Respiratory Protection with PPE
of Health Care Workers Project
Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN
Project Director
Professor and Director, North Carolina Occupational Safety and Health Education and
Research Center and Occupational Health Nursing Program
School of Public Health, University of North Carolina, Chapel Hill, NC, USA
Kathleen Buckheit, MPH, COHN-S/CM/SM
Project Coordinator
North Carolina Occupational Safety and Health Education and Research Center
School of Public Health, University of North Carolina, Chapel Hill, NC , USA
Edie Alfano-Sobsey, PhD, MT (ASCP)
Project Consultant
Epidemiologist, Wake County Human Services, Raleigh, NC, USA
Personal Protective Equipment Selection, Use and Expectations:
PPT Stakeholder Meeting and Workshop
Pittsburgh, PA, March 20-21, 2012
Influenza in the United States
 Annually 36,000 deaths in the United States
 Attacks disproportionately young, old,
immunocompromised, those with chronic diseases
 Novel H1N1 generally affected young, old, pregnant
women
 Transmission route debate:


Airborne
Droplet
Respiratory Protection/ PPE
 Surgical masks


Aerosol particle penetration 4 to 90%
Open on sides, top, bottom
 Respirators (N95)



Filter 95% to 99% of relevant aerosol particles
Cover mouth and nose
Fit-test required
 PPE acts as barrier devices (i.e., gloves, gowns,
respirators, eye, and hearing protection)

Respirators/PPE
 Difficulty in communication
 Difficulty in breathing
 Difficulty in maintaining tactile sensitivity (gloves)
 Hot/uncomfortable
Health Care Workers at Risk
 13.6 million in US
 35% hospital
 23% nursing/residential facilities
 17% physician offices
Project Purpose
Evaluate respiratory usage for respiratory infection
among health care workers in a sample of North
Carolina acute care hospitals
 Assessment of written respiratory protection
program (RPP) policies
 Survey to assess knowledge and beliefs about
respiratory protection among direct health care
workers and managers
 Use of respiratory protection among health care
workers
 Observation of respirator use
Sample
21 Hospitals in North Carolina were selected by bed
size in metropolitan and rural areas:




<150 beds
151-300 beds
301-500 beds
>500 beds
Survey participants were selected on units if at-risk of
respiratory infection.
Of these participants, 69 were observed for respirator
usage.
Instruments
 Healthcare Worker Interview
 Unit Manager Interview
 Hospital Manager Interview
 Respiratory Protection Observation Checklist
 Respiratory Protection Policy Assessment Checklist
Health Care Worker Instrument
Assessed:
 General information
 Risk assessment and medical evaluation
 Fit testing
 RPP training
 Program evaluation
 Infection prevention
Plus workplace safety checklist
Respiratory Observation Checklist
Assessed:
 Location of observation
 Availability of respirators and type
 Sinks or hand rub availability
 Waste receptacle
 Donning criteria
 Doffing criteria
Project Results
Health Care Worker N=342*
Unit Managers N=64*
Hospital Managers N=17*
Demographic Information
Years of
experience
Health Care
Worker
Less than 1
year
1-2 years
2-4 years
5 or more
years
Unit Manager
Hospital Manager
n
%
n
%
n
%
48
14.1
7
10.9
1
5.9
72
104
117
21.1
30.5
34.3
6
18
33
9.4
28.1
51.6
2
5
9
11.8
29.4
52.9
Clinical Information
Health Care Worker N=378** ICU
ER
Pediatric
Med/Surg
Other
Unit Manager
Hospital Manager
n
%
n
%
n
%
103
59
12
132
72
27.2
15.6
3.2
34.9
19.0
16
9
3
15
29
22.2
12.5
4.2
20.8
40.3
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
* Missing data excluded
**Responses > the sample size = More than one choice selected
Project Results
Position Title for Health Care Worker
Registered Nurse
Public Health Nurse
Licensed Vocational Nurse
Nursing Assistant
Infection Prevention
Technician-Radiology, Other
Respiratory Therapy
Therapist - Speech, Physical, Other
Phlebotomist
Receptionist/Clerk
Housekeeping
Other
248
2
5
54
1
3
20
1
1
2
1
4
72.5%
0.6%
1.5%
15.8%
0.3%
0.9%
5.8%
0.3%
0.3%
0.6%
0.3%
1.2%
Project Results
Trigger elements for use of respiratory protection
Health Care Worker
Total Responses** 677
Patients signs and
symptoms
Laboratory confirmation of
disease
Physicians order
Sign on door of patient’s
room
Verbally informed by coworker
Don’t Know
Other
Unit Manager
Total Responses** 134
Hospital Manager
Total Responses** 36
n
181
%
26.7
n
33
%
24.6
n
8
%
22.2
114
16.8
21
15.7
8
22.2
109
171
16.1
25.3
29
38
21.6
28.4
3
13
8.3
36.1
90
13.3
11
8.2
3
8.3
3
9
0.4
1.3
0
2
0.0
1.5
0
1
0.0
2.8
** Responses > the sample size = More than one choice selected
Project Results
Medical evaluation and clearance before wearing
respirator
Health Care
Worker
Total Responses**
677
Yes
No
Don’t Know
n
300
24
12
**Responses > the sample size = More than one choice selected
%
89
7.1
3.6
Unit Manager
n
55
6
2
%
87.3
9.5
3.2
Hospital
Manager
n
17
0
-
%
100
0.0
-
Project Results
Health Care Workers (Only):
Receive seasonal influenza vaccine
Yes
No, but I intend to get it
No, and I do not intend to
get it
Don’t Know
271
8
58
79.5%
2.3%
17.0%
4
1.2%
Project Results
Written respiratory protection program at facility
Health Care
Worker
Yes
No
Don’t Know
Unit
Manager
Hospital
Manager
n
%
n
%
n
%
261
3
75
77.0
0.9
22.1
61
1
2
95.3
1.6
3.1
17
0
-
100
0
-
Health care worker or Unit manager input into
respiratory protection program policy decisions
Yes
No
Don’t Know
Health Care
Worker
n
%
66
19.5
218
64.5
54
16.0
Unit
Manager
n
%
34
54
15
23.8
14
22.2
Hospital
Manager
n
%
16
94.1
1
5.9
0
0.0
Project Results
Fit-tested for respiratory protection at hire
Health Care Worker
Yes
No
Don’t Know
Unit Manager
Hospital Manager
n
%
n
%
n
%
265
51
23
78.2
15
6.8
60
3
1
93.8
4.7
1.6
16
1
0
94.1
5.9
0.0
How do you know which model(s) and size(s) of respirators
you have been fit-tested for?
Health Care Worker
Unit Manager
Hospital Manager
Total Responses** 378
Informed verbally
Given written copy of
results
Given a pocket card
Don’t Know
Other
n
%
n
%
n
%
91
152
24.1
40.2
9
34
14.1
53.1
2
5
11.8
29.4
115
9
11
30.4
2.4
2.9
16
3
2
25.0
4.7
3.1
8
1
1
47.0
5.9
5.9
** Responses > the sample size = More than one choice selected
Project Results
Problems for Health Care Workers when wearing N95
Total Responses**
I find it difficult to breath
I’m bothered by moisture buildup
It interferes with the wear of other PPE
It interferes with the wear of my glasses
I find it difficult to speak/be understood
I find it uncomfortably warm
I am claustrophobic
** Responses > the sample size = More than one choice selected
472
94 19.9%
82 17.4%
21 4.4%
52 11.0%
58 12.3%
120 25.4%
45
9.5%
Project Results
If unsuccessful fit-test
Given a PAPR
Reassigned to a
lower risk job
Don’t Know
Other
Health
Care
Worker
n
%
179 53.4
7
2.1
117 34.9
32 9.6
Unit
Manager
Hospital
Manager
n
%
56 87.5
0 0.0
n
%
16 94.1
0 0.0
2
6
3.1
9.4
1
5.9
Project Results
Training about respiratory protection
Yes
No
Don’t Know
Health Care
Worker
n
%
320
94.4
12
3.5
7
2.1
Unit Manager
n
64
0
-
%
100
0.0
-
Hospital
Manager
n
%
16
100.0
0
0.0
-
When is training provided
At hire only
At hire, and then
annually
At hire, then as
required by physician
No requirements
Don’t Know
Other
Health Care
Worker
n
%
20
5.9
254
74.5
Unit Manager
n
7
52
%
10.9
81.3
Hospital
Manager
n
%
1
6.7
12
80.0
8
2.4
0
0.0
1
6.7
10
40
9
2.9
11.7
2.6
1
4
-
1.6
6.3
-
0
0
1
0.0
0.0
6.7
Project Results
Length of training about respiratory training
1-15 minutes
16-30 minutes
31-60 minutes
More than 60 minutes
Don’t Know
Other
Health Care
Worker
n
%
130
38.6
119
35.3
24
7.1
2
0.6
61
18.1
1
0.3
Unit Manager
n
30
21
2
1
10
-
%
46.9
32.8
3.1
1.6
15.6
-
Hospital
Manager
n
%
10
58.8
5
29.4
0
0.0
0
0.0
2
11.8
-
Can direct health care workers wear a respirator without training
Yes
No
Don’t Know
*Missing data are excluded
Health Care
Worker
n
%
14
4.1
286
84.1
40
11.8
Unit
Manager
n
%
1
1.6
60
93.8
3
4.7
Hospital
Manager
n
%
0
0.0
17 100.0
-
Project Results
Is worker input solicited during program evaluation
Yes
No
Don’t Know
Health Care
Worker
n
%
91
27.0
171
50.7
75
22.3
Unit
Manager
n
%
12
30.8
9
23.1
18
46.2
Hospital
Manager
n
%
4
57.1
1
14.3
2
28.6
Yes
No
Don’t Know
Health Care
Worker
n
%
158
46.7
111
32.8
69
20.4
Unit
Manager
n
%
24
60.0
5
12.5
11
27.5
Hospital
Manager
n
%
5
71.4
1
14.3
1
14.3
Is there observation about correct wearing of
respirators by supervisor
Project Results
Are respirators properly maintained
Yes
No
Don’t Know
Health Care Worker
n
%
153 45.3
6
1.8
179 53.0
Unit Manager
n
%
17 42.5
9 22.5
14 35.0
Hospital Manager
n
%
5 71.4
1 14.3
1 14.3
Project Results
Minimum level of respiratory protection required to use when
in close contact with a patient who has a suspected or
confirmed infectious disease requiring airborne precautions,
such as measles
None
Surgical Mask
N-95 (disposable)
respirator
Elastomeric half-face N95 respirator
Powered Air Purifying
Respirator (PAPR)
Don’t Know
Other
Health Care Worker
n
%
2
0.6
55
16.1
250
73.1
Unit Manager
n
0
16
44
%
0.0
25.4
69.8
Hospital Manager
n
%
0
0.0
3
17.6
13
76.5
10
2.9
2
3.2
1
5.9
4
1.2
0
0.0
0
0.0
19
2
5.6
0.6
1
‐
1.6
‐
0
‐
0.0
‐
Project Results
Minimum level of respiratory protection required to use when
performing aerosol-generating procedures on a patient who
has a suspected or confirmed infectious disease requiring
airborne precautions, such as measles
None
Surgical Mask
N-95 (disposable)
respirator
Elastomeric half-face N95 respirator
Powered Air Purifying
Respirator (PAPR)
Don’t Know
Other
Health Care
Worker
n
%
2
0.6
27
8.0
251
74.0
Unit
Manager
n
%
0
0.0
7
11.1
47
74.6
Hospital
Manager
n
%
0
0.0
1
5.9
14 82.4
6
1.8
3
4.8
1
5.9
9
2.7
2
3.2
1
5.9
43
1
12.7
0.3
4
-
6.3
-
0
-
0.0
-
Project Results
Minimum level of respiratory protection required to use when
in close contact with patients who have suspected or
confirmed seasonal influenza
None
Surgical Mask
N-95 (disposable)
respirator
Elastomeric half-face N95 respirator
Powered Air Purifying
Respirator (PAPR)
Don’t Know
Other
Health Care
Worker
n
%
10
3.0
241
71.5
75
22.3
Unit
Manager
n
%
1
1.6
46
75.4
10
16.4
Hospital
Manager
n
%
0
0.0
12
70.6
4
23.5
1
0.3
2
3.3
0
0.0
1
0.3
1
1.6
0
0.0
6
-
1.8
-
1
-
1.6
-
0
1
0.0
5.9
Project Results
Minimum level of respiratory protection you are required to
use when performing aerosol-generating procedures on a
patient who has seasonal influenza
None
Surgical Mask
N-95 (disposable)
respirator
Elastomeric half-face N95 respirator
Powered Air Purifying
Respirator (PAPR)
Don’t Know
Other
Health Care
Worker
n
%
3
0.9
153
45.4
135
40.1
Unit
Manager
n
%
1
1.6
24
37.5
32
50.0
Hospital
Manager
n
%
1
6.3
10 62.5
5
31.2
3
0.9
0
0.0
0
0.0
3
0.9
0
0.0
0
0.0
37
3
11.0
0.9
4
1
6.3
1.6
0
-
0.0
-
Project Results
Written policy for redonning (reuse) of respirators at
facility
Yes
No
Don’t Know
Health Care Worker
n
%
145
43.2
58
17.3
133
39.6
Unit Manager
n
32
17
14
%
50.8
27.0
22.2
Hospital Manager
n
%
7
43.8
8
50.0
1
6.3
How are respirators stored between doffing and redonning?
Health Care Unit Manager
Worker
In a plastic bag
In a paper (breathable) bag
In a rigid plastic box
Carried by the employee
Hangs in designated area
Don’t Know
Other
n
35
28
7
5
29
29
10
%
24.5
19.6
4.9
3.5
20.3
20.3
7.0
n
13
9
0
0
5
1
0
%
44.8
31.0
0.0
0.0
17.2
3.4
0.0
Hospital
Manager
n
2
4
1
0
0
2
0
%
22.2
44.4
11.1
0.0
0.0
22.2
0.0
Respiratory Observation Results of
Health Care Workers
N=69*
Type of healthcare worker observed
Physician/Physician Assistant or
Nurse Practitioner
Registered Nurse/Public Health Nurse
Licensed Vocational Nurse/Nursing
Assistant or Patient Care Assistant
Infection Preventionist
Respiratory Therapist
Environmental Services or
Housekeeping
Other
*Sub-sample of survey participants
n
%
0
0
50
10
72.4
14.4
2
2
3
2.9
2.9
4.3
2
2.9
Respiratory Observation Results of
Health Care Workers
Respirators available in work area
Yes
No
n
68
1
%
98.6
1.4
n
67
1
1
%
97.1
1.4
1.4
Type of respirator
N95
PAPR
Elastomeric
Respiratory Observation Results of
Health Care Workers
Proper hand hygiene performed before use
Yes
No
n
37
32
%
53.6
46.4
Respirator positioned correctly on HCWs face
Yes
No
n
61
8
%
88.4
11.6
Respiratory Observation Results of
Health Care Workers
Is a sink or hand rub available?
Yes
No
n
15
54
%
21.7
78.3
Is a waste receptacle available?
Yes
No
n
59
10
%
85.5
14.5
Respiratory Observation Results of
Health Care Workers
Facial hair under the seal
Yes
No
N/A
n
3
37
29
%
7.5
92.5
-
Respirator straps correctly placed *
Yes
No
*Missing data are excluded
n
45
23
%
66.2
33.8
Respiratory Observation Results of
Health Care Workers
Nose clips used properly
Yes
No
n
62
7
%
89.9
10.1
n
19
50
%
27.5
72.5
User seal check performed
Yes
No
Respiratory Observation Results of
Health Care Workers
Respirator removed properly (doffing)
Yes
No
n
43
26
%
62.3
37.7
Respirator disposed of after use
Yes
No
n
47
22
%
68.1
31.9
Respiratory Observation Results of
Health Care Workers
Was there proper hand hygiene after use?
Yes
No
n
47
22
%
68.1
31.9
n
48
21
%
69.6
30.4
Maintenance/Storage
Yes
No
Respiratory Protection Written Policy
N=21
Presence of Written RPP: To provide a clear policy
and specific procedures for the use of respirators in
protecting employees from respiratory hazards
Yes:
No:
Partial:
Program Administrator: To assign responsibility
for ensuring full implementation and evaluation of
the written program to a suitably trained workers
Yes:
No:
Partial:
Medical Evaluation: To ensure that employees are
able to wear respirators safely
Yes:
No:
Partial:
Fit-testing: To choose the brand, model, and size of
respirator that provides the best fit for each
individual employee and to provide an opportunity to
review proper donning and doffing procedures
Yes:
No:
Partial:
n
%
17
3
1
n
81.0
14.3
4.8
%
15
5
1
n
71.4
23.8
4.8
%
21
0
0
n
100.0
0.0
0.0
%
18
0
3
85.7
0.0
14.3
Respiratory Protection Written Policy
Recordkeeping: To maintain a record of individual
medical evaluations and fit tests and to ensure the
availability of the written program.
Yes:
No:
Partial:
n
%
19
1
1
n
90.5
4.8
4.8
%
19
1
95.0
5.0
Training and Information: To ensure that employees
understand the facility's written program and the
purpose of and limitations of respirators, and that they
are trained in the specific procedures for proper use and
maintenance
n
%
Yes:
No:
Partial:
11
6
4
n
52.4
28.6
19.0
%
13
8
0
61.9
38.1
0.0
Are individual medical records separate from
personnel record?(1 missing)
Yes:
No:
Respirator Selection: To determine which types of
NIOSH-approved respirators will be required for each job
or task based on an evaluation of respiratory hazards.
Yes:
No:
Partial:
Respiratory Protection Written Policy
Use of Respirators: To provide clear, written
policies and procedures for proper use of
respirators by employees:
Yes:
No:
Partial:
Maintenance and Care of Respirators: To
provide clear, written procedures for
storage, care, and maintenance of
respirators.
Yes:
No:
Partial:
Program Evaluation: To ensure that the
written program is being implemented and
that it continues to be effective:
Yes:
No:
Partial:
n
%
9
10
2
42.9
47.6
9.5
n
%
13
6
2
61.9
28.6
9.5
n
%
10
8
3
47.6
38.1
14.3
RPP Training/Information Present
N=19
Why the respirator is necessary
How improper fit, use, or maintenance
can compromise its protective effect
Limitations and capabilities of the
respirator
Effective use in emergency situation
How to inspect, use, and check the seals
How to don and duff
Maintenance and storage
Recognition of medical signs and
symptoms that may limit or prevent
effective use
Training provided prior to use
Retraining annually
n
%
17
89.5
13
68.4
5
26.3
13
14
8
12
68.4
73.7
42.1
63.2
9
47.4
19
15
100.0
78.9
Recommendations
 Complete policy review
 More thorough training
 Donning/Doffing
 Seal checks
 Return demonstrations
 Better understanding of influenza
transmission/prevention strategies
 Program effectiveness evaluation
 Communication
Thank you