Respiratory Protection: Lessons Learned from a Global Pandemic

Figures & data

Table 1 Panelist Experiences – Pre-COVID-19 Pandemic Vs During COVID-19 Pandemic: Selection, Storage, Usage of Respiratory Protection Equipment

Before COVID-19 Pandemic	During COVID-19 Pandemic
OEHS Management
LOW demand for surgical FFRs	Extremely HIGH demand for NIOSH-approved surgical FFRs
Limited or no use of reusable elastomeric respirators (RR) in patient care areas– PAPRs often reserved for highly infectious diseases (eg, Ebola), staff who could not wear tight fitting respirators, or other respiratory hazards in non-patient care areas.	Increased use of reusable elastomeric respirators (RR) and PAPRs to help combat or relieve demand for FFRs
Disposable culture, short use of FFRs, typically disposed of after every patient encounter or doffing.	Implemented extended use and limited re-use policies for FFRs per CDC guidelines. Implemented decontamination policies for FFR re-use according to FDA emergency use authorization; since expired June 2021
Limited and sometimes intermittent collaboration with supply chain coordinators	Enhanced and frequent collaboration with supply chain coordinators
Limited FFR models stocked – primarily to accommodate different face sizes	Welcomed stock of many alternatives to NIOSH-approved FFR models to combat shortages
Local supply relegated to central supply/availability on isolation carts	Supply more tightly controlled
Use of NIOSH-approved respiratory protection for airborne infectious particles in clinical areas and other respiratory hazards in non-clinical areas	Considered other options such as high-quality, tight-fitting masks or non-NIOSH-approved FFRs for facilities and support personnel not in direct contact with patients to combat demand for NIOSH-approved FFRs.
Infection Prevention
Patient diagnosis and national transmission-based precaution guidelines drove requirements for usage of NIOSH-approved FFRs and other respirator types for patient care	Allocation of NIOSH-approved FFRs, very little evidence-based guidance available to drive recommendations on usage of non-NIOSH-approved FFRs
Nursing
Limited use of NIOSH-approved surgical FFRs and PAPRs for clinical/patient care for those with airborne infectious diseases in acute care	Use of non-NIOSH-approved and different models of FFRs in hospitals and community care setting Introduction on the use of elastomeric respirators, especially as re-use policies were implemented
NIOSH-approved surgical FFRs were single use only	Extended use and re-use of NIOSH-approved FFRs became standard practice
Local supply managed and distributed by central supply departments	Charge Nurse or managers (hospitals) and nurses (community care) managed local distribution of FFRs

Abbreviations: CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; FFR, filtering facepiece respirator; NIOSH, National Institute for Occupational Safety & Health; OEHS, Occupational and Environmental Health & Safety; PAPR, Powered Air Purifying Respirator.

Table 2 Major Challenges Encountered by Panelists During COVID-19 Pandemic

OEHS and Infection Prevention	Nursing
NIOSH-approved FFR supply shortages Introduction of new FFRs as alternative supply	Stocking and maintaining FFR supply
Communication of quickly changing and complex regulatory and agency guidance related to respiratory protection. Including extended use and reuse.	Keeping abreast of rapidly changing guidelines from multiple sources related to respiratory protection
Challenges with fit of non-NIOSH-approved FFRs which were made available by US FDA EUA to help increase the supply of respirators in the US.	Lack of supply of familiar respirators
Improper donning/wear FFRs (eg, masking over FFRs)	Communicating with patients while wearing respirators
Slow adoption of RR usage	Overcoming patient anxiety when treating while wearing respirators
Proper cleaning and disinfection of RR and PAPR– health care vs industrial setting	Potential for discomfort related to prolonged usage of respirators.
Safety concerns related to reuse and extended use	Safety concerns related to reuse and extended use
Returning to conventional (pre-COVID-19) policies	Returning to conventional (pre-COVID-19) policies
Maintaining focus on proper fit Lack of fit testing (and seal checks) in health care setting (misinterpretation of OSHA directives on annual fit testing)	Educating public about COVID-19 and need for respiratory protection.

Abbreviations: EUA, Emergency Use Authorization; FDA, Food and Drug Administration; FFR, filtering facepiece respirator; NIOSH, National Institute of Occupational Health; OEHS, Occupational and Environmental Health & Safety; OSHA, Occupational Safety and Health Administration; PAPR, Powered Air Purifying Respirator; RR, Elastomeric Reusable Respirator; US, United States.

Box 1 Advisory Panel Recommendations on Respiratory Protection Needs of Health-Care Workers in Clinical or Community Settings During a Global Pandemic

Recommendations

During respiratory protection surge demand circumstances, alternative recommendations related to respiratory protection selection and use in accordance with US regulatory and agency guidance needs to be clearly communicated. The need for effective and ongoing collaboration between Infection Prevention and Occupational and Environmental Health and Safety including a broader multidisciplinary team of stakeholders. Adequate stockpiling, inventory rotation, and a mix of respiratory protective device options that will accommodate most health care workers are necessary. Efficient and innovative strategies to effectively communicate evolving regulations and recommendations as well as deliver appropriate training are needed. Facilities should look to the respirator manufacturer to help educate on current implementation and use recommendations. Additional research is necessary on filtering facepiece respiratory protection usage to balance infection prevention best practices with a sustainable process.

Figure 1 The SAARA Communication Framework (developed by Whitney Line, BSN, RN, PHN) aims to enhance messaging for facility-/field-based health care workers by improving the relay of guidance, policy, education, and important complex information.