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IOM: Protecting HCWs is 'integral' to quality care
Panel supports new OSHA rule, PAPR design
The H1N1 influenza pandemic may prompt lasting changes in the personal protective equipment for health care workers and the rules that govern them.
In the wake of the pandemic, a new report from the Institute of Medicine supports the creation of an infectious disease standard with protections that parallel those in the Bloodborne Pathogens Standard. The U.S. Occupational Safety and Health Administration has included such a standard in its regulatory agenda, although no draft language has been issued.
The IOM panel also supports the establishment of standard criteria for face masks and the development of a powered air-purifying respirator (PAPR) specifically for health care.
Although the report is primarily designed to guide future research, it wades into issues that have been hotly debated and urges that they not be sidelined until the next pandemic. Health care providers need clear guidelines about how to protect workers from a novel viral respiratory infection, and there needs to be more research on the protections provided by face masks compared to respirators, the panel said.
The bottom line: "While there are clear gaps and deficiencies in our knowledge base...there should be universal acknowledgement that PPE [personal protective equipment] use is an integral component of providing quality health care."
The IOM report is an important step toward a respirator that health care workers will tolerate and wear, says Lewis J. Radonovich, MD, director of the National Center for Occupational Health and Infection Control in the Office of Public Health and Environmental Hazards of the Veterans Health Administration in Gainesville Florida and Washington DC. "What's needed now is development of respiratory protection devices that are tailored to the needs of health care workers," says Radonovich, who is spearheading a project to work with manufacturers on improved design.
Confusion over H1N1 guidance
From supply shortages to differing guidance, challenges emerged for hospitals in the effort to protect health care workers from the novel influenza virus.
The Centers for Disease Control and Prevention advised using N95 respirators when caring for patients with the novel influenza, but some state or local health departments recommended using face masks unless performing aerosol-generating procedures. "Delayed and/or disparate recommendations often led to confusion among health care personnel and their employers, who had to decide what to tell personnel about what type of PPE to wear and when," the IOM panel said.
The result was that health care workers in different parts of the country or at different facilities received different levels of protection from the H1N1 influenza. "During the 2009 H1N1 pandemic, the California standard was the only workplace standard in the United States that required a mandatory level of worker protection to be provided to health care personnel," the panel said.
"What we found was wide variation in the use of personal protective equipment during the H1N1 pandemic," says Bill Kajola, industrial hygienist with the AFL-CIO in Washington, DC, and a member of the IOM panel. "Some employers adhered to the [Centers for Disease Control and Prevention] and OSHA guidelines in their entirety, other employers followed some of the recommendations and other employers did very little."
An infectious diseases standard "is a means to put everybody on the same level playing field as far as the protections that all health care workers should expect," he says.
Need more info on face masks
A central question emerged from the debate over appropriate PPE: How protective are face masks?
The IOM panel called for "an expedited mechanism for funding these studies" on influenza transmission, face masks and respirators. The National Institute for Occupational Safety and Health (NIOSH) currently is sponsoring research on masks and respirators.
Face masks should be certified and required to meet a set of standards if they are used as personal protective equipment, the IOM panel said. And in a twist on the traditional concept of personal protective equipment, the panel cited research that shows greater protection to the health care worker if the patient wears a mask an infection control measure that is part of "respiratory hygiene."
"There needs to be more research to validate that" protection before "source control" could be considered a form of PPE for health care workers, says Maryann D'Alessandro, PhD, associate director for science at the NIOSH's National Personal Protective Technology Laboratory (NPPTL).
The decision about PPE ultimately hinges on the risk of infection. And not enough is yet known about the transmission of influenza, says Roland Berry Ann, deputy director of the NPPTL.
"Not knowing the infectivity or the level of exposure for the [infectious] agent, it's hard to determine what level of protection is adequate whether the lower protective factor of a surgical mask is sufficient to stop the transmission or if you need the aerosol stopping characteristics of the respirator," he says.
Meanwhile, NIOSH is moving forward with its "total inward leakage" rule that will set a new criteria for fit for N95 respirators. The agency also will focus research on another area highlighted by the IOM: The need for a simpler fit-test.
Creating a health care-specific PAPR may actually be easier than resolving some of the N95 challenges. Current PAPRs were designed for industry and must meet performance standards under silica dust loading conditions for four hours, says Berry Ann. "We've heard from some of the [health care] stakeholders that they may only need it for 15 minutes [at a time]," he says.
With different filtering requirements, a health care PAPR could be lighter and quieter, he says.
[Editor's note: The IOM report, "Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel Update 2010," is available at www.nap.edu/catalog.php?record_id=13027.]