focus, while ongoing preparedness training is not
- Respirators (N95s) are most commonly used for TB.
- Healthcare workers are infrequent N95 respirator users
- Healthcare workers are improperly donning and doffing respirators

Novak observes, "Over time and through these studies we began to see that workers were not using respiratory protection either at all or using it correctly." This comes as little surprise to Novak, who points to the scientific literature demonstrating marginal compliance with the proper use of respiratory protection. "Redonovich (2008) put the compliance factor at less than 60 percent, but even scarier is what OSHA is telling us in terms of illness and injury in healthcare facilities," Novak says. "I was alarmed to see the recent OSHA statistics that in 2010 healthcare organizations were No. 1 in terms of illness and injury. Clinical events like H1N1, then illness and injury rates from OSHA, and the fact that so many safety climates are woefully inadequate -- combine those factors together, which makes the proper use of respiratory protection an issue we need to pay attention to."

To help healthcare organizations prevent worker and patient exposures to hazardous agents, NIOSH and the NPPTL are using the results of these REACH studies to develop an educational monograph containing effective practices, tools and resources to help hospitals improve their respiratory protection programs. The monograph is a welcome tool, seeing that healthcare facilities now must find much of their instruction in the OSHA standard itself.

OSHA's respiratory protection standard, 29 CFR 1910.134, declares, "In the control of those occupational diseases caused by breathing air contaminated with harmful dusts, fogs, fumes, mists, gases, smokes, sprays, or vapors, the primary objective shall be to prevent atmospheric contamination. This shall be accomplished as far as feasible by accepted engineering control measures (for example, enclosure or confinement of the operation, general and local ventilation, and substitution of less toxic materials). When effective engineering controls are not feasible, or while they are being instituted, appropriate respirators shall be used pursuant to this section." [1910.134(a)(1)]. It also states, "A respirator shall be provided to each employee when such equipment is necessary to protect the health of such employee. The employer shall provide the respirators which are applicable and suitable for the purpose intended. The employer shall be responsible for the establishment and maintenance of a respiratory protection program, which shall include the requirements outlined in paragraph (c) of this section. The program shall cover each employee required by this section to use a respirator." [1910.134(a)(2)]
The respiratory standard establishes the requirement that in places of employment where respirators are used -- such as in healthcare facilities -- a written respiratory protection program with worksite-specific procedures must be created and maintained.

The employer must include in the program the following:
- Procedures for selecting respirators for use in the workplace
- Medical evaluations of employees required to use respirators
- Fit testing procedures for tight-fitting respirators
- Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations
- Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators
- Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators
- Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations
- Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance
- Procedures for regularly evaluating the effectiveness of the program

In addition, the employer must establish and implement those elements of a written respiratory protection program necessary to ensure that any employee using a respirator voluntarily is medically able to use that respirator, and that the respirator is cleaned, stored, and maintained so that its use does not present a health hazard to the user. The employer must also designate a program administrator who is qualified by appropriate training or experience that is commensurate with the complexity of the program to administer or oversee the respiratory protection program and conduct the required evaluations of program effectiveness. OSHA also expects the employer to provide respirators, training and medical evaluations at no cost to the employee.

Novak says that OSHA's respiratory standard is the main driver for respiratory protection in the healthcare workplace, and says she is concerned that many facilities lack a structured program that ensures compliance.

"One of the things we have been advocating for is a working group in which an infection preventionist, the healthy and safety officer, the risk manager, and the respiratory protection administrator are all sitting down at the same table and working it out," Novak says. "But that's a best practice that smaller healthcare facilities may or may not be able to accomplish."

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