Many of my colleagues and I are a bit disturbed by this, and I am looking opinions/advice.
Paraphrasing the official fliers that are making their rounds, we are required to wear gown, gloves, masks, and eye protection for any suspected/confirmed H1N1 cases. The policy states that gowns and gloves are both single use items and should be thrown away after one use. The big change is that we are being "encouraged" to reuse masks - not just N95 respirators (which I can kinda understand) - but surgical masks as well until they "become wet or soiled." And while they "cannot hang on any hook, fixture, or door handle" they can "be carried in uniform pockets when not in use."
Now granted, I am still a noob of a nurse, but this goes against every bit of training related to PPE I remember.
Not only are they encouraging reusing masks, our access to supplies of them is being severly limited. My floor has unoficially been designated the "Flu Floor," 18 of our 34 patients where suspected/confirmed H1N1 last night (not to mention our plain old MRSA/VRE/etc patients). Coming onto the floor, we were told that floor stocks of masks were almost out (which proved accurate). It took 2 staff nurses, a back-up charge RN and the Clinical Coordinator to wrestle an a box and a half of various masks from central supply, because "masks are being very tightly controlled." We ended up sending out staff throughout the night on scrounging missions to dig up more to make it through the shift and give the oncoming day people some wiggle room.
Now granted, there could be some sort of mask shortage I am unaware of. But honesly, the situation is getting flat out disturbing. Especially since everything seems to be set policy. Is anyone else experiencing anything like this? Do my collegues and I have any avenue to express our concerns (the "J" acronym has been mentioned)? Should we start a fund to buy our own supplies? Or should we just take a collective chill pill and get over it?
Our policy is almost the same. Except the eyewear. We have also been told that "according to manufacturer" you can reuse masks as long as they are not soiled. We were told to put them in a paper bag though not our pockets. There is a shortage of N95 masks already (1 in particular I forget the name but its the one we used most frequently). If a pt is suspected to have the flu they are placed on contact and droplet so in we go with gloves, gowns and masks.
I had an issue last week with N95 masks. There were no small masks in the cart outside of my pt's room so I went to another supply cart and pulled out about 8 N95s. One of the intensivists saw me and told me "you only need one mask all shift."
I said "not according to OSHA." After my shift, I went home and researched. There is quite a bit of info on H1N1 and N95 masks on the CDC site. NO, you shouldn't wear the same mask the entire shift. If it becomes bent, (like in your pocket), or soiled you should NOT reuse it. Generally, I use about 5 during my shift. If the hospital doesn't like it, I will give them the info on the CDC website.
WOWSER, I just went to the CDC site and they have changed there recommendations since last week! Here is the new info for those interested:
I knew this was coming once they started saying that an N95 should be used with each flu patient. Not only are N95's expensive, but many nurses might opt to use the mask rather than get a flu vaccine. As for reusing a mask, I cannot disagree more, especially on different patients. Would you ever looks at your gloves and say, "hey, these don't look soiled, I think I'll use them on the next guy."? Aside from the fact that hundreds of years of influenza has told us that it is not airborne, the experts have still insisted that we should use an N95 for flu patients. The flu is spread through droplet and indirect transmission. So when little Johny coughs on his desk and little Sally puts her hand on the desk and then by her mouth she gets the flu. So a patient is going to breath or cough on your mask, then you put it in your pocket, then you put your hand in your pocket? I fail to see how this is effective infection control. Plus, there are going to be droplets on the outside of that mask even if it is not "visibly soiled", and the last time I checked virus particles weren't exactly visible to the naked eye. So when you have droplets on the outside of your mask, and you hang it on a door or put it in your pocket, those droplets are going to get into your pocket, and on that door handle for everyone to touch. Plus, what happens when you go into the next patient's room? The mask filters the droplets and particles from getting to you, but they are still sitting on your mask. So if you laugh, breath heavy or talk loud, the force of your own air is going to throw those droplets off the outside of your mask and in the area of your next patient. That's infection control? If officials and hospitals want us to wear space suits everywhere in the wake a flu season, then they can't be cheap about it at the same time. Eventually you're going to run out of masks, in which case, as suggested, a phone call to OSHA would not be a bad idea.
According to my town's OEM (office of emergency management) there IS a shortage of N-95 masks - so i can see that one to an extent... but as far as the regular surgical masks - I'm not aware of any shortage or impending shortage.
Though keep in mind, disposable masks are a relatively new invention. And reuasble cotton masks are a fashion statement in Asia!!
We had a memo hanging in our OR that there is a shortage of regular surgical masks, particularly the kind with fluid shields attached. As of now, we are not feeling the pinch but I can see a day when we will have to start hiding them. Unfortunately, the rest of the hospital seems to think we're Walmart..they steal our scrubs. They call us for equipment and supplies before they've even tried the CS dept. For pete's sake, a cardiac floor had a pt. with a pacemaker coding. They called us and wanted to have our magnet, because they didn't have one?! It's gotten so bad that we take down your name and department when you come to borrow something..I'm all for making them leave something for collateral.
As far as the carrying them around in a pocket, no, it's not the ideal but you can certainly get away with wearing it until it's wet or soiled. Especially if you're not wearing it for sterility purposes.
I don't altogether get the eye protections, never needed it before, now we do, and we're constantly running out of the disposable "glasses" and the masks with the shields attached.
I spent 2 days listening to the IOM hearings on PPE for HCW. I had been wondering about the eyeshields also. What they said was that you can be infected with influenza via the lacrimal ducts if you do not wear eye protection.
Surgical masks are better than nothing but the research indicates that you are far better protected with the N95.
Surgical masks didn't stop the spread of flu and other respiratory illnesses during a five-week study involving 1,936 health-care workers at 24 hospitals in Beijing last winter. Thicker versions designed to better fit the face, called N95 masks and made by 3M Co., reduced flu by 75 percent. The N95s cost 5 to 10 times more, said study author Raina MacIntyre, head of public health at the University of New South Wales in Sydney.
"Surgical masks are probably most useful when worn by patients to catch respiratory droplets that otherwise might spread directly to their close contacts or contaminate surfaces," McNiece said.
"It would not be ethical to recommend surgical masks for health-care workers," MacIntyre said in an interview prior to her presentation. "They have significant leakage around the face. The findings fit everything we know from the experimental data about the poor quality of filtration, the poor fit."
Aside from the fact that hundreds of years of influenza has told us that it is not airborne, the experts have still insisted that we should use an N95 for flu patients. The flu is spread through droplet and indirect transmission.
Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A:
This letter is focused solely on airborne exposures that would require respiratory protection. Respiratory particles setle slowly from air and are able to disperse throughout the room. Thus inhalation exposure to respirable particles does not require close contact with an influenza patient, although exposure intensity is higher closer to the patient. Large droplet particles settle more rapidly from air and do not disperse throughout the room. Thus exposure to these particles tends to require close contact with the influenza patient, although there is a continuum of distances traveled from the point of emission depending on particle size.
Evidence from environmental and animal studies has supported the role of airborne exposure in the transmission of influenza virus. the 2008 IOM report reviewed research on airborne transmission including animal studies and observational studies on the effect of ultraviolet light and air circulation (IOM, 2008b). Newer studies published since the 2008 IOM report provide additional evidence regarding airborne transmission. For example, Fabian and colleagues (2008) showed that persons ill with influenza A (and B) emit the virus as respirable-size particles in exhaled breath and in coughs. In a study using stationary and personal sampling and measurement in a healthcare clinic attended by patients with influenza A (and B), researchers confirmed the presence of the airborne influenza virus in various clinic locations and in the breathing zones of healthcare workers, with more than fifty percent of detectable virus particles in the respiratory range (Blanchere et al., 2009). Mubareka and colleagues (2009) found that guinea pigs infected with the influenza A virus (H3N2) can efficiently transmit the infection to susceptible guinea pigs via inhalation, presumably by virus carried on respirable particles. (Mubareka et al., 2009). Other recent studies show that ferrets infected with nH1N1 virus transmitted the infection to susceptible animals via inhalation. Inhalation transmission was less efficient compared to a seasonal H1N1 virus in the study by Maines and colleagues (2009) but was found to be efficient in the second study (Munster et al., 2009).
Current evidence supports airborne exposure as likely being one of the routes of nH1N1 virus transmission in healthcare settings absent appropriate exposure control measures. This does not preclude transmission by the droplet spray, and contact routes absent appropriate control measures. Therefore, the committee concluded that recent animal and environmental studies have demonstrated the importance of airborne transmission of nH1N1 virus, however the relative contribution of each of the possible routes of transmission is yet to be determined. Without knowing the contributions of each of the possible route(s) of transmission, all routes must be considered probable and consequential.
I spent 2 days listening to the IOM hearings on PPE for HCW. I had been wondering about the eyeshields also. What they said was that you can be infected with influenza via the lacrimal ducts if you do not wear eye protection.
My understanding has always been that touching eyes with dirty hands was a sure way to pick up a virus..makes sense to me to need to shield the eyes...
Yes, now they have allowed a loophole for facilities to prioritize the N95 masks. It is called "prioritized respirator use mode" and it will be difficult to tell if they are really out of masks are just being stingey....We will never know if "reasonable efforts to obtain and maintain a sufficient supply" have been made.
Prioritized respirator use:
Where a shortage of respirators exists despite reasonable efforts to obtain and maintain a sufficient supply for anticipated needs, in particular for very high exposure risk situations such as some aerosol-generating procedures (listed below), a facility should consider shifting to a prioritized respirator use mode. In this mode, respirator use is prioritized to ensure availability for healthcare personnel at most risk from 2009 H1N1 influenza exposure. Even under conditions of prioritized use, personnel attending aerosol-generating procedures on patients with suspected or confirmed 2009 H1N1 influenza should always use respiratory protection at least as protective as fitted N95 respirators. An example of prioritization for personnel not attending aerosol-generating procedures is shown in Table 2. Prioritization should be adapted to local conditions and should consider intensity and duration of exposure, personal health risk factors for complications of infection, and vaccination status. When in prioritized respirator use mode, respirator use may be temporarily discontinued for employees at lower risk of exposure to 2009 H1N1 influenza or lower risk of complicated infection. Gathering of personal information for the purposes of pandemic planning and response must be done in a fashion that is compliant with all applicable rules and regulations, including the Americans with Disabilities Act (ADA):
http://www.eeoc.gov/facts/pandemic_flu.html. Contingency crisis planning is critical to efficient implementation of prioritized use during supply shortages. In making decisions about prioritization, facilities should consider needs for managing patients with diseases other than influenza that require respiratory protection (e.g. tuberculosis) and also considerations related to the timetable for obtaining more respirators. To assure that respirators are likely to be available for the most important uses, facilities should maintain a reserve sufficient to meet the estimated needs for performing aerosol-generating procedures and for managing patients with diseases other than influenza that require respiratory protection until supplies are expected to be replenished.
Facemasks for healthcare personnel who are not provided a respirator due to the implementation of prioritized respirator use: If a facility is in prioritized respirator use mode and unable to provide respirators to healthcare personnel who provide care to suspected and confirmed 2009 H1N1 influenza cases, the facility should provide those personnel with facemasks. Facemasks that have been cleared for marketing by the U.S. Food and Drug Administration have been tested for their ability to resist blood and body fluids, and generally provide a physical barrier to droplets that are expelled directly at the user. Although they do not filter small particles from the air and they allow leakage around the mask, they are a barrier to splashes, droplet sprays, and autoinoculation of influenza virus from the hands to the nose and mouth. Thus, they should be chosen over no protection. Routine chemoprophylaxis is not recommended for personnel wearing facemasks during the care of patients with suspected or confirmed 2009 H1N1 influenza.
In response to complaints, OSHA inspectors will ensure that healthcare employers implement a hierarchy of controls, including source control, engineering, and administrative measures, encourage vaccination and other work practices recommended by the CDC. Where respirators are required to be used, the OSHA Respiratory Protection standard must be followed, including worker training and fit testing.
The CDC recommends the use of respiratory protection that is at least as protective as a fit tested disposable N95 respirator for healthcare personnel who are in close contact (within 6 feet) with patients with suspected or confirmed 2009 H1N1 influenza.
"Employers should do everything possible to protect their employees," Acting Assistant Secretary of Labor Jordan Barab said. Barab emphasized, however, that where respirators are not commercially available, an employer will be considered to be in compliance if the employer can show that a good faith effort has been made to acquire respirators. The employer will also need to implement a hierarchy of controls such as feasible engineering controls, administrative controls, and the use, as appropriate, of personal protective equipment, such as gloves and respirators to protect workers while providing close-contact care.
Since a shortage of disposable N95 respirators is possible, employers are advised to monitor their supply, prioritize their use of disposable N95 respirators according to guidance provided by CDC, and to consider the use of elastomeric respirators and facemasks if severe shortages occur. Healthcare workers performing high hazard aerosol-generating procedures (e.g., bronchoscopy, open suctioning of airways, etc.) on a suspected or confirmed H1N1 patient must always use respirators at least as protective as a fit-tested N95, even where a respirator shortage exists. In addition, an employer must prioritize use of respirators to ensure that sufficient respirators are available for providing close-contact care for patients with aerosol-transmitted diseases such as tuberculosis.
We can reuse eyeshields provided the patient doesn't cough while we're in the room. I'm horrified by the suggestion of reusing N95 masks, though - apart from the likelihood of of contaminating your side of the mask while removing, storing and reapplying it you're likely to get infected droplets inside the pocket the mask's stored in, which could contaminate anything else you put in your packet - like your hands.
I work on an ID unit and have looked after dozens of suspected and confirmed H1N1 patients. My hospital has made having adequate supplies a high priority - any money saved by skimping on equipment will be well and truly outweighed by the cost of even one extra case, particularly if that's a staff member.
AuntieRN
678 Posts
Our policy is almost the same. Except the eyewear. We have also been told that "according to manufacturer" you can reuse masks as long as they are not soiled. We were told to put them in a paper bag though not our pockets. There is a shortage of N95 masks already (1 in particular I forget the name but its the one we used most frequently). If a pt is suspected to have the flu they are placed on contact and droplet so in we go with gloves, gowns and masks.