During the current COVID-19 pandemic and the outbreak of H1N1 in 2009, the use of N95 respirators versus surgical masks for protection has been a sticking point.
The global COVID-19 pandemic has moved beyond simply dominating daily headlines, it has started to impact Americans' day-to-day lives. Many employees are being told to work from home, schools are closing, and some states have even closed bars and restaurants.
Yet, those who work in healthcare don't necessarily have the ability to do their jobs remotely. Those working on the frontlines need to protect themselves, their patients, their colleagues, and their families from the COVID-19 virus.
But there have been challenges obtaining proper personal protective equipment during this outbreak, particularly N95 respirators and facemasks. According to the Centers for Disease Control and Prevention, orders "are up to 10-fold normal demand for these items." On March 10, the CDC updated its recommendations and advised that facemasks for clinical providers are an acceptable alternative when there is a shortage of N95 respirators.
The American Nurses Association has taken issue with this. While acknowledging the difficulty of ensuring an adequate PPE supply, the organization is concerned that the updated CDC recommendations are based solely on supply chain and manufacturing challenges, according to a news release. Instead of focusing on supply chain demands, recommendations should be based on "evidence that reflects a better understanding of the transmission of COVID-19."
This is not the first time the use of N95 respirators has been debated during a large-scale outbreak. In 2009, there was also disagreement over the use of N95 respirators versus surgical masks during the H1N1 pandemic.
Editor's note: The rest of the article describes this disagreement. This section of the article was written in 2009, but remains popular to our readers and is still timely as the U.S. grapples with a shortage of much needed PPE. For more on the current COVID-19 pandemic, visit this link.
N95 Supply During the H1N1 Outbreak
Since H1N1 outbreaks surfaced in April, infectious disease doctors, employee health managers, healthcare workers, and infection prevention associations have debated a variety of factors regarding the new virus. But without question the most hotly contended issue has been the use of N95 respirators versus surgical masks for protection.
Meanwhile, many wondered if OSHA would take a side, and it released a clarification supporting CDC guidelines that require N95s for protection against H1N1. Healthcare facilities that do not comply could be cited for serious violations under the General Duty Clause or the Respiratory Protection Standard.
"I think these guidelines tell the players and the referees the rules of engagement," says Marge McFarlane, PhD, MS, CHSP, safety consultant and owner of Superior Performance, LLC. "I look at it as tell me what you expect and I'll see what I can do, rather than you come and say, 'Well you didn't make my expectations.' People don't have time to be a mind reader, so for better or for worse OSHA compliance takes the guessing out of what is expected."
Conduct an exposure risk assessment
Smaller facilities such as outpatient clinics, ambulatory surgery centers, or physician offices may find their procedures don't involve high-risk exposure, or they can initiate other preventative measures to protect staff members.
For example, the first procedure listed on the hierarchy of controls—a list of prioritized infection prevention procedures created by the CDC—is eliminating the hazard of H1N1 whenever possible. Outpatient offices are in a unique position to easily reschedule patients who may have contracted H1N1, reducing exposure to staff and minimizing the need to wear N95s.
"It's really crucial to do a risk assessment because ambulatory care is far, far different from acute care, which is different than long-term care," says Irena B. Kenneley, PhD, APRN-BC, CIC, community health clinical nurse specialist and assistant professor at Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. "In a risk assessment, you see who is most at risk and what prevention measures can be taken to reduce the risk for each area."
Reusing N95 respirators
One important addition to your respiratory protection plan should be reuse of N95 respirators during a shortage. The OSHA directive indicates that a respirator can be reused as long as it "maintains its structural and functional integrity and the filter material is not physically damaged or soiled."
"Employers must address in their respiratory protection program the circumstances under which a disposable respirator will be considered to be contaminated and not available for extended use or reuse," the directive reads.
Outpatient facilities and doctor's offices may have particular trouble receiving N95 shipments, so reuse of N95s may be a priority. Educate employees to wear a surgical mask over the N95, wash their hands when donning and doffing the respirator without touching the inside, and store it in a breathable bag, McFarlane says.
"Does that take more work than just slapping it on and taking it off? Yes it does, but desperate times call for more attention," she says.
Managing N95 supplies
One of the primary complaints from IPs and safety officers has been that N95s from state or federal stockpiles are often a different brand or style from the hospital, which means employees need to be fit tested again if they are going to use the masks.
Although it is certainly a daunting task to fit test every employee in your hospital a second time, MacFarlane suggests siphoning any outside N95 supplies to a captive population of employees.
For example, ER staff members rarely work outside of the ER, and would have access to their masks all the time, MacFarlane says. Therefore an IP could use the outside supply of respirators to refit that specific population, and save the in-house supply for the rest of the hospital staff members.
"Depending on the size of your hospital you might only have to re-fit test 15, 20, 30 people," MacFarlane says.
Not only will this system save time fit testing employees, it will also provide an effective respiratory protection system, and ensure a sufficient supply for the time being.
"I talked to an infection control practitioner at one of the hospitals and she really thought that idea of just fit testing a captive population might be a good way to transition, and it might buy you just enough time until your regular supplier brings out the masks again," MacFarlane says.
For more guidance on OSHA regulations including the directive for respiratory protection against H1N1, fit testing for N95s, and pandemic preparedness tools, visit OSHA Healthcare Advisor.