Overview of NPPTL Healthcare Respiratory Protection Surveillance and Intervention Research

1. Overview of NPPTL Healthcare Respiratory Protection Surveillance and Intervention Research Debra A. Novak PhD, RN CDC/NIOSH National Personal Protective Technology Laboratory (NPPTL)Pittsburgh, PA University of Cincinnati September 16, 2014

2. Learning Objectives Upon completion of this presentation the participants will: • Understand recent clinical events and related research findings evidencing marginal compliance with recommended proper use of respiratory personal protective equipment (PPE). • Identify suggested strategies to reinforce healthcare workers’ proper use of respiratory protection.

3. Why Healthcare Respiratory Protection is a Priority • Healthcare is the fastest-growing sector of the U.S. economy, employing over 18 million workers • Healthcare personnel (HCP) are at higher risk of exposure to infectious respiratory pathogens than workers in non-healthcare settings • Preferred methods of reducing exposure (elimination, substitution, administrative, and engineering controls) are often not possible or practical to implement, especially during an emerging outbreak or pandemic.

4. Occupational Statistics Every Day • 9,000 U.S. workers sustain disabling injuries • 16 die from a work injury • 137 die from work-related illnesses Healthcare Industry • In 2007 general medical and surgical hospitals reported more injuries and illnesses than any other industry ….. in 2010 hospitals again held the # 1 position with over 30% of all lost time nonfatal occupational illness and injuries. • OSHA describes healthcare as having a “weak culture of worker safety”……. “Very poor safety performers.”

5. Compliance with Use of PPE • Evidence of marginal compliance with respiratory protection guidance….less than 60%. • Specifically, there was a lack of adherence to the proper use of infection control precautions (respiratory protection) documented during the H1N1 influenza pandemic. CDC “ Infection control (IC) practices are not being faithfully followed... failure to recognize patients and activities that warrant specific IC practices.” CDC “ Compliance with routine infection control procedures is an increasingly important issue .” OSHA https://www.osha.gov/OshDoc/Directive_pdf/CPL_03-00-016.pdf

6. Office of the Director, NIOSH Office of Extramural Programs Office of Mine Safety and Health Research National Personal Protective Technology Laboratory (NPPTL) Division of Respiratory Disease Studies (DRDS) Division of Safety Research (DSR) Health Effects Laboratory Division (HELD) Education and Information Division (EID) Division of Applied Research and Technology (DART) Division of Surveillance Hazard Evaluations and Field Studies (DSHEFS) Division of Compensation Analysis and Support (DCAS) Office of Research and Technology Transfer Spokane Research Laboratory NIOSH Divisions & Laboratories

7. NIOSH PPT / NPPTL Vision & Mission The VISION is to be the leading provider of quality, relevant, and timely PPT research, training, and evaluation. The MISSION of the PPT program is to prevent work-related injury, illness and death by advancing the state of knowledge and application of personal protective technologies (PPT). PPT in this context is defined as the technical methods, processes, techniques, tools, and materials that support the development and use of personal protective equipment worn by individuals to reduce the effects of their exposure to a hazard. Photos courtesy of MSA, Moldex, and MSA (left to right)

8. Interventions PPT Research Surveillance* Standards Certification* Identification of best practices Improved respirator designs and Development of National Surveillance System Early intervention response and Improved Workplace Practices *OSHA Respiratory Protection Standard: 29 CFR 1910.134; OSHA 42 CFR Part 84

9. Dynamics of Disease Transmission PPE Compliance Availability of PPE Healthcare Worker Status Cost of PPE Variables Influencing Healthcare Workers’ Use of PPE Occupational Exposures www.thelancet.com/infection Vol 9 December 2009

10. PPE Compliance The protective effect of PPE is inconsequential if a HCW is non-compliant.

11. Respiratory Protection in Healthcare • N95 Filtering Facepiece Respirators (FFRs) are the most commonly used type of respirator in healthcare • NIOSH 42 CFR Part 84 • FDA “Surgical N95 respirator”

12. Clinical Events California Bacterial Meningitis H1N1 NPPTL Research Initiatives REACH I REACH II AAOHN Survey Clinical Challenges Compliance with Proper Use

13. California Bacterial Meningitis Background Two individuals became seriously ill and hospitalized with a highly virulent strain of meningitis. Hefty fines were issued by Cal/OSHA to the medical center and the police and fire departments. Lesson The individuals who voluntarily wore respiratory protection (N95s) did not get sick. Accessed from: www.sfgate.com/2010/04/21

14. H1N1 Respirator Supply Issues • N95 supply shortages… stockpiles rapidly depleted • Just-in time and traditional supply chains collapsed • Where to access re-supply of respirators? • When to use a surgical mask? • When to use an N95? • What to use? • How to properly use recommended equipment (N95)? • How to mass fit-test employees? • How to fit-test for the re-supplied models of N95s ?

15. H1N1 Take Home Messages • Healthcare organizations displayed confusion. • Preparedness was weak….plans exist on paper. • Most HCWs recall fit test at hire with minimal updates. • Fit-testing was the focus…ongoing RPE training was a practice gap. • HCWs are infrequent and complacent users of RPE. • HCWs are improperly using (donning and doffing) respirators. • Respirators (N95s) used for TB. • HCW unprotected H1N1 exposures & deaths were reported.

16. RPP Best Practices Monograph 2013-2014 National Toolkit for HCW RPP Analysis REACH II Data REACH II CA RPP Toolkit REACH I MN 2009 CA 2010-2012 AAOHN Survey 2013-2014 AAOHN Competencies Educational Modules REACH II Dissemination 2014 RP Prevalence Survey NC CDPH CA 2010 NY MI 2011 RTI 2012 OSHA & NIOSH * Respirator Evaluation for Acute Care Hospitals 2012-2014

17. RespiratoryUse Evaluation in AcuteCare CaliforniaHospitals“REACH I” California Department of Public Heath & NPPTL/NIOSH Source: Beckman S, Materna B, Goldmacher S, Zipprich J, D’Alessandro M, Novak D and Harrison, R. (2013). Evaluation of respiratory protection programs in California hospitals during the 2009-2010 H1N1 influenza pandemic. AJIC ( published online 9 August).

18. Overview Purpose of the Study Assess the usage of respiratory protection for influenza exposure among healthcare workers. Study Methods • Sixteen healthcare organizations participated in the study. • Onsite surveys (15-21) and observational data collection methods were employed in each facility. • 204 healthcare workers participated in the study from a variety of clinical specialties. Approved by California and NIOSH IRBs as public health practice

19. Respirator Reuse N=85 No – 116 (57.7%) Yes – 85 (42.3%) Note - More than one response may have been selected by each respondent

20. “How do you know that you need to wear a respirator?” N=201 Note - More than one response may have been selected by each respondent

21. What do healthcare workers believe? N=203

22. Other findings • 50% of the hospital managers reported that their facility had experienced a shortage of respirators between April 2009 and the survey period (January 20 - February 23, 2010). • The observational data indicate improper use of respiratory protective equipment as evidenced by donning and doffing practices. • Not performing a seal check • Improper strap placement • Touching the facepiece upon doffing

23. Problems with N95 Respirators Note - More than one response may have been selected by each respondent

24. REACH II Purpose: Evaluate hospitals’ respiratory protection programs and respirator usage in five regions of the U.S. Regions: North Carolina, Minnesota/Illinois, New York, Michigan, California Data Set Includes: • 98 Hospitals • 1500 hospital managers, unit managers & healthcare workers (HCW) • 300 demonstrations of donning & doffing

25. REACH II Findings 1.CDC recommendations regarding respiratory protection in the presence of patients with seasonal influenza. Healthcare workers appear to be unaware of the recommended procedures when in close contact with these patients. Healthcare workers and their managers (both hospital and unit managers) appear to be unaware of the recommended protection while performing aerosol-generating procedures. 2. Best practice procedures for monitoring and evaluating the hospital’s respiratory protection program (RPP). The REACH II surveys suggest that many hospitals do not have a formal mechanism for evaluating their RPP or documenting respirator use, supply, defects, or problems; do not maintain their respirators properly; do not seek input from healthcare workers; and do not determine whether staff are using respirators as required.

26. REACH II Findings 3. Medical evaluation and fit testing requirements. Most hospitals are not following guidelines about the frequency of medical evaluations or methods for notifying staff about which model and size of respirators they may use. 4 Training requirements. The REACH II surveys suggest healthcare workers are unaware of how often training is required and that staff are not allowed to wear a respirator without periodic training. 5. Fit testing. Healthcare workers at most REACH II hospitals are not aware of the required procedures if they cannot successfully be fitted with a respirator. 6. Manufacturers’ recommendations for respirator use. Healthcare workers at many REACH II hospitals did not demonstrate awareness of user seal check procedures, proper respirator removal and disposal, using the straps, and the correct placement of the straps.

27. REACH II Findings 7. CDC recommendations regarding respiratory protection in the presence of patients with infectious disease. In over a third of the REACH II hospitals, healthcare workers were unaware of required procedures. The survey data suggested that hospital managers and unit managers tended to be aware of recommended/required practice, whereas many healthcare workers were not. In addition, this pattern was evident in almost all of the topics addressed in this study: Adherence rates based on the hospital manager and unit manager surveys were higher than the rates based on the healthcare workers survey. Thus, the closer respondents were to the “bedside” (i.e., the more patient contact they had), the less likely they were to provide answers that reflected knowledge of the recommended or required respiratory protection practice.

28. Does your facility have PAPRs available for use when employees need them?

29. Does your facility have PAPRs available for use when employees need them? Hospital Managers Unit Managers HCW 100 90 80 70 60 Percentage 50 40 30 20 10 0 Yes No Don't Yes No Don't Yes No Don't Yes No Don't Yes No Don't Yes No Don't Know Know Know Know Know Know IL CA NC MN MI NY

30. What happens if an employee cannot be successfully fit tested?

31. During the program evaluation, do you determine whether respirators are being maintained properly? For example, PAPRs are disinfected after use.

32. REACH II Reuse Items Does your facility have a written policy for redonning (reuse) of respirators? • Yes • No • Don’t Know How are employees instructed to store respirators between doffing (removing) and redonning? In a plastic bag In a paper (breathable) bag Carried by the employee Other (specify) Don’t know

33. REACH II Guidance Items Which guidelines are used to determine the infectious disease exposures (i.e., transmission precautions) that require respiratory protection? • CDC recommandations • OSHA • State Department of Health recommendations • Other (specify) What would trigger the staff’s use of respiratory protection? • Patient’s signs and symptoms (i.e., fever, cough, sputum production) • Laboratory confirmation of disease • Physician order • Sign on the door of a patient’s room • Verbally informed by co-workers • Other – Depending on unit/department

34. REACH II Summary • REACH II findings indicate that knowledge related to N95 FFR reuse policy, storage of reused N95 FFRs needs to be reinforced. • REACH II observational findings indicate that the proper use procedures for donning and doffing need to be reinforced.http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf • Reuse and Extended Use Policies and Procedures should be developed within the organization and in collaboration with community emergency preparedness agencies. • Best practice healthcare organizations utilize a Respiratory Protection team approach (i.e. Occup.Health, Safety, IC, Emergency Preparedness).

35. REACH I &II Common Findings • Respiratory protection program plans exist on paper Response differences between HCWs, unit & hospital managers regarding operations of RPP. • Most HCWs recall fit test at hire with minimal updates. • Fit-testing is the focus…ongoing preparedness training isn’t(<15 minutes annually). • HCWs are unclear about WHEN to use respiratory protection. • HCWs are unclear about WHAT type of respirator should be used. • HCWs are unclear about HOW to properly donnand doff respirators (strap positions, seal checks, disposal). Reference: Beckman S, Materna B, Goldmacher S, Zipprich J, D’Alessandro M, Novak D and Harrison, R. (2013). Evaluation of respiratory protection programs in California hospitals during the 2009-2010 H1N1 influenza pandemic. AJIC 41: 1024-31.

36. Prevalence Survey Purpose: To capture information regarding the types of respiratory protective devices used in healthcare settings. Design: Online, eleven item survey hosted by AAOHN disseminated to AOHP and ANA. Response Demographics: • 322 completed surveys from 47 states • AAOHN (53%), AOHP (34%) • Midwest (35%), South (30%) census regions Photo courtesy of Maxair AAOHN: American Association of Occupational Health Nurses AOHP: Association of Occupational Health Professionals in Healthcare ANA: American Nurses Association

37. N95s and EHFRs were most prevalent in the Northeast, as PAPRs were in the Midwest & West PAPRs=88% N95s=98% EHFRs=35% EHFR- Elastomeric half-facepiece respirators

38. Prevalence Survey Results *Assigned numbers represent all answers in the “yes” category

39. Prevalence Survey Results

40. Prevalence Survey Results

41. IOM Letter Report (2011)Improving OHN Education and Training • Occupational health nurses are front-line advocates for preventing workers injury and illness and promoting a culture of safety health in the workplace….. • Committee found varying amounts of dedicated time and resources devoted to respiratory protection content ….. • Committee generated seven recommendations to strengthen respiratory protection education and training…..

42. Respiratory Protection Educational Competencies and Training Project • The Working Advisory Group on Respiratory Protection initiated a grassroots, non-funded national survey of occupational health nurses (OHNs) to address the IOM Letter Report’s Recommendation 1. • Online / web-based survey, conducted by AAOHN, opened May 2, 2012 with data collection ongoing until May 30, 2012. • 2,263 respondents, averaging 17 years experience, professionally affiliated and OHN certified.

43. AAOHN Survey Findings • 88% work in facilities with respiratory protection programs (RPP). • 50% of the OHNs report being primarily responsible for RPP. • 50% perform respiratory fit testing. • NIOSH spirometry certification is current for 31% of the sample. • 27% report being not at all comfortable or slight comfort and 20% report moderate comfort in explaining the difference between a surgical mask and an N95. • 67% reported that their respiratory protection educational preparation occurred on-the-job. • Years of OHN experience was associated with both comfort and self-perceived RP competency.

44. Survey Findings The top three industries represented were healthcare (35%), manufacturing (26%), and government (9%). Many types of professionals are involved with RPPs – Safety, Industrial Hygiene, etc. Safety culture was significantly associated with both competence and comfort in RP.  Average comfort level for all aspects of RPP was in the moderate range with highest comfort in medical evaluation for respirator use. Writing a RPP policy and inspection, cleaning and repair of respiratory equipment had lowest comfort scores.

45. HCWs are vulnerable!Compliance is marginal! So there needs to be an improved focus on: • Infection Control Education • Respiratory Protection Proper Use Practices

46. OHN Knowledge Gaps • High comfort with performing respiratory medical evaluations • Low comfort with writing the respiratory protection program, inspection, cleaning and repair of respiratory equipment • Explaining the difference between a N95 Respirator vs. Surgical Mask • Not comfortable, slightly comfortable (27%) • Moderate comfort (20%) Reference: Burgel B, Novak D, Burns C et al. (2013). Perceived competence and comfort in respiratory protection: Results of a nationwide survey of occupational health nurses. Workplace Health and Safety 61(3): 103-115 Air Leakage

47. How Many? Commonly asked Questions Facemask or N95? Seal Check? Fit Testing! Who to Ask?

49. Course Modules Overview of OSHA’s Respiratory Protection Standard OSHA’s Permissible Practice Respiratory Hazard Assessment NIOSH Approved Respirators Respirator Selection Respirator Maintenance Medical Evaluation Fit Testing Worker Training 10. Written Respiratory Protection Program & Program Evaluation

50. Updated Recommendations Published March 2014 http://www.cdc.gov/niosh/topics/hcwcontrols/RecommendedGuidanceExtUse.html