Improving Respiratory Protection Programs in California Acute Care Hospitals

Improving Respiratory Protection Programs in California Acute Care Hospitals: Pilot Test of a Resource Toolkit for Program Administrators

Kate Durand, MHS, Barbara Materna, PhD, CIHCalifornia Department of Public Health, Occupational Health Branch

Debra A. Novak, RN, DSN, Ed Fries, MS, Maryann DAlessandro, PhDNational Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory

CSTE Annual Meeting June 14, 2011 Pittsburgh, PA

1BackgroundIncreased use of respiratory protection during 2009 H1N1 influenza pandemic

Cal/OSHA Aerosol Transmissible Diseases (ATD) standard became effective August 5, 2009

Due to CDC & CDPH (& CalOSHA & FedOSHA) guidelinesATD std makes public health guidelines enforceable:N95 for patient care & novel virus or infectious disease requiring airborne precautionsN95 for seasonal influenza & high-hazard proceduresPAPR for high-hazard procedures & infectious disease requiring airborne precautions2Respirator Use Evaluation in Acute Care Hospitals (REACH) field project: 2009-10 influenza season Hospitals followed public health guidelines & Cal/OSHA ATD Standard on N95 respirator useDeficiencies in written policies and implementation of respiratory protection programs (RPPs)NIOSH partnered with CDPH to develop, implement, and evaluate an intervention to improve programsBackgroundREACH funded by NIOSH NPPTL; acknowledge Bob Harrison PI 3ObjectivesIdentify one or more common deficiencies in hospital respiratory protection programs as the focus of the intervention effort.Develop and implement a selected set of intervention strategies in a sample of acute care hospitals.Evaluate effectiveness of intervention strategies.Report back to NIOSH.[Consider statewide dissemination of strategies.]#1 based on REACH findings & recommendations[incorrect donning/doffing, inadequate written programs, lack of program evaluation, possible unfamiliarity with PAPRs required for high-hazard procedures on certain patients starting Sept 2010]

#2: these could be guidance materials, training materials, suggested processes for evaluating programs4CDPH staff visited 14 of 16 REACH hospitalsPresented REACH findings & recommendationsInvited participation in follow-up projectDiscussed RPP deficiencies & what types of tools would be helpfulInvited one additional SF hospital because of interest expressed by their safety professional

Methods:Recruitment of Hospital ParticipantsParticipants completed a pre-project assessment questionnaire evaluating their RPP by phone; gave input on desired tools.CDPH industrial hygienists identified existing tools & developed new tools to address common deficiencies in RPPs.Toolkit was developed with input from NIOSH and Cal/OSHA.Methods:Tool DevelopmentQuestionnaire asked the RPA to assess implementation of their RPP, identify most important areas for improvement.Gathered more input on useful tools.

Acknowledge Roland Berryann, NPPTL IH6Most Deficient Areas of Written ProgramsDesignation of a Respirator Program AdministratorRecordkeepingFit testing protocolTrainingProgram evaluation

Based on REACH results7Areas Hospitals Identified as Needing ImprovementAreas of implementation with greatest need for improvement determined subjectivelySelection of appropriate respirator for task and suspected/confirmed infectious disease riskDonning/doffing N95Regular evaluation of programEmployee use of the specific respirator they were fit tested forBased on input from RPAs8The ToolkitGuide for Respiratory Protection Program Administrators in HospitalsStep-by-step how-to instructions for developing and implementing a RPP in a hospital settingDesigned to be used by staff with little or no formal training in health and safetyBest practices shared by a few hospitalsDVD enclosed with other tools useful for RPP development and implementationDVD Contents:Cal/OSHA Standards and AppendicesCal/OSHA Respiratory Protection Standard (full standard)Appendix A: Fit Test ProtocolsAppendix B: Medical QuestionnaireAppendix D: Information for Voluntary Users

Cal/OSHA Aerosol Transmissible Diseases Standard (full standard)Appendix B: Alternate Medical QuestionnaireDVD Contents:Public Health Guidance DocumentsCDC Prevention Strategies for Seasonal Influenza in Healthcare SettingsCDPH Guidance on Influenza Prevention (11/5/2010)Cal/OSHA Guidance for the 2010-2011 Influenza Season (11/5/1010)DVD Contents:Administrative ToolsList of Links Useful Web SitesWritten Respiratory Protection Program TemplateRespiratory Protection Program Evaluation ChecklistSample Respirator Fit Test RecordSample Respirator Fit Test and Training Verification CardSample PAPR Program Flow Chart developed by a Hospital in CaliforniaTemplate: tailored for hospital environmentEvaluation checklist: includes instructions on how to use it for required periodic program evaluation12DVD Contents:Training Tools and Educational MaterialsList of Links Useful Web SitesCal/OSHA PowerPoint presentation: Respiratory Protection in SNFs and Primary CareCDC PowerPoint presentation: Guidance for the Selection and Use of PPECDPH PowerPoint presentation: Fit Test PrinciplesOSHA video: Difference Between Respirators and Surgical MasksOSHA video: Donning and DoffingSample Mask and Respirator Flyer *Quick Reference Table for Respirator Selection *

* Adapted from material provided by Mercy General Hospital, Sacramento, CAUseful Web Sites: existing stuff we found NIOSH & OSHA topic pages & tools, source for professional training in respiratory protection, training tools & educational materials13Methods:Toolkit Pilot Testing and EvaluationParticipants attended a webinar with overview of toolkit and expectations for pilot testing.Hospitals pilot tested guide and toolkit for ~ 4 months with industrial hygiene technical support.Feedback form provided to record use of tools & input.CDPH re-visited hospitals for feedback, post-project assessment, & brief observation of RPP implementation.

Methods:Feedback from StakeholdersAlso sent materials to 14 stakeholders for review: Cal/OSHA Hospital and infection control professional associationsNurses unions

Visited 12 of 16 REACH hospitals.Ten hospitals completed feedback form regarding their experience with the guide and toolkit.Positive feedback received on tools, including from hospitals that did not use or feel they needed them.Most frequently used tools: Guide (10), web links list (7), RPP template (6), and program evaluation checklist (6).OSHA videos were also popular.Results: Participant Feedback on Tools5 hospitals used the video on the difference between a mask and a respirator and 4 hospitals used the one on donning and doffing.Results:Post-Project RPP EvaluationAll written RPPs were improved during the project.Some were improved in response to REACH results, before toolkits were received.Six hospitals used the provided RPP template.

Several deficiencies in implementation still apparent in spite of improvements.Weakest on correct donning/doffing and staff ability to choose appropriate respirator.

Based on the assessment tool17Results:Stakeholder Feedback on ToolsValuable feedback received from:Several unions representing nursesInfection prevention trade associationTwo participants who did not end up implementing tools, but provided feedback on the guideOne practicing infection prevention nurse from outside the projectNo feedback from Cal/OSHA yetNone from CHACACC CA APIC chapter Anne Marie FloodDenise Bleak18Results:Stakeholder Feedback on ToolsOverall impression: The guide and toolkit could be very useful to RPP administrators.Unions raised concerns about writing style and tone of the guide letting management off the hook in some places.Suggested using less text and more graphics and boxed info for better readability.No comments on specific tools on the DVD.

19Guide & toolkit useful for many participants likely to be useful to other hospital RPP administrators struggling with implementation.More improvement in training needed deficiencies noted in effective implementation of proper use of respirators.A similar guide and toolkit could be useful for other types of health care facilities e.g., clinics and long-term care facilitiesConclusions20Next StepsRevise the guide using input from stakeholders and participants.Use professional graphic artist and printer to produce a final toolkit for statewide distribution.Conduct outreach and disseminate to health care sector.Post the guide and toolkit on CDPH website. 21Questions?Barbara.Materna@cdph.ca.gov