Preparing for an Influenza Pandemic Personal Protective Equipment for Healthcare Workers (2008) / Chapter Skim
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1 Introduction
1 Introduction
Pages 19-46
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From page 19... ...
One vital aspect of pandemic influenza planning is the use of personal protective equipment (PPE) 1 -- the respirators, gowns, gloves, face shields, eye protection, and other equipment that will be used by healthcare workers and others in their day-to-day patient care responsibilities.
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The increased emphasis on healthcare PPE and the related challenges that are anticipated during an influenza pandemic necessitate prompt attention to ensuring the safety and efficacy of PPE products and their use. In 2000, the Institute of Medicine (IOM)
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SCOPE OF THIS REPORT The IOM committee was charged with examining research directions, certification and the establishment of standards, and risk assessment issues specific to PPE for healthcare workers during an influenza pandemic. The committee was specifically asked to focus on • research needed to understand and improve the efficacy and effectiveness of PPE, particularly respirators, for an influenza pandemic, with attention to improving functionality and addressing human factors such as wearability, compliance, and communications; • necessary certification, testing, and standards development requirements, with attention to clarifying the roles of NIOSH, NPPTL, the Food and Drug Administration (FDA)
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Ethical Considerations In an influenza pandemic, ethical quandaries are likely to be faced, especially as needed supplies become scarce. In addition, priorities will have to be determined regarding the use and distribution of vaccines and 2 The term healthcare facilities is used in this report to encompass all sites of healthcare delivery including hospitals, long-term care facilities, pre-hospital facilities, home care, and private medical and dental offices.
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and to anticipate the ethical challenges and the needs of healthcare employers and workers, the better prepared the nation will be for an influenza pandemic. One ethical issue being discussed in this pre-pandemic planning period is the assessment of risks for healthcare workers.3 The expertise of healthcare workers is an integral and principal component of the response to a pandemic.
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On the other hand, if adequate protective measures are not secured, providing patient care may be considered high risk and should be questioned. In this instance, it is the obligation of the healthcare organization to provide adequate protective measures to safeguard the healthcare worker and workforce.
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The definition would also include health professional students who are working at or receiving instruction in healthcare facilities. As indicated in Tables 1-2 and 1-3, the breadth of the term healthcare workers encompasses professional and support services; includes individuals involved in administration, patient care, and facilities care; and represents individuals working for private- and
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. Hospitals, constituting about 2 percent of the total number of healthcare facilities in 2004, were the largest healthcare employers, employing 41.3 percent of healthcare workers.
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Percentage Total, all healthcare occupations 13,062 100.0 Management, business, and financial 574 4.4 occupations Professional and related occupations 5,657 43.3 Registered nurses 1,988 15.2 Licensed practical and licensed vocational 586 4.5 nurses Physicians and surgeons 417 3.2 Therapists 358 2.7 Diagnostic-related technologists and 269 2.1 technicians Clinical laboratory technologists and 257 2.0 technicians Health diagnosing and treating practitioner 226 1.7 support technicians Social workers 169 1.3 Dental hygienists 153 1.2 Counselors 152 1.2 Emergency medical technicians and 122 0.9 paramedics Dentists 95 0.7 Physician assistants 53 0.4 Service occupations 4,152 31.8 Nursing aides, orderlies, and attendants 1,230 9.4 Food preparation and serving-related 462 3.5 occupations Home health aides 458 3.5 Building cleaning workers 365 2.8 Medical assistants 361 2.8 Personal and home care aides 312 2.4 Dental assistants 257 2.0 Physical therapist assistants and aides 95 0.7 Medical transcriptionists 81 0.6 Office and administrative support occupations 2,379 18.2 NOTE: This table does not list all specific occupations within each category; therefore, totals do not achieve 100 percent.
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Thus, opportunities are available to incorporate an emphasis on worker safety and to integrate worker and patient safety efforts. For many healthcare workers, the use of some type of PPE, particularly medical gloves, occurs on a daily basis as part of infection control precautions that are designed to protect both the healthcare worker and the patient from disease acquisition.
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• Other areas addressed include hand hygiene, cleaning of patient care equipment and the environment, care and disposal of soiled linens, occupational health protections regarding bloodborne patho gens, and patient placement. Tier 2 -- -- Transmission-Based Precautions Used in addition to standard precautions.
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In addition to standard precautions, airborne precautions require the following: • Respiratory protection- -- Wear a fit-tested NIOSH-approved N95 or higher level respirator for respiratory protection when entering the room or home of a patient who is suspected or confirmed to have an airborne infectious disease. • Other areas addressed include patient placement, patient transport, personnel restrictions, and exposure management.
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were involved in the intubation of a patient with SARS. Multiple factors were likely responsible for SARS in these healthcare workers, including the performance of high-risk patient care procedures, the inconsistent use of PPE, fatigue, and lack of adequate infection prevention and control training.
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Teleman et Case-control study in Adjusted odds ratio (multivariate analysis) al., 2004 Singapore of 36 associated with transmission of SARS: healthcare workers • Wearing of N95 mask: 0.1 (95% CI 0.02 with probable SARS to 0.9, p = 0.04)
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infections on a pediat- ▪ Did not wear masks or goggles: 61% ric inpatient service Madge et al., Prospective study of • Combination of cohort nursing with use 1992 four infection control of gowns and gloves significantly re strategies in prevent- duced RSV infection ing RSV in four • Use of gowns and gloves alone did not pediatric wards result in a significant reduction of infection Continued
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Identifying Healthcare PPE: Clarifying the Role of Medical Masks One of the challenges for the healthcare field is to clearly understand the differences among respirators and medical masks as well as their appropriate uses. Medical masks (the term is used in this report to encompass surgical masks and procedure masks)
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Because medical masks are readily available to healthcare workers and are lower in cost than respirators, but are not designed to provide respiratory protection, there is a need to clearly delineate the differences for healthcare management and workers and to consistently use standard terminology. Efforts to achieve definitional clarity are needed, as are distinct and easy-to-understand ratings of the protective effectiveness of the equipment (Chapter 3)
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. The two major issues related to air-purifying respirators are the filter and the fit -- the effectiveness of the filter and the extent to which the respirator has a tight seal with the wearer's face that restricts inward leakage.
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Influenza precautions emphasize the need for healthcare workers to be vaccinated with the most recent seasonal human influenza vaccine. In addition to providing protection against human influenza, vaccination 6 Hand hygiene is another important and effective component of infection control of respiratory diseases (Ryan et al., 2001; White et al., 2003)
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The reasons for additional precautions for avian influenza include the following: • the potential for highly pathogenic avian influenza to cause serious disease and higher death rates may be significantly greater than from human influenza; • each time avian influenza is transmitted to humans, there is an increased chance for the strain to adapt and gain the ability to be transferred more easily to other humans; and • the emergence of a possible pandemic strain could be linked with human-to-human transmission of avian influenza. OVERVIEW OF RELEVANT AGENCIES AND ORGANIZATIONS The testing, regulation, and use of PPE for healthcare workers involves a number of government and nongovernmental agencies and organizations.
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. Because respirators, gloves, and gowns used by healthcare workers are considered medical devices (as are medical masks)
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Although significant national and worldwide investments have been made in pandemic planning and research, many basic and critical questions remain to be answered. This report focuses on opportunities for answering the questions relevant to providing protection against potential infection of healthcare workers during an influenza pandemic.
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, but with dedicated resources and new technologies, more can be known about the extent of droplet, aerosol, and contact transmission and the optimum ways to prevent transmission. • Making the commitment to worker safety and appropriate use of PPE -- Healthcare workers often do not wear the protective equipment needed to ensure that they are adequately protected from exposure to hazardous agents including infectious disease.
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S., and HICPAC (Hospital Infection Control Practices Advisory Committee)
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2005. Preparing for an influenza pandemic: Ethical issues.
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2006. Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control pre cautions: A case series.
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American Journal of Infection Control 31(6)
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