Reuse of masks sparks labor complaint
OSHA allows reuse in supply shortage
One evening, ICU nurse Janet Braillard, RN, returned to work at Sutter Solano Medical Center in Vallejo, CA, after being out with a respiratory illness and discovered a new memo. There was a shortage of N95 respirators, the hospital said, and nurses would need to place their respirators in a plastic bag, keep them in their lockers, and reuse them until they were visibly damaged or soiled.
"I was really shocked. I've been a nurse for 34 years and I've never encountered any kind of restriction like that," says Braillard.
That night, Braillard cared for a patient who was on a ventilator, in isolation, and being tested for the novel H1N1. (The patient eventually became a confirmed case.) She had another patient on a ventilator as well. "I was very sweaty that night being in an enclosed room with a reused mask," she says. Coincidentally, the hospital had shut off the water in the unit for six hours that night as a part of scheduled maintenance.
Eventually, Braillard became frustrated, disposed of her N95, and got a new one. When she returned to work a few days later, she found the same scenario, except additionally, a box of different respirators was available. Although the hospital was scheduling fit-tests, Braillard and some of her colleagues had not yet been fit-tested for the new brand and model of respirator. "It upset me so much," she says of the respirator situation. "I no longer trust that my employer has my best interests or my safety at the forefront."
Braillard and other nurses filed a complaint with the California Division of Occupational Safety and Health (Cal-OSHA), asserting that nurses should not be asked to reuse a product that is made for one-time use and that nurses were asked to wear a different respirator before they had been properly fit-tested.
The case highlights important questions about respirator supply and what to do when an N95 shortage occurs. The hospital contends that it acted properly to conserve respirators and followed federal and state guidelines. Nurses were asked to use one respirator per patient per shift, says Sy Neilson, spokesman for Sutter Solano.
The supply issue emerged in mid-June, as H1N1 continued to spread in the community, he says. "We determined if masks were not reused by our staff, we would have a shortage. We are on allocation [from the distributor]. We have an order, but they only supply us with a certain amount [not the full order]. It doesn't come in on a regular basis."
However, a spokesperson for the National Nurses Organizing Committee/California Nurses Association in Oakland questioned why the hospital had a shortage when others did not. "As far as we're aware, this hasn't been an issue in other facilities," says Liz Jacobs, RN, who says the union is surveying nurses at other hospitals. "We're anticipating a virulent flu season with the reemergence of H1N1. We want our nurses to be as prepared as possible with the latest and best technology and policies in place to ensure their protection."
The California Division of Occupational Safety and Health (Cal-OSHA) is currently investigating the complaint and is seeking clarification from the U.S. Occupational Safety and Health Administration (OSHA) on respirator reuse.
Differing guidance on reuse
Can health care workers safely reuse N95 respirators in a supply shortage? Different federal agencies and panels have provided contradictory answers to this question.
OSHA currently says: "Once worn in the presence of an infectious patient, the respirator should be considered potentially contaminated with infectious material, and touching the outside of the device should be avoided. Upon leaving the patient's room, the disposable respirator should be removed and discarded, followed by proper hand hygiene.
"If a sufficient supply of respirators is not available during a pandemic, health care facilities may consider reuse as long as the device has not been obviously soiled or damaged (e.g., creased or torn), and it retains its ability to function properly.
"If disposable respirators need to be reused by an individual user after caring for infectious patients, employers should implement a procedure for safe reuse to prevent contamination through contact with infectious materials on the outside of the respirator" (www.osha.gov/SLTC/pandemicinfluenza/pandemic_health.html).
The National Institute for Occupational Safety and Health (NIOSH), which certifies respirators, is continuing to research the issues surrounding respirator reuse, such as the potential for re-aerosolization of viral or bacterial particles on the respirator.
"Our position would be that you could wear the respirator from patient to patient or room to room, so long as you kept it on," says Roland BerryAnn, deputy director of NIOSH's National Personal Protective Technology Laboratory. "If you take it off, you should dispose of it and wash your hands. The recommendation would be not to handle and rehandle the respirator that could have surface contamination."
Recent research indicates that the likelihood of spreading infectious aerosols from a mask worn in different patient rooms is extremely small, even if the wearer coughs or sneezes, notes BerryAnn.
When an Institute of Medicine Panel considered the issue of reuse, it concluded that "disposable N95 respirators cannot be effectively cleaned or disinfected and should therefore be discarded after each use." However, the panel went on to advise how an "individual user" should handle a respirator if it needs to be reused:
1. Protect the respirator from external surface contamination when there is a high risk of exposure to influenza (i.e., by placing a medical mask or cleanable face shield over the respirator so as to prevent surface contamination but not compromise the device's fit).
2. Use and store the respirator in such a way that the physical integrity and efficacy of the respirator will not be altered.
3. Practice appropriate hand hygiene before and after removal of both the respirator and, if necessary and possible, appropriately disinfect the object used to shield it.1
The Food and Drug Administration regulates surgical masks and N95 respirators as medical devices. The FDA asserts that "Disposable N95 respirators are not intended to be used more than once. They should also never be shared. Their protective capabilities cannot be assured when they are reused either by yourself or another person."
If you must reuse an N95 respirator, is it advisable to protect the respirator from surface contamination by covering it with a surgical mask? That may have some drawbacks, noted Deborah Gold, MPH, CIH, senior safety engineer in the research and standards health unit at Cal-OSHA in Oakland.
"In placing the surgical mask over a respirator, are you going to alter the fit of the respirator? It may contribute to dislodging the respirator [or cause] increased breathing resistance," she says. "That will affect the respirator [fit] because the more resistance there is to breathing through the filter, the more likely air is to leak around the seal.
"Certainly one option is to use a face shield because a face shield won't interfere with the operation of the respirator," she says.
NIOSH is researching the utility of protecting the surface of a respirator by covering it with a surgical mask, says Berry Ann.
"There is an increase in the breathing resistance because of the extra layer and there is a slight increase in the buildup of CO2 in the inhaled breath," he says. "The findings we've gotten so far indicate that it's not really a perceptible difference in performance."
NIOSH also is testing different potential decontamination methods. One study found that ultraviolet germicidal irradiation, ethylene oxide, and vaporized hydrogen peroxide showed promise as decontamination agents. Microwave oven irradiation melted portions of the respirators, and bleach left a noticeable scent.2
To avoid a shortage, flu experts advise hospitals to stockpile respirators as a part of pandemic influenza planning or to purchase reusable respirators, such as elastomeric or powered air-purifying respirators (PAPRs).
References
1. Institute of Medicine. Reusability of facemasks during an influenza pandemic. Washington, DC: National Academies Press; 2006. Available at www.nap.edu/catalog.php?record_id=11637. Accessed on July 23, 2009.
2. Viscusi DJ, Bergman MS, Eimer BC, et al. Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occup Hyg 2009; in press.
One evening, ICU nurse Janet Braillard, RN, returned to work at Sutter Solano Medical Center in Vallejo, CA, after being out with a respiratory illness and discovered a new memo. There was a shortage of N95 respirators, the hospital said, and nurses would need to place their respirators in a plastic bag, keep them in their lockers, and reuse them until they were visibly damaged or soiled.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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