June 26, 2009
Charlotte Carneiro RN, MS, COHN-S,
CIC
charlotte925@comcast.net
On the cusp of seasonal influenza 2009,
and the next wave of the novel influenza A (H1N1), it is time to review
policies and procedures for respiratory protection particularly in the
outpatient setting.
Historically, the OSHA Standard for
Respiratory Protection [29 CFR 1910.139] focused on specific work sites
with respiratory hazards, industrial sites and health care facilities.
While occupational health professionals have implemented these programs
for others, focus has not been on these same occupational health care
professionals.
Epidemics aside, the risk of a nurse
acquiring a respiratory illness from a patient regardless of the setting
is ever present. The MMWR June 19, 2009 further underscores this notion.
While the numbers are small in the sample, most of the health care workers
who acquired the novel influenza A (H1N1) were not wearing personal
protective equipment. Infection control practitioners in hospitals have
noted this for years with daily breaches in wearing protection. Reasons
for not using PPE range from reasonable to ridiculous; not enough time
or unavailability to invulnerability.
Personally, this is not surprising.
While working in various OHN clinics I have noted the array of available
respiratory protection. A first step in PPE is to have stock available.
Some clinics are well stocked with both surgical masks and N-95 masks.
In other clinics, the masks were old and pushed to the back of the cupboard.
NIOSH has not approved surgical masks
for filtering Tuberculosis and does not require fit testing for these.
Surgical masks have been used for diseases with large droplets such
as rubella, meningococcal disease and influenza. NIOSH has approved
N-95 respirator masks and they satisfy the OSHA requirements for respiratory
protection for TB and diseases with larger micron particles.
OSHA's respiratory standard has largely
been directed at specific hazards but the general duty clause states
that the employer must provide hazard protection for the employees.
This includes nurses and health care workers in an outpatient setting.
This includes all respiratory hazards, not just Tuberculosis. OSHA also
has specific procedures for fit testing of a N-95 mask and the requirement
that the employee can choose the mask of preference to be used.
Annual fit testing is still the requirement within the standard.
N-95 masks are required for TB and
highly recommended for influenza especially when aerosols are generated
(when suspecting TB and pandemic influenza). More guidance will emerge
from at least the Centers for Disease Control in the coming weeks and
months on mask type and use with pandemic flu. In the meantime, masks
and gloves should be in a treatment/exam room, readily available preferable
on the counter in the original box away from water, for the OHN to use
for someone who has a cough and high fever. Fluid resistant gowns should
be stored in a marked cabinet or on a wall hanger to grab and go.
Supervisors of OHNS are responsible
for the risk assessment of hazards in the OHN's work place.
While the focus of this article today is on respiratory protection for
novel influenza, hazard risk assessments are needed at least annually
for all respiratory hazards. Risks particularly for TB and other novel
pathogens can change as employees travel and are exposed. This is particularly
relevant in the greater Washington Metropolitan area with public and
private organizations working nationally and internationally.
See references for the full reports
and recommendations highlighted here.
www.OSHA.gov publications
www.cdc.gov MMWR vol58/no23