Rebecca Leach, RN, BSN, MPH, CIC

As the coronavirus disease 2019 (COVID-19) pandemic has disrupted and derailed 2020, many see the promise of a vaccine as the pathway back to “normal.” As of this August writing, there are 26 vaccines in various stages of clinical trials and 139 vaccines in preclinical trials across the globe.1 Vaccine development typically takes years from design to US Food and Drug Administration (FDA) approval and readiness for mass market. Even with the increased funding and drive to create and distribute a vaccine that protects against COVID-19, it may be well into 2021 before one is available for the public. And even when it is available, the efficacy of the vaccine will be unknown until large populations have received it.2 Given this timeframe, and other factors associated with vaccination as a tool in pandemic response, the road to normalcy may not be as smooth as many hope.

Infection preventionists (IPs) are collaborators with other departments, such as occupational health, human resources, and clinical leadership, to promote and implement vaccination programs for healthcare providers (HCPs). Typically, staff vaccination programs are owned by occupational health departments and IPs work closely to monitor trends and help remove barriers and provide recommendations on special cases or accommodations. When the vaccine for COVID-19 is available, this again will be a collaborative moment to develop the plan for vaccination, tracking, and promoting.

Infection prevention will likely need to be a resource for education about the vaccine, including concerns over side effects or any booster or follow-up needed based on how the vaccine is designed.

Another role for IPs in this pandemic will be to work with local public health programs to promote vaccination of the public, including patients and residents of congregate settings, such as nursing homes, acute rehab facilities, and inpatient mental health centers.

One example of a way that IPs can collaborate with other departments to implement a vaccination program is to work with occupational health and emergency response departments to have a mass vaccination drill.

This is a way for many programs to meet requirements and also provide a vaccine to staff in a rapid and coordinated process. When having these types of drills, it’s important that the vaccine be brought to where the staff is located, so having roving carts or teams is important. Also having stations at staff entrances that are manned during shift change can capture staff members as they come into the facility.

There are many examples of vaccination programs and lessons-learned about ways to increase staff compliance; however, even with a vaccine in development, the role of infection prevention will need to be strong for COVID-19 response for the foreseeable future.

Vaccines are one weapon that is often used in outbreak response for vaccine-preventable diseases (VPD). Countries with strong emergency response and public health programs have vaccination plans in place for such diseases as cholera, polio, and Hepatitis A.3

Disaster preparedness teams in hospitals need to have plans in place for potential increases in VPD and recognize that the typical vaccine administration will be interrupted by that disaster, whether it is a natural disaster, conflict and warfare, or a pandemic.

In this case, given the lag time we have until the vaccine is developed, planning can be done to address the other issues of regulatory barriers, looking at how to store and stockpile vaccine doses and administration supplies, roles of local, national and international partners in the distribution, communication and marketing, enhanced surveillance for adverse response and for effectiveness and the general mobilization and operationalization of the vaccine to the populations of need.3

These are huge undertakings, especially within a global pandemic. However, looking at historical mass-vaccination efforts can provide some guidelines on best practices and lessons learned and can be a resource to help guide the COVID-19 vaccine response plan.In order for the vaccine response to be successful, these areas of operation need to be addressed. Also, the social aspects of vaccine administration are equally important to understand and develop plans for before the vaccine is ready. These areas include vaccine hesitancy, access to healthcare, health equity, and mistrust of government institutions.4

Many of these barriers can be addressed with similar tactics, including assessing areas of vulnerable populations where these social constructs exist and working with local community leaders to build relationships and establish trust. Build capacity in healthcare organizations to address these concerns and to engage the community to provide accurate information. Healthcare providers are the most trusted source on vaccine acceptance.4 If providers have a clear understanding of the benefits of vaccination and have the communication skills to educate their patients, then the likelihood of vaccine uptake may increase. Similarly, HCPs are a high-risk group and their opinions on the COVID-19 vaccine can sway others.

When looking at influenza vaccine compliance, in recent years the percentage of HCPs taking the vaccine has increased, with a reported 81.1% overall compliance in 2019.5 One reason this has increased is because of many organizations making a flu vaccine a requirement for employment. In HCPs who did not have a work requirement or any work-related promotion, the compliance rate was just 42.1%. If we extrapolate this data to a COVID-19 vaccine, likely without work requirements, we would see low levels of uptake within HCPs as well. Not only does this increase potential for transmission in this high-risk population, but it also sends the message to their patients and community that the vaccine is not important.

A recent survey found that less than half of Americans would get a COVID-19 vaccine right away.6 Nearly 25% of respondents would “not get the vaccine anytime soon” or “never” get the vaccine.6 African-American respondents were the least likely to want to receive a COVID-19 vaccine right away compared with other races and ethnicities. These data show that there is much pre-work to be done, in particular with minority groups who have been disproportionately impacted by the disease, to increase vaccine acceptance and address underlying issues that are influencing these responses. Interestingly, respondents who reported receiving the annual flu vaccine were nearly twice as likely to report willingness to get the COVID-19 vaccine.6 Understanding what influences people to get the annual flu vaccine may help guide programs to use similar tactics to influence COVID-19 vaccine uptake.

Even if the vaccine is widely accepted and trusted, how long will it take to establish the level of population immunity necessary to prevent transmission? It’s estimated that, for COVID-19, with the reproduction number (R0) of around 1, about 50% of the population needs to have immunity.7 This is ideally achieved through vaccination, but can also include natural disease acquisition. With COVID-19, most speculate that the vaccine will not provide 100% immunity, and liken it more so to the influenza vaccine, with 40-60% efficacy depending on the annual strains.

Certainly, in the early days of a COVID-19 vaccine roll-out, high-risk groups and vulnerable populations should be targeted first, with prioritization then expanding to general population over time. Given the complexities of such an effort, the timing to reach the 50% threshold could be months to years. Confounding this work is the concept that we may need to have annual boosters or vaccine modifications if the predominant viral strains mutate.

Based on all these challenges with vaccine development, acceptance, and administration, there will need to be a continued emphasis on the basic infection control practices we are currently employing to mitigate risks: wearing masks, social distancing, updating personal protective equipment guidelines in healthcare facilities for universal masking/eye protection, and developing surveillance programs tracking coronavirus activity to be able to adjust the vaccine to fit predominant strains.

These basic tenants are what will provide the most protection against transmission until such a time as we have an effective and widely accepted vaccine. And even after that time, as emerging infectious diseases continue to impact global health, these practices should become part of our culture and part of our national response to outbreaks of respiratory disease.

In disease prevention, it is important to remember that the science exists on a continuum and having all-or-none thinking only impedes progress and understanding. When dealing with a pandemic, multiple approaches are necessary to reach full effect. In infection prevention, we are used to working with bundles for prevention of central line infections, surgical site infections, and other hospital-associated infections. The same approach needs to be taken with COVID-19. We must not dilute the response to relying on a vaccine to “cure” the pandemic. Disease prevention requires a broad range of interventions, including vaccines, in order to be effective and truly address the risks of transmission.

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

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https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines

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Walldorf JA, Date KA, Sreenivasan N, et al. Lessons Learned from Emergency Response Vaccination Efforts for Cholera, Typhoid, Yellow Fever, and Ebola. 

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Bean M. 48% of Americans would get COVID-19 vaccine right away, survey finds. Becker’s Hospital Review. Published August 5, 2020. Accessed August 9, 20202. 

https://www.beckershospitalreview.com/public-health/48-of-americans-would-get-covid-19-vaccine-right-away-survey-finds.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_source=BHRE&utm_medium=email&oly_enc_id=7243F3869212B6R

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https://academic.oup.com/cid/article/52/7/911/299077

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Why a COVID-19 Vaccine Might Not Be the Answer We’re Hoping For

Standard precautions have a long history in healthcare, being practiced in some form since the Middle Ages. The Centers for Disease Control and Prevention (CDC) formalized these precautions into what was then called universal precautions in response to the HIV epidemic in the late 1980s. Universal precautions were focused on protecting healthcare workers from blood borne pathogens, focusing on the use of personal protective equipment (PPE) such as gowns and gloves. The concept treats all blood and body fluids as potentially infectious. Universal precautions were revised and became standard precautions in 1996 and became more inclusive of an overall infection prevention aspect when engaging in patient care. Respiratory hygiene was added to standard precautions in 2007, in recognition of the increasing risk of respiratory spread of illnesses such as pandemic influenza.

Transmission based precautions were developed in the 1970s, and were revised to be a next higher level of precautions for those infectious diseases that were spread through contact, droplet and airborne transmission. The emergence of antimicrobial resistant pathogens drove the need to update standard precautions so that healthcare environments could prevent transmission as well as keep providers safe. Just as the need for transmission-based precautions was driven by emergence of pathogen resistance, it is now time to look again at the concept of standard and transmission-based precautions and determine if additions or changes are needed in the wake of the COVID-19 pandemic.

Recent outbreaks and epidemics have shown that infection prevention needs to become more sophisticated with standard precautions, travel history and general awareness of national and international epidemiology and diseases of public health concern. Over the last two decades, the majority of the significant outbreaks was due to viral respiratory illnesses (severe acute respiratory syndrome (SARS), middle eastern respiratory syndrome (MERS), avian influenza). The SARS epidemic in part prompted the CDC to update the standard precautions to include respiratory etiquette.

In these recent outbreaks, and the current pandemic, healthcare workers (HCWs) are at increased risk for acquiring the infections purely as a result of doing their jobs. Data has shown that HCWs made up roughly 20% of cases in the SARs outbreak and 18% in the MERS outbreak.

 It is still unknown how many HCWs have become infected in the COVID-19 pandemic, but current estimates as of this writing are greater than 65,000 cases.1 Many factors can contribute to HCW infections, but often early in outbreaks and pandemics, lapses in infection control practices play a major role. Not having the appropriate type or amount of PPE, lack of isolation of infectious patients, and lack of awareness of epidemiological risk factors, such as recent travel or congregate living status, all play a part. With any type of outbreak, there is always an initial gap in awareness and understanding of the pathogen, transmission factors, and virulence. At this time is when HCWs can be most vulnerable and the outbreak has the potential to grow from a local or regional level. It is during this time when traditional application of standard precautions may not be enough.

Recent articles in the press have been debating the role of airborne transmission in COVID-19 spread.

 While there is not a clear consensus, what does appear to be clear is the need to develop more nuanced definitions of droplet and airborne transmission. The desire to have a very mutually exclusive and clear separation of the types of transmission makes it easier to educate, implement, and monitor. However, science shows that it is more of a continuum that is impacted by many variables, which leaves much up to the bedside practitioner to evaluate and assess risk levels.

Environmental factors, such as humidity level, air exchanges, pressure differentials, can all impact the amount of aerosolization that can occur with respiratory droplets.

 Patients themselves impact, with activity levels, cough etiquette and other host factors that can potentially impact communicability of the virus. The strain of the virus can be more infectious than others, which is not known at the time of admission to the healthcare facility. Manipulations and treatments that are done to the patients also impact the ability of aerosolization, such as oxygenation modalities, endotracheal intubation, bronchoscopies or nebulizing medication treatments.

 All of these factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions.

With the knowledge that respiratory illnesses have been the greatest international impact on recent outbreaks, it is time to again review the items included in standard and transmission-based precautions and potentially include some variation of universal masking for patient encounters. In particular, this may be most essential in frontline areas, such as emergency departments, urgent care centers, ambulances and first responders, where there is no known history for the patient and unknown exposure risks. Also, in areas where many aerosol generating procedures are occurring, such as intensive care units, procedural areas, respiratory care units and dental clinics.

Another difficult lesson learned from the COVID-19 pandemic is the inadequate supply of respirator options that are available across the healthcare continuum for staff. Traditional N95 masks that require fit testing were in short supply as the pandemic ratcheted up. In even shorter supply were other types of respirators that did not require fit testing, such as PAPRS, CAPRS and other full-face respirator options.

And with almost all of these types of respirators, there are still contraindications for use, such as facial hair, eyeglasses, severe asthma, or other health conditions of the worker. This has revealed a long feared weak link in the ability of a facility to provide adequate protection to all its healthcare workers at the most crucial time it is needed. Efforts to increase not only the availability of current respirators, but also develop new technologies that offer the same level of protection, but have more universal fit and application to a wide variety of users, should be a push from manufacturers and vendors for healthcare and other essential workers.

More research is needed in the field of disease transmission, and in particular for respiratory illnesses. Many studies are based on animal models, which have limitations with human physiology, or are lab-based, which have limitations in real-world scenarios. Understanding of how effective the airborne or aerosol spread is for various respiratory diseases would provide much needed information on how best to develop transmission-based precautions that are effective. A review of the current recommendations of airborne precautions would also elucidate which components are most effective in breaking the chain of disease spread.

And based on these types of data, precautions for specific viral illness could be more specific and also more customizable based on transmission factors. However, until that time comes, and with the continued threat of emerging viral respiratory pathogens, consideration of universal masking guidelines as part of standard precautions may be the beginning of another evolution of how we approach infection prevention practices in healthcare organizations.

has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

Xiao J, Fang, M, Chen Q, He B. SARS, MERS and COVID-19 among healthcare workers: A narrative review. 

World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations.WHO website.https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations#.XxIWGGzGYPA.email

Klompas M, Baker MA, Rhee C. Airborne transmission of SARS-CoV-2:theoretical considerations and available evidence. JAMA Network. Published online July 13, 2020. doi:10.1001/jama.2020.12458

Shiu EYC, Leung NHL, Cowling, B. Controversy around airborne versus droplet transmission of respiratory viruses: implication for infection prevention. 

Many factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions. 

Revamp Standard Precautions for Infection Preventionists

Let’s assume that hand hygiene compliance has increased during the coronavirus disease 2019 (COVID-19) pandemic. Now the challenge for infection preventionists (IPs) and others on the frontlines of infection control and prevention: Sustain those gains. But how?

Employ the concepts of behavioral change, including informal leaders, social pressures, cultural norms, and immediate and personal feedback. Informal leaders are people within a work area who are respected and seen as individuals who can be trusted and followed.

Informal leaders can either undo an intervention or change it if they don’t accept it, or they can vastly move a program forward if they are brought in as a stakeholder from the beginning. Social pressures and cultural norms exist on a large scale down to a small scale, such as a profession, hospital, unit within a hospital, and even a shift within the unit. These norms dictate acceptable behaviors, and social pressures can change the norms to reflect changes in what is acceptable for that particular culture.

Finally, personal feedback can help reinforce the behavior that is desired by noticing and praising the person when it’s done. Also, personal feedback that is done through consideration can also be used to help identify when a norm or behaviors don’t meet expectations and to help the person understand what behavior is expected. Successful feedback needs to be timely, specific, and focus on the actions or behavior that is observed.

IPs could perform informal surveys of staff perceptions of hand hygiene in this time and use that information to help find the reasons why people are doing the right thing. They can also use that knowledge to develop campaigns and materials that will continue to encourage positive change. Studies have shown that to enact social change, only about 25% of a group needs to adopt the change and move the rest of the group forward.

In the past, when there have been major national health threats, such as anthrax attacks and Ebola, the federal government earmarked funding for grants and programs that would be used for public health efforts or for hospitals to obtain training or personnel to focus on preparedness efforts. If funding becomes available for healthcare facilities as a result of increased government grants or programs, it would be ideal to use some of those funds to invest in technology that would improve hand hygiene compliance, such as the electronic monitoring systems.

Another option is telemedicine, using electronic communication to decrease the number of times staff have to come in and out of the patient rooms, therefore removing one of the known barriers to hand hygiene compliance. But ultimately technology cannot solve all the barriers for hand hygiene compliance and, to truly have sustained change, a cultural shift must occur within the facility.

Role modeling, timely feedback, consistent monitoring, and data reports all help support the clean hands culture that is needed in healthcare facilities. At this time, months into the COVID-19 pandemic, some of the behavior change will start to normalize. Before habits return to pre-COVID ways, IPs have the opportunity to build on the renewed importance of hand hygiene in healthcare and start to build the foundations of a new hand hygiene campaign in their facilities.

Leadership involvement is key, as well as finding those informal leaders in the unit level who can be local champions and the role models needed to help drive overall behavior. The core of much of what an IP does requires them to become change agents. A strong change agent needs to be curious, persistent, and collaborative. There are many examples of research on how to influence behavior change and how to utilize some of the informal leaders, social pressure, and feedback to create that culture shift within an organization. An IP does not receive formal education on behavior change science, but it would be beneficial to seek out some of these resources and perhaps work with local and national professional organizations to offer course work, online classes and other avenues to include these topics into the IP trainings.

Behavior change during a pandemic is related to several factors: risk assessment, personal fears, social factors, informational campaigns, and cultural expectations.

 Social factors in a healthcare setting are peer pressure, role modeling, and social comparisons with other units or departments. Also, patients are more acutely aware of the role of hand hygiene in a pandemic and are another source of social pressure to perform.

Hand hygiene has always been the most common way that IPs have talked about preventing the spread of infection, and that has been true with COVID-19. The first item listed on the US Centers for Disease Control and Prevention (CDC) website on how to prevent the spread is hand hygiene and it has been consistently educated to the public. During this time, as the pandemic is making disease transmission and the chain of infection come to life for everyone, hand hygiene is again being seen as everyone’s responsibility.

One challenge to understanding how hand hygiene habits changed in healthcare during COVID-19 is the ability to accurately measure and report compliance data. Hand hygiene is most typically monitored via secret shopper observations. During times of pandemics, the staff who would typically be doing these observations, such as nursing supervisors, ancillary staff, and infection preventionists may be pulled into other duties or not available. Monitoring and observing for hand hygiene may not be a top priority when other patient care concerns are paramount.

Also, secret shopper observations have an inherent flaw in observational bias and Hawthorne effect, which have been recognized as a well-known shortcoming of data reported using that type of data collection. These limitations create a gap in knowledge to understand whether compliance increased or whether that is a perception or assumption.

Changing the culture won’t be easy. It’s been tried again and again and points back to the most basic of questions: Why do healthcare workers not perform hand hygiene, even when they understand the importance of that task to prevent the transmission of infections? Many studies have looked at common reasons why hand hygiene opportunities are missed including: inconvenient placement of dispensers/sink; broken dispenser/sink; distractions; perception of lack of time; inappropriate glove use; skin irritation; workflows do not provide opportunity; and frequent entry and exit of the patient care area.

Healthcare facilities have struggled with achieving and sustaining high compliance rates of hand hygiene, despite the awareness and knowledge of its importance for centuries. Semmelweis was the first hand hygiene champion in 1858, and was met with disdain at first, eventually gaining some acceptance before being sent to a mental institution.

 Studies have found that, on average, compliance is usually around 50%, with some healthcare workers having more than 100 opportunities for hand hygiene during a normal work shift.

Electronic hand hygiene monitoring systems have been shown to provide more reliable data and also can improve compliance rates.

 These systems help remove the Hawthorne effect and observation bias associated with secret shopper programs. Also, some have reminder capabilities that would help notify staff when they have nearly missed a hand hygiene opportunity. Another benefit of these programs is the data analytics and ability to share nearly real-time data with staff and leadership. One of the biggest barriers for IP programs to adopt electronic monitoring is the cost associated with establishing and sustaining these programs.

Often IP does not have a budget, and the costs can be substantial, therefore the approval to spend the funds must be made from top leadership of the organization. IPs can help make the business case for these programs, focusing on where other organizations have seen success and published results, use those numbers to get an idea of the changes that could happen and try to equate that to HAIs prevented and potential cost savings for the organization.

During a time of pandemic, many hospitals are actually struggling financially because the usual elective patients are not coming to the hospital. Therefore, there is even less room in budgets to invest in an electronic program.

The process for establishing the cost-benefit analysis of these electronic systems can improve hand hygiene compliance and therefore improve the ability to respond to future outbreaks and keep patients and staff safe.

Given so many reasons why hand hygiene is not performed, as an IP it is important to acknowledge these barriers and attempt to address them within the organization to ensure that healthcare workers can feel supported to do the right thing and be given the type of environment that supports hand hygiene. Part of this includes developing a safety culture within the organization that will encourage compliance with all infection prevention protocols and initiatives.

Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to 

, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

Catherine A. Sanderson, CA. Changing social norms in the time of a pandemic. 

https://www.psychologytoday.com/us/blog/norms-matter/202003/changing-social-norms-in-the-time-pandemic

Samson, A. Under pressure: good behavior in the COVID-19 pandemic. 

https://www.psychologytoday.com/us/blog/consumed/202005/under-pressure-good-behavior-in-the-covid-19-pandemic

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https://www.beckershospitalreview.com/quality/what-causes-hand-hygiene-noncompliance-24-issues.html

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Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. CDC website. 

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Radtke, J. Improve your hand hygiene compliance rates: three insights from the University of Tennessee Medical Center. 

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To enact social change such as better hand hygiene, only about 25% of a group needs to adopt the change and move the rest of the group forward.

Hand Hygiene in the Post-COVID-19 Era

The topic of appropriate personal protective equipment (PPE) is continuously in the media and trade articles thanks to the COVID-19 pandemic. PPE supply and use is a daily topic for those who work in infection prevention and one of the main tools used to prevent the spread of infection in healthcare facilities. The use of N95 respirators, and their equivalent, is currently a subset of the PPE focus that has many facilities scrambling to provide the best PPE available to staff and keep their stock in hand. 

Respiratory protection programs mandated by the Occupational Safety and Health Association (OSHA) include the process of training, providing medical clearance, and fit testing for respirator use in healthcare facilities. These programs are often run by an occupational or employee health department in collaboration with safety, emergency management, infection prevention, and human resources. Several requirements include ensuring that health care providers (HCP) know how to use respirators, how to don and doff appropriately, when to use the respirator, and how to maintain their PPE to maximize the lifespan of that respirator. 

Traditionally, these are accomplished via an annual fit test through occupational health, which is done for HCPs who may have contact with infectious agents that require airborne precautions (ie, tuberculosis, measles, chicken pox). 

Typically, the fit testing depends on the annual anniversary of hire date, department-specific dates for testing, or some other pre-determined timeframe to have staff come through on a scheduled basis so as to not overwhelm the occupational health department. In a pandemic situation of a respiratory illness, when many staff members need to have quick access to appropriate respirators, the process for fit testing has to change to a different model of operationalization.

Just-in-time (JIT) fit testing allows a healthcare organization to offer evaluation, training, and fitting of HCPs during rapid intervals, as needed, based on specific patient care assignments. Many institutions have JIT fit testing as part of their plans for pandemic influenza or Ebola preparations. In order to implement JIT programs, many key components need to be considered. Also, in March 2020, OSHA issued a temporary guidance that allows healthcare facilities to suspend annual fit testing due to shortages, as long as staff have a prior fit test with the same model respirator.

 This allows for JIT fit testing to be accomplished for staff in a rapid pace needed to keep up with patient care needs.

Another way to better implement JIT fit testing is to utilize qualitative test methods versus quantitative. The more commonly used qualitative method involves the use of a sweet, saccharin solution sprayed into a hood while the HCP wears the respirator. If the HCP can taste the sweet solution, then essentially, they fail the fit test for that respirator. 

Quantitative fit testing involves modifying the respirator to allow access for a sampling port, therefore damaging the respirator so that it cannot be used after the fit test. Again, in recognition of PPE shortages (so glaringly revealed during the COVID-19 pandemic), OSHA recommended using qualitative fit testing over quantitative to conserve respirators and making JIT more feasible. OSHA did so in the same March 2020 temporary guidance.

Occupational health programs historically control the fit testing process. However, in an emergency situation, occupational health would likely not have the capacity to offer JIT fit testing at all times for HCPs, therefore a cadre of staff need to be trained into the roles and assigned a schedule to have the service available 24/7. 

Occupational health departments can train staff, make sure they are certified to teach the process, thereby making a labor pool of fit testers available in the facility for the times and days needed. Often in pandemics-and, again, as we’ve seen recently with COVID-19-job roles need to be adjusted, so there may be staff from low work-load areas that comprise the JIT fit testing team. 

Having this resource staffed consistently meets the needs of HCPs and can reduce the anxiety about finding the appropriate size mask in a moment. Another method of training staff for fit testing that has been shown to be effective is through a video.

 If occupational health is not available, or there are a large number of locations and staff that need training, having a video option for training with a competency would be a reasonable alternative. 

Part of the JIT process needs to include a tracking mechanism for staff. Having a searchable database of all the sizes that staff have fitted would be a helpful tool. Along with a database that is kept by the JIT program staff, develop a way for staff to also track their own mask types and sizes that they can fit. This can be accomplished by having a sticker or badge accessory so that staff will always have it written on their badges and available whenever at the facility. During pandemic situations, the usual masks that an organization uses for annual fit testing and patient care may not be available, so new products will be brought in regularly as alternatives. Having a log of which sizes work for HCPs and also a document that shows comparable products that tend to be similar in size is helpful as well to decrease guessing and wasting masks that may not fit staff.  

Similarly, working with logistics support to review the options available for respirators, tracking usage and days on hand, projecting volumes, estimating how a surge of a certain percentage would impact supply, and reporting those data regularly creates a successful program. Other supplies needed for JIT include the hoods or test kit components and the saccharin or bitter testing solution. During pandemics, these supplies can also be in high demand and integrating those into the tracking helps prevent any unforeseen delays in JIT testing. 

Part of the JIT process is to prioritize or delineate the HCPs who would need to use respirators. This can be accomplished by looking at job roles and departments that would interact with patients who require airborne precautions and tasks that are done by the various job roles. Cross training staff, such as having nurses perform phlebotomy or administer nebulizing treatments, can limit staff who need to interact with patients in airborne precautions when PPE are in demand. 

Also, adjust when some processes should be implemented. For instance, only have the room cleaned by housekeeping after discharge. In addition, wait the allotted time for appropriate air exchanges in the room so that environmental services staff won’t need to don N95 respirators to perform their duties. Also, cohort patients and staff so that the JIT fit testing can be focused on that select group who will have the most need.

The use of JIT fit testing is essential to providing HCPs with the appropriate PPE during outbreaks, pandemics, and emergent respiratory illness disasters. Part of the planning for emergency preparedness can involve developing JIT guidelines and program guidance so that can be used in training and be available when the next outbreak occurs. Currently, many organizations are using JIT testing as part of their response to the COVID-19 pandemic. Documentation of operations of those programs will be key and any lessons learned from current experiences can be utilized for future planning.

Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to Infection Control Today®, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

1.      US Department of Labor, Occupational Safety and Health Administration. Temporary enforcement guidance-healthcare respiratory protection annual fit-testing for N95 filtering facepieces during the COVID-19 outbreak. 

https://www.osha.gov/memos/2020-03-14/temporary-enforcement-guidance-healthcare-respiratory-protection-annual-fit

2.     Harper et al. Comparison of three respirator user training methods. 

Just-in-time (JIT) fit testing allows a healthcare organization to offer evaluation, training, and fitting of HCPs during rapid intervals, as needed, based on specific patient care assignments. 

Author | Rebecca Leach, RN, BSN, MPH, CIC

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