Respiratory Protection and Healthcare Facilities

Recent studies by the National Institute for Occupational Safety and Health (NIOSH) have shown that healthcare workers who routinely come in contact with hazardous chemicals and other airborne materials often lack training and awareness of necessary procedures to protect themselves from exposures to these materials.  These studies are derived in part from the NIOSH Health and Safety Practices Survey of Healthcare Workers, a federally funded web-based survey.  In a 2013 study called Respiratory Evaluation Acute Care Hospitals (REACH), researchers at NIOSH conducted a study to determine healthcare workers’ familiarity with respiratory protection practices including proper selection of devices for various scenarios where respiratory protection would be used.  The study concluded that overall, workers were often unaware of when to wear respiratory protection, what type is needed in many scenarios and how to use it properly.

Because of the nature of their work, healthcare workers (HCWs) may be exposed to various infectious respiratory illnesses where the route of exposure is airborne and may include inhalation of droplets.  These airborne exposures include tuberculosis and seasonal influenza as well as other bacteria, viruses, and chemicals from medical procedures that can be inhaled by personnel and cause injury or illness.  However, the use of respiratory protection has not always been well implemented.  HCWs were one of the most affected groups during the H1N1 pandemic in 2009, because respiratory protection was not commonly worn or it was improperly worn.  Appropriate precautions against airborne and droplet transmission is critical to prevent aerosolized transmissible diseases (ATD) among HCWs who work directly with patients.  However a NIOSH study in 2011 following the H1N1 pandemic found that only 20% of healthcare known to be affected by contagious patients reported using respiratory protection during patient interactions.  As part of emergency preparedness efforts, healthcare facilities should include planning for healthcare workers to properly use respiratory protection as part of response actions.  As referenced in the NIOSH study about 50% of hospitals indicated that they do not maintain a stockpile of respiratory protection in case of a pandemic emergency.

There is sometimes confusion between the difference between respirators and surgical masks.  Surgical masks can be used as a source of control to protect patients from a healthcare worker’s respiratory secretions as well as protect the worker from large droplet splashes or sprays of bodily fluids from patients.  Surgical masks are typically disposable, for one time use, loose fitting and do not provide a tight seal to the mouth and nose.  They are not designed to capture small particles and therefore cannot prevent the wearer from inhaling particles that may be transmitted by coughs, sneezes and from certain aerosol-generating medical procedures and will not provide protection against exposure to airborne transmissible diseases (e.g., influenza, TB, etc.).  Respirators including N95 dust masks provide (if worn properly) a seal against the skin to filter out a wide range of airborne particles.

The Cal/OSHA respiratory protection standard, (Title 8 California Code of Regulations, Section 5144,) requires fit testing for all employees using tight fitting respirators including filtering facepiece respirators (e.g., disposable N95 respirators).  The fit test must be performed before the respirator is used in the workplace and must be repeated at least annually and whenever a different respirator facepiece is used or a change in the employee’s physical condition could affect the respirator fit.  The NIOSH study indicated that many HCWs did not know when they were fit-tested or what type(s) of respirators they had been fit-tested and trained on.

The procedures being performed on a patient with a suspected or confirmed infectious disease (i.e., aerosol-generating procedure or close contact) will affect the type of respiratory protection that should be provided.  Guidelines should be developed by the healthcare facility to ensure the proper choice of respiratory protection.  The NIOSH study showed that many facilities have a written respiratory protection program but do not follow recommended practices for respiratory protection and in some case do not use respiratory protection when they should.  A NIOSH study published in the March 2016 Journal of Occupational and Environmental Hygiene regarding safe handling practices for antineoplastic drugs found the number of times the nurse administered the antineoplastic drug during the week has a negative association with personal protective equipment use.  The NIOSH studies have shown that proper respiratory protection selection, availability and training are often overlooked in healthcare facilities and implementation is too casual.  Healthcare facilities need to have effective respiratory protection programs and ensure workers are trained (at least yearly) and are following the respiratory protection program and infection control guidelines and know when, what type and how to properly care for respiratory protection.  We can assist in developing and implementing an effective respiratory protection program.