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PAPRs end frustration of fit-test failures
Hospital diverts funds to reusables
At DuBois (PA) Regional Medical Center, employees were failing N95 fit tests in alarming numbers. In the cardiology department, about 46% of employees failed fit-tests even after trying a variety of models and sizes. Things weren't much better in anesthesia (35%), cardiovascular ICU (34%), or the emergency department (26%).
The most important number the one that prompted the hospital to switch to powered air-purifying respirators (PAPRs) was the cost: about $37,000, mostly in loss of productivity of clinicians who had to spend an average of 35 minutes to complete a fit-test. By comparison, the investment in PAPRs and education cost about $38,000, including about $5,000 for education the only annual cost.
"We were investing a significant time commitment and money every year, and the [fit-test] failure rates were higher than we were comfortable with," says Sue Miller, RN, COHN-S/CM, director of employee health.
Fortuitously, DuBois made the transition to PAPRs in 2008, a year before hospitals were faced with the novel H1N1 strain of influenza. That reinforced the benefits of reusable respirators, as the hospital avoided the scramble for supplies and massive fit-testing efforts.
"For us, it was a good return on investment. It made our life so much easier during the crisis," says Miller. "I'm definitely very happy we went with this solution."
The switch to PAPRs began with the simple conviction that there had to be a better way to provide respiratory protection. Miller researched the use of PAPRs, particularly by John Hopkins Medical Center in Baltimore, MD, where PAPRs are the mainstay of respiratory protection.
She drafted a proposal that outlined the problems with the N95 fit-testing, the benefits of PAPRs and the cost comparison.
Hospital leadership agreed with the plan to use the money that was usually budgeted for annual fit-testing toward the purchase of 50 PAPRs enough for five per patient care unit with negative pressure rooms, including the Emergency Department. Five were maintained for regular use in the ED, three in bronchoscopy and two in pediatrics. Others were stored or kept on carts used in isolation rooms. There also is one for each of the primary care physician offices.
PAPRs require training, maintenance
Switching to PAPRs did present some logistical challenges. Employees in various roles and departments needed to learn how to use the PAPRs, from environmental services and maintenance to radiology and physical therapy. A train-the-trainer program made that process manageable. Each year, 660 employees complete respirator fit questionnaires on the system's intranet.
Central processing takes charge of maintaining the PAPRs charging the units and cleaning the hoods, when necessary. Employees wear disposable OR bonnets for enhanced infection control. The hoods can then be wiped down and used by another employee, if necessary, says Miller. The cuffs are also wiped down between uses and replaced when soiled, she says. DuBois also chose the MaxAir because it was designed for health care and could accommodate a stethoscope.
Health care workers are concerned about how the PAPRs will affect patient care. Pediatric clinicians were especially worried that children might be frightened of them if they can in with a hooded respirator. Miller shared an article that refuted that concern. Meanwhile, the hospital's public relations department contacted the local newspaper and was able to arrange an article on the new respirators so the public would know what to expect.
Noise was not a problem, either, says Miller. The PAPRs produce 62 decibels, which is about the level of background conversation, she says. "I'm very soft spoken. If they could hear me when they were wearing their PAPRs, they could definitely hear their patients," she says.
Meanwhile, unlike with masks, patients could see their caregivers facial expressions, or even read lips if they were hard of hearing. And in an unexpected benefit, the cadre of aging nurses appreciated the blast of cool air, particularly in contrast to the heat that builds with long-term use of N95s.
"One nurse said we should buy one for every peri-menopausal female," Miller quips. "The comfort level was huge."
Then, of course, came the surge of patients with suspected H1N1. Emergency room triage nurses still wore N95s, based on their preference. But that required only a limited supply as other departments relied on the reusable respirators.
By preventing exposures, the hospital may have also reduced its absenteeism, Miller says. At the peak, only six health care workers out of 1,800 employees were out sick on the same day, she says.
"It enabled us to provide the protection to our employees and our patients that we needed to during this crisis," she says.
1. Forgie, S., et. al. (2009) The "fear factor" for surgical masks and face shields, as perceived by children and their parents. Pediatrics 2009; 124; 3777-3781.