In the hierarchy of Centers for Disease Control and Prevention/National Institute of Occupational Safety and Health (CDC/NIOSH) infection prevention and control measures, respiratory protection (RP) is an important means of mitigating healthcare personnel (HCP) airborne exposures. The Occupational Safety and Health Administration (OSHA) 1998 Respiratory Protection standard (29 CFR 1910.134) requires that employers provide workers with respirators “when such equipment is necessary to protect the health of such employee[s]” and “shall be responsible for the establishment and maintenance of a respiratory protection program.”1
Several government agencies, professional, and trade organizations have issued guidance about the proper use of RP in the healthcare workplace (Table 1). Despite an abundance of information about what organizations must do (regulatory) and what organizations should be doing (guidance), evidence suggests inconsistent RP practices and programmatic adherence.Reference Yarbrough, Ficken and Lehmann2–Reference Peterson, Novak, Stradtman, Wilson and Couzens4 Between 2009 and 2016, the increased number of CDC/NIOSH queries led to a NIOSH-funded study undertaken by The Joint Commission to identify clinical RP issues needing additional guidance or clarification.
Examples of Standards, Guidance, and Recommendations Related to Respiratory Protection (RP) in Health Care
Methods
To guide the project, an 8-member expert Technical Advisory Panel (TAP) was convened. Issues were gathered through e-mail queries, interviews, and an electronic questionnaire. A project webpage was developed with the questionnaire link for direct submission. To solicit traffic to the webpage, several methods were used, including e-mail blasts, postings on social media, professional listservs, and flyer distribution at 5 national healthcare conferences.
Structured interviews were conducted with each TAP member and expert clinicians. All submitted data were entered into Microsoft Excel (Redmond, WA) for content analysis; each issue was counted as a discrete record. Staff grouped issues by topic area and reviewed existing guidance to identify issue-specific available answers. A list of issues was sent to each TAP member for determination as to whether the issue was a “clinical conundrum” or an “operational issue.” A clinical conundrum was defined as an issue for which there was no specific recommendation in an existing evidence- or consensus-based guideline, or where there was conflicting guidance. An operational issue was one causing practical, or programmatic implementation challenges. Descriptive frequencies were calculated for each topic area.
Results
Overall, 34 people submitted issues across all information-gathering mechanisms, of which half submitted multiple issues. Among submitters, 13 were physicians, 7 were occupational health practitioners, 5 were respiratory therapists, 4 were infection preventionists, and 2 were nurses (3 missing). Almost half of the submitters (n = 16) were affiliated with academic hospitals.
A total of 95 issues were identified: 49 via the structured interview, 21 from the questionnaire and 25 from queries. The most frequently identified issues related to equipment (n = 24), hospital-specific practices (n = 19), and airborne infectious pathogens (n = 18) (Table 2). Also, 13 issues were answerable using published guidance, 34 were considered operational issues, and 48 required TAP determination (16 of which required additional discussion to reach consensus on whether or not it was a clinical conundrum). Ultimately, 27 issues (28.4%) were categorized as clinical conundrums and 68 issues (71.6%) were categorized as operational issues (Table 2).
Summary of Issues and Examples of Clinical Conundrums and Practical Challenges
Note. RP, respiratory protection; HCW, healthcare worker; TB, tuberculosis; MERS, Middle Eastern respiratory syndrome; SARS, severe acute respiratory syndrome; HPV, human papilloma virus; PAPR, powered air purifying respirator; MRI, magnetic resonance imaging; USP, United States Pharmacopeia; EHFR, elastomeric half-face respirator; PPE, personal protective equipment.
Discussion
This study identified RP issues in hospital settings for which there was no specific recommendation in existing guidance as well as numerous ongoing operational issues. Frequently, submitted topics presented clinical as well as programmatic and/or operational challenges. Selection of respirators for staff with facial hair continues to cause confusion, especially in surgical or procedural settings. Respiratory protection related to visitors is another such topic. An example is how to prevent HCP exposures to family members who may be the source of a child’s tuberculosis (TB). Though not supported by evidence-based guidelines, a 2014 survey of hospital epidemiologists indicated many hospitals require visitors to wear N95 respirators when entering airborne isolation rooms.Reference Munoz-Price, Banach and Bearman5
Another conundrum related to ambulatory settings that may occasionally encounter patients with airborne infectious diseases (eg, urgent care). Although the OSHA standard applies to all settings, many specialized outpatient settings lack the infrastructure for robust RP programs. In such cases, the value of formal RP programs should be considered relative to the costs and likelihood of encountering such patients.
Although many guidance documents are available, published guidance is not widely recognized among HCP for a variety of reasons. Given multiple sources, it can be difficult to find the answers to RP-related questions quickly, and not all guidance is available in the public domain. The mechanism for disseminating guidance to frontline users varies widely, which limits timely awareness in the field. For example, during public health emergencies, frequently updated information may be incomplete or confusing due to unknown mode of transmission, etc.
Frontline users also vary substantially in discipline (eg, medicine, nursing, respiratory therapy, environmental services, pharmacy, laboratory) and training. Administrators responsible for respiratory protection programs often face the dual challenge of patient care oversight and safeguarding workers and visitors, which is subject to numerous barriers including resource constraints, competing priorities, and poor safety culture. Even if recommendations and guidance were perfectly consistent across sources and were well understood, information and knowledge gaps and unanticipated situations would eventually emerge that require real-time decision making, as exemplified by the changing RP recommendations during the Severe Acute Respiratory Syndrome, Ebola and 2009 H1N1 influenza outbreak.Reference Liverman, Harris, Rogers and Shine6
Our findings suggest potential opportunities for improvement and longer-term solutions:
Consolidate information. Since much guidance already exists, it may be useful to repackage information so it is more practical and easily accessible during a public health emergency.7 A single, free, website resource that centralizes all guidance could be developed by key stakeholders like that done for the “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.”Reference Yokoe, Anderson and Berenholtz8
Convene experts. Consensus is needed to address key gaps in RP program operational guidance. For example, what are the best strategies for conducting risk assessments? How can medical clearance and fit-testing processes be streamlined during a public health emergency? When faced with ambiguous situations and incomplete information, it often makes sense to base RP decisions on the “precautionary principle.”Reference Martuzzi and Tickner9 When and how to step down to less intensive precautions are equally important.7
Improve safety culture. Healthcare leaders should promote a culture of safety for HCP and patients. Empowering people to speak up when witnessing unsafe practices helps establish new norms for the desired behaviors.
Pursue pragmatic research. Translational effectiveness research is needed to help solve clinical or technical conundrums, such as RP for fungal infections, surgical smoke, and contingency planning for shortages, including reprocessing. Research is underway on improved respirator designs that address user discomfort and clinical assessment challenges.Reference Gosch, Shaffer, Eagan, Roberge, Davey and Radonovich10
To our knowledge, this is the first attempt to identify clinical issues in which clarification of RP guidance might be needed from a wide range of stakeholders. Nevertheless, our study has several limitations. We cannot assume that the results are generalizable or that the issues are comprehensive, and we may have missed existing guidance pertaining to clinical conundrums.
Our findings are consistent with those of Peterson et al. Reference Peterson, Novak, Stradtman, Wilson and Couzens4 in that hospital staff were often unclear about which type of RP was needed and about when and how to use it. Challenges related to respirator discomfort (eg, heat, diminished visual field, and communication difficulties) are similar to findings from previous research regarding respirator tolerability.Reference Radonovich, Cheng, Shenal, Hodgson and Bender3
Finding answers to clinical conundrums, operational programmatic gaps, and practice gaps should be addressed through future research, education, and policy initiatives. Addressing these issues is the first and necessary step to improved RP. The health and safety of healthcare workers and patients depends on it.
Author ORCIDs
Barbara I. Braun, 0000-0002-7098-6800
Acknowledgments
We are sincerely grateful to those individuals who contributed responses and issues to this study, either via e-mail, phone interview, or online submission.
Financial support
This work was supported by the Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), National Personal Protective Technology Laboratory (NPPTL contract no. 200-2016-M-90738).
Conflicts of interest
All authors report no conflicts of interest related to this article.
