Reusable Elastomeric Respirators in Health Care Considerations for Routine and Surge Use (2019) / Chapter Skim
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3 Implementing Reusable Elastomeric Respirators in Health Care Settings: Routine and Surge Use
3 Implementing Reusable Elastomeric Respirators in Health Care Settings: Routine and Surge Use
Pages 117-152
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From page 117... ...
The respirator used predominantly in health care settings is the disposable filtering facepiece respirator. In a survey of occupational health professionals in health care facilities, 94 percent of the facilities reported using this type of respirator, while 78 percent reported use of PAPRs, and 31 percent re 117
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From page 118... ...
These numbers, extrapolated to the U.S. population of approximately 320 million individuals, imply an estimated need of 1.95 billion disposable filtering facepiece respirators or 3.4 million reusable elastomeric respirators.
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From page 119... ...
Annual cost of RPD 512–1,001 74–127 18,343–18,502 274–526 87–160 103–201 stockpile (thousand $) a RPD indicates respiratory protective device, including accessories.
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Figure 3-1 illustrates many of the respirator-related factors associated with each of the stakeholders collectively. FIGURE 3-1 Use of elastomeric respirators in health care: viewpoints of stakeholders.
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From page 121... ...
Additionally, compliance with the use of respirators by health care workers is driven not only by the regulations and by the types of respirators that have been purchased and are available but also by the safety culture and climate of the health care institution, which largely emanates from the leadership and management. Making decisions about stockpiling respirators for a potential infectious disease emergency is challenging.
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From page 122... ...
However, in past public health crises there has been inconsistent communication on pertinent standards and inconsistent guidance on respiratory protection for health care workers for specific emerging infectious threats (Sheets and Payne, 2014)
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The committee determined that there are knowledge gaps in training assessments for the broader community of health professionals and for settings outside of acute-care hospitals. How do health care workers at risk of respiratory infectious agent exposure get adequate and updated information on respiratory protection, and how is this monitored in terms of effective training?
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From page 124... ...
Furthermore, professional organizations should incorporate respiratory protection concepts into continuing education curricula, and professional certification bodies should include respiratory protection in certification examinations. Such content should address the array of available respiratory protection, including disposable filtering facepiece respirators, PAPRs, and reusable elastomeric respirators.
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From page 125... ...
This is an opportunity to educate workers about the range of respiratory protective devices, including reusable elastomeric respirators, particularly if elastomerics are an option that would be used by the health care facility in the event of an emergency. Ensuring that the trainers are knowledgeable about the demands of clinical care and the use of respirators in health care settings is essential.
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From page 126... ...
Storage, Cleaning, and Disinfection The logistics of respiratory protection are complex because of the nature of health care. Health care workers spend large percentages of their work hours caring for and interacting with multiple patients who have varying health conditions and who are in a number of separate rooms or other settings.
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From page 127... ...
Furthermore, physicians and other clinicians and health care workers may be in and out of several office and clinic locations, or they may practice in one or more hospitals or nursing homes -- each of which may have a different risk profile, respiratory protection program, and choice of respirators. Other health care workers deliver food or clean numerous rooms across the facility.
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From page 128... ...
The storage and transport system will need to become part of the initial staff training on respirators and also need to be incorporated into refresher training. Health care facilities that make the decision to use reusable elastomeric respirators routinely will need to have a staff whose members are fit tested, trained, and familiar with elastomerics, which will make it easier to move into a surge situation if needed, where the elastomeric respirators may be used more extensively.
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From page 129... ...
If the cleaning and disinfection is to be done by individual health care workers on their units, there will be challenges in finding the space for these efforts and also in setting up and maintaining the cleaning and disinfecting stations. If the cleaning and disinfection are to be done in a centralized reprocessing facility, challenges can arise in transporting the respirators to the central location and in storing the clean respirators, as noted in the study in British Columbia (Ciconte et al., 2013)
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From page 130... ...
As previously discussed, these protocols would need to be part of the just-in-time training. The familiarity and standard operating procedures that a health care facility will have when it uses reusable elastomeric respirators as part of its routine respiratory protection program should make it easier to scale up in a pandemic situation.
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From page 131... ...
Considerations Regarding Routine Use Both medical clearance and fit testing are a mandatory part of routine use of respirators. In health care facilities that stock reusable elastomeric respirators for use in emergencies, the annual fit test provides an opportunity to fit and size the elastomeric respirator as well so that the employees who are part of the respiratory protection program are ready to use either type of respirator.
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From page 132... ...
The respiratory protection program administrator, in partnership with infection prevention and control, value analysis, occupational health, and other pertinent departments, must determine the appropriate size and scope for the organization's specific respiratory protection program during both routine and surge situations. Consideration has been given to stratifying the risks experienced by health care workers according to the types of work that they do and the locations of their work.
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From page 133... ...
. Procurement and Supply Logistics and Emergency Stockpiles It is not possible to implement a respiratory protection program without access to a supply of respirators whose purchase and use require a complex chain of decisions involving multiple clinical and administrative teams in health care facilities working with suppliers and, in some cases, directly with manufacturers.
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From page 134... ...
In 2009, the manufacturing and supply chain limitations quickly became apparent when orders for disposable filtering facepiece respirators rapidly spiked and created a 2- to 3-year backlog (Patel et al., 2017)
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From page 135... ...
is higher than that of disposable filtering facepiece respirators (estimated at $0.25 to $0.65 per respirator) and lower than PAPRs (estimated at $500 to $800 per respirator)
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From page 136... ...
A value-analysis approach to health care supply decision making is one in which all relevant clinical and business issues and impacts are considered throughout the cycle of purchase, use, and product evaluation, with consideration paid to the clinical impact on patient care, quality, and safety. For respirators, the relevant clinical inputs include infection prevention and control, respiratory care, occupational health, and environmental health.
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10–11) This was a deployment of approximately 75 percent of the SNS cache of disposable filtering facepiece respirators (Patel et al., 2017)
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From page 138... ...
It became apparent early on, during several coordinating calls with the highly affected medical centers and regions in California, that several medical centers were consuming an inordinately high volume of disposable filtering facepiece respirators as a result of the extraordinary precautions -- which were called for -- that they were taking in response to this novel virus. Information was pro vided by health systems and medical centers to the California Depart ment of Public Health (CDPH)
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From page 139... ...
Not only did this procurement strategy match what was being used on a day-to-day basis in the state's hospitals and health systems, it also matched the strategy used by the Centers for Disease Control and Prevention, which also stockpiled vari ous models of disposable filtering facepiece respirators, including a large number of the model ordered by California. After distribution of the stockpiled respirators, several of Kaiser Permanente's medical centers, which did not regularly use the stockpiled model, reported an unusually high number of fit-test failures.
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The culture of safety is reflected in the organizational policies, standard operating procedures, structures, and expected norms of behavior of the health care workers. A component of the safety culture is
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A study of 98 hospitals across 6 states in which more than 1,105 health care workers were surveyed found that front line health care workers perceived the safety climate for respiratory protection less positively than hospital and unit managers (Peterson et al., 2016)
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BOX 3-4 Key Components of Safety Culture Change Investment resources time priorities Participation leadership and management supervision employees Assessment problems context goals progress/effectiveness Capacity facilitation training recognition Communication regular reliable complete open SOURCE: DeJoy, 2018.
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From page 143... ...
Health care staff will pay close attention to the transmission route of the disease and be attentive to safety measures including, as needed, respiratory protection. During the 2009 H1N1 pandemic, the demand at health care facilities for respirators was high and the initial supplies of the product were rapidly used (Patel et al., 2017)
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From page 144... ...
.2 The act notes that it covers medical devices that are defined, cleared, or approved under the Federal Food, Drug, and Cosmetic Act. 3 This coverage would apply to the surgical N95 disposable filtering facepiece respirators approved by FDA, but it is not clear that reusable elastomeric respirators would be covered.
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From page 145... ...
35) Agreement on guidance and standards across agencies, coupled with streamlined and frequent communication through a broad array of media platforms, will increase the likelihood of adherence to recommended standards and optimal health for health care workers and their patients.
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From page 146... ...
146 REUSABLE ELASTOMERIC RESPIRATORS IN HEALTH CARE TABLE 3-2 Overview of 2009–2010 H1N1 Policies and Practices Regarding Personal Protective Equipment and H1N1 Influenza Public Health CDC CDC CDC Agency Guidance Guidance Guidance of 4/29/09 10/15/09 for Canada Novel Novel Seasonal Guidance Pandemic Pandemic Influenza WHO for Novel Influenza Influenza 9/20/10 Guidance H1N1 Recom- Standard Standard Adhere to Standard Tiered mended and con- and drop- standard and drop- approach level of in- tact pre- let pre- and drop- let pre fection con- cautions cautions let pre- cautions trol and eye cautions precautions protection Recom- NIOSH- NIOSH- Medical Medical Medical mended approved approved mask mask mask respiratory N95 N95 except for except for except PPE respirator respirator aerosol- aerosol- for generat- generat- aerosol ing proce- ing generat dures, proce- ing pro use N95 dures cedures or better Did the res- Yes -- Yes -- Yes -- Yes Yes piratory PPE direct direct direct recommen- care care care dation differ versus versus versus by indirect indirect aerosol work task? patient patient generat contact contact ing procedure NOTE: CDC = Centers for Disease Control and Prevention; NIOSH = National Institute for Occupational Safety and Health; PPE = personal protective equipment; WHO = World Health Organization.
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2017. Evaluation of 9 health care organizations' respiratory protection programs and respiratory protective device practices: Implications for adoption of elastomerics.
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From page 148... ...
to be used by healthcare workers during management of patients with confirmed Ebola or persons under investigation for Ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in U.S. hospitals, including procedures for donning and doffing PPE.
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2014. Implementing hospital respiratory protection programs: Strategies from the field.
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2016. The American Association of Occupational Health Nurses' respiratory protection education program and resources webkit for occupational health professionals.
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2018. Development of competencies for respiratory protection for health care workers.
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