Storage and Availability of Elastomeric Respirators in Health Care

Lessons learned in establishing and sustaining elastomeric half mask respirator-based respiratory protection programs: An impact evaluation

Developing and overseeing Respiratory Protection Programs (RPPs) is crucial for ensuring effective respirator use among employees. To date, a gap exists in research that focuses on elastomeric half mask respirators (EHMRs) as the primary respirator in health delivery settings which would necessitate additional considerations in RPPs beyond the more common N95 filtering facepiece respirators. This paper presents lessons learned during a one-year impact evaluation with healthcare and first responder settings that received EHMRs from the Strategic National Stockpile in 2021 and 2022. The study explored the advantages and disadvantages associated with EHMRs and the challenges related to establishing, implementing, maintaining, and sustaining EHMR-based RPPs. Data was received from 42 organizations that participated in EHMR demonstration projects to address (1) the most important, perceived, elements and practices of an EHMR-based RPP to support a long-term program; and (2) differences in perceptions of the most important elements and practices based on organizational and company size (i.e., small, medium, and large). Sustaining an EHMR program was considered the most important area to focus future efforts (M = 2.94; SD = 1.12 on a 4-point scale), followed by daily maintenance of the program (M = 2.72; SD = 0.974), development and implementation of the program (M = 2.42; SD = 1.05), and access to EHMRs (M = 1.91; SD = 1.11), respectively. Findings also revealed statistically significant differences in perceptions based on organization size, particularly in access to EHMR models/designs. Results underscored the significance of user accountability, organizational support, and culture in EHMR-based RPPs to support emergency preparedness efforts.

Identifying leadership practices to support the uptake of reusable elastomeric half mask respirators in health delivery settings

An increase in reusable Elastomeric Half Mask Respirators (EHMRs) among healthcare personnel has been documented during pandemic emergencies; however, research has not detailed leadership practices to support their use. Forty-three organizations implemented EHMRs received from the United States federal government which prompted interviews with 73 individuals who managed respirator distribution and fit testing between October 2021 and November 2022. Interview data was qualitatively analyzed. Themes around organizational culture and leadership practices emerged when discussing how elastomeric half mask respirators were integrated into health delivery settings including communication and outreach methods to aid worker support. Example included on-line and hands-on training, peer support, leadership support, and a culture that supports respirator use. To support a shift to reusable respiratory protection being procured and implemented, organizational- and individual-level perspectives are needed. Employee engagement, respirator champions, and updated verbal and written communication mechanisms are important takeaways for leaders to consider during any routine or emergency scenario.

Provider experiences with daily use of elastomeric half-mask respirators in health care

BACKGROUND

During public health emergencies, demand for N95 filtering facepiece respirators (N95 FFRs) can outpace supply. Elastomeric half-mask respirators (EHMRs) are a potential alternative that are reusable and provide the same or higher levels of protection. This study sought to examine the practical aspects of EHMR use among health care personnel (HCP).

METHODS

Between September and December 2021, 183 HCPs at 2 tertiary referral centers participated in this 3-month EHMR deployment, wearing the EHMR whenever respiratory protection was required according to hospital protocols (ie, when an N95 FFR would typically be worn) and responding to surveys about their experience.

RESULTS

Participants wore EHMRs typically 1 to 3 hours per shift, reported disinfecting the respirator after 85% of the removals, and reported high confidence in using the EHMR following the study. EHMRs caused minimal interference with patient care tasks, though they did inhibit communication.

DISCUSSION

HCP who had not previously worn an EHMR were able to wear it as an alternative to an N95 FFR without much-reported interference with their job tasks and with high disinfection compliance.

CONCLUSIONS

This study highlights the feasibility of the deployment of EHMRs during a public health emergency when an alternative respirator option is necessary.

Health Care Workers' Comfort Ratings for Elastomeric Half-Mask Respirators Versus N95® Filtering Facepiece Respirators During the COVID-19 Pandemic

BACKGROUND

Reusable elastomeric half-mask respirators (EHMR) are an alternative to address shortages of disposable respirators. While respirator discomfort has been noted as a barrier to adherence to wearing an N95 filtering facepiece respirator (FFR) among health care personnel (HCP), few have examined EHMR comfort while providing patient care, which was the purpose of this study.

METHOD

Among a cohort of 183 HCP, we prospectively examined how HCP rated EHMR tolerability using the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI) questionnaire at Study Week 2 and Week 10. At the completion of the study (Week-12), HCP compared EHMR comfort with their prior N95 FFR use. Overall R-COMFI scores and three subscales (comfort, wear experience, and function) were examined as well as individual item scores.

FINDINGS

The HCP reported an improved overall R-COMFI score (lower score more favorable, 30.0 vs. 28.7/47, respectively) from Week 2 to Week 10. Many individual item scores improved or remained low over this period, except difficulty communicating with patients and coworkers. The overall R-COMFI scores for the EHMR were more favorable than for the N95 FFR (33.7 vs. 37.4, respectively), with a large proportion of workers indicating their perception that EHMR fit better, provided better protection, and they preferred to wear it in pandemic conditions compared with the N95 FFR.

CONCLUSION/APPLICATION TO PRACTICE

Findings suggest that the EHMR is a feasible respiratory protection device with respect to tolerance. EHMRs can be considered as a possible alternative to the N95 FFR in the health care setting. Future work is needed in the EHMR design to improve communication.

Evaluation of the effects of wiping decontamination for filter cartridges of elastomeric half-mask respirators (EHMRs)

BACKGROUND

A major concern among health care experts is a shortage of N95 filtering facepiece respirators during a pandemic. If the supply of N95 filtering facepiece respirators becomes limited, reusable elastomeric half-mask respirators (EHMRs) may be used to protect health care workers. The focus of this study was to evaluate the effects on the filter performance of wiping decontamination for EHMR P100 filter cartridges.

METHODS

The filter cartridge exterior of EHMR Honeywell, Moldex, and Mine Safety Appliance (MSA) models was wiped using quaternary ammonium and sodium hypochlorite wipes. These filter cartridge properties were assessed including observational analysis and filter performance tests. These wiping and assessing procedures were repeated after each set of wiping cycles (50, 100, 150, 200, and 400 cycles) to determine the effects of wiping decontamination.

RESULTS

For sodium hypochlorite wipes, Honeywell, Moldex, and MSA models passed the National Institute for Occupational Safety and Health (NIOSH) liquid particulate penetration criteria for all wiping cycles from 50 to 400 (penetrations<0.014%). For quaternary ammonium wipes, filter penetrations of Moldex failed (penetrations>0.03%) after 150 cycles, while the filter penetrations of Honeywell and MSA passed for all wiping cycles (penetrations ≤0.013%).

CONCLUSIONS

Wiping decontamination methods using sodium hypochlorite and quaternary ammonium wipes could be considered promising decontamination candidates for Honeywell, Moldex, and MSA reuse, except for the wiping number selection for Moldex (<150 cycles) when using the quaternary ammonium wipe.

Elastomeric half-mask respirator disinfection practices among healthcare personnel

BACKGROUND

Disposable N95 respirator shortages during the COVID-19 and 2009 H1N1 influenza pandemics highlighted the need for reusable alternatives, such as elastomeric half-mask respirators (EHMRs). Two US medical organizations deployed reusable EHMRs during the COVID-19 response. In addition to wipe-based disinfection following patient care episodes expected per local policies at both organizations, postshift centralized cleaning and disinfection (C&D) was expected at one site (A), permitting shared-pool EHMR use, and optional at the other (Site B), where EHMRs were issued to individuals. Using a survey, we evaluated disinfection practices reported by EHMR users and predictors of disinfection behaviors and perceptions.

METHODS

Surveys assessed EHMR disinfection practices, occupational characteristics, EHMR use frequency, training, and individual-issue versus shared-pool EHMR use.

RESULTS

Of 1080 EHMR users completing the survey, 76% reported that they disinfect the EHMR after each patient encounter, which was the expected practice at both sites. Increasing EHMR use, recall of disinfection training, and work in intensive care or emergency settings significantly influenced higher reporting of this practice. 36% of respondents reported using centralized C&D, although reporting was higher at the site (A) where this was expected (53%). Confidence in cleanliness of the EHMR following centralized C&D was not influenced by individual versus shared-pool EHMR issue.

CONCLUSIONS

Most EHMR users reported adherence with expected post-care individual-based disinfection of EHMRs but did not necessarily use standardized, centralized C&D. Future efforts to limit reliance on behavior related to respirator disinfection may improve EHMR implementation in healthcare to avert dependence on single-use, disposable N95 respirators.

Examining the Roles of Training, Fit Testing, and Safety Climate on User Confidence in Respiratory Protection: A Case Example with Reusable Respirators in Health Delivery Settings

A lack of confidence in the efficacy of respiratory protection can contribute to uncertainty among workers and cast doubt on workplace safety. To date, no research has been conducted to study and understand the introduction of elastomeric half-mask respirators (EHMRs)-without exhalation valves (EVs) or with exhalation valve filters (EVFs), both representing new designs that address source control-in the workplace. To study this issue, researchers collaborated with partners at 32 health delivery settings that received EHMRs from the Strategic National Stockpile during the COVID-19 pandemic. EHMR users (n = 882) completed an online survey between October 2021 and September 2022. Analyses demonstrated that employees were statistically significantly more confident in the efficacy of EHMRs with no EV/with an EVF (including the efficacy in protecting the user from COVID-19) if they had been fit tested and received training. Respondents were also statistically significantly more confident in the efficacy of their EHMR if they had a more positive perception of their organization's safety climate. The results provide insights for tailored fit testing and training procedures as manufacturers continue to improve respirator models to enhance worker comfort and use. Results also show that, even during a public health emergency, the role of safety climate cannot be ignored as an organizational factor to support worker knowledge, attitudes, and participation in health and safety behaviors specific to respirator use.

Characteristics Associated With Health Care Worker Knowledge and Confidence in Elastomeric Half-Mask Respirator Use

OBJECTIVE

This study evaluated health care workers' (HCWs') knowledge and confidence in using elastomeric half-mask respirator (EHMR) attributes known to influence usage.

METHODS

Health care workers were surveyed regarding their EHMR donning and doffing experience. Respondents were categorized into competency categories based on their scores. Category differences were analyzed using χ 2 and multiple logistic regression.

RESULTS

Seventy-two percent showed high levels of EHMR donning and doffing knowledge and confidence (mastery); however, 21% had greater confidence than knowledge (misinformed). Respiratory therapists had greater odds of mastery than other HCWs ( P < 0.05), whereas those working in medical/surgical and pediatric units had greater odds of doubt than other HCWs ( P < 0.01).

CONCLUSIONS

Although most HCWs show high knowledge and confidence with EHMR use, strategies to confirm respirator use competency may ensure greater HCWs protection.

Personal protective equipment implementation in healthcare: A scoping review

BACKGROUND

Adherence to infection prevention and control (IPC) measures, including the proper use of protective personal equipment (PPE), in health care is complex and is influenced by many factors. Isolated interventions do not have the potential to achieve optimal PPE adherence and appropriate provision, leading to incomplete PPE implementation.

OBJECTIVE

To map PPE implementation in health care with a focus on its barriers and facilitators.

METHODS

A scoping review was conducted across 14 electronic databases using the Joanna Briggs Institute methodology.

RESULTS

Seventy-four papers were included in the review. Findings were analyzed and synthesized into categories to match the Consolidated Framework for Implementation Research domains. The content was then synthesized into barriers for PPE implementation and interventions to address them. The main barriers were discomfort in clinical work; shortage, supply and logistics problems; inadequacies in facilities infrastructure, weakness in policies and communication procedures; and health workers' (HW) psychological issues and lack of preparedness. Implementation interventions reported were related to HW wellbeing assurance; work reorganization; IPC protocols; adoption of strategies to improve communication and HW training; and adoption of structural and organizational changes to improve PPE adherence.

CONCLUSIONS

PPE implementation, which is critical IPC programs, involves multilevel transdisciplinary complexity. It relies on the development of context-driven implementation strategies to inform and harmonize IPC policy in collaboration with local and international health bodies.

Respirators in Healthcare: Material, Design, Regulatory, Environmental, and Economic Considerations for Clinical Efficacy

Maintaining an ample supply of personal protective equipment continues to be a challenge for the healthcare industry, especially during emergency situations and times of strain on the supply chain. Most critically, healthcare workers exposed to potential airborne hazards require sufficient respiratory protection. Respirators are the only type of personal protective equipment able to provide adequate respiratory protection. However, their ability to shield hazards depends on design, material, proper fit, and environmental conditions. As a result, not all respirators may be adequate for all scenarios. Additionally, factors including user comfort, ease of use, and cost contribute to respirator effectiveness. Therefore, a careful consideration of these parameters is essential for ensuring respiratory protection for those working in the healthcare industry. Here respirator design and material characteristics are reviewed, as well as properties of airborne hazards and potential filtration mechanisms, regulatory standards of governmental agencies, respirator efficacy in the clinical setting, attitude of healthcare personnel toward respiratory protection, and environmental and economic considerations of respirator manufacturing and distribution.

The pragmatic use of industrial elastomeric facemasks in health care practice during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has forced health care workers to explore alternative personal protective equipment (PPE) strategies due to traditional product shortages in the setting of increased global demand. Some physicians have chosen to use elastomeric face masks (EFMs), traditionally used in non-healthcare industries.

METHODS

We performed a prospective cohort study of Emergency Medicine (EM) physicians working at a Level 1 Trauma Center who chose to use self-supplied EFMs for PPE. All subjects used commercial EFMs with disposable filters (N95, P95, or P100). All subjects chose their mask size independently with no input from employee health regarding appropriate fit. Per study protocol, subjects were fit tested periodically during clinical shifts over the course of the 6-week study period. All investigators performing fit testing underwent OSHA qualitative fit testing training. Data collected included mask/filters age, subjective assessment of mask seal quality, and fit test results. The data were analyzed using descriptive statistics.

RESULTS

105 fit tests were performed on physicians wearing EFMs over the course of 49 shifts. Physicians felt their fit was adequate for all tests performed. There were no fit test failures in any subjects.

CONCLUSIONS

EFMs have an extremely low failure rate. Physicians are able to assess the adequacy of fit and accurately choose EFM size.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review

OBJECTIVES

To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types.

DESIGN

Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare.

DATA SOURCES

Websites of international standards organisations, Medline and Embase, hand-searching of references and citations.

STUDY SELECTION

Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use.

RESULTS

We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators.

CONCLUSION

A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

Mask shortage during epidemics and pandemics: a scoping review of interventions to overcome limited supply

OBJECTIVE

To characterise published evidence regarding preclinical and clinical interventions to overcome mask shortages during epidemics and pandemics.

DESIGN

Systematic scoping review.

SETTINGS

All healthcare settings relevant to epidemics and pandemics.

SEARCH STRATEGY

English peer-reviewed studies published from January 1995 to June 2020 were included. Literature was identified using four databases (Medline-OVID, EMBASE, CINAHL, Cochrane Library), forwards-and-backwards searching through Scopus and an extensive grey literature search. Assessment of study eligibility, data extraction and evidence appraisal were performed in duplicate by two independent reviewers.

RESULTS

Of the 11 220 database citations, a total of 47 articles were included. These studies encompassed six broad categories of conservation strategies: decontamination, reusability of disposable masks and/or extended wear, layering, reusable respirators, non-traditional replacements or modifications and stockpiled masks. Promising strategies for mask conservation in the context of pandemics and epidemics include use of stockpiled masks, extended wear of disposable masks and decontamination.

CONCLUSION

There are promising strategies for overcoming face mask shortages during epidemics and pandemics. Further research specific to practical considerations is required before implementation during the COVID-19 pandemic.

COVID-19: Biosafety in the Intensive Care Unit

PURPOSE OF REVIEW

COVID-19 is a new, highly transmissible disease to which healthcare workers (HCWs) are exposed, especially in the intensive care unit (ICU). Information related to protection mechanisms is heterogeneous, and the infected HCWs' number is increasing. This review intends to summarize the current knowledge and practices to protect ICU personnel during the patient management process in the context of the current pandemic.

RECENT FINDINGS

The transmission mechanisms of SARS-CoV-2 are mainly respiratory droplets, aerosols, and contact. The virus can last for a few hours suspended in the air and be viable on surfaces for several days. Some procedures carried out in the ICU can generate aerosols. The shortage of respirators, such as the N95, has generated an increase in the demand for other protective equipment in critical care settings.

SUMMARY

The probability of transmission depends on the characteristics of the pathogen, the availability of quality personal protective equipment, and the human factors associated with the performance of health workers. It is necessary to have knowledge of the virus and availability of the best possible personal protection equipment, develop skills for handling equipment, and develop non-technical skills during all intensive care process; this can be achieved through structured training.