IOM affirms CDC guidance on N95 use in H1N1 setting

[HonestRN]

Sep 3, 2009 (CIDRAP News) - The Institute of Medicine (IOM) today affirmed existing federal guidance that healthcare workers caring for H1N1 influenza patients should wear fit-tested N95 respirators, not just surgical masks, to protect them from the virus.

At the same time, the IOM called for additional research on flu transmission and the effectiveness of various respiratory protection tools in clinical settings, along with efforts to develop new respiratory protection technologies to enhance safety and comfort.

"Based on what we currently know about influenza, well-fitted N95 respirators offer health care workers the best protection against inhalation of viral particles," said Kenneth Shine, chair of the committee that wrote the report, in an IOM news release.

"But there is a lot we still don't know about these viruses, and it would be a mistake for anyone to rely on respirators alone as some sort of magic shield," added Shine, who is executive vice chancellor for health affairs in the University of Texas System, Austin, and former president of the IOM.. "Health care organizations and their employees should establish and practice a number of strategies to guard against infection, such as innovative triage processes, hand washing, disinfection, gloves, vaccination, and antiviral drug use."

But the IOM report drew criticism today from a representative of the Association of Professionals in Infection Control and Hospital Epidemiology (APIC), who said the recommendation to wear N95s fails to recognize the many practical and logistical problems related to N95 use, including discomfort, costs, shortages, and the difficulty of fit testing....................

On the murky question of the extent to which flu viruses spread through the air, the IOM committee concluded that studies show that "airborne (inhalation) transmission is one of the potential routes of transmission.".............

The IOM's recommendation to use fit-tested N95s drew criticism on practicality grounds today from Ruth Carrico, an infection control expert at the University of Louisville School of Public Health and Information Sciences and a former APIC board member. Carrico was on a panel of experts who reviewed the IOM report in draft form.

"I think the IOM has missed the mark," Carrico told CIDRAP News.

She acknowledged that the panel of authors was specifically charged with looking only at the science and not the logistical and economic issues. But she said it's difficult to separate the scientific issues from the logistical matters, such as the ability of health workers to follow the guidance and its applicability in clinical settings.

"As a human being, if you're being told this is the best protection for your and you go to work and that protection is not available, how likely are you to go to work the next day?" she asked.

Noting that the recommendation specifically calls for the use of fit-tested respirators, Carrico said there are "lots of gaps" in the information about fit testing. Given the cost and time requirements of fit testing, she said, "Does it really make sense and is it a valid point? We have to be concerned about that in our economic times."

More generally, she said, "Divorcing the recommendations from the practicality of implementation represents a serious problem for healthcare workers who are trying to figure out, 'What do I do to provide care for my patients in a safe manner?'"

Hospitals say they do fit testing as best they can, but "there's no way to be fit tested for all the kinds of respirators used," Carrico continued. For example, this past spring, some hospitals ran out of respirators and hence used respirators from the government's Strategic National Stockpile. Those were a different type from what hospitals normally use, which created a need for additional fit testing, she said.

Keeping respirators on hand is a continuing problem, she added. "There are back orders; there are constant calls about interruptions in supply. We simply do not have the supply line of these types of materials in order to apply these recommendations." As a result, hospitals try to save their respirators for us in the highest-risk settings.

The shortages and other problems lead to inconsistent and changing hospital policies, which confuse workers, she added. "We're hearing about workers who will say 'I refuse to care for this patient because I don't feel safe,'" she said.

http://www.cidrap.umn.edu/cidrap/content/influenza/biz-plan/news/sep0309iom.html

[indigo girl]

Thank you, IOM for not bowing down to the economic pressure and selling us out. Now, how do you get our facilities to follow these guidelines, and protect us?

Thank you, Honest RN for posting this.

[indigo girl]

As suspected, the use of the face mask in our facilities seems to be based more on cost and convenience than safety.

[indigo girl]

Nurses Association demands medical masks be mandatory to protect against swine flu

http://www.nydailynews.com/ny_local/2009/09/05/2009-09-05_nurses_dont_mask_flu_fears.html

Whoa! Is the New York Dept of Health prepared to disagree with the IOM and the CDC? I don't think that "adequate" is going to cut it given what the IOM has decided.

No vax until mid-October = no antibodies until Thanksgiving...

Nurses across the state are demanding medical masks that effectively protect them from swine flu.

A day after scientists said health care workers who come in close contact with flu patients should wear an N95 respirator, the New York State Nurses Association rallied its 37,000 members.

In an open letter to State Commissioner of Health Richard Daines, the association called for respirators to be standard in New York, saying airborne germs are a "clear hazard for workers."

"Surgical face masks are not sufficient and particles can get through," said registered nurse Renee Gecsedi, the association's director of education practice and research.

Claire Pospisil, spokesperson for the State Department of Health, said the state's current guidelines are adequate and that nurses will be protected by mandatory vaccinations.

N95 respirators, which have filters and a tight seal, can be up to 12 times more effective than surgical masks against airborne swine flu germs, according to Institute of Medicine scientists, who advise the federal government.

(hat tip pfi/monotreme)

[RedWeasel, RN]

how did i know this would happen....grr

[HonestRN]

Whoa! Is the New York Dept of Health prepared to disagree with the IOM and the CDC? I don't think that "adequate" is going to cut it given what the IOM has decided.

No vax until mid-October = no antibodies until Thanksgiving...

I suspect that this will happen at more hospitals across the nation as they confront increased H1N1 cases and the increased cost of providing the recommended respirators. Unfortunate.

[spacey]

There is the link I've been looking for! -- Our hospital has issued a policy that states the flu is transmitted by Droplets....and that caregivers should wear a surgical mask when caring for the patients. I KNEW I had read that the N95 was the appropriate protection. People (staff) who have infected family members at home are required to wear a surgical mask at work for 7 days from their initial exposure. (guess how much compliance we're getting on that?) People who have been sick may return to work after 24 hours with no fever....regardless of the fact that some cases have no fever. Doc's are no longer testing unless pt's are critical, so it becomes hard to determine who has been actually exposed and who has presumed exposure.

[indigo girl]

Nurses Applaud New H1N1 Flu Safety Recommendations and Call on CDC to Maintain Stringent Safety Guidelines

http://www.infectioncontroltoday.com/hotnews/nurses-applaud-iom-recommendations.html

The California Nurses Association/National Nurses Organizing Committee (CNA/NNOC) says it applauds the Institute of Medicine (IOM) for recommending strong protections for patients and caregivers to avoid airborne transmission during the H1N1 flu pandemic, and calls on the Centers for Disease Control and Prevention (CDC) to meet the same stringent standards.

"America's registered nurses have significant experience dealing with H1N1 flu, and we know that we need the highest level of safety protection for patients and nurses alike, including the N95 masks," said Deborah Burger, RN, co-president of CNA/NNOC. "We've seen infection clusters caused by inadequate safety gear, and hospitals cutting corners on their preparedness for the virus. We need to ensure that any guidelines improve patient care and safety in hospitals -- not weaken it."

Last Tuesday the Institute of Medicine (IOM) issued a report, "Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A," reviewing all available scientific literature, and concluding that the evidence on transmission makes clear that nurses and other caregivers caring for H1N1 and suspected H1N1 patients should use NIOSH-certified respirator masks of N95 or better that have been tested to ensure proper fit. They specifically argued that: "...the committee noted that in the recent outbreak of H1N1 in Mexico, strict adherence of infection control measures including the use of N95 respirators prevented healthcare workers from contracting influenza-like illness...One study that has been submitted for publication compared the clinical efficacy of medical [surgical] masks versus N95 respirators in healthcare workers and found that N95s had statistically significant efficacy while medical masks showed no efficacy..."

On the heels of the IOM recommendations, the CDC held a conference call with healthcare organizations questioning much of the report, leading many nurse and caregiver organizations to fear that the IOM recommendations would be replaced with weaker standards not borne out by the scientific evidence.

The IOM recommendations come after a recent survey sponsored by CNA/NNOC of 190 American hospitals that found wide gaps in H1N1 preparedness. Nurses at 15 percent of hospitals report they do not have access to the proper respirator masks, exposing nurses and patients to infection; at up to 40 percent of the hospitals, nurses are expected to reuse masks, in violation of Centers for Disease Control guidelines and IOM recommendations. In addition, at more than one-fourth of the hospitals, nurses cite inadequate isolation of swine flu patients, increasing the risk of infection to others.

(hat tip pfi/monotreme)