Emergency Medicine

Airborne Disease Preparation

Emerging infectious diseases have long presented enormous challenges to healthcare workers. Whether it be Ebola, HINI, MERS or SARS, outbreaks have proven to cause serious problems for healthcare systems, problems that are often compounded by lapses in respiratory protection. Nonetheless, studies have repeatedly shown that these lapses persist.  

To address this threat, safety agencies assembled a comprehensive compilation of resources concerning respiration protection programs. These resources represent the collective effort to improve all aspects of hospital respiratory protection.

One such publication was released in May. The Hospital Respiratory Protection Program Toolkit, jointly issued by the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Health and Safety (NIOSH), emphasizes aerosol transmissible diseases. A monograph by The Joint Commission detailing best-practice case studies, “Implementing Hospital Respiratory Protection Programs: Strategies from the Field,” accompanied the report. Prior to this release the American Association of Occupational Health Nurses (AAOHN) have made educational modules discussing respiratory protection available to medical professionals free of charge.

Based on a similar toolkit released in 2012 by the California Department of Public Health, the OSHA/NIOSH publication delves into the many facets of respiratory protection, including standard respirator use, hazard assessment, current public health guidelines, and respiratory protection program development. Furthermore, the toolkit provides editable respiratory tools that hospitals can tailor to the specificities of their program and additional resources on hospital respiratory protection.

Ingraining proper practice is key, notes Debra Novak, RN, DSN, a senior service fellow with NIOSH’s National Personal Protective Technology Laboratory. As the project officer of both the toolkit and the accompanying monograph, Novak says: “If you use your best practices every day, when there’s an outbreak you’re ready.” Repetition breeds familiarity, and consistent procedure allows for a deeper level of understanding of protocol. “The best preparedness is good day-to-day practice” Novak reemphasizes.

Despite respiratory protection being an integral responsibility of health professionals, many employees learn about the protection protocols not during formal education but rather while on the job, laments MaryAnn Gruden, MSN, CRNP, NP-C COHN-S/CM. Gruden is the manager of employee health services at Allegheny Health Network in western Pennsylvania, as well as an association community liaison for the Association of Occupational Health Professionals in Healthcare (AOHP). In 2012, the AOHP released a survey finding that half of the members of association were tasked with managing their hospital’s respiratory protection programs.

Respiratory protection has often been a source of confusion — and concern. When two Dallas nurses became infected with Ebola while caring for a patient, attention soon turned to their respiratory protection, or lack of it. The nurses reported that they initially only wore surgical masks, per guidance from the Centers for Disease Control and Prevention. CDC later revised the guidance and recommended respirators.

Inadequate respiratory protection is a serious concern and has gained more attention as a result of recent high profile infectious diseases. One particular case was especially impactful when, in Dallas two nurses contracted Ebola after attending to an infected patient. The nurses said that they wore surgical masks in accordance with CDC recommendations, and the CDC later updated guidelines and recommended respirators, reflecting the lessons of these unfortunate events.

Likewise, transmission of SARS to healthcare workers in Toronto also brought up the issue of whether surgical masks were inadequate protection. An AAOHN survey conducted recently showed that nearly one in four occupational health nurses have difficulty or are uncomfortable in adequately discerning surgical masks from respirators. Yet another layer to the debate was added when a Canadian meta-analysis of clinical studies published recently concluded there is no significant difference in respiratory infection prevention efficacy between respirators and surgical masks.

Attempting to address the issue of respirators, the OSHA/NIOSH toolkit clarifies in no uncertain terms that surgical masks are not respirators. Still, the guidelines provide a glimpse into the conflicts that currently exist between the infection control perspective and the occupational safety perspective. For instance, the toolkit takes care to define and emphasize “droplet precautions,” a common infection control protocol in which surgical masks protect a healthcare worker from large droplets produced by a patient coughing or talking. The toolkit also then states that modes of transmission are never definitive and warns that symptoms of serious airborne infection can initially mimic other, more benign respiratory viruses.

“A prudent approach,” the toolkit advises, “is to implement the use of respirators early on based on suspected diagnosis, for example in the emergency department, and discontinue it later if the patient is subsequently diagnosed with a disease that does not require respiratory protection.”

Nonetheless, Lisa Brosseau, ScD, CIH, a respiratory protection expert and director of the Industrial Hygiene Program at the University of Illinois at Chicago, is seriously concerned about the potential implication within the toolkit that surgical masks can operate as personal protective equipment, shielding the medical professional from airborne disease. On the contrary, Brosseau notes, surgical masks were created to prevent wound site infection of patients undergoing surgery.

Brosseau expressed her concern at the toolkit’s implication potentially misinforming doctors: “[The toolkit’s recommendations] continue to confuse people about what a surgical mask or respirator is … . They continue to indicate that surgical masks offer protection for inhalation and they do not. They were never meant to and were not designed for that.”

As an example of the potentially confusing factors, Brosseau brings up a chart that shows surgical mask use as appropriate protection against “viral hemorrhagic fevers.” Footnotes concerning the piece, however, do state that “5 October 2014 CDC guidance for Ebola virus disease recommends at least an N95 respirator.”

Novak, meanwhile, assures that the toolkit simply reflects the CDC’s current respiratory protection guidelines and that surgical masks can indeed be used as a barrier against droplet spray. She does say, however, that prior to any decisions made about respirator use, hospitals should enact thorough hazard evaluation and an infectious disease expert should be available in case the healthcare workers have any questions or points of confusion.

Another positive of the toolkit and its monograph is the potential it has to improve training and coordination in respiratory protection programs. Funded by NIOSH, the Respirator Use Evaluation in Acute Care Hospitals (REACH) project uncovered the unfortunate finding that healthcare workers frequently are under-trained and therefore do not properly utilize respirators. Supporting this finding is a 2009-10 survey that found that annual instruction on proper respirator use lasted sometimes as little as one minute and typically fell between one to 15 minutes. A follow-up REACH study was conducted in 2011-12, identifying an extensive understanding deficit regarding proper respirator use.

The toolkit, once introduced to a hospital, Novak says, “takes the essential [OSHA-]mandated elements for a respiratory protection program and gives you a very organized, orderly, and comprehensive manual for how to develop the program properly.”

The toolkit advises that respiratory protection programs have a sole administrator. The Respiratory Protection Standards outlined by OSHA mandate that employers enact hazard evaluations to determine employees who have potentially been exposed. Hazards present in hospitals are often infectious diseases, surgical smoke, disinfecting agents, and aerosolized hazardous drugs. The toolkit notes that particularly in the case of procedures that generate aerosol, a high level of protection is warranted.

The toolkit explains the required aspects for any respiratory prevention program, from the necessity of a written program and fit-testing to ensure compliance prior to implementation as well as the vitality of recordkeeping and evaluation in ensuring continued adherence to standards.

In a companion document, The Joint Commission solicited strategies for respiratory protection programs from hospitals around the country.

A companion document by the Joint Commission surveyed the nation’s hospitals to glean the most effective practices and programs around the country.

A few of the traits found in the effective programs are listed below

  • Emphasis by leadership on valuing the health of both workers and patients, not just the latter.
  • Multidisciplinary collaboration.
  • Sweeping approaches to the identification and mitigation of current or potential respiratory hazards
  • Integrated respiratory protection and emergency preparation
  • High levels of awareness and visibility regarding the measures used to ensure respiratory protection

The implementation of all of these elements is not easy. Even established respiratory protection programs struggle to implement adequate respiratory protection, as the protocols are often lost amid a sea of in-hospital priorities, points out Barbara Braun, PhD, the associate director of the Department of Health Services Research in The Joint Commission’s Division of Healthcare Quality. Braun, as the head of the monograph project, urges that education should be ongoing. That is doubly important when healthcare professionals do not use respirators each and every day, as though they may not necessarily encounter situations meriting respirators every day, they face the possibility any and every day, and need to be able to appropriately adhere to the protocol to remain safe.

Hospital responses reveals many ways to teach staff about respiratory protection, particularly regarding which instances merit respirator use. In one such example, certain hospitals place signs directly outside airborne isolation rooms that inform workers to don a respirator prior to entering the room. Other hospitals may require employees to demonstrate a level of competency in respirator use before allowing the worker to don the mask or enter an airborne isolation room. Some hospitals even adjusted their training regimen to their particular staff, including offering respirator training in multiple languages.

“Anecdotally, hospitals reported better buy-in when staff understood why they were wearing a respirator,” Braun concludes.