March 2014

US $39.00

S P E C I A L

R E P O R T

PPE Utilization in a Pandemic:

More Research Needed to Fuel Preparedness During a pandemic, the proper and appropriate use of personal protective equipment (PPE) is essential to help protect healthcare workers, patients and visitors. Because the availability of antiviral medications may be variable in an emergency situation such as a pandemic, N95 respirators, masks, gowns and gloves are the first line of defense against the spread of pathogenic organisms.

By Kelly M. Pyrek

Infection Control Today • Pandemic Preparedness 2014

1

infectioncontroltoday.com

INFECTION CONTROL T

O

D

A

Y

Table of Contents PPE Utilization in a Pandemic: More Research Needed to Fuel Preparedness ..............3 Stockpiling and Surge Capacity During a Pandemic .......8 Estimating of the Cost of Hospital Preparedness ............8 Prioritizing the Use of PPE ........................................10 Reusing Masks During a Pandemic ...........................13 H1N1 PPE Guidance: Confusion and Controversy........18 Making the Case for Pandemic Preparedness .............19 Addressing Apathy ..................................................23 Education and the Impact of IPs................................24 References ............................................................25

Copyright © 2014 VIRGO Publishing, LLC. All rights reserved. The publisher reserves the right to accept or reject any advertising or editorial material. Advertisers, and/or their agents, assume the responsibility for all content of published advertisements and assume responsibility for any claims against the publisher based on the advertisement. Editorial contributors assume responsibility for their published works and assume responsibility for any claims against the publisher based on the published work. Editorial content may not necessarily reflect the views of the publisher. Materials contained on this site may not be reproduced, modified, distributed, republished or hosted (either directly or by linking) without our prior written permission. You may not alter or remove any trademark, copyright or other notice from copies of content. You may, however, download material from the site (one machine readable copy and one print copy per page) for your personal, noncommercial use only. We reserve all rights in and title to all material downloaded. All items submitted to Infection Control Today become the sole property of VIRGO Publishing, LLC.

Infection Control Today • Pandemic Preparedness 2014

2

infectioncontroltoday.com

PPE Utilization in a Pandemic:

More Research Needed to Fuel Preparedness By Kelly M. Pyrek

D

uring a pandemic, the proper and appropriate use of personal protective equipment (PPE) is essential to help protect healthcare workers, patients and visitors. Because the availability of antiviral medications may be variable in an emergency situation such as a pandemic, N95 respirators, masks, gowns and gloves are the first line of defense against the spread of pathogenic organisms. The SARS outbreak in 2003-2004 and the H1N1 pandemic in 2009-2010 illustrated the critical importance of basic infection prevention and control practices According to the in healthcare facilities. According to the World Health Organization (WHO, World Health 2006) transmission of SARS in healthcare facilities was frequently associated with noncompliance with standard precautions. Unless the Centers for Disease Organization Control and Prevention (CDC) and WHO indicate otherwise, healthcare providers (WHO, 2006) should practice standard, airborne, droplet, and contact precautions. Disposable transmission PPE should be used whenever possible, because viruses can remain infectious of SARS in on garments for long periods of time. Individuals who should wear PPE during healthcare a pandemic include: All healthcare professionals who provide direct patient care (such as physicians, nurses, nursing assistants, etc.); all support staff, including facilities was medical aides and environmental services personnel; all laboratory professionals frequently handling specimens from a patient being investigated for the prevalent pandemic associated with influenza strain); all central service and sterile processing professionals handling noncompliance equipment that requires decontamination and has come from a patient with the with standard prevalent pandemic influenza strain; and family members/visitors. Lessons from previous pandemics include being more vigilant about PPE precautions. inventory. Rebmann, et al. (2009) acknowledge that “During past infectious disease disasters, such as the early part of the 2009 H1N1 pandemic, shortages of disposable N95 respirators were reported.” (Rebmann and Wagner, 2009). These researchers noted that less than a month after the first case of laboratory-confirmed novel H1N1 was reported in the United States, the CDC had deployed 25 percent of the Strategic National Stockpile (SNS) of N95 respirators. Rebmann and Wagner (2009) also reported supply issues of prime concern included running out of respirators or certain sizes of respirators and facing back orders early in the pandemic. And for hospitals virtually unaffected by the 2009 H1N1 pandemic, it pays to test the system, as British researchers discovered. Phin, et al. (2009) reported on a 24-hour exercise

Infection Control Today • Pandemic Preparedness 2014

3

infectioncontroltoday.com

in a hospital in northwest England during which all staff on an acute general The researchers medical ward wore PPE and adopted the procedures described in the UK found that although pandemic influenza infection control guidance. Teams of infection control World Health nurses observed and recorded staff behavior and practice throughout the Organization exercise, including staff attitudes toward the use of PPE. The researchers recommendations found that although World Health Organization recommendations on the likely use of high-level PPE proved to be excessive, more gloves and surgical on the likely use masks were used than expected. They say that despite pre-exercise training, of high-level PPE many staff lacked confidence in using PPE and following infection control proved to be measures. Hospital personnel found PPE to be uncomfortable, with even excessive, more basic tasks taking longer than usual. Large quantities of clinical waste were gloves and surgical generated: an additional 12 bags per day. As Phin, et al. (2009) describe, “The simulation successfully highlighted issues associated with the implementation masks were used of national guidance and quantified the associated use of PPE in a typical UK than expected. hospital setting. In the worst-case scenario during the height of a pandemic, a cohorted ward could expect to use up to 5,250 aprons per week compared to normal use of 400; 8,400 pairs of gloves compared to 850; 4,550 surgical masks compared to <10; and 90e100 FFP3 respirators and fluid-repellent gowns, none of which are commonly used on wards. With regard to aprons, gloves and surgical masks, there would be increases in use of up to 13-, 10- and 450-fold, respectively. This has significant implications not only for cost and procurement but also for storage; accommodating supplies on the ward for the 24 hours of the exercise was difficult.” British health officials had issued infection control guidance for pandemic flu in October 2005, calling for healthcare workers to don gloves, a plastic apron or gown, and a surgical mask when coming within three feet of pandemic influenza patients. They recommended the use of an FFP3 respirator (equivalent to a U.S. N-99 respirator, designed to stop 99 percent of small airborne particles) and eye protection during aerosol-generating procedures. The researchers say that estimates of PPE usage within this exercise challenge assumptions that large amounts of high-level PPE are required, with significant implications for healthcare budgets. A program of ongoing infection control education is needed, the researchers say, and that healthcare in a pandemic situation is not simply a case of applying pandemic influenza infection control guidance to current practice; hospitals need to consider changing the way care and services are delivered. As Rebmann, et al. (2009) emphasize, “Healthcare facilities and agencies must address shortages of respiratory protection in their emergency management plan, including ways to conserve respirators. It is essential that this takes place before the facility’s respiratory protection supplies are depleted.” PPE utilization during a pandemic is challenging to calculate. The Association for Healthcare Resource & Materials Management (AHRMM, 2009) notes that the Occupational Safety and Health Administration (OSHA) estimates that for healthcare workers, masks will be

Infection Control Today • Pandemic Preparedness 2014

4

infectioncontroltoday.com

changed four times per 12 hour shift for direct patient-care givers; most healthcare workers think this is well underestimated. OSHA also indicates that in emergency departments during a pandemic, direct-care givers may use as many as one mask between each patient and that each person visiting the ER should be issued an N-95 mask to prevent transmission. As AHRMM (2009) notes further, “The number is staggering and might indicate that in some cases, Materials managers might be better served to seek reusable alternatives.”The organization adds that “Initial volume will not be 100 percent occupancy but will start with a significant surge in daily use and crescendo at full census. Heightened awareness should be made for the potential of sensitive medical PPE departing with the workforce. At the onset, estimates of daily use should be calculated and the initial 96 hours of use should be brought on site. Work with established suppliers and with the workforce to establish potential alternatives to disposable N-95 face masks. Assure that the correct type of mask or respirator is used in the most appropriate instance, e.g.: surgical masks used where appropriate and disposable N-95s only used where essential.” Swaminathan, et al. (2007) conducted a simulation study in nine Australian hospital emergency departments designed to evaluate the number of contacts between patients and healthcare personnel and to determine the number of types of PPE that would be required. Compliance of healthcare personnel in using the appropriate PPE was also examined. The study focused on only the first six hours of contact with a suspected case. The researchers reported an average of 12 close contacts, with 19 exposures per case, and estimated that approximately 20 N95 respirators, 22 gowns, and 25 gloves would have been required to protect healthcare personnel during the first six hours of care. Given the rates of compliance noted in this study, up to 40 percent of healthcare personnel may have required post-exposure prophylaxis. In Japan, Hashikura and Kizu (2009) developed a PPE calculation system which can calculate the number of PPE from only the location and scale of the hospital. In their system, the stockpile of PPE is calculated by multiplying the average number of healthcare workers determined automatically by the location and scale of the hospital, the number of PPE sets required for healthcare workers per day, and the length of the pandemic period. As Hashikura and Kizu (2009) note, “According to the U.S. Department of Labor, the number of PPE required for HCWs in a high-risk group is four sets per day. It is also considered that two sets of PPE are required for HCWs in medium- and low-risk groups because HCWs work around 12 hours a day and are required to change PPE

Infection Control Today • Pandemic Preparedness 2014

5

The researchers reported an average of

12 close contacts, with 19 exposures per case, and estimated that approximately

20 N95 respirators, 22 gowns, and 25 gloves would have been required to protect healthcare personnel during the first six hours of care.

infectioncontroltoday.com

every six hours during pandemics.” They add, “The number of gloves depends on how many patients HCWs can treat because gloves should be changed for each patient. We suppose that 20 pairs of gloves/doctor (high risk)/day will be required because one SARS report showed that one doctor can treat five to 10 patients per day from the view of infection control. Furthermore, the use of masks by patients is also important to block virus transmission. The U.S. Department of Labor indicates that one surgical mask per day is necessary for outpatients and two for inpatients. All medical and nonmedical workers in the hospital, such as doctors, nurses, medical technologists, pharmacists, caregivers who provide critical care or spiritual care, respiratory therapists, reprocessors of reusable medical devices, and cafeteria workers, in addition\ to the family members and visitors, also require at least two surgical masks per day.” Murray, et al. (2010) examined the use of facial protective equipment in several Vancouver, Canada, hospitals. During that time, 865 patients with suspected cases of H1N1 influenza were admitted, with 149 patients having laboratory-confirmed H1N1 influenza infection; 134,281 masks and 173,145 N95 respirators were used. Comparisons were made of the number of respirators, masks, and protective eyewear used within the same period in 2008, with increases of 107 percent in the number of respirators, 70 percent in the number of eyewear, and 196 percent in the number of masks. The authors reported that the Ministry of Health plans for pandemic influenza called for hospitals to have a 10-week supply of PPE equipment, but they did not account for increases in the supplies that would be needed. Radonovich, et al. (2009) acknowledge little to no guidance on stockpiling and other inventory metrics and describe a project conducted in their VA healthcare system to help bridge the gap between policy and procedure. They provide details about their healthcare system’s approach to building a cache of supplies for the next influenza pandemic and to help identify critical gaps in knowledge that must be addressed for adequate preparedness: Radonovich, et al. (2009) defined their healthcare system’s universe of patients as the number of individually enrolled persons who sought care at VA facilities during the previous fiscal year; this figure enabled the researchersto calculate system and facility needs in a standardized fashion. Once the number of patients was established, they used the HHS 1918-scale pandemic model and FluSurge version 2.0 software to estimate the number of persons who would be expected to seek care, be hospitalized, be admitted to an intensive care unit (ICU), or be treated with mechanical ventilation. The only modification to the HHS model was in the proportion of the population likely to contract influenza. The model calls for 40 percent disease incidence for children, 20 percent for healthy adults, and a somewhat higher incidence for elderly persons. The researchers say 25 percent was a reasonable number for the VA, an institution that does not provide healthcare to children. They based calculations on the population likely to request care, not on the physical or personnel capacity of the facility. The researchers asserted that physical capacity would be increased and standards of healthcare would be lowered, as necessary, during a pandemic to permit serving as many people as possible.

Infection Control Today • Pandemic Preparedness 2014

6

infectioncontroltoday.com

Radonovich, et al. (2009) assumed a length-of-stay (non-ICU) figures of five days per patient, an additional 10 days for those requiring an ICU stay, and an average time receiving mechanical ventilation of 10 days. They also assumed that sole use of disposable N95 respirators would be prohibitively expensive or otherwise not possible because of global shortages, and instead, decided that staff with prolonged periods of exposure would be issued a reusable elastomeric half-face mask with three sets of filters. They estimated that about 1,000 of these masks and reusable goggles would be needed for each 50,000 patients served. Disposable masks would be limited to the beginning of the pandemic and to personnel with infrequent exposure. Using these principles, the researchers calculated the workload, supplies, and medication required to care for typical influenza patients. Accordingly, estimates were produced for the average needs of influenza patients requiring >1 types of services, including outpatient, inpatient medical ward, or ICU settings with or without mechanical ventilation. Radonovich, et al. (2009) acknowledge the uncertainty inherent to these types of calculations: “No one knows what the next pandemic will bring. We believe that it is better to plan for a more severe event that will leave No one knows what the system over-prepared than to risk being under-prepared. However, this the next pandemic approach may be viewed by some as unnecessary or too expensive. A stratified purchase plan, in which a fraction of essential items is purchased periodically, will bring. We is recommended on the basis of availability of funds. The formation and believe that it is management of a pandemic supply cache would require considerable human better to plan for and financial resources. The level of commitment may be viewed by some a more severe healthcare systems as too costly, especially in an era of economic instability event that will leave and healthcare system instability likely requiring major reform. Some of the more resource-intensive components of the proposed approach, such as the system overthe storage of items in a staffed central facility, were facilitated by the large prepared than to size of our healthcare system and available resources. Achieving a similar risk being underproduct in the private sector, where healthcare systems are typically much prepared. smaller than those in the federally managed VA, might require a partnership among multiple healthcare systems in a region ...The estimated cost of purchasing all supplies and medications needed to provide healthcare to a population of 500,000 during a wave of an influenza pandemic, including negotiated and contracted prices, was about $11 million, or approximately half that amount if one only considers purchasing priority A items. This amount is considerably higher than the amount estimated elsewhere. This difference may stem from the way we calculated our needs: we did not assume that we could reach a full capacity. Instead, we attempted to estimate the population that is likely to seek care and assumed that under the dire circumstances of a severe pandemic facilities would decrease standards of care, open alternate sites of care, and creatively care for those patients who came for treatment. We also did not assume that we would have a shortage of personnel to care for these patients. Through altered

Infection Control Today • Pandemic Preparedness 2014

7

infectioncontroltoday.com

standards of care; emergency privileging and cross-training of healthcare workers, volunteers, and other persons willing and able to care for our patients, a temporary and substantially changed workforce would be expected to emerge.” Currently developing metrics to help guide PPE stockpiling decisions is Eric Toner, MD, senior associate with the UPMC Center for Health Security. “Stockpiling and utilization issues are tough problems and I sympathize with healthcare administrators and accountants because if your job is to balance the ledgers, how do you begin to know what value to place on a possible pandemic event, the probability of which is indeterminate,” Toner says.

Estimating of the Cost of Hospital Preparedness Toner and Waldhorn (2006) say that the average hospital (164 beds) will require an initial infusion of approximately $1 million for minimal preparedness. Component costs to achieve minimal preparedness: Develop specific pandemic plan

Staff education/ training

Stockpile minimal PPE

Stockpile basic supplies

$200,000

$160,000

$400,000

$240,000

“You can accept the fact that a pandemic can be severe but you just don’t know when or if it will happen, and if your job is to budget for the hospital, it is really challenging to do so. There is no current methodology for actually calculating how much stockpiling is necessary, and so we are working on a project right now to come up with metrics for those kinds of calculations.”

Stockpiling and Surge Capacity During a Pandemic A word about stockpiling is in order. The CDC recommends that healthcare facilities consider stockpiling enough consumable and durable supplies for the duration of a pandemic wave, estimated to be between six and eight weeks. A pandemic could occur in multiple waves as it did in the 1918 “Spanish Flu” which occurred in three waves. In the event of an outbreak, worldwide demand for medical products will most likely escalate and global supply will be stressed. The World Health Organization (2006) says that due to the global “just-in-time” inventory system that many hospitals employ, stockpiling these items now and increasing par levels is the best method of insuring that your facility will have the necessary resources in the event of a large scale patient surge. Experts agree that during a pandemic it will be critical to limit nosocomial spread of the virus to protect healthcare workers, prevent the hospital from being a disease amplifier

Infection Control Today • Pandemic Preparedness 2014

8

infectioncontroltoday.com

and protect non-flu patients from infection. During a pandemic, health systems will be overwhelmed and will most likely be understaffed. Employing strict infection prevention and control precautions will help prevent the pandemic from spreading in the facility. The following is a list of some of the medical supplies that the CDC recommends hospitals consider stockpiling:  Hand hygiene supplies (antimicrobial soap and alcohol-based, waterless hand hygiene products) Disposable N95 respirators, surgical and procedure masks  Face shields (disposable or reusable)  Gowns  Gloves  Facial tissue  Central line kits  Surface disinfectants  Ventilators  Respiratory care equipment  Beds  IV pumps Estimating the impact of a pandemic on a hospital’s surge capacity is critical to planning efforts. The U.S. Department of Health and Human Services (HHS) has developed planning assumptions based on a mild to moderate pandemic like the 1968 pandemic, or a more severe pandemic like 1918. Based on initial estimates, even a mild pandemic would overwhelm many hospitals that already operate close to capacity. Using these assumptions, the CDC has released FluSurge 2.0, a spreadsheet-based model which helps facilities and public health officials estimate the surge in demand for hospital-based services during a potential influenza pandemic. FluSurge estimates the number of hospitalizations and deaths and compares the number of persons requiring ICU care and ventilator support with existing hospital capacity information. The calculations are based on a number of variables and assumptions that can be altered by the user. To download FluSurge, visit: www.pandemicflu.gov/plan/tools.html. The CDC says that healthcare facilities should take a multi-layered approach when designing a strategy to reduce exposure of healthcare personnel and patients to influenza and prevent influenza transmission within healthcare settings. The CDC outlines the following four ways of conserving respirators:  Minimize the number of individuals who need to use respiratory protection through the use of engineering and administrative controls  Use alternatives to disposable N95 respirators where feasible (alternatives include other NIOSH-certified N-, R-, or P-class respirators, as well as re-useable elastomeric respirators and powered air purifying respirators)

Infection Control Today • Pandemic Preparedness 2014

9

infectioncontroltoday.com

 Extend the use, and consider reuse of disposable N95 respirators  Prioritize the use of N95 respirators for those personnel at highest risk of exposure Materials management professionals say that in estimating your PPE needs, you may want to consider factors that would be present during a pandemic such as an increased number of employees and/or volunteers donning PPE, a higher level of infection control precautions observed, and an increased use of respirators. Regarding storage of PPE supplies, based on your facility’s available storage onsite, you may need to consider working with your distributor partner or renting a storage facility that will provide you quick access to your supply when needed. Depending on the particular supplies being stockpiled, your facility will also need to consider a system to rotate the inventory to ensure product is not expired when needed. Hospitals should be cultivating strong relationships with their PPE suppliers, including developing a contingency plan that addresses how potentially limited medical supplies will be distributed among manufacturers’ customers; ensure that suppliers complete and maintain a Business Pandemic Influenza Planning Checklist established by the U.S. government; ensure that relationships with multiple suppliers are cultivated in dispersed geographical areas in case manufacturers’ operations are interrupted by a pandemic; re-evaluate inventory levels regularly to stay on top of fluctuating demand; ensure that all supplier contracts contain a Force Majeure clause that specifically addresses a pandemic. AHRMM’s schematic, “Stages of Preparedness Level for Materials Managers Related to Pandemic Influenza Levels,” is a good tool that hospitals can use to help determine their materials management efforts during a pandemic scenario:  Interpandemic (WHO phases 1-3): Maintain normal supply level, stay in close contact with distribution channel for planning, obtain a copy of the distributor’s disaster plan to ensure supply lines to the customers, and do not hoard supplies.  Pandemic Alert (WHO Phase 4): Increase in flu patients will place pressure on supplies within medical facilities, increase supply quantities accordingly, and do not hoard supplies.  Pandemic (WHO Phases 4-6): Continue to increase purchases and frequency to handle the increased volume without hoarding, realize that this may last four to eight weeks.  Post-Peak: Supply levels should level off with patient activity.  Post-Pandemic: Supply levels should taper down with decreased patient activity.

Prioritizing the Use of PPE PPE must be prioritized when supplies are limited in healthcare institutions during a pandemic. The APIC position paper, “Extending the Use and/or Reusing Respiratory Protection in Healthcare Settings During Disasters (Rebmann, et al., 2009) indicates that healthcare institutions should prioritize allocation of N95 respirators and masks based on exposure risk: “If respirator/mask supplies are scarce or insufficient even after the facility has obtained additional supplies from local, regional, or national sources, examined the

Infection Control Today • Pandemic Preparedness 2014

10

infectioncontroltoday.com

feasibility of reusable respirators (PAPRs, elastomeric respirators, etc.), and implemented extended use and/or reuse procedures, protocols should be followed to prioritize healthcare personnel to receive respirators/masks based on their exposure risk; exposure risk should be determined based on the healthcare facility’s exposure risk analysis that is part of emergency management planning, including personnel’s immune status.” The APIC position paper (2009) makes the following recommendations:

1 Facilities should maintain a reserve stock of respirators/masks that will be used during aerosol-generating procedures and/or with patients who are known or suspected of being infected with an airborne microorganism, such as Mycobacterium tuberculosis. Consider a contingency plan wherein reusable respiratory protection, such as PAPRs, is\ available for personnel who need to care for those with suspected or active TB disease.

Protocols should be followed to prioritize healthcare personnel to receive respirators/ masks based on their exposure risk.”

2 Airborne-transmitted diseases: Priority for respirator use should be given to healthcare workers providing care for patients with obligate and preferential airborne-transmitted diseases, such as active tuberculosis disease.

3 Aerosol-generating procedures: Priority for respirator use should be given to healthcare personnel performing aerosol-generating procedures. During disasters involving an airborne spread disease, aerosol-generating procedures should only be performed by staff wearing an N95 respirator or other respiratory protection that is at least as protective as an N95 respirator. If the healthcare facility is completely out of respirators (disposable or reusable) and aerosol-generating procedures must be performed on a patient with an airborne spread disease, the healthcare personnel involved in the procedure should wear a surgical/ procedure mask. Use of a surgical/procedure mask in this type of dire situation is preferable to using no facial protection at all. It is important to note that this scenario should not occur; healthcare facilities should use contingency planning to ensure they have adequate respiratory protection supplies for staff by obtaining additional respirators, utilizing reusable respirators, extending the use and/or reusing disposable respirators, and implementing control measures (such as vaccinating personnel) to decrease the need for respirators. In addition, healthcare personnel in this situation should follow infection prevention strategies to decrease their risk of infection, including following Standard Precautions and performing hand hygiene.

4 Healthcare personnel at risk of infectious complications: Allocating limited supplies of respirators should be prioritized for healthcare staff who are at greatest risk from complications of infections. The risk analysis will vary from event to event, depending on the infectious agent involved, but should include assessing the task being performed in terms of the duration and intensity of the encounter (i.e., personnel exposure risk), personnel immune/ vaccination status, and personnel health status that may affect their risk of infection (such as being immunocompromised, etc.)

Infection Control Today • Pandemic Preparedness 2014

11

infectioncontroltoday.com

5 Healthcare staff who are not in the high-exposure/priority groups (i.e., those who are not assigned to care for patients who are known or suspected of being infected with an airborne transmissible disease, involved in routine patient care that does not involve aerosolgenerating procedures, and/or those who do not meet the criteria for being at high risk of complicated infection) should be provided with FDA-cleared surgical/procedure masks. Switching to an FDA-cleared surgical/procedure mask for healthcare staff who are not in the high-exposure/priority groups during prioritized respirator use mode is considered a temporary measure only. Every effort should be made to obtain additional respirators as soon as possible.

6 If the facility is unable to obtain or conserve N95 respirators per the prioritized respirator use protocols and/or supplies of N95 respirators are depleted despite conservation efforts:  Surgical/procedure masks can provide benefits against large droplet exposure, and should be worn by healthcare personnel when providing care to patients who have signs/ symptoms of a respiratory illness.17 In time of such dire shortages, they should be used in order to reduce exposure potential.  Select surgical/procedure masks that can be tied tightly or have elastic straps (not ear loop masks that do not form a seal)  Disposable surgical/procedure masks should fit the user’s face tightly and be discarded immediately after use. If the mask gets wet or dirty with secretions, it must be changed immediately  Perform hand hygiene before and after touching/handling the mask

7 If supplies of surgical/procedure masks are insufficient or unavailable:  If supplies of FDA-cleared healthcare surgical/procedure masks become depleted:  Consider the use of full face shields that protect the wearer’s eyes and mouth for staff who have been immunized against the specific agent involved in the infectious disease disaster rather than having them use a respiratory protective device when caring for a patient who is known to be infected with the agent involved in the infectious disease disaster. This will help conserve the supply of\ respirators/masks for personnel at high risk from complications of infection (i.e., non-immunized personnel).  Respirators that are FDA-cleared for general public use during public health emergencies can be used in healthcare settings, but do not provide the same level of protection as N95 or higher level respirators; it is not known if FDA-cleared respirators are more protective than FDA-cleared surgical/procedure masks. Respirators that are FDA-cleared for general public use during public health emergencies should only be used in healthcare settings in dire circumstances. All other efforts at conserving and obtaining NIOSH-certified respirators or FDA-cleared surgical/procedure masks should be made before proceeding with this type of respirator in healthcare settings.  Controversies exist regarding how to proceed when supplies of disposable N95 or higher level respirators, FDA-cleared healthcare surgical/procedure masks, and masks/ respirators that are FDA-cleared for general public use during public health emergencies are depleted/unavailable.

Infection Control Today • Pandemic Preparedness 2014

12

infectioncontroltoday.com

Reusing Masks During a Pandemic The Institute of Medicine (2006) says that in the event of an influenza pandemic, public health officials will need to resort to multiple measures to reduce the impact: “If effective vaccines and anti-viral medications do not exist or are not available in adequate quantities during a pandemic situation, respirators and medical masks could help prevent or slow influenza transmission. Non-pharmacological interventions (e.g., hand hygiene, social distancing, and respiratory hygiene/cough etiquette, including the use of masks by the public) will also play a critical role in pandemic preventive strategies. Stockpiling or ramping up production of respirators and medical masks, in addition to adequate time and planning, would ensure a plentiful supply for those who need them, but it is possible that not enough masks and respirators will be available for healthcare workers and the general public. A shortage may require that disposable respirators and medical masks be pushed beyond their approved uses in the hope that they will provide some level of protection beyond their intended limits of use. Individuals with no access to respirators or masks, even disposables, may feel driven to invent their own measures. For example, they may put on woven masks not approved for medical uses Non-pharmacological in the United States, or use household items such as towels or sheets.” interventions (e.g., Based on the assumption that efforts to produce and stockpile sufficient hand hygiene, social supplies of disposable masks and/or respirators may fall short in the event of a pandemic, the Department of Health and Human Services asked the distancing, and Institute of Medicine (IOM) to assess what measures can be taken to permit respiratory hygiene/ the reuse of disposable N95 respirators in healthcare settings and assess what cough etiquette, is known about the need for reusable face masks for healthcare providers including the use of and the general public. The resulting report, “Reusability of Facemasks masks by the public) During an Influenza Pandemic: Facing the Flu,” concluded that very little is currently known regarding the potential to disinfect and reuse either medical will also play a critical masks or respirators. Fundamental research, both in the epidemiology of role in pandemic influenza and in the material properties of medical masks and respirators, preventive strategies. is needed before methods of disinfection and reuse can be developed. In spite of that lack of research, the committee was able to develop a method of use that may allow for extended use of an N95 respirator. (IOM, 2006) It’s important to understand the differences in respiratory protection. As the IOM report (2006) explains: “Medical masks are unfitted devices intended to reduce transfer of potentially infectious bodily fluids between individuals and are designed to be disposable. In contrast, a respirator is a fitted device that protects the wearer against inhaling harmful contamination: that is, it protects the wearer from others who are or might be infected. Properly fitted respirators provide better protection against airborne transmission of infection than do medical masks. In addition, some respirators can be reusable. However, the less expensive and more common respirators, called “N95 filtering face piece respirators,” or more simply “N95 respirators,” are designed to be disposable. N95 respirators that are

Infection Control Today • Pandemic Preparedness 2014

13

infectioncontroltoday.com

certified by the National Institute for Occupational Safety and Health and properly fitted are likely to provide the best protection against airborne influenza virus. Similarly, a closely fitting high-efficiency medical mask is also likely to provide appropriate protection against infectious fluids. Although not much is known about the effectiveness of medical masks as a form of respiratory protection against influenza, they are likely to provide better protection than woven masks, homemade alternatives such as handkerchiefs and scarves, or no protection at all. It is important to remember that no device is failsafe and effectiveness depends on fit, level of exposures, and appropriate use. Finally, none of these devices protect against contact transmission, and appropriate hand hygiene is necessary when using and after removing these devices.” Medical masks are The UPMC Center for Health Security’s expert, Eric Toner, MD, unfitted devices acknowledges the politically charged nature of the issue. “The official guidance from the CDC and NIOSH has to be very conservative, as intended to reduce they cannot go out on a limb and say something that is not based on transfer of potentially absolute solid science,” Toner says. “So they must say that you can’t infectious bodily fluids reuse masks, or you must change them very frequently, but there may be between individuals some reason to think that perhaps you can use masks for longer periods and are designed of time, or perhaps you can reuse some masks, and perhaps you can even sterilize the mask — but all of that is somewhat controversial and to be disposable. In will never, in my view, make it into official guidance. But in the event contrast, a respirator of a severe pandemic, people will reuse masks and change them less is a fitted device that frequently, and maybe that’s OK. But the official guidance has to be protects the wearer overly conservative.” against inhaling harmful Toner adds, “The things we have learned over the course of the last eight years or so is that, in most circumstances with most respiratory contamination pathogens, a simple surgical mask provides a high degree of protection. Does it provide complete protection? Does it provide as much protection as an N95 or PAPR? No. But in most medical settings — and clearly this is true with SARs, seems to be true with MERS, and is true with various flu viruses — a surgical mask does seem to provide sufficient protection in most circumstances. So there is a lot of controversy and a lot of hand-wringing over the issue of N95s — I think at this point it’s very reasonable to say N95s or better should be used in aerosol-generating procedures, but for most other settings, it’s probably true that a surgical mask is sufficient.” The IOM report (2006) indicates that a properly fitted N95 respirator is likely to be both the least expensive and the most widely available respirator for protecting healthcare workers and the public against airborne infection. However, without manufacturing modifications, disposable N95 respirators cannot be effectively cleaned or disinfected and should therefore be discarded after each use. In addition, the need for fit-testing respirators is critical and must be an integral part of any program that promotes their use. The IOM report (2006) also found that:

Infection Control Today • Pandemic Preparedness 2014

14

infectioncontroltoday.com

 There are no simple modifications to the manufacturing process The IOM report that would permit disposable N95 respirators to be reused without (2006) indicates that increasing the likelihood of infection. a properly fitted N95  Any method of decontaminating a disposable N95 respirator must respirator is likely remove the viral threat, be harmless to the user, and not destroy any part to be both the least of the respirator. The committee found no method of decontamination that met all three criteria. expensive and the  There are no simple modifications to currently existing N95 respirators most widely available that would prevent the need for fit-testing. respirator for protecting  Many versions of reusable respirators on the market have face pieces healthcare workers that can be cleaned and reused. These respirators are more expensive and the public against than the disposable N95 respirators, but should be considered as an alternative to filtering face pieces. airborne infection. Despite these findings about the constraints of reuse, if an individual user needs to reuse his or her own disposable N95 respirator, it should be done in the following manner, according to the IOM report (2006):  Protect the respirator from external surface contamination when there is a high risk of exposure to influenza (i.e., by placing a medical mask or cleanable face shield over the respirator so as to prevent surface contamination but not compromise the device’s fit).  Use and store the respirator in such a way that the physical integrity and efficacy of the respirator will not be altered.  Practice appropriate hand-hygiene before and after removal of both the respirator and, if necessary and possible, appropriately disinfect the object used to shield it. The IOM report (2006) adds, “Medical masks are made of materials that are likely to degrade with standard means of disinfection (e.g., chemicals, heat, radiation) and are intended for disposal after use. However, several disposable masks currently on the market can be used repeatedly by the same wearer until they become damaged, moist, difficult to breathe through while wearing, or visibly soiled. In addition, because reuse of the same device by infected patients is unlikely to increase the risk of contamination, medical masks can be reused by patients until they reach this state. Any method of decontaminating a medical mask must remove the viral threat, be harmless to the user, and not compromise the integrity of the various elements of the mask (e.g., tear or deform the filter, stretch the elastic attachments, bend the nose clip). No validated method of decontamination meets these criteria. Regulatory standards require that a medical mask should not permit blood or other potentially infectious fluids to pass through to or reach the wearer’s skin, mouth, or other mucous membranes under normal conditions of use and for the duration of use. It is not clear that cloth masks or improvised masks (e.g., towels, sheets) can meet these standards. Without better testing and more research, cloth masks or improvised masks can not be recommended as effective respiratory protective devices or as devices that

Infection Control Today • Pandemic Preparedness 2014

15

infectioncontroltoday.com

would prevent exposure to splashes. However, these masks and improvised devices may be the only option available for some individuals during a pandemic. Given the lack of data about the effectiveness of these devices in blocking influenza transmission, the committee hesitates to discourage their use but cautions that they are not likely to be as protective as medical masks or respirators. The committee is concerned that their use may give users a false sense of protection that will encourage risk-taking and/or decrease attention to other hygiene measures.” The APIC position paper, “Extending the Use and/or Reusing Respiratory Protection in Healthcare Settings During Disasters (Rebmann, et al. 2009) outlines recommendations for extending the use and/or reusing respirators. Rebmann, et al. (2009) point to a 2005 MMWR report (CDC, 2005) noting that disposable N-95 respirators, when used solely to prevent occupational exposure to Mycobacterium tuberculosis, can be safely reused until contaminated, damaged, or no Several disposable masks longer form a good seal and add, “Unlike Mycobacterium tuberculosis, which is transmitted exclusively via airborne droplet nuclei, most other currently on the market respiratory pathogens are transmitted primarily via direct and indirect can be used repeatedly (droplet) contact with respiratory secretions. Therefore the exterior by the same wearer until of respiratory protection used in caring for patients with respiratory they become damaged, pathogens other than tuberculosis can become contaminated and moist, difficult to breathe serve as a reservoir for infectious agents. Special precautions must be taken when extending the use or reusing disposable respiratory through while wearing, or protection to prevent healthcare personnel exposure.” visibly soiled. The APIC position paper (2009) defines the extended use of respiratory protection is defined as the wearing of a disposable respirator during serial patient encounters without the removal or re-donning of the device between encounters, and that reuse of respiratory protection consists of removing and re-donning the device between encounters. As Rebmann, et al. (2009) underscore, “Both of these actions pose a transmission risk to healthcare personnel due to potential respirator contamination. This transmission risk can be minimized if healthcare personnel adhere stringently to hand hygiene before and after handling the respiratory protection device.” The APIC position paper (2009) concedes that if respiratory protection supplies are limited in a pandemic scenario, healthcare organizations should conserve supplies as follows:

1 Strongly encourage healthcare personnel to be vaccinated against the agent involved in the infectious disease disaster (such as influenza vaccine during an influenza pandemic), when such vaccine is available. This will create an immunized cadre of healthcare personnel for whom respiratory protection will be less critical. 2 Extending the use or reusing respiratory protection is preferred over prioritizing the allocation of N95 respirators and surgical/procedure masks based on exposure risk

Infection Control Today • Pandemic Preparedness 2014

16

infectioncontroltoday.com

3 Extended use is preferred over reuse Practices for extending the use and/or reusing a respirator:  The respirator should only be worn and/or reused by a single wearer  The respirator should not be removed, adjusted, or touched during patient care activities  Avoid contamination during use by not touching the outside of the respirator  Care should be taken to prevent touching the inside of the respirator  The respirator should be discarded after being used during an aerosol-generating procedure  The respirator should be discarded if it becomes grossly contaminated with the patient’s body fluids, including blood or respiratory secretions. Note: this may be difficult for the wearer to discern. Healthcare personnel should be aware that even if not visibly soiled, the external surface of the respirator is considered to be contaminated  The respirator must be discarded if it becomes obviously soiled or damaged (e.g., creased, torn, or saturated) or if breathing through the device becomes difficult  Consider using a surgical/procedure mask or face shield over the respirator to reduce/ prevent contamination of the device. If masks are also in short supply, face shield use should be encouraged to help conserve masks  Care should be taken during removal of the mask or face shield to ensure the respirator is not contaminated  The surgical/procedure mask must be discarded after a single use. If reusable, the face shield must be decontaminated between uses  Hand hygiene should be performed after removing the face shield or mask and before removing the respirator  Perform hand hygiene before and after handling/touching the respirator In addition, the APIC position paper (2009) says the following recommendations should also be followed when reusing a respirator:  The respirator should be removed carefully to avoid cross-contamination  Personnel should be instructed to use hand hygiene after putting the respirator on and following removal/placement in a storage location  The respirator should be stored in a clean, dry location that prevents it from becoming contaminated and maintains its physical and functional integrity  Store the respirator in a breathable container, such as a paper bag, or hang the respirator in a designated area If the respirator is to be stored in a container, the container/bag should be labeled with the user’s name. The container/bag is a single use item because the inside can become contaminated due to storing a used respirator; therefore, the container/bag should be discarded after the respirator is re-donned.  Consider labeling the respirator with the user’s name to prevent staff from reusing another’s respirator; labeling should be written on the straps whenever feasible to prevent damage to the respirator

Infection Control Today • Pandemic Preparedness 2014

17

infectioncontroltoday.com

 The respirator should be inspected before each use to ensure its physical integrity is intact and a seal-check should be performed by the healthcare personnel to ensure an adequate fit  Respirators that are damaged or cannot achieve an adequate fit during the seal check should be discarded

The best respirator or medical mask will do little to protect the individual who refuses, or who misunderstands how and when to use it correctly.

The bottom line here may be best summarized by the IOM report (2006): “Many factors will influence the effectiveness of respiratory protection used by healthcare workers and the public to slow or prevent infection in the event of an influenza pandemic. Experience with previous efforts to improve infection control in the hospital and elsewhere have demonstrated that the efficacy of an intervention alone does not guarantee its success. The best respirator or medical mask will do little to protect the individual who refuses, or who misunderstands how and when, to use it correctly. Any public health effort aimed at extending the usefulness of existing devices must be delivered with clarity and truthfulness and proper education.”

H1N1 PPE Guidance: Confusion and Controversy The H1N1 pandemic of 2009 exposed not only some hospitals’ lack of preparedness, but created a significant amount of confusion and controversy regarding PPE guidance. The Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), and Association of Professionals in Infection Control and Epidemiology (APIC) expressed significant concern with the federal guidance concerning the use of PPE by healthcare workers in treating suspected or confirmed cases of H1N1 influenza. These organizations contend that the federal PPE guidance and requirements do not reflect the best available scientific evidence, which demonstrates that N95 respirators are not superior to surgical masks in the prevention of transmission of influenza in most patient-care settings. In fact, Lautenbach et al. (2010) reported on a survey of healthcare epidemiologists, administrators, and other members of SHEA in May 2009 found that 19.3 percent of respondents strongly agreed and 52.7 percent agreed that “the recommendation for airborne precautions for suspected H1N1 cases was appropriate at the beginning of the H1N1 crisis” at his or her institution. When asked whether airborne precautions for suspected cases were appropriate throughout the H1N1 crisis, 7.5 percent strongly agreed and 17.5 percent agreed. Supplies of N95s were a concern with some respondents; 16.9 percent disagreed and 8.8 percent strongly disagreed with the statement that “N95 masks were readily available throughout the H1N1 crisis at my institution.” As Larson and Liverman (2011) explain, “The arrival of novel H1N1 influenza A in 2009 was accompanied by a number of policy questions relevant to PPE. The lack of precise information about the modes of influenza transmission, the contagiousness, the virulence of novel H1N1 influenza A, the at-risk population, and the efficacy of different devices in preventing transmission led to a variety of recommendations at different times by federal

Infection Control Today • Pandemic Preparedness 2014

18

infectioncontroltoday.com

and local government public health agencies. Delayed and/or disparate recommendations often led to confusion among healthcare personnel and their employers, who had to decide what to tell personnel about what type of PPE to wear and when. In addition, little research was available to guide health system officials in making decisions about the quantities of various types of PPE needed to protect their workforce. A major problem encountered was a slow response in tailoring recommendations as more knowledge about virulence and affected populations became available.” Larson and Liverman (2011) say that during the initial phase of the 2009 H1N1 influenza pandemic, infection control guidelines from some of the major public health organizations did not agree on respiratory protection needed by healthcare workers: “The World Health Organization (WHO) recommended standard and droplet precautions (including a face mask, a gown, gloves, eye protection, and hand hygiene) for those working in direct contact with patients, and additional precautions for aerosol-generating procedures, including wearing a facial particulate Larson and Liverman respirator. The WHO recommendations took into account the need for (2011) say that during sustainability in a variety of countries and encouraged each country to issue its own guidelines. CDC recommended a fit-tested, disposable the initial phase of the N95 respirator or better for healthcare personnel who enter the rooms 2009 H1N1 influenza of patients in isolation with suspected or confirmed novel H1N1 pandemic, infection influenza. For emergency medical responders, CDC recommended control guidelines from a fit tested, disposable N95 respirator for those personnel “who are some of the major public in close contact” with patients with confirmed or suspected 2009 H1N1, for personnel ‘engaged in aerosol generating activities,’ and health organizations did for personnel involved in the ‘interfacility transfer’ of patients with not agree on respiratory suspected or confirmed 2009 H1N1.”

Making the Case for Pandemic Preparedness

protection needed by healthcare workers.

Toner and Waldhorn (2006) make a sound argument for pandemic preparedness: “Thirty influenza pandemics have occurred in the past 400 years—three in the past century. There is consensus that the next pandemic is not far off. The threat of an influenza pandemic has caused worldwide concern and stimulated international, national, and local planning and preparedness efforts. Without adequate supplies of an effective vaccine, most planning has focused on how to contain a pandemic at its source and limit or slow its spread in a community. But these containment measures will likely be of only limited usefulness in an influenza pandemic where disease may be spread by people even before they have symptoms. In the event of a 1918-scale flu pandemic, hospitals would be flooded with sick patients seeking care. The impact of an influenza pandemic on hospitals is expected to be severe in the best of circumstances. Currently, U.S. hospitals routinely operate at or near full capacity and have limited ability

Infection Control Today • Pandemic Preparedness 2014

19

infectioncontroltoday.com

to rapidly increase services. There are shortages of healthcare workers Thirty influenza of all kinds. Emergency departments are overcrowded and often have pandemics have to divert patients to other hospitals. In recent years, there has been a occurred in the past reduction in the overall number of hospitals, hospital beds, and emergency 400 years—three in rooms. During an epidemic, the healthcare work force would be greatly the past century. There reduced. Healthcare workers would face a high risk of infection because of contact with infected patients, and, in the absence of vaccine, they is consensus that the might fear coming to work lest they bring a lethal infection home to next pandemic is not their families. Many would need to stay home to care for sick children far off. or relatives. The provision of medical services to non-flu patients would be adversely affected in most communities. Toner and Waldhorn (2006) define preparedness as “Every hospital, in collaboration with other hospitals and with public health agencies, will be able to provide appropriate care to flu victims requiring hospitalization while maintaining other essential medical services in the community, both during and after a pandemic.” They add that this definition recognizes that what constitutes “appropriate care” and the criteria for hospital admission may well change during a pandemic. Three years before the H1N1 pandemic, Toner and Waldhorn (2006) offered recommendations on what hospitals should do to prepare for an influenza pandemic. For their paper, they analyzed the consequences of a flu pandemic, reviewed many existing hospital plans, studied the federal government’s recommendations, and cultivated perspectives from leaders in healthcare, public health, and emergency management. They propose specific actions and priorities for the purpose of making the discussion of hospital pandemic preparedness issues more operationally useful. They outline the following priorities:

 Comprehensive and realistic planning based on actual HHS FluSurge projections within each hospital, and collaborative planning among all hospitals in a region  Limiting the nosocomial spread of the virus to: (a) protect the healthcare workers and thus maintain a sufficient hospital workforce, (b) prevent the hospital from being a disease amplifier, and (c) protect the non-flu patients from infection, so as to maintain the ability to provide essential non-flu healthcare  Maintaining, augmenting, and stretching the hospital workforce  Allocating limited healthcare resources in a rational, ethical, and organized way to do the greatest good for the greatest number of people To implement these goals, Toner and Waldhorn (2006) suggest the following actions:

1 To achieve comprehensive and realistic planning for pandemic influenza, hospitals should:  Employ a full-time disaster coordinator in each hospital.  Create a pandemic preparedness committee (or use an existing disaster preparedness committee) that includes representatives of all clinical and support departments as well as senior administration.

Infection Control Today • Pandemic Preparedness 2014

20

infectioncontroltoday.com

 Participate in a regional hospital coordinating group that includes neighboring hospitals, local public health officials, and emergency management personnel. Create mutual aid memoranda of understanding. If your hospital is already a member of a multihospital health system, integrate systemwide planning with local planning with other local hospitals.  Use the CDC’s FluSurge 2.0 and HHS planning assumptions to guide planning for both a moderate and a severe pandemic. Note that the default assumptions in FluSurge are based on a 1968-like pandemic. To model a severe pandemic, FluSurge allows the assumed number of hospitalizations to be modified to correspond to the HHS planning assumptions for a severe pandemic.  Be able to make 30 percent of licensed bed capacity available for flu patients on one week’s notice. About 10 percent to 20 percent of a hospital’s bed capacity can be mobilized within a few hours by expediting discharges, using discharge holding areas, converting single rooms to double rooms, and opening closed areas, provided staff is available. Another 10 percent can be made available within a few days by the conversion of “flat spaces” such as waiting areas.  Collaborate in regional plans to be able to make 200% of licensed bed capacity in the region available for flu patients on 2 weeks’ notice. This is the number of beds that would be necessary to accommodate the surge of patients predicted for a severe 1918-like scenario according to FluSurge software and HHS planning assumptions. 2 To limit the nosocomial spread of the virus during an influenza pandemic, hospitals should:  Limit accidental droplet contamination of the hospital environment by implementing respiratory etiquette and by having everyone entering the facility use simple surgical masks. Assuming that resupply may be difficult during a pandemic, hospitals should stockpile enough masks for three weeks.  Prevent staff involved in direct patient care from getting infected by training healthcare workers on the use of personal protective equipment (PPE) and infection control procedures. Fit-tested N95 respirators should be used in aerosol-generating procedures, in cardiopulmonary resuscitation, and in situations that call for repeated direct contact with patients with influenza or pneumonia, and it is prudent to use them for other direct patient care activities. Shortages of N95 masks should be anticipated, so they should be stockpiled and their use monitored in real time. If no other masks are available, surgical masks, which will provide droplet protection, should be used. Powered air purifying respirators (PAPRs) should be available for use in highrisk aerosol-generating procedures.  Limit the number of staff who are exposed to flu patients by assigning them to a “cohort”—that is, grouping patients by the likelihood that they have flu and assigning staff dedicated to each patient group. Use overtime and long shifts for staff in the flu units to limit the number of staff needed. When possible, use staff who are immune (vaccinated or recovered) in the flu units.

Infection Control Today • Pandemic Preparedness 2014

21

infectioncontroltoday.com

 Prevent infected staff from working (except with flu patients) by Currently, U.S. tracking staff who are sick and testing for flu and keeping a log of staff hospitals routinely who have had confirmed flu or have been vaccinated. operate at or near full 3 To maintain, augment, and stretch the hospital workforce in the capacity and have event of an influenza pandemic, hospitals should: limited ability to rapidly  Minimize the duration of illness in staff by making rapid testing (if available and reliable) for influenza available to staff 24/7 and initiating increase services. antiviral treatment within six hours after onset of symptoms.  Using screened volunteers, organize in-home childcare for well children of healthcare workers if schools are closed.  Provide medical daycare for sick family members.  Allay fear through open, honest, and transparent planning and careful training.  Shift clinical staff to highest need areas from areas that may be closed or quiet, employing “just in time” education (i.e., training staff “on the job” in new procedures) and pairing staff new to an area with more experienced staff.  Augment clinical staff with nontraditional personnel, employing “just in time” education.  Coordinate with other hospitals in the region on plans to recruit and use volunteers. 4 Hospitals will need to allocate limited healthcare resources in a rational, ethical, and organized way so as to do the greatest good for the greatest number of people. This can be done by deferring nonemergency care and, if necessary, instituting alternative patient care routines. Hospitals should:  Prioritize which services and types of procedures can be deferred, for how long, and with what consequences, and create an alternative plan for patients who will be deferred. Create a process for refining and updating this plan as circumstances change. Create a process to track patients whose services have been deferred.  Plan for the smooth alteration of patient care routines. In a severe pandemic, not all patients in need of intensive care will be able to be accommodated in the ICU. Normal staffing ratios and standard operating procedures will not be able to be maintained.  Plan for alternative sites to provide ICU-like care within the hospital, such as the catheterization lab, catheterization recovery, operating rooms, the post-anesthesia care unit, or the endoscopy unit.  Acknowledge that alterations in normal care routines will be justified when those routines cannot be maintained despite the use of all available resources including mutual aid arrangements. The legal and ethical frameworks for these decisions should be considered well in advance of a crisis. Alterations in hospital policy and procedures should be implemented by an active decision of the hospital leadership in consultation with the medical staff and civil authorities.  Create criteria and clinical guidelines for use (or denial) of resource-intensive services (e.g., admission, mechanical ventilation, invasive monitoring) based on national guidelines, in regional collaboration with other hospitals.

Infection Control Today • Pandemic Preparedness 2014

22

infectioncontroltoday.com

 Establish a process for triage of patients who are competing for limited resources, including admission, early discharge, and life support. These decisions should not be made by one person. The criteria used to make these decisions should be created in advance and formally sanctioned by the medical staff and hospital administration. Other actions that enhance hospital readiness include:  Improving hospital surveillance  Planning internal and external communications  Developing education and training  Expanding occupational health  Implementing a process to assure appropriate use of limited antivirals and vaccines  Anticipating supply and pharmaceutical needs  Planning excess morgue capacity

Addressing Apathy While the healthcare community’s last experience with an influenza pandemic came in 2009-2010 with the H1N1 virus, experts fear complacency can creep in and hamper a hospital’s state of readiness. The UPMC Center for Health Security’s expert, Eric Toner, MD, acknowledges a false sense of security that may build in between pandemics. “It is my general impression that except for a few hospitals whose ICUs were severely impacted by the 2009 pandemic, most hospitals got by without too much trouble and I think that has put a damper on the priority that hospitals had previously placed on pandemic preparedness,” Toner says. “Unfortunately, it seems like an event that impacts the individual hospital is what it takes to get people to take it seriously. In the absence of a lot of new funding, which is not It is my general impression likely in the foreseeable future, I think the event needs to be made that except for a few very real and it doesn’t seem to me that happens by watching events in Saudi Arabia or China. So I don’t know what kind of hospitals whose ICUs were an event — hopefully not a severe pandemic, but some sort of severely impacted by the infectious disease event — is probably what would be required to 2009 pandemic, most see change in how seriously people take pandemic preparedness.” hospitals got by without too What causes apathy toward pandemic preparedness is multimuch trouble and I think factorial, according to Toner. “One factor, surprisingly enough, is still a lack of knowledge among many healthcare workers about that has put a damper on what a severe pandemic would be like,” he says. “As amazing the priority that hospitals as that is, I talk to people with frequency who really don’t know had previously placed on what has happened in the past and what is possible with a severe pandemic preparedness.” strain of influenza. I think it’s also true that denial is a very powerful —Eric Toner, MD mechanism — it’s easy to think it’s not going to happen, or it’s

Infection Control Today • Pandemic Preparedness 2014

23

infectioncontroltoday.com

not going to happen to me. Another factor is simply the overwhelming challenges that people in healthcare are facing today. There is so much change going on and there are so many stressors that healthcare providers are experiencing right now, that they just can’t deal with another source of stress. Even if they were to recognize it as rational, they just can’t emotionally deal with it. Hopefully in a year or two after the dust settles following the Affordable Care Act and hospitals are not in such a state of turmoil, maybe healthcare professionals will have time to think about pandemic preparedness.”

Education and the Impact of IPs At the beginning of this report we looked at the simulation exercise conducted by British researchers. In their study Phin, et al. (2009) also There’s no magic bullet, took note of the exercise’s impact on infection control: “Infection but I do think persistent control teams wishing to assess the effect of their educational activity education does work, at and adequacy of their training are encouraged to use robust validated least with some people, end-points. This was not done during this simulation. Observers and participating staff were, however, encouraged to record their and right now I think perceptions and experiences in order to inform future staff training. that’s the best we can Overall, observers felt that while staff had a good grasp of basic do, keep the issue alive, infection control precautions they were unsure about the additional keep talking about it, measures recommended in the pandemic situation, despite training in and do what you can.” the two weeks preceding the exercise. Uncertainty was also evident in participating staff as ICN observers occasionally gave conflicting advice, —Eric Toner, MD suggesting that interpretation of the guidance by specialists was not uniform. One-off infection control training is unlikely to be sufficient, and, during WHO’s pandemic schematic Phases 4 and 5, more sustained efforts will be needed to ensure that staff are adequately trained.” As Toner emphasizes, “It’s a marathon, it’s not a race, and I think infection preventionists (IPs) need to continue to have regular in-services, invite guest speakers to their hospitals, work with local public health experts, have grand rounds on the topic and keep educating healthcare workers. There’s no magic bullet, but I do think persistent education does work, at least with some people, and right now I think that’s the best we can do, keep the issue alive, keep talking about it, and do what you can.”

Infection Control Today • Pandemic Preparedness 2014

24

infectioncontroltoday.com

References AHRMM. Pandemic Flu Preparedness and Update (slide show). April 30, 2009. Centers for Disease Control and Prevention. (2009). Interim guidance on infection control measures for 2009 H1N1 influenza in healthcare settings, including protection of healthcare personnel. Accessible at: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm Centers for Disease Control and Prevention. (2009). Questions and answers regarding respiratory protection for infection control measures for 2009 H1N1 influenza among healthcare personnel. Accessible at: http://www.cdc.gov/h1n1flu/guidance/ill-hcp_qa.htm Centers for Disease Control and Prevention. (2005). Guidelines for the prevention of TB in healthcare settings. Morbidity and Mortality Weekly Report, 54(RR17), 1-141. Hashikura M and Kizu J. Stockpile of personal protective equipment in hospital settings: Preparedness for influenza pandemics. Am J Infect Control 2009;1-5. Institute of Medicine (IOM) of the National Academies. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu, Report Brief. April 2006. Larson EL and Liverman CT, editors. Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Workers: Update 2010. National Academies Press. 2011. Murray M, Grant J, Bryce E, Chilton P, Forrester L. 2010. Facial protective equipment, personnel, and pandemics: impact of the pandemic (H1N1) 2009 virus on personnel and use of facial protective equipment. Infect. Control Hosp. Epidemiol. 31:1011–1016. Phin NF, Rylands AJ, Allan J, Edwards C, Enstone JE, Nguyen-Van-Tam JS.Personal protective equipment in an influenza pandemic: a UK simulation exercise. J Hosp Infect. 2009 Jan;71(1):15-21. doi: 10.1016/j.jhin.2008.09.005. Epub 2008 Nov 17. Radonovich LJ, Magalian PD, Hollingsworth MK and Baracco G. Stockpiling Supplies for the Next Influenza Pandemic. Emerg Infect Dis. 2009 June; 15(6): e1. Rebmann T, et al. and the APIC Emergency Preparedness Committee, Public Policy Committee and Regulatory Review Panel. APIC Position Paper: Extending the Use and/or Reusing Respiratory Protection in Healthcare Settings During Disasters.

Infection Control Today • Pandemic Preparedness 2014

25

infectioncontroltoday.com

Rebmann T and Wagner W. Infection preventionists’ experience during the first months of the 2009 Novel H1N1 Influenza A pandemic. Am J Infect Control. Dec;37(10):e5-e16. 2009. Rebmann T, Wilson R, Bartley J and Stricof RL. Update on infection prevention in disaster planning: New resources and policies. American Journal of Infection Control, 37(3), 205-255. 2009. Swaminathan A, Martin R, Gamon S, Aboltins C, Athan E, Braitberg G, Catton MG, Cooley L, Dwyer DE, Edmonds D, Eisen DP, Hosking K, Hughes AJ, Johnson PD, Maclean AV, O’Reilly M, Peters SE, Stuart RL, Moran R, Grayson ML. Personal protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza. Emerg Infect Dis. 2007 Oct;13(10):1541-7. Toner E and Waldhorn R. What Hospitals Should Do to Prepare for an Influenza Pandemic and BioTerrorism: Biodefense Strategy, Practice and Science, Volume 4, Number 4, 2006. Toner E, Waldhorn R, Maldin B, et al. Hospital preparedness for pandemic influenza. Biosecur Bioterror 2006;4(2):207–217. U.S. Department of Health and Human Services. HHS Pandemic Influenza Plan. Available at: http:// www.hhs.gov/pandemicflu/plan/ World Health Organization Avian Influenza, Including Influenza A (H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities. Amended April 24, 2006.

Infection Control Today • Pandemic Preparedness 2014

26

infectioncontroltoday.com