Reusable Elastomeric Respirators in Health Care Considerations for Routine and Surge Use (2019) / Chapter Skim
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Keeping health care workers healthy is an ethical commitment both in terms of addressing the occupational risks faced by health care workers and of providing for the continuity of patient care and services needed to maintain the health of individuals and communities. During a public health emergency, challenges will arise concerning the availability of respiratory protective devices (i.e., respirators)
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OVERVIEW OF RESPIRATORY PROTECTION AND ELASTOMERIC RESPIRATORS Protecting health care workers from workplace risks involves a range of administrative, engineering, and environmental hazard controls designed to ensure workplace safety and to integrate into a larger system of accountability and enforcement. The overarching goals of these controls are to minimize the number of health care workers exposed, to limit the intensity of exposure, and to provide the best available protection.
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The majority of health care facilities in the United States have opted to provide their health care workers with disposable filtering facepiece respirators, or PAPRs, with some limited use of reusable elastomeric respirators. The committee is aware of only a few health care facilities in the United States that currently use reusable elastomeric respirators either exclusively or primarily.
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Health care workers are currently accustomed to disposing of filtering facepiece respirators between patients, so the initial implementation of cleaning and disinfection protocols would be challenging. If the cleaning and disinfection is to be done by individual health care workers on their units, there will be chal
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The production capacity for respirators, particularly the U.S.-based capacity, will be a major concern in a public health crisis, particularly a crisis in which there is global demand for respiratory protection. As noted by the authors of a review of lessons learned from recent public crises: A significant proportion of the respiratory protective device supply chain is produced offshore and may not be available to
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Health care facilities often do not have the capacity to store large quantities of supplies, and the storage space they do have is needed for a wide variety of products and devices. In the 2009 pandemic, 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.
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Respiratory protection programs would be able to use the existing fit-testing process to fit test employees for both disposable filtering facepiece respirators and reusable elastomeric respirators. Existing training materials would be in place and could be expanded to all affected employees.
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Advantages of integrating reusable elastomeric respirators into day-to-day practice and regular training would include the increased familiarity of staff with these respirators and the imple mentation and continued improvement of policies and practices for
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Conclusion 4: Health Care Needs Regarding Respirator Protection The committee concludes that addressing the respiratory health needs of health care workers -- across their wide range of settings and jobs (including home health caregivers, rural clinic personnel, outpatient emergency medical personnel, food and custodial staff, nursing home staff, and hospital staff) -- will require the design of innovative reusa ble respirators and the implementation of robust respiratory protection programs.
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10 REUSABLE ELASTOMERIC RESPIRATORS IN HEALTH CARE Lack of standardized processes for the cleaning and disinfec tion of reusable respirators; General lack of knowledge among health care workers and leaders about the transmission of airborne infectious diseases and about protective equipment (e.g., droplet versus aerosol pathways for airborne transmission, differences between res pirators and medical masks) ; Need for estimates of the total costs of using reusable elasto meric respirators including costs of training, cleaning, disin fection, and maintenance and comparisons of total costs of using other types of respiratory protection; Paucity of education programs, training materials, and strate gies for change that focus on both basic routine use and tran sitions from routine to surge situations for respiratory protection; Need for harmonized and consistent guidance and standards by regulatory and policy-making authorities that include clear direction on the level of respiratory protection needed and on the stockpiling responsibilities of government and private sector organizations; Need for collaborative efforts by health care management and workers to considerably improve the monitoring and champi oning of respiratory protection in clinical care across the wide range of health care settings and professions in routine health care and surge situations; Need for well-integrated and comprehensively evaluated im plementation plans for transitioning between regular and surge use of respirators and between types of respirators; Need for established accountability policies for each facility's respiratory protection program that include responsibilities of health care leaders, including administrators and managers, health care workers, infection prevention and control special ists, and occupational health and safety professionals; and Incomplete information for health care facilities concerning stockpiling expectations and the make and model of respira tors stored in state and federal stockpiles.
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The committee's conclusions and recommendations focus on reusable elastomeric respirators, but given the task of exploring the feasibility of these respirators in health care settings, broader issues of respiratory protection for health care workers are integral to these discussions and are also addressed. Incentivize and Conduct Research Respiratory protection and its implementation in the health care field continue to evolve and will require extensive research and development efforts.
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This research should involve the collaborative efforts of a nationwide network of health care facilities that can address the research gaps, expand and refine the results for under served health care settings, and share lessons learned and best practices. Infection Risk Research for Hazard Assessment o Determine and better understand the relative con tribution of the routes of transmission for poten tially airborne transmissible pathogens to under pin and improve hazard assessment in health care to ensure proper respiratory protection; Cleaning and Disinfection Research o Identify and disseminate guidance and standards for cleaning and disinfecting reusable respirators (including cleaning and disinfection agents that are mycobacterial, viral, and sporicidal)
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; ease of cleaning and disinfection; communication intelligibility while speaking; attention to visual aesthetics to en hance patient perceptions and interpersonal inter actions; individual fit customization; sensors to detect breaches and provide notifications concern ing end of service life; and potentially disposable pre-filters to minimize cross-contamination; o Develop and evaluate rapid fit-test methods and new user seal-check training methods for reusable respirators, including exploring new technologies that provide an indicator of the quality of the fit; o Standardize respirator sizing parameters among manufacturers to facilitate fit testing, with atten tion to seamless and rapid transitions to products from different manufacturers during a health care crisis; Market Research o Conduct research to understand the barriers to market entry for a health care–specific, reusable respirator; o Develop robust value-analysis processes for deci sions on respirator purchases that include inter professional decision making and input from manufacturers and product distributors; o Develop total cost estimates for reusable elasto meric respirators (including purchase, storage, cleaning, training, fitting, use) to compare with to tal cost estimates of other types of respirators;
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An effective respiratory protection program should be viewed as a continuum of safety that begins with engineering/environmental controls and administrative controls and ends with the individual's personal protective equipment. What makes respiratory protection efforts effective is a function of the efficacy of the respirator; the compliance by health care workers including organizational monitoring, which is driven by the culture of safety in the organization and its leadership; and the organization's commitment, which is driven by the logistics and economics of the program.
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Such engagement is critical to ensure the health and safety of health care workers at all times, especially in the event of a public health emergency. Recommendation 2: Ensure Robust Respiratory Protection Programs and Training The leadership of health care facilities, professional associa tions, professional schools (including continuing education programs)
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With a focus on public health preparedness and on the health and safety of all health care workers, efforts are needed to improve the adoption and implementation of reusable respirators by reducing the variances and harmonizing the standards and guidelines. Without attention to this issue, facilities may be ill prepared to respond to a respiratory disease pandemic that exhausts respirator supplies and could put the safety of health care workers and the care of patients at risk.
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for all types of workers in health care facilities; Provide clear, practical, and standardized guidance on effective cleaning and disinfection processes for reus able respirators, including harmonizing manufactur ers' recommendations for cleaning and disinfection without damaging the integrity of the device; and Clarify and broadly communicate the expectations and responsibilities for emergency preparedness stockpiling of respirators among federal, state, and private-sector agencies and entities and provide health care facilities with information as to the makes and models of respirators in stockpiles. CONCLUDING COMMENTS Although this report is focused on one type of respiratory protective device -- half-facepiece reusable elastomeric respirators -- the paramount issues are much broader and center on ensuring the safety and health of health care workers and the continuity of high-quality patient care.
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2017. Personal protective equipment supply chain: Lessons learned from recent public health emergency responses.
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