Re: Are You Using the Right Mask?

Masking Our Disappointment

http://afludiary.blogspot.com/2009/0...pointment.html

Originally Posted by afludiary.blogspot.com

There is now a move afoot to lower the recommendation from using the more expensive (and widely assumed to be more protective) N95 respirators to using surgical masks (which are more plentiful) in a healthcare setting.

The same surgical masks we’ve been told for years provided `little or no protection’ against the influenza virus.

This recommendation comes from the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).

http://www.apic.org/Content/Navigati..._Guideline.pdf

Originally Posted by www.apic.org

As some of you are aware, a number of state health departments, after recognizing that the Novel H1N1 influenza was similar to the seasonal influenza, advised healthcare organizations within their jurisdictions that standard and droplet precautions should be followed for patients with Novel H1N1 rather than airborne infection isolation.

After a systematic review of the transmission of airborne infections, the H1N1 Working Group arrived at the following recommendations for minimum isolation precautions:

• Healthcare personnel should wear a surgical mask when caring for patients with suspected or confirmed cases.
• An N95 respirator is recommended for select procedures that are potentially aerosol-generating (e.g. bronchoscopy, intubation, CPR, open airway suctioning, and sputum induction).
• Healthcare personnel should adhere to standard and droplet precautions for 7 days after the onset of illness or until symptoms resolve, whichever is longer.

How long before these recommendations trickle down to all healthcare facilities? They are relying solely on the untried, and not yet released vaccine to protect everyone?

Whose health is on the line here? Not those making these recommendations.

Re: Are You Using the Right Mask?

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/...ct-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.

As for discontinuation of isolation precautions, this is our current directive from Infection Prevention and Control:
Admitted suspect Influenza A H1N1 patient or resident:
Only on receipt of a negative Respiratory Viral Panel Nucleic Acid Test (PCR) result from Nasopharyngeal
Swab/Aspirate or Bronchial Alveolar Lavage specimen.
Confirmed Influenza A H1N1 patient or resident (except those listed below):
When all symptoms have resolved and not before 7 days from the start of symptoms*. If in doubt, contact IPC.
Patient admitted to Critical Care / Intensive Care Units:
Not before 10 days from beginning of symptoms* and with consultation of IPC.
Child under 5 years of age:
Not before 10 days from beginning of symptoms* and with approval of IPC.
Severely Immunocompromised Patient (e.g. bone marrow and other transplant recipients, oncology
patients, etc.):
Only with approval of IPC.

* Repeat Respiratory Viral Panel for Influenza A is not required to discontinue precautions.
This Directive is subject to change as more information becomes available about Influenza A H1N1.

So far we've only had three confirmed cases on our unit... the thin edge of the wedge.

Re: Are You Using the Right Mask?

Originally Posted by janfrn

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/...ct-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?

Re: Are You Using the Right Mask?

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/owad...ARDS&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.

Re: Are You Using the Right Mask?

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?

Originally Posted by afludiary.blogspot.com

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/2009/0...-for-hcws.html

Re: Are You Using the Right Mask?

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)

Re: Are You Using the Right Mask?

Originally Posted by indigo girl

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.)

Originally Posted by indigo girl

When are goggles required?

Whenever a mask is used.

Originally Posted by indigo girl

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!)

Originally Posted by indigo girl

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...

Re: Are You Using the Right Mask?

Originally Posted by 3rdcareerRN

In regard to fit-testing, this link has the procedures: http://www.osha.gov/pls/oshaweb/owad...ARDS&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.

Originally Posted by 3rdcareerRN

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.

Originally Posted by 3rdcareerRN

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

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

Re: Are You Using the Right Mask?

Originally Posted by janfrn

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.

Re: Are You Using the Right Mask?

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