478
Table 1. (Continued ) Source
Society for Healthcare Epidemiology of America (SHEA)
The Joint Commission
Barbara I. Braun et al
Reference
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation precautions for visitors. Infect Control Hosp Epidemiol 2015;36:747–758.
The Joint Commission. Implementing Hospital Respiratory Protection Programs: Strategies from the Field. Oakbrook Terrace, IL: The Joint Commission; 2014. The Joint Commission website.
https://www.jointcommission.org/topics/respiratory_protection_ hospitals_resources_practices.aspx. Published 2014. Accessed December 2018.
American Association of Occupational Health Nurses (AAOHN)
Individual manufacturers
Respiratory protection program training and resources. American Association of Occupational Health Nurses website. http://aaohn. org/respiratory-protection. Accessed March 30, 2018.
Manufacturer instructions for use; guidance and locations vary according to manufacturer
Focus of RP-Related Content
Recommendations for visitors of patients on droplet and airborne precautions
Recommendations and case studies to help hospitals implement RP programs
RP course and resources about OSHA’sRP standard and requirements
Equipment use, cleaning and maintenance
Results
Overall, 34 people submitted issues across all information-gather- ing mechanisms, of which half submitted multiple issues. Among submitters, 13 were physicians, 7 were occupational health practi- tioners, 5 were respiratory therapists, 4 were infection prevention- ists, 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 inter-
view, 21 from the questionnaire and 25 from queries. Themost fre- quently 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 conun- drums and 68 issues (71.6%) were categorized as operational issues (Table 2).
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 opera- tional 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 visi- tors to wear N95 respirators when entering airborne isolation rooms.5
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 set- tings, many specialized outpatient settings lack the infrastructure for robust RP programs. In such cases, the value of formal RP pro- grams 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 rea- sons. 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, medi-
cine, nursing, respiratory therapy, environmental services, phar- macy, 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 con- straints, competing priorities, and poor safety culture. Even if rec- ommendations 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.6 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 prac- tical 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.”8
•
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 ambigu- ous situations and incomplete information, it often makes sense to base RP decisions on the “precautionary principle.”9 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
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