Are You Using the Right Mask?

Nurses COVID

Published

http://afludiary.blogspot.com/2009/08/though-your-mask-is-lovely-its-wrong.html

I continue to read of nurses being given surgical masks for protection with swine flu cases. You would think that by now, nurses everywhere would know better, but these stories keep popping up. So for the few of you, who don't know, the N95 is the currently recommended PPE for swine flu. Goggles are recommended as well.

Be careful out there.

NHS workers battling swine flu have been put at extra risk after being given the wrong protective face masks, nurses have claimed.

A mix-up with orders of specialised fluid-repellent masks has left frontline workers having to wear ordinary surgical masks which are virtually useless at protecting those wearing them against swine flu.

One NHS worker from Swansea, who asked not to be named, said: "We were all given masks but then they sent out a letter to everyone to say they were the wrong ones and would have to be replaced.

"Some of the nurses queried straight away whether they were the correct ones and it turns out they weren't.

"Staff are still wearing the masks but they know they do not offer a lot of protection."

The nurse said many of the workers felt let down by the failure and said it had increased the risk of doctors and nurses catching the disease.

Specializes in Too many to list.
We're isolating everyone with respiratory symptoms. Period. Our infection control folks have modified our droplet precautions to include N95s and goggles for all aerosolizing activities on ALL such patients, but have decided that a surgical mask is adequate unless there is a risk of aerosolizing. We have a poster - http://www.albertahealthservices.ca/files/News/ns-2009-06-24-flu-ipc-contact-droplet.pdf

So the other night I was helping another PICU nurse bathe a patient with confirmed H1N1. I was wearing my fit-tested and designated N95 respirator, and I COULD SMELL THE SOAP. The day of my fit test, I could taste the Bittrex all the way through the test, and the tester told me that unless it was "really strong" I had a good fit. He also told me that the fogging I was seeing on my glasses wasn't a problem. Do I believe him?

Oh, and we're reusing the disposable goggles our unit is providing. We're to use the same pair for the whole shift and then put them in a bucket for cleaning.

Thanks for wading into the fray, janfrn.

I want to make sure that I understand you clearly. The poster says that if you are within 2 meters doing routine care, wear a surgical mask. How about if the patient is coughing while you are doing that care?

When are goggles required?

You are trying to be very careful if you are wearing a respirator for bathing a confirmed case, not that I am blaming you. On the contrary, I think N95 should be the standard whenever we are in the room with these patients until we know more about this virus because it is a very transmissible virus. I feel very uncomfortable with a decision being made without any of us getting a look at the supposed data it is based upon, and knowing that the decision makers are not doing direct care themselves.

There are some disturbing stories from Argentina about deaths of HCW. There is probably some truth to this, but how much is not clear yet. The death of the California nurse may not be an anomaly. Some of us are going to get sick, and though most of us will recover, some may not. We can be infected in our communities, but without the N95, our risk of being infected on the job is increased.

You seem very unreassured that your N95's fit will protect you. How do you feel about using the surgical mask with these patients?

Specializes in Mostly: Occup Health; ER; Informatics.

As a nurse and former full-time instructor, I strongly believe in making resources available to those who care. Thus my posts...

Just another link for respirator topics (not just for H1N1), from the U.S. authority:

http://www.cdc.gov/niosh/npptl/topics/respirators/

In regard to fit-testing, this link has the procedures: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9780 Step 11 of the Bitrex test clearly states that no taste = good fit.

As someone trained in (and performing) fit tests, I think that all N-95/99/100 users should more deeply understand that:

- the mask requires proper fitting AT EACH WEARING,

- a soaked mask is of no use (thus "disposable")

- removing it contaminates the wearer's hand because the hand touches what got filtered.

The occupational-health nurse at your facility should be a resource.

Specializes in Too many to list.

IOM Meeting On PPEs For HCWs

Mark it on your calendar if you want to listen in to two live webcasts of these meetings. These people are going to be deciding what PPE we are going to be allowed to use. There are some famous names on this panel like Dr. Palese. I do respect his expertise regarding influenza viruses. I am not as familiar with the other panelists.

As the following commentary points out, we will be running out of the N95 anyway if we are in a prolonged situation. Does this have anything to do the necessity for this meeting? I think so. Why change the guidance if it was not necessary?

The workshop has four goals:

Examine the emerging science and clinical experience base associated with nH1N1

Discuss criteria used to delineate infection control guidelines

Discuss criteria used to assess risk to the health care workforce

Examine what's known about the effectiveness of medical masks, respirators, gowns, gloves, and eye protection in preventing nH1N1 and seasonal influenza transmission

Further information at this link including how to access the webcasts:

http://afludiary.blogspot.com/2009/08/iom-meeting-on-ppes-for-hcws.html

Specializes in Too many to list.

Agenda: Workshop on Personal Protective Equipment for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A

http://www.iom.edu/CMS/3740/71769/71867/71870.aspx

This gives us a better view of who will be providing the information, and what the topics will be.

(hat tip FlaMedic)

Specializes in NICU, PICU, PCVICU and peds oncology.

I want to make sure that I understand you clearly. The poster says that if you are within 2 meters doing routine care, wear a surgical mask. How about if the patient is coughing while you are doing that care?

Well, you see, that's the problem. What I've seen happen is the nurse is in the room in her surgical mask and goggles doing her charting. The patient starts coughing and the ventilator goes nuts. The nurse then runs to the anteroom, removes her mask and gloves, does her hand hygiene, dons an N95 and fresh gloves then runs back into the room to suction the patient. When I asked our management about the safety (patient and nurse) and practicality of this directive, I was told that we're all quite welcome to wear N95 protection all the time... and then the same manager has gone to a room and told the nurse that she only needs surgical mask. (Oh, and on the long weekend we ran out of gowns.)

When are goggles required?

Whenever a mask is used.

I feel very uncomfortable with a decision being made without any of us getting a look at the supposed data it is based upon, and knowing that the decision makers are not doing direct care themselves.

But isn't that the way most decisions in health care are made? By someone in an office-with-a-view in another part of the city, someone who may NEVER have set foot into an ICU or HDU. (That's how our hospital chose to turn a storage room into a two patient room that we're using for some types of isolation even though there's no door on the room!)

You seem very unreassured that your N95's fit will protect you. How do you feel about using the surgical mask with these patients?

You're right about that. Until I could smell the soap the other night, I half believed the guy from OHS&W who said that bit about "residual" taste being okay. Now I'm not so sure. One of our nurses doesn't fit any of the common masks and has been bounced between management - "GET FITTED ASAP!!" - and OHS&W - "Well, we don't have the equipment right now... We don't have any open appointments now... We are only here for a few hours a day, can you come to the regional office?" She works permanent nights and she does patient transports... she needs to be protected. She's been trying for more than two months to get fitted... ("And no, we aren't going to pay you for all these appointments you showed up for two hours after your shift ended and 10 hours before your next shift starts because you still didn't get fitted.")

As for the surgical mask thing... I think I'll just wear N95s all the time, even though I'm not sure mine is protecting me. I was fit-tested in a hurry because I was assigned to a patient that was a suspected H1N1 and we hadn't had a fit-test done in more than 2 years. That patient turned out not to have it, but there's an ever-increasing risk. And I have an immunocompromised family member at home...

Specializes in NICU, PICU, PCVICU and peds oncology.

In regard to fit-testing, this link has the procedures: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9780 Step 11 of the Bitrex test clearly states that no taste = good fit.

Thank you for this link, 3rd. It appears I'm NOT protected. And it appears that our OHS&W crew are skipping a lot of steps in the process. If the process as described is followed, it should take upwards of an hour and more than a small office space... not the 10 minutes and tiny room we used. So now I don't know what to think.

As someone trained in (and performing) fit tests, I think that all N-95/99/100 users should more deeply understand that:

- the mask requires proper fitting AT EACH WEARING,

- a soaked mask is of no use (thus "disposable")

- removing it contaminates the wearer's hand because the hand touches what got filtered.

We have been given this message more than once. The "proper fitting" part is a problem, see my previous post.

The occupational-health nurse at your facility should be a resource.

See my previous post. "We can see you a week from never."

Specializes in Too many to list.

Well, you see, that's the problem. What I've seen happen is the nurse is in the room in her surgical mask and goggles doing her charting. The patient starts coughing and the ventilator goes nuts. The nurse then runs to the anteroom, removes her mask and gloves, does her hand hygiene, dons an N95 and fresh gloves then runs back into the room to suction the patient. When I asked our management about the safety (patient and nurse) and practicality of this directive, I was told that we're all quite welcome to wear N95 protection all the time... and then the same manager has gone to a room and told the nurse that she only needs surgical mask. (Oh, and on the long weekend we ran out of gowns.)

I don't know how long virus particles remains in the air even after the patient has finished coughing or the nurse has finished suctioning or the nebulizer treatment is over. It seems unwise to be with in the room without the N95 on.

Specializes in Ortho/Joint/Trauma.

I work in a 1200 bed, level one trauma, teaching facility. We were told that all influenza A cases this year are turning out to be H1N1 by CDC reports from last week. As of last week we have stopped using a special respiratory isolation and now are using droplet and contact precaution only. Gone are the goggles and n95 masks. We are treating this like any other flu

Specializes in Too many to list.
I work in a 1200 bed, level one trauma, teaching facility. We were told that all influenza A cases this year are turning out to be H1N1 by CDC reports from last week. As of last week we have stopped using a special respiratory isolation and now are using droplet and contact precaution only. Gone are the goggles and n95 masks. We are treating this like any other flu

Thank you, NurseTink.

As of last week, huh? They didn't waste any time. Facilities are no doubt, eager to implement the use of the less costly surgical masks especially since they probably did not have many N95s in stock to begin with.

This seems like a done deal already. Why are they are even bothering to hold these IOM meetings next week?

The next few months are likely to be very difficult for many staff. I work in psych so this is not likely to affect me personally as much. I can't help but think that this is the wrong way to go, and that we do not know enough about what this virus is going to do yet. Add to that, the lack of transparency about fatalities in this country lately. I don't want to say that this is intentional because it may not be. Public health departments are really stretched for funds and staff. They are going to be extremely busy soon as most of you will be as well. The only way we are going to be able to get the big picture of how bad things are is thru govt telling us, (and I have some reservations about how much they are going to be willing to say), what the media says, and our own experience.

Only time, and the stats will tell us if choosing the surgical mask was a wise decision.

Specializes in Mostly: Occup Health; ER; Informatics.

The reason I care so much about fit-testing and associated refresher teaching for N95 users:

"Formal fit testing does not predict future adequacy of fit, unless frequent, routine use is made of the respirator. The utility of fit testing among infrequent users of N95 respirators is questionable."

from

Respirator-fit testing: does it ensure the protection of healthcare workers against respirable particles carrying pathogens?

Infect Control Hosp Epidemiol. 2008 Dec;29(12):1149-56.

Lee MC, Takaya S, Long R, Joffe AM.

PMID: 18980503

http://www.ncbi.nlm.nih.gov/pubmed/18980503?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Of course if we all wear n95s 24x7 during this pandemic, we'll fall into the "frequent users" category...until we run out of stock :)

Specializes in Too many to list.

http://www.hindustantimes.com/StoryPage/FullcoverageStoryPage.aspx?sectionName=HomePage&id=01b84caf-0341-405f-8967-0da1319d8f3fSwineflu_Special&Headline=Three+doctors+test+positive+for+swine+flu+in+Delhi

But he was wearing a surgical mask!

Of course, he could have been infected at the grocery store, but who did he spend most of his time with...

After a doctor was found infected by H1N1 virus in Pune, three doctors in New Delhi have also tested positive on Friday. According to media reports, these doctors belong to Safdarjung Hospital and CGHS Hospital.

This has happened despite the reports that hospitals are cautious of the infection and are taking all the precautions.

There were reports that all the gate keepers, security men, doctors and even the visiting media personnel were all wearing surgical masks at the hospitals in New Delhi as hundreds of people, from pregnant women to students, flocked to the swine flu testing centre on Friday.

Earlier, on Friday a doctor suffering from swine flu was admitted to the ICU of a hospital in Pune.

The doctor, who works with Inlaks hospital in camp area, has been kept in a ICU in a quarantined ward of the Sassoon General Hospital, according to R R Pardeshi, civic medical officer.

I do not understand WHY, every time I work, a patient's indicators get CHANGED to contact/droplet.

Routine: A pt is admitted from ER during the night with resp distress or fever of unknown origin. During morning rounds, the attending says, hey, maybe we should do an NP wash. This causes NURSING to say, well, if you're going to do that, they have to go on doplet and be isolated.

(I emphasize NURSING, because it's not policy for NURSING to decide who goes on isolation; this is a physician responsibility, which they, especially interns (which are all new as of July, do not take nearly seriously enough.)

Do these pts turn out to have H1N1?? Yes, as someone else said, pretty much ALL flu is coming back H1N1 now.

This cavalier attitude toward precautions/isolation, causes many HCW's to say, oh, well, I've been taking care of this pt for X amount of time already, too late, no point now.

And we often have no appropriate rooms to put these pts in, anyway, so again, we just say, oh well.

As far as the masks, we use surgical with eye shields now. We did get an email reminding us that eye protection is not optional. Also, pg HCW's are not to be assigned to suspected flu cases. However, as I mentioned previously, the possbility that a pt might have flu comes very late in the game.

It's all very frustrating, and I dread the fall when it will get a billion times worse.

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