Kate Durand, MHS, Barbara Materna, PhD, CIH

1. Improving Respiratory Protection Programs in California Acute Care Hospitals: Pilot Test of a Resource Toolkit for Program Administrators Kate Durand, MHS, Barbara Materna, PhD, CIH California Department of Public Health, Occupational Health Branch Debra A. Novak, RN, DSN, Ed Fries, MS, Maryann D’Alessandro, PhD National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory CSTE Annual Meeting – June 14, 2011 – Pittsburgh, PA

2. Background • Increased use of respiratory protection during 2009 H1N1 influenza pandemic • Cal/OSHA Aerosol Transmissible Diseases (ATD) standard became effective August 5, 2009

3. Background • Respirator Use Evaluation in Acute Care Hospitals (REACH) field project: 2009-10 influenza season • Hospitals followed public health guidelines & Cal/OSHA ATD Standard on N95 respirator use • Deficiencies in written policies and implementation of respiratory protection programs (RPPs) • NIOSH partnered with CDPH to develop, implement, and evaluate an intervention to improve programs

4. Objectives • Identify one or more common deficiencies in hospital respiratory protection programs as the focus of the intervention effort. • Develop and implement a selected set of intervention strategies in a sample of acute care hospitals. • Evaluate effectiveness of intervention strategies. • Report back to NIOSH. • [Consider statewide dissemination of strategies.]

5. Methods:Recruitment of Hospital Participants • CDPH staff visited 14 of 16 REACH hospitals • Presented REACH findings & recommendations • Invited participation in follow-up project • Discussed RPP deficiencies & what types of tools would be helpful • Invited one additional SF hospital because of interest expressed by their safety professional

6. Methods:Tool Development Participants completed a pre-project assessment questionnaire evaluating their RPP by phone; gave input on desired tools. CDPH industrial hygienists identified existing tools & developed new tools to address common deficiencies in RPPs. Toolkit was developed with input from NIOSH and Cal/OSHA.

7. Most Deficient Areas of Written Programs • Designation of a Respirator Program Administrator • Recordkeeping • Fit testing protocol • Training • Program evaluation

8. Areas Hospitals Identified as Needing Improvement • Areas of implementation with greatest need for improvement – determined subjectively • Selection of appropriate respirator for task and suspected/confirmed infectious disease risk • Donning/doffing N95 • Regular evaluation of program • Employee use of the specific respirator they were fit tested for

9. The Toolkit • Guide for Respiratory Protection Program Administrators in Hospitals • Step-by-step “how-to” instructions for developing and implementing a RPP in a hospital setting • Designed to be used by staff with little or no formal training in health and safety • “Best practices” shared by a few hospitals • DVD enclosed with other tools useful for RPP development and implementation

10. DVD Contents:Cal/OSHA Standards and Appendices • Cal/OSHA Respiratory Protection Standard (full standard) • Appendix A: Fit Test Protocols • Appendix B: Medical Questionnaire • Appendix D: Information for Voluntary Users • Cal/OSHA Aerosol Transmissible Diseases Standard (full standard) • Appendix B: Alternate Medical Questionnaire

11. DVD Contents:Public Health Guidance Documents • CDC Prevention Strategies for Seasonal Influenza in Healthcare Settings • CDPH Guidance on Influenza Prevention (11/5/2010) • Cal/OSHA Guidance for the 2010-2011 Influenza Season (11/5/1010)

12. DVD Contents:Administrative Tools • List of Links – Useful Web Sites • Written Respiratory Protection Program Template • Respiratory Protection Program Evaluation Checklist • Sample Respirator Fit Test Record • Sample Respirator Fit Test and Training Verification Card • Sample PAPR Program Flow Chart developed by a Hospital in California

13. DVD Contents:Training Tools and Educational Materials • List of Links – Useful Web Sites • Cal/OSHA PowerPoint presentation: Respiratory Protection in SNFs and Primary Care • CDC PowerPoint presentation: Guidance for the Selection and Use of PPE • CDPH PowerPoint presentation: Fit Test Principles • OSHA video: Difference Between Respirators and Surgical Masks • OSHA video: Donning and Doffing • Sample Mask and Respirator Flyer * • Quick Reference Table for Respirator Selection * * Adapted from material provided by Mercy General Hospital, Sacramento, CA

14. Methods:Toolkit Pilot Testing and Evaluation • Participants attended a webinar with overview of toolkit and expectations for pilot testing. • Hospitals pilot tested guide and toolkit for ~ 4 months with industrial hygiene technical support. • Feedback form provided to record use of tools & input. • CDPH re-visited hospitals for feedback, post-project assessment, & brief observation of RPP implementation.

15. Methods:Feedback from Stakeholders • Also sent materials to 14 stakeholders for review: • Cal/OSHA • Hospital and infection control professional associations • Nurses’ unions

16. Results: Participant Feedback on Tools • Visited 12 of 16 REACH hospitals. • Ten hospitals completed feedback form regarding their experience with the guide and toolkit. • Positive feedback received on tools, including from hospitals that did not use or feel they needed them. • Most frequently used tools: • Guide (10), web links list (7), RPP template (6), and program evaluation checklist (6). • OSHA videos were also popular.

17. Results:Post-Project RPP Evaluation • All written RPPs were improved during the project. • Some were improved in response to REACH results, before toolkits were received. • Six hospitals used the provided RPP template. • Several deficiencies in implementation still apparent in spite of improvements. • Weakest on correct donning/doffing and staff ability to choose appropriate respirator.

18. Results:Stakeholder Feedback on Tools • Valuable feedback received from: • Several unions representing nurses • Infection prevention trade association • Two participants who did not end up implementing tools, but provided feedback on the guide • One practicing infection prevention nurse from outside the project • No feedback from Cal/OSHA yet

19. Results:Stakeholder Feedback on Tools • Overall impression: The guide and toolkit could be very useful to RPP administrators. • Unions raised concerns about writing style and tone of the guide – letting management off the hook in some places. • Suggested using less text and more graphics and “boxed” info for better readability. • No comments on specific tools on the DVD.

20. Conclusions Guide & toolkit useful for many participants– likely to be useful to other hospital RPP administrators struggling with implementation. More improvement in training needed – deficiencies noted in effective implementation of proper use of respirators. A similar guide and toolkit could be useful for other types of health care facilities – e.g., clinics and long-term care facilities

21. Next Steps • Revise the guide using input from stakeholders and participants. • Use professional graphic artist and printer to produce a final toolkit for statewide distribution. • Conduct outreach and disseminate to health care sector. • Post the guide and toolkit on CDPH website.

22. Questions? Barbara.Materna@cdph.ca.gov