Evaluation of Minnesota and Illinois hospital respiratory protection programs and health care worker respirator use

Elastomeric half-mask respirator disinfection practices among healthcare personnel

BACKGROUND

Disposable N95 respirator shortages during the COVID-19 and 2009 H1N1 influenza pandemics highlighted the need for reusable alternatives, such as elastomeric half-mask respirators (EHMRs). Two US medical organizations deployed reusable EHMRs during the COVID-19 response. In addition to wipe-based disinfection following patient care episodes expected per local policies at both organizations, postshift centralized cleaning and disinfection (C&D) was expected at one site (A), permitting shared-pool EHMR use, and optional at the other (Site B), where EHMRs were issued to individuals. Using a survey, we evaluated disinfection practices reported by EHMR users and predictors of disinfection behaviors and perceptions.

METHODS

Surveys assessed EHMR disinfection practices, occupational characteristics, EHMR use frequency, training, and individual-issue versus shared-pool EHMR use.

RESULTS

Of 1080 EHMR users completing the survey, 76% reported that they disinfect the EHMR after each patient encounter, which was the expected practice at both sites. Increasing EHMR use, recall of disinfection training, and work in intensive care or emergency settings significantly influenced higher reporting of this practice. 36% of respondents reported using centralized C&D, although reporting was higher at the site (A) where this was expected (53%). Confidence in cleanliness of the EHMR following centralized C&D was not influenced by individual versus shared-pool EHMR issue.

CONCLUSIONS

Most EHMR users reported adherence with expected post-care individual-based disinfection of EHMRs but did not necessarily use standardized, centralized C&D. Future efforts to limit reliance on behavior related to respirator disinfection may improve EHMR implementation in healthcare to avert dependence on single-use, disposable N95 respirators.

Using a Critical Safety Behavior Scoring Tool for Just-in-Time Training for N95 Respirator Use

BACKGROUND

Historically, health care workers (HCWs) have exhibited marginal adherence to proper N95 respirator use. During the COVID-19 pandemic, HCWs with little to no prior training on N95 respirator use are relying on N95s as their primary respiratory protection. There is a need for simple, effective, and easily implementable just-in-time training (JITT) interventions to improve N95 respirator-related safety behavior. This study investigated two JITT interventions.

METHODS

A pilot experimental pretest posttest study design was used to evaluate two training interventions for N95 respirator donning/doffing performance at a Midwestern hospital system. HCW participants were randomly assigned to an intervention: one used a 4-minute instructional video alone, while the other used the same video but added a video reflection intervention (participant watched and scored a video of their own performance). All performances were scored using a 10-point Critical Safety Behavior Scoring Tool (CSBST).

FINDINGS

Sixty-two HCWs participated (32 video alone, 30 video reflection). The two groups' CSBST scores were not significantly different at pretest. Averaged participant scores on the CSBST improved immediately following both interventions. Scores were significantly higher on the posttest for the reflective practice intervention (p<.05). Years of experience and frequency of N95 respirator use did not predict pre or post scores.

CONCLUSIONS/APPLICATIONS TO PRACTICE

We provide evidence to support the use of a time-efficient JITT intervention to improve HCW N95 respirator donning/doffing practices during the COVID-19 pandemic and beyond. Hospital safety professionals should consider this type of training for HCWs required to wear respiratory protection.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review

OBJECTIVES

To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types.

DESIGN

Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare.

DATA SOURCES

Websites of international standards organisations, Medline and Embase, hand-searching of references and citations.

STUDY SELECTION

Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use.

RESULTS

We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators.

CONCLUSION

A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

A simulation approach to measure critical safety behaviors when evaluating training methods for respirator education in healthcare workers

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N95 respirators are a common tool in healthcare for airborne isolation and pandemic response.

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Simulation can be used to train healthcare workers.

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Reflective practice may be a training intervention to improve N95 respirator use compared to video alone.

Background

The N95 respirator is the most common safety tool used in hospitals to protect health care workers (HCW) from inhaling airborne particles. Focusing on HCW behavior related to respirator use is an effective route to improve HCW safety and respiratory health.

Methods

Participants were asked to perform the donning and doffing of an N95 respirator to camera. Then they were randomized to a video alone or a reflective practice intervention. After the intervention they repeated the donning and doffing to camera. A critical safety behavior scoring tool (CSBST) was developed to compare the performance of the participants over time at pretest, post-test and 1 month later for follow-up.

Results

The reflective practice intervention group was found to have significantly higher scores on the CSBST at post-test and follow-up than the video alone group. In the reflective practice intervention group, the participants perceived they were better at performing the N95 donning and doffing than the experts scored them.

Conclusions

The CSBST is a tool to measure the performance of HCWs on a specific targeted safety behaviors. The addition of a reflective practice intervention may result in a measurable and sustained improvement in the safety behaviors demonstrated when using the N95 respirator.

Respiratory Protection Program Compliance in Iranian Hospitals: Application of Fuzzy Analytical Hierarchy Process

In hospitals, health care workers (HCWs) are exposed to a wide range of respiratory hazards, which requires using respiratory protective equipment and implementing Respiratory Protection Programs (RPPs). The aim of this cross-sectional study was to investigate RPP implementation in 36 teaching hospitals located in the Fars province of Iran. A researcher-developed checklist, including nine components of the RPP standard, was completed by industrial hygienists in the study hospitals. The Fuzzy Analytical Hierarchy Process (FAHP) was used to determine the weight coefficient of RPP components. Finally, a Respiratory Protection Program Index (RPPI) was developed to calculate hospital compliance with RPP. The results showed that RPP were not fully implemented in the studied hospitals, and the highest and lowest RPPI scores were related to training and fit testing, respectively. To promote the implementation of RPP, significant efforts are required for all components, especially fit testing and worker evaluation.

Development and initial validation of the Respirator Comfort, Wearing Experience, and Function Instrument [R-COMFI]

Filtering face-piece respirators (FFRs) are worn to protect health care personnel from airborne particles; however, clinical studies have demonstrated that FFR adherence is relatively low in some settings, in part, due to discomfort and intolerance. The objective of this study was to develop and initially evaluate the psychometric properties of an instrument designed to measure the comfort and tolerability of FFRs. Instrument items were developed through literature reviews, focus groups, and several iterations of ranking and refining by experts. Psychometric evaluation of the instrument was conducted using Rasch partial credit model (PCM) analysis. Pivot anchoring was used to specify the threshold defining item difficulty; in our analyses, this was the point that participants moved from possessing none of the trait to some of the trait. The final instrument was completed by 165 health care personnel from 3 Veterans Health Administration facilities, and data were analyzed using Rasch PCM. Seven items were removed because they: (1) violated the assumption of independence; (2) were mis-fitting; and/or (3) were deemed not relevant. Category function analysis demonstrated that all categories progressed monotonically. Principal components analysis demonstrated the existence of three subscales (Discomfort, General Wearing Experience, and Function). Final reliability analyses showed that the scale had moderate to high person reliability and high item reliability. The final instrument contained 21 items. Until now, to our knowledge no instrument with evidence supporting its reliability and validity to assess discomfort and tolerance of FFRs among health care personnel has been published. A 21-item psychometrically sound measure of comfort and tolerability of FFRs, Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), was developed. The significance of developing such an instrument is that it will help identify respirators that are likely to have better adherence in practice settings. The R-COMFI may be used within and beyond the VA healthcare system as a psychometrically sound instrument to evaluate the comfort and tolerability of respirators, including developmental prototypes.

Aerosol transmission of infectious disease

OBJECTIVE

The concept of aerosol transmission is developed to resolve limitations in conventional definitions of airborne and droplet transmission.

METHODS

The method was literature review.

RESULTS

An infectious aerosol is a collection of pathogen-laden particles in air. Aerosol particles may deposit onto or be inhaled by a susceptible person. Aerosol transmission is biologically plausible when infectious aerosols are generated by or from an infectious person, the pathogen remains viable in the environment for some period of time, and the target tissues in which the pathogen initiates infection are accessible to the aerosol. Biological plausibility of aerosol transmission is evaluated for Severe Acute Respiratory Syndrome coronavirus and norovirus and discussed for Mycobacterium tuberculosis, influenza, and Ebola virus.

CONCLUSIONS

Aerosol transmission reflects a modern understanding of aerosol science and allows physically appropriate explanation and intervention selection for infectious diseases.

Respirator Use in a Hospital Setting: Establishing Surveillance Metrics

Information that details use and supply of respirators in acute care hospitals is vital to prevent disease transmission, assure the safety of health care personnel, and inform national guidelines and regulations.

OBJECTIVE

To develop measures of respirator use and supply in the acute care hospital setting to aid evaluation of respirator programs, allow benchmarking among hospitals, and serve as a foundation for national surveillance to enhance effective Personal Protective Equipment (PPE) use and management.

METHODS

We identified existing regulations and guidelines that govern respirator use and supply at Vanderbilt University Medical Center (VUMC). Related routine and emergency hospital practices were documented through an investigation of hospital administrative policies, protocols, and programs. Respirator dependent practices were categorized based on hospital workflow: Prevention (preparation), patient care (response), and infection surveillance (outcomes). Associated data in information systems were extracted and their quality evaluated. Finally, measures representing major factors and components of respirator use and supply were developed.

RESULTS

Various directives affecting multiple stakeholders govern respirator use and supply in hospitals. Forty-seven primary and secondary measures representing factors of respirator use and supply in the acute care hospital setting were derived from existing information systems associated with the implementation of these directives.

CONCLUSION

Adequate PPE supply and effective use that limit disease transmission and protect health care personnel are dependent on multiple factors associated with routine and emergency hospital practices. We developed forty-seven measures that may serve as the basis for a national PPE surveillance system, beginning with standardized measures of respirator use and supply for collection across different hospital types, sizes, and locations to inform hospitals, government agencies, manufacturers, and distributors. Despite involvement of multiple hospital stakeholders, regulatory guidance prescribes workplace practices that are likely to result in similar workflows across hospitals. Future work will explore the feasibility of implementing the collection and reporting of standardized measures in multiple facilities.

Comparing written programs and self-reported respiratory protection practices in acute care hospitals

Airborne biological hazards in hospitals require the use of respiratory protection. A well-implemented respiratory protection program can protect health care workers from these exposures. This study examines the relationship between written respiratory programs and reported practices in health care settings. Twenty-eight hospitals in Illinois and Minnesota were recruited to a study of respiratory protection programs and practices in acute care settings. Interviews were conducted with hospital managers, unit managers, and health care workers from departments where respirators are commonly required. Each hospital's written respiratory protection program was scored for the 11 elements required by the Occupational Safety and Health Administration (OSHA), using a standardized tool, for a maximum possible score of 22 (2 pts. per element). Twenty interview questions associated with program practices were also scored by percent correct responses. Written program scores ranged from 2-17 with an average of 9.2. Hospital and unit managers scored on average 82% and 81%, respectively, when compared to the OSHA standard; health care workers scored significantly lower, 71% (p < 0.001). Minnesota written program scores were not significantly higher than Illinois hospitals (p = 0.16), while all Illinois survey respondents scored higher than those in Minnesota (p < 0.001). There was no trend between written programs and interview responses. Written respiratory protection programs in the study sites did not provide the level of detail required OSHA. Interview responses representing hospital practices surrounding respiratory protection indicated that hospitals were aware of and following regulatory guidelines.