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

Experiences when using different EHMR models: Implications for different designs and meeting user expectations

BACKGROUND

New elastomeric half-mask respirator (EHMR) models without exhalation valves (EVs) or with exhalation valve filters (EVFs) are facilitating expanded use in health settings to reduce workers' exposure to airborne hazards while acting as source control to prevent pathogen spread. The physical comfort of new models has not been assessed in comparison to previously used EHMRs with EVs.

METHODS

Researchers assessed 1,962 health care and emergency medical service personnels' self-reported adverse experiences from 2 cohorts while wearing EHMR models with EVs (cohort 1, n = 1,080) and without EVs or with EVFs (cohort 2, n = 882). Fisher exact test identified differences between the cohorts accounting for organizational factors when possible.

RESULTS

Cohort 1 respondents experienced communication challenges and discomfort when wearing the EHMR > 1 hour statistically significantly more often than cohort 2. Cohort 2 respondents reported statistically significantly more instances of difficulty breathing, moisture buildup, being uncomfortable to wear < 1 hour, and being uncomfortably warm.

CONCLUSIONS

Discomfort is prevalent among end users and more often among those wearing EHMRs without an EV/with an EVF. As EHMR research and development advances, prevalence in use may increase for emergency and routine situations. Organizations may not only need guidance about respirator selection but also model-specific selection.

Health Care Workers' Comfort Ratings for Elastomeric Half-Mask Respirators Versus N95® Filtering Facepiece Respirators During the COVID-19 Pandemic

BACKGROUND

Reusable elastomeric half-mask respirators (EHMR) are an alternative to address shortages of disposable respirators. While respirator discomfort has been noted as a barrier to adherence to wearing an N95 filtering facepiece respirator (FFR) among health care personnel (HCP), few have examined EHMR comfort while providing patient care, which was the purpose of this study.

METHOD

Among a cohort of 183 HCP, we prospectively examined how HCP rated EHMR tolerability using the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI) questionnaire at Study Week 2 and Week 10. At the completion of the study (Week-12), HCP compared EHMR comfort with their prior N95 FFR use. Overall R-COMFI scores and three subscales (comfort, wear experience, and function) were examined as well as individual item scores.

FINDINGS

The HCP reported an improved overall R-COMFI score (lower score more favorable, 30.0 vs. 28.7/47, respectively) from Week 2 to Week 10. Many individual item scores improved or remained low over this period, except difficulty communicating with patients and coworkers. The overall R-COMFI scores for the EHMR were more favorable than for the N95 FFR (33.7 vs. 37.4, respectively), with a large proportion of workers indicating their perception that EHMR fit better, provided better protection, and they preferred to wear it in pandemic conditions compared with the N95 FFR.

CONCLUSION/APPLICATION TO PRACTICE

Findings suggest that the EHMR is a feasible respiratory protection device with respect to tolerance. EHMRs can be considered as a possible alternative to the N95 FFR in the health care setting. Future work is needed in the EHMR design to improve communication.

A comparative study of point-of-care protection from N95 filtering face-piece respirators in a Residential Aged Care Facility and a Tertiary Hospital-Respiratory protection challenges remain amidst long-term impacts of COVID-19

This study compared the effectiveness of N95 FFRs in providing respiratory protection for healthcare staff in a residential aged care facility (RACF) and tertiary teaching hospital (TTH) who had previously passed their occupational respiratory protection program fit test. A total of 126 healthcare workers who were regularly using N95 FFRs and who had previously passed a fit test participated in this comparative study. In this study, participants were again fit tested with the PortaCount machine, and their self-assessed tolerability of wearing an N95 FFR was assessed using a standardized questionnaire. The main outcome measures included the pass rate of the fit test and the assessment of tolerability and comfort of the N95 FFR. Across all participants, the fit test pass rate was low (27%), indicating persistent gaps in respiratory protection programs for healthcare workers during the ongoing COVID-19 pandemic. Hospital workers were 3.7 times more likely to pass the test compared to their counterparts in RACFs (p < 0.001). It was also found that workers in RACFs reported higher levels of discomfort and overall dissatisfaction with N95 FFRs compared to hospital staff. These findings highlight the need for targeted interventions and improvements in respiratory protection practices beyond annual fit testing, particularly in RACFs, to ensure the safety of healthcare workers and the vulnerable population they serve.

Impact of Hydrocolloid Dressing and Moisturizing Cream as Facial Skin Protectants Among Health Care Workers

INTRODUCTION

During the novel coronavirus disease 2019 pandemic, health care workers experienced facial problems from prolonged use of N95 masks, including skin irritation, pigmentation changes, and contact dermatitis. We assessed the use of hydrocolloid dressing versus dimethicone cream to prevent skin breakdown among military health care workers while wearing an N95.

MATERIALS AND METHODS

Participants were recruited using convenience and snowball sampling in this nonblinded, randomized, cross-over study with 2 active treatments, hydrocolloid dressing and dimethicone cream, across 3 time points. The skin was assessed using photographs and subepidermal moisture scanner (SEM). N95 seal integrity was assessed using qualitative fit test. Institutional review board approval was obtained from the Madigan Army Medical Center Institutional Review Board.

RESULTS

Among the 73 participants, wearing an N95 alone versus with dimethicone cream or hydrocolloid dressing caused more adverse skin reactions. There were no significant differences in qualitative fit test failure rate between groups. Participants experienced minimal to no dizziness, loss of energy/tiredness/fatigue, claustrophobia, shortness of breath, difficulty breathing, and dry or itchy eyes. For all interventions, wearing an N95 did not interfere with participants' concentration, verbal communication, hearing, vision, and, importantly, delivery of care.

CONCLUSIONS

Using a skin protectant with an N95 may prevent adverse skin reactions while preserving health care workers' ability to safely and competently care for patients in routine and pandemic conditions.

Hill CA. Use of Elastomeric Half-Mask Respirator in the Clinical Care Environment: Health Care Worker Perceptions

BACKGROUND

Elastomeric half-mask respirators (EHMR) reduce health care workers' exposure to airborne hazards including bioaerosols but have primarily been used in the industrial setting.

PURPOSE

To assess health care workers' perceptions, attitudes, and experiences wearing EHMRs in a clinical environment.

METHODS

Employees within a single health care system who wore the EHMR continuously during their shift completed an investigator developed survey. Descriptive statistics and thematic analysis were used.

RESULTS

Of the 8273 EHMR "fit-tested" eligible employees, 1478 met inclusion criteria and participated. Respondents reported that they felt well protected with the EHMR and confident in their care and maintenance of the EHMR. Although skin changes developed, they were primarily managed by adjusting the straps. Clarity of communication was a concern across all respondents and disciplines.

CONCLUSIONS

The EHMR was preferred over reusing the N95 although clarity in communication was challenging.

Health effects of filtering facepiece respirators: Research and clinical implications of comfort, thermal, skin, psychologic, and workplace effects

Filtering facepiece respirators (FFR's) such as N95s have become widely used in appropriate settings for personal respiratory protection and are increasingly used beyond workplace settings. Concerns about possible adverse effects have appeared in many publications, particularly since the COVID-19 pandemic led to much more widespread use. This paper synthesizes known effects based upon review of publications in PubMed since 1995, addressing effects other than pulmonary and cardiovascular (reviewed elsewhere). Findings: (1) Subjective discomfort is very frequently reported; this includes general discomfort or organ-system-specific complaints such as respiratory, headache, dermatologic, and heat. Research methods are widely divergent, and we propose a taxonomy to classify such studies by methodology, study population (subjects, experimental vs. observational methodology, comparator, specificity, and timeframe) to facilitate synthesis. (2) Objective measures of increased heat and humidity within the mask are well documented. (3) Frequency and characteristics of dermatologic effects have been insufficiently evaluated. (4) Physical mask designs are varied, making generalizations challenging. (5) More studies of impact on work performance and communication are needed. (6) Studies of effect of FFR design and accompanying training materials on ease and consistency of use are needed.

Tolerability, User Acceptance and Preference for a Novel Reusable Respirator Among Healthcare Workers

BACKGROUND

The CleanSpace Technology Halo respirator combines a clear face mask and a powered air supply, without belts or hoses. Although providing higher protection than other respirators used in healthcare, user acceptance of this device has not been assessed with validated tools.

METHODS

We surveyed healthcare workers (HCWs) within a US medical system using Halo respirators in 2021. Subjects completed three surveys over eight weeks, which included the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), a validated tool to assess respirator tolerability. The survey included additional questions about user acceptability and respirator preference. Responses were evaluated for change over time and for significant predictors.

RESULTS

Of 113 HCWs who completed the initial survey (29% response rate), mean ± SD R-COMFI score was 9.1± 5.1, (scale 0-47, lower = more tolerable) and did not change over time (p = 0.42). Fewer years in healthcare significantly predicted better R-COMFI score (p=0.01). Many users preferred Halo in both usual care (45-52%) and care of patients with COVID-19 (60-64%).

DISCUSSION

Halo respirators received favorable tolerability scores by HCWs, who often preferred them, especially during care of patients with COVID-19.

CONCLUSIONS

Given demand for respirator use in healthcare, the innovative design provides higher protection than other respirators with a favorable user experience.

Personalised 3D printed respirators for healthcare workers during the COVID-19 pandemic

Widespread issues in respirator availability and fit have been rendered acutely apparent by the COVID-19 pandemic. This study sought to determine whether personalized 3D printed respirators provide adequate filtration and function for healthcare workers through a Randomized Controlled Trial (RCT). Fifty healthcare workers recruited within NHS Lothian, Scotland, underwent 3D facial scanning or 3D photographic reconstruction to produce 3D printed personalized respirators. The primary outcome measure was quantitative fit-testing to FFP3 standard. Secondary measures included respirator comfort, wearing experience, and function instrument (R-COMFI) for tolerability, Modified Rhyme Test (MRT) for intelligibility, and viral decontamination on respirator material. Of the 50 participants, 44 passed the fit test with the customized respirator, not significantly different from the 38 with the control (p = 0.21). The customized respirator had significantly improved comfort over the control respirator in both simulated clinical conditions (p < 0.0001) and during longer wear (p < 0.0001). For speech intelligibility, both respirators performed equally. Standard NHS decontamination agents were able to eradicate 99.9% of viral infectivity from the 3D printed plastics tested. Personalized 3D printed respirators performed to the same level as control disposable FFP3 respirators, with clear communication and with increased comfort, wearing experience, and function. The materials used were easily decontaminated of viral infectivity and would be applicable for sustainable and reusable respirators.

Effect of Cloth Masks and N95 Respirators on Maximal Exercise Performance in Collegiate Athletes

This study compared exercise performance and comfort while wearing an N95 filtering facepiece respirator (N95), cloth mask, or no intervention control for source control during a maximal graded treadmill exercise test (GXT). Twelve Division 1 athletes (50% female, age = 20.1 ± 1.2, BMI = 23.5 ± 1.6) completed GXTs under three randomized conditions (N95, cloth mask, control). GXT duration, heart rate (HR), respiration rate (RR), transcutaneous oxygen saturation (SpO2), transcutaneous carbon dioxide (TcPCO2), rating of perceived exertion (RPE), and perceived comfort were measured. Participants ran significantly longer in control (26.06 min) versus N95 (24.20 min, p = 0.03) or cloth masks (24.06 min, p = 0.04). No differences occurred in the slope of HR or SpO2 across conditions (p > 0.05). TcPCO2 decreased faster in control (B = −0.89) versus N95 (B = 0.14, p = 0.02) or cloth masks (B = −0.26, p = 0.03). RR increased faster in control (B = 8.32) versus cloth masks (B = 6.20, p = 0.04). RPE increased faster in the N95 (B = 1.91) and cloth masks (B = 1.79) versus control (B = 1.59, p < 0.001 and p = 0.05, respectively). Facial irritation/itching/pinching was higher in the N95 versus cloth masks, but sweat/moisture buildup was lower (p < 0.05 for all). Wearing cloth masks or N95s for source control may impact exercise performance, especially at higher intensities. Significant physiological differences were observed between cloth masks and N95s compared to control, while no physiological differences were found between cloth masks and N95s; however, comfort my differ.

Evaluating Filtering Facepiece Respirator Wearing-Comfort of Lebanese Red Cross Healthcare Providers

Introduction

The COVID-19 pandemic significantly increased the usage of various types of face masks. In addition, it triggered the rapid manufacture of new production lines of masks to cope with the unprecedented demand to overcome worldwide shortages. Such masks, which were previously used mostly by the health care personnel, became a daily necessity to the greater mainstream population. This rapid and sudden increase in their usage and the fact that new masks' innovations are progressively emerging to meet the growing global shortage requires an ongoing analysis on the factors associated with the fit and comfort while using these masks.

Methods

This paper presents the first translation and validation of the R-COMFI questionnaire to evaluate the comfort of a newly developed filtering face-piece respirator by the research team at the University of Antwerp. The questionnaire, which consists of 3 sections: Discomfort, General wearing experience, and Function, was translated from English to Arabic and involved 43 participants in the Lebanese Red Cross healthcare field based in Lebanon.

Results

The results showed discomfort factors that are mostly related to breathability and sweating caused by mask usage. Additionally, the results revealed that female respondents found the mask significantly less comfortable than male respondents (p-value with the two-tailed test is 0.0319), which confirmed that future validations should consider the concerns of both genders, and validated the R-COMFI translation exercise detailed in this paper.

Discussion

The contribution of this paper can be pinned down into three findings. The first finding is related to the discomfort issues. The second finding highlighted a significant difference in comfort experience between females and males. The last finding is the translation validation of the R-COMFI instrument, which confirmed that the questionnaire can be applied among wider geographical locations.

Development and validation of the discomfort of cloth Masks-12 (DCM-12) scale

During the COVID-19 pandemic, the use of face masks by the public has helped to slow the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the community. Cloth masks have been recommended because of their effectiveness, availability, and reusability. Like other types of face masks, however, user discomfort while wearing cloth masks is thought to engender behaviors that limit the effectiveness of cloth masks as source control (e.g., adjusting or removing one's mask temporarily while in public). To design cloth masks that are more tolerable, a measurement instrument for assessing subjective user discomfort is needed. Across two studies, we identified and confirmed a two-dimensional factor structure underlying the discomfort of cloth masks - discomfort related to the breathability and discomfort related to the tightness of the mask against the face and head. Additionally, we provide replicable evidence that both factor-subscales predict the self-reported frequencies of problematic mask-wearing behaviors.

Health care workers' perceptions and reported use of respiratory protective equipment: A qualitative analysis

BACKGROUND

Little is known about health care workers' (HCW) perceptions of, or experiences using, respiratory protective equipment (RPE). We sought to characterize their perceptions and identify reasons underlying inappropriate use.

METHODS

We conducted 12 focus groups with nurses and nursing assistants at 4 medical centers. We analyzed the thematic content of 73 discrete "stories" told by focus group participants.

RESULTS

We identified 5 story types surrounding RPE use: 1) policies are known and seen during work routines; 2) during protocol lapses, use is reinforced through social norms; 3) clinical experiences sometimes supersede protocol adherence; 4) when risk perception is high, we found concern regarding accessing RPE; and 5) HCWs in emergency departments were viewed as not following protocol because risk was ever-present.

DISCUSSION

HCWs were aware of the importance of RPE and protocols for using it, and these supported use when protocol lapses occurred. However, protocol adherence was undermined by clinical experience, perceived risk, and the distinct context of the emergency department where patients continually arrive with incomplete or delayed diagnoses.

CONCLUSIONS

Protocols, visual cues, and social norms contribute to a culture of safety. This culture can be undermined when HCWs experience diagnostic uncertainty or they mistrust the protocol and instead rely on their clinical experiences.

A tolerability assessment of new respiratory protective devices developed for health care personnel: A randomized simulated clinical study

BACKGROUND

U.S. health care personnel (HCP) have reported that some respiratory protective devices (RPD) commonly used in health care have suboptimal tolerability. Between 2012 and 2016, the U.S. National Institute for Occupational Safety and Health, and the Veterans Health Administration collaborated with two respirator manufacturers, Company A and B, to bring new RPD with improved tolerability to the U.S. health care marketplace. The purpose of this study was to compare the tolerability of four new prototype RPD to two models commonly used in U.S. health care delivery.

METHODS

A randomized, simulated workplace study was conducted to compare self-reported tolerability of four new prototype RPD (A1, A2, B1, and B2) worn by HCP and two N95 control respirators commonly used in U.S. health care delivery, the 1870 and 1860, manufactured by 3M Corporation. A new survey tool, the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), developed previously in part for the current study, was used as the primary outcome metric. With a maximum total score of 47, lower R-COMFI scores reflected better self-reported tolerability. Poisson regression analyses were used to estimate prototype relative risks compared to controls.

RESULTS

Conducted between 2014 and 2015 in two inpatient care rooms at the North Florida/South Georgia Veterans Health System, among 383 participants who enrolled, 335 (87.5%) completed the study. Mean total R-COMFI scores for the 3M 1870, 3M 1860, and prototypes A1, A2, B1, and B2 were 8.26, 9.36, 5.79, 7.70, 6.09, and 5.71, respectively. Compared to the 3M 1870, total R-COMFI unadjusted relative risks (RR) and 95 percent confidence intervals (CI) were A1 (RR 0.70, CI 0.60, 0.82), A2 (RR 0.93, CI 0.82, 1.06), B1 (RR 0.74, CI 0.64, 0.85), and B2 (RR 0.69, CI 0.60, 0.80). Compared to the 3M 1860, prototype total R-COMFI unadjusted RR and 95 percent CI were A1 (RR 0.62, CI 0.53, 0.72), A2 (RR 0.82, CI 0.73, 0.93), B1 (RR 0.65, CI 0.57, 0.74), and B2 (RR 0.61, CI 0.53, 0.70). Similarly, models adjusted for demographic characteristics showed that prototypes A1, B1, and B2 significantly improved tolerability scores compared to both controls, while prototype A2 was significantly improved compared to the 3M 1860.

CONCLUSIONS

Compared to the 3M 1870 and 3M 1860, two RPDs commonly used in U.S. health care delivery, tolerability improved for three of four newly developed prototypes in this simulated workplace study. The R-COMFI tool, used in this study to assess tolerability, should be useful for future comparative studies of RPD.