Are You Using the Right Mask?

Katnip, RN · Aug 4, 2009

Actually, in the US APIC (the infection control association here) just came out with the recommendation that HCWs working with H1N1 patients wear regular surgical masks.

N-95 respirators should only be used for bronchoscopy, intubation, CPR, open airway suctioning, and sputum induction.

These recommendations were done after intensive review of different masks and respirators. I remember in one of their classes, they stated that the N-95 really doesn't offer any significant protection over a regular surgical mask.

indigo girl · Aug 4, 2009

Katnip, no offense, but I am not following those recommendations. Is it possible that they mean for use with seasonal flu and not swine flu? The CDC link below indicates that guidance is not the same for both. Can you send us a link to the recommendations you are referring to?

My hospital for all its faults, is insisting that we use N95 masks. I have to say that personally, if a suspected swine flu case is coughing in my face, I am not going to feel safe in anything but the N95. I will not work without that level of protection. Why would any nurse accept anything less? After reading about the death of this previously healthy nurse, absolutely not!

http://www.sacbee.com/ourregion/story/2071046.html

Are they worried that we will run out of the more expensive masks? Well, we probably will. HHS has been warning about an impending pandemic for over 3 years now, and HCW should not be taking the brunt of anyone's lack of planning. If they insist on using surgical masks, then that is what it is going to come down to.

Here is what CDC had to say.

http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

All healthcare personnel who enter the rooms of patients in isolation with confirmed, suspected, or probable novel H1N1 influenza should wear a fit-tested disposable N95 respirator or better. Respiratory protection should be donned when entering a patient’s room.
Note that this recommendation differs from current infection control guidance for seasonal influenza, which recommends that healthcare personnel wear surgical masks for patient care. The rationale for the use of respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus. This recommendation is also outlined in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic”.

indigo girl · Aug 5, 2009

100+ Nurses to Rally in SF Wed. to Demand Stronger Swine Flu Safety Protections: California Hospitals Remain Unprepared Despite First Nurse Death

http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/08-04-2009/0005071948&EDATE

More than 100 registered nurses from across California will rally in San Francisco Wednesday to protest gaps by California hospitals in safety preparation for the H1N1 pandemic, the California Nurses Association/National Nurses Organizing Committee announced today.
The nurses will protest the recent firing by UCSF of an RN who blew the whistle on unsafe patient care involving swine flu at their facility, as well as wider problems that a CNA/NNOC preliminary survey of California hospitals has uncovered, including systemic problems with safety gear for nurses and infection control procedures for patients, as well as an emerging pattern of retribution against nurses who speak out about unsafe care.
WHAT: 100+ nurses in scrubs and masks protest swine flu dangers
WHEN: Wednesday, August 5, 12:30 p.m.
WHERE: UCSF Campus, main entrance to medical center, 505 Parnassus,
San Francisco
The protest follows the first death of a nurse due to swine flu last week, a 51-year-old marathon runner in excellent health, who worked in a Sacramento hospital, as well as a General Accounting Office report to Congress this week that warned the U.S. is still not adequately prepared for a worse outbreak of H1N1 this fall.
"Hospitals across California--and possibly the entire country--are putting registered nurses and other front-line caregivers at risk by inadequately preparing for this pandemic," said CNA/NNOC co-president Deborah Burger, RN.
"If hospitals do not take urgent precautions to reverse this lack of preparation, we may see our health care facilities become vectors for infections. That is especially worrisome for hospital patients who already have compromised immune systems, and our nurses who may be unable to respond because of their own sickness," Burger said.
On Wednesday, CNA/NNOC will call for broader public awareness of the fragility of the public safety net, and legislative action to assure proper safety conditions in California hospitals and protections for RNs and other healthcare workers.
CNA/NNOC is also proposing contract language in represented hospitals to assure provision of appropriate equipment, full adherence to current Centers for Disease Control guidelines and protocols, and other measures to protect nurses and patients.
One immediate cause of the protest is the firing of a nurse who had recently started work at the facility when was exposed to the virus in June. While still suffering from the infection, she protested to management about inadequate hospital safety standards that she felt contributed to her illness. Ultimately, the RN was fired in what CNA/NNOC calls retaliation against a swine flu whistle-blower.
Concurrently, CNA/NNOC has been surveying preparedness in a number of hospitals and will report a series of troubling patterns.
These include:
Unclear policies on how to respond to swine flu
Policies falling short of CDC guidelines--including some facilities lacking N95 masks, others re-using them after contact with infected patients
Lack of consistent isolation procedures for swine flu-infected patients
Retaliation for whistle-blowing
Lack of sick leave for infected nurses, and no presumptive eligibility of worker's compensation for nurses who fall ill due to swine flu
Among the preliminary reports from working nurses:
At Sutter Solano hospital in Vallejo, Calif., nurses were refused access to adequate N-95 respirator masks, prompting RNs to file a complaint currently under investigation by Cal-OSHA.
Nurses throughout California widely report that swine flu patients are being placed in non-negative pressure isolation rooms.
Nurses at Kaiser-Oakland report that the facility has not properly fit tested their N-95 masks.
At Long Beach Memorial, RNs report that five RNs were infected after being told to reuse masks.
Nurses at Mills-Peninsula Hospital in San Mateo report that they are not being notified in a timely manner when they have been exposed to a patient with swine flu.
RNs at Tenet Healthcare's Sierra Vista Hospital in San Luis Obispo report having no access to N-95 masks on most units.
These problems mirror what the GAO reported July 29th in Influenza Pandemic: Gaps in Pandemic Planning and Preparedness Need to Be Addressed: "Further actions are needed to address the capacity to respond to and recover from an influenza pandemic, which will require additional capacity in patient treatment space, and the acquisition and distribution of medical and other critical supplies. . ."
"The recent GAO report should be a wake-up call to America's hospitals, but right now nurses and patients are being put at risk by these gaps in preparedness, and we need urgent changes in policy and safety precautions," Burger said.

(hat tip flutrackers/jeremy)

indigo girl · Aug 5, 2009

http://www.osha.gov/dsg/guidance/stockpiling-facemasks-respirators.html

working directly with suspected or confirmed swine flu cases means that you fall into the extremely high risk and/or high risk categories.

no, it's not a law, but use of the n95 is an osha recommendation. if your facility has chosen not to protect you in this way, perhaps you should be asking why they are ignoring cdc as well as osha guidelines. make copies, and ask the facility to explain the rationale for choosing a lesser level of protection for staff.

the only reason that i can think of not to offer the safer ppe is cost. yes, it's more expensive, but aren't you worth it?

very high exposure risk:
healthcare employees (for example, doctors, nurses, paramedics, or dentists) performing aerosol-generating procedures on known or suspected pandemic patients (for example, cough induction procedures, tracheal intubations, bronchoscopies, some dental procedures, or invasive specimen collection). my note: cdc includes giving nebulizer tx as very high risk for pregnant nurses, and recommends being reassigned.-
healthcare or laboratory personnel collecting respiratory tract specimens from known or suspected pandemic patients.
high exposure risk:
healthcare delivery and support staff exposed to known or suspected pandemic patients (for example, doctors, nurses, and other hospital staff that must enter patients' rooms).
staff transporting known or suspected pandemic patients (for example, emergency medical technicians).
staff performing autopsies on known or suspected pandemic patients.
estimating respirator usage in workplaces classified at high exposure risk for pandemic influenza:
employees covered:
healthcare delivery and support staff working closely with (either in direct contact or within 6 feet of) people known or suspected to be infected with pandemic influenza virus.
staff transporting patients who are known or suspected to be infected with pandemic influenza virus (for example, emergency medical technicians).
staff performing autopsies on known or suspected pandemic patients.
respirators are recommended to protect employees working closely with people/patients known or suspected to be infected with pandemic influenza. such protection can be accomplished by a disposable filtering facepiece (e.g., n95, surgical respirator), a reusable elastomeric respirator or a powered air purifying respirator (papr).

(thank you flamedic)

3rdcareerRN · Aug 6, 2009

Actually, in the US APIC (the infection control association here) just came out with the recommendation that HCWs working with H1N1 patients wear regular surgical masks.
...

Here's the link: http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/HICPAC_H1N1_Guideline.pdf

And here is a link to the CDC's current process for gathering best evidence on the issue:

http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/June2009HICPAC.pdf

Katnip, RN · Aug 6, 2009

Thanks for posting the link.

Indigo, yeah it was done in conjunction with the CDC. Not sure what will come of this because each facility will determine what they'll do. I think what's driving this is a fear of running out of N-95s altogether if the season gets bad.

indigo girl · Aug 6, 2009

Thanks to both of you for providing this information. I very much appreciate it. I will be passing it on to my local health reporter who is going to be doing a series on the impact of the pandemic.

The people who made those recommendations are not likely to be doing patient care. They are like war strategists in the rear that tell the troops what to do, but they are not at the front feeling the impact, are they?

indigo girl · Aug 6, 2009

I would appreciate it if some others would give the links a read also. My first impression, and I have only skimmed them once, was that this was a choice that they made, and they could just have easily chosen the other option.

Maybe you are right catnip, that it was cost driven. As we continue to track the fatalities especially in HCW, this might prove to be a costly choice, but again, they aren't the ones at the bedside providing care.

On a positive note, the report did say that pregnant staff should be reassigned, but this is not official policy at most facilities yet. How many of you are working in places that are reassigning pregnant staff away from suspected or confirmed cases of swine flu? Mostly I am hearing from pregnant nurses trading with colleagues or individuals volunteering to take those cases to protect pregnant co-workers.

indigo girl · Aug 6, 2009

This just came out from CDC dated 8/5/09.

http://www.cdc.gov/h1n1flu/masks.htm

CDC tracks H1N1 infection in HCW, and they have not made a change in recommendations. They are the ones with access to the info on the deaths of HCW in Argentina, and what happened in Mexico. As we move further into the pandemic, if we see no further deaths in HCW perhaps they will change their minds. But, the death of that athletic RN in California does not bode well for what could happen this fall/winter if we do see a big surge in numbers of ill patients that we must care for.

Is anyone else confused by what the US APIC has decided? I would like to review the research that would cause them to make this choice. CDC admits that there is an absence of clear scientific data. They appear to be erring on the side of caution. Who would you want guiding your hospital's infection control policy?

I would continue using N95's even if I had to buy them myself. I am not working without them.

This guidance replaces other CDC guidance on mask and/or respirator use that may be included in other CDC documents in regards to the outbreak of novel H1N1 virus. No change has been made to guidance on the use of facemasks and respirators for health care settings. This document includes guidance on facemask and respirator use for a wider range of settings than was included in previous documents and includes recommendations for those who are at increased risk of severe illness from infection with the novel H1N1 virus compared with those who are at lower risk of severe illness from influenza infection.
Information on the effectiveness of facemasks and respirators for decreasing the risk of influenza infection in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in decreasing the risk of novel influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment, the historical use of facemasks and respirators in other settings for preventing transmission of influenza and other respiratory viruses, and on current information on the spread and severity of the novel influenza A (H1N1) virus.
There are important differences between facemasks and respirators. Facemasks do not seal tightly to the face and are used to block large droplets from coming into contact with the wearer's mouth or nose. Most respirators (e.g. N95) are designed to seal tightly to the wearer's face and filter out very small particles that can be breathed in by the user. For both facemasks and respirators, however, limited data is available on their effectiveness in preventing transmission of H1N1 (or seasonal influenza) in various settings. However, the use of a facemask or respirator is likely to be of most benefit if used as early as possible when exposed to an ill person and when the facemask or respirator is used consistently. (Ref. 1. MacIntyre CR, et al. EID 2009;15:233-41. 2. Cowling BJ, et al.
A respirator is designed to protect the person wearing the respirator against breathing in very small particle aerosols that may contain viruses. A respirator that fits snugly on the face can filter out virus-containing small particle aerosols that can be generated by an infected person...

(Thanks to FlaMedic for the link)

indigo girl · Aug 6, 2009

Masking Our Disappointment

http://afludiary.blogspot.com/2009/08/masking-our-disappointment.html

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/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/HICPAC_H1N1_Guideline.pdf

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.

Pediatric Critical Care Columnist · Aug 7, 2009

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.

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.