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Full text of "Healthcare Worker PPE, March 2 - 3, 2010"

National Personal Protective 
Technology Laboratory 

HEALTHCARE WORKER UNIVERSAL 
PRECAUTIONS INTERFACES AND 
ASSOCIATED ISSUES 

Raymond Roberge, MD, MPH 
Research Medical Officer, NIOSH/NPPTL 



♦ 



March 2-3, 2010 



PROTECTIVE 

CLOTHING 
REQUIRED 



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UNIVERSAL PRECAUTIONS 



Universal Precautions refers to the practice, in 
medicine, of avoiding contact with patients' bodily 
fluids, by means of wearing of nonporous PPE such as 
gloves, gowns, respirators, surgical masks, goggles, 
and face shields. The assumption is that all bodily fluids 
are potentially infectious and must be so treated. 



Standard Precautions apply to 1) blood; 2) all body 
fluids, secretions, and excretions, except sweat, 
regardless of whether or not they contain visible blood; 
3) non-intact skin; and 4) mucous membranes. 



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EYEMERGING" INFECTIOUS DISEASES 



Under Occupational Health and Safety Act (OHSA) 
Standards 29CFR "masks in combination with eye 
protection devices, such as goggles, glasses with 
side shields or chin length face shields shall be worn 
whenever splashes, spray, splatters or droplets of 
blood or other infectious materials may be generated 
and eye, nose or mouth contamination can 
reasonably be anticipated." 

No definitive study to address ophthalmic exposure 
when the aforementioned mechanisms are absent 
but risk is considered minimal (Buckland and Tyrrell, 
1964) 

Affinity of ophthalmic receptors for various viruses 
may be important limiting factor for some pathogens 
(e.g., Avian influenza) N 

Nasolacrimal duct function is important for 
infectious agents w/o significant binding to 
ophthalmic receptors 




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HOW IMPORTANT IS FACIAL PROTECTION 

DURING SURGERY? 



50% of caesarean sections and 32% of 
vaginal deliveries associated with 
measurable contamination of the face 
shield surface that was not detected by the 
physician (Kouri and Ernest, 1993) 

Polycarb glasses worn by surgical team 
members were contaminated in 62% of 
orthopedic cases (Giachino etal, 1988) 

Face shield contamination was 
documented in 33% of facial 
dermatological surgical procedures (Birnie 
etal, 2007) 






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HEALTHCARE WORKER EYE PROTECTION 

COMPLIANCE/CONCERNS 

• 32% wore regular spectacles during surgery 
and 24% wore no eye covering of any kind 
(Akdumanetal, 1999) 

10% of emergency department and ICU staff 
reported never wearing eye protection (Bryce et 

• Reasons cited for lack of wear (Lombardi etal, 
2009; Greenland etal, 2007; Hutcheon, 2004): 

-lack of comfort/fit 

-fogging 

-scratching of eyewear 

-interference with medical procedures (e.g., 

fibreoptic intubation, operative loops, etc.) 

-claustrophobic sensations \ 




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HEALTHCARE WORKER EYE PROTECTION 



• Goggles, glasses, face shields, visors 



i i EmHf T / 

mm Hp^ *U^^^| TfM \ % -T 

Ml Mi 





(courlaa/ Jk'il) 





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EYE PROTECTION/RESPIRATORY PROTECTION 

INTERFACES 



r 




With permission - Canadiai 
J ournal of Anesthesiology 





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SURGICAL GLOVES 



The most used HCWPPE 

Helps prevent transmission of infectious 
agents 

Innovative uses: 

-increased grip when performing some 

procedures (e.g., shoulder reduction), 
-can be used as a tourniquet 
-can be used as an ice bag 
-can be used to make pediatric 

playthings (Mr. Fingerhead) 








ourtesy of Dermatology 
OnlineJ ournal 




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SURGICAL GLOVES - ISSUES 

Alter the sense of touch. 

Decrease agility with some delicate procedures. 

Size issues: 

-gloves that are too large for the individual allow finger 

slippage leading to decreased dexterity 

-gloves that are too small cause discomfort (decreased blood 

flow to fingertips; pulling on hand and digit hair) and constrain 

finger and hand movements 

Become entangled in some instruments 

Friction from gloves against the skin can make some procedures 
more difficult (e.g., inserting an IV) 

Allergy concerns (latex) 

Overuse can lead to decreased hand washing 



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GLOVE/SLEEVE INTERFACE 

"Roll Down" - slippage resulting from low 
frictional resistance between the glove inner 
surface and the gown sleeve increases risk of 
body fluid contamination. w 

"Channeling" - as a result of the glove being 
pulled over the sleeve, the sleeve is bunched 
up under the glove and forms channels along 
the wearer's wrist that may allow body fluids 
running down the outside of the sleeve to 
gain access to the interior of the glove. 

Taping may not be effective because the 
adhesives are subject to attack by water and 
body fluids. 





ZamorctfJ . X E. et al. CMAj 2006;175:249-254 
Courtesy of CMAJ 



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POWERED AIR-PURIFYING RESPIRATOR 

INTERFACES 



Visual interface- use of other concurrent eye 
protection 



Equipment interface- use of stethescope, 
ophthalmoscope, fibreoptic bronchoscope, etc 



• Dermal interface - use of shrouds 




With permission - Canadian 
J ournal of Anesthesiology 




Cuurlcsy uf iluUai d 



Zamora, J . E . et al. C MAJ 
2006;175:249-254 Courtesy of C MAJ 



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FFR PHYSIOLOGICAL 
INTERFACES 

• Phase I - N95 FFR and N95 FFR/EV vs Controls (no FFR) treadmill 
exercising at 1.7mph and 2.5 mph x 1 hr: 

• No significant differences in HT, V T , \A, Sa0 2 ,tcPCO 
controls versus FFR or FFR/EV at either work rate x one 
hour. 

• Slight increase (not statistically significant) in V T (range, 38 
mL - 148 mL) with respirator use 

No significant difference in mean mixed 
inhalation/exhalation V D resB CO, (2.86%, 2.92%[p=0.47]) and 



hour 

• tcPC02 increases (non-significant) were: 0.54/1.26 mm Hg at 
1.7/2.5 mph, respectively, for N95 FFR/EV, 1.22 mm Hg for 
N95 FFR at 2.5 mph and -.72 mm Hg at 1.7 mph for N95 FFR 
(2 subjects > 50 mm Hg) 

• No difference in comfort & exertion scores, or moisture 
retention 

• Roberge RJ , Coca A, Williams WJ , Powell J B, Palmiero AJ . (2010) Physiological impact ofN95 filtering facepiece 
respirator ("N95 Masks") use on healthcare workers. Respiratory Care (in press) 



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FFR/SURGICAL MASK PHYSIOLOGICAL 

INTERFACES 



Phase 2 - N95 FFR and N95 FFR/EV vs N95 FFR/SM and N95 
FFR/EV/EM treadmill exercising at 1.7mph and 2.5 mph x 1 hr: 

No significant differences for N95 FFR/SM and N95 FFR/EV/SM 
compared to standard models, for HR,f B , V T , V E , Sa0 2 xone 
hour. 

Compared with controls, significant decrease in V D resp oxygen 
levels with N95 FFR/SM at 1.7 mph (p=0.03) and for N95 
FFR/EV/SM at 2.5 mph (p=0.003). 

Two subjects had elevated tcPC02 levels (48,60) 

No significant differences in comfort & exertion scores, or 
moisture retention 



Roberge RJ , Coca A, Williams WJ , Palmiero AJ , Powell J B (2010) Surgical mask placement over N95 
filtering facepiece respirators: physiological effects on healthcare workers. Respirology (in press) 



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EAPR PHYSIOLOGICAL INTERFACES 



Phase 3 - elastomeric half facepiece air-purifying 
respirator vs control (no respirator) treadmill 
exercising at 1.7mph and 2.5 mph x 1 hr: 

No significant differences in HR, Sa0 2 , and tcPC0 2 x 
one hour compared with controls 

Significantly lower f B associated with elastomeric 
respirators at both work rates (p=0.02, p=0.03, 
respectively) 

Significant decrease in V T at 1.7 mph compared with 
controls (p=0.009) 

Half of subjects at each work rate had elevated tcPCO ; 
levels (*45 mm Hg) at the one hour 

No significant differences in comfort & exertion 
scores, and moisture retention. 




Roberge RJ , Coca A, Williams WJ , Powell J B, Palmiero AJ . (2010) Reusable 
elastomeric air-purifying respirators: physiological impact on healthcare wc 
American J ournal of Infection Control (in press) 



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FFR/SURGICAL MASK INTERFACE AND 
BREATHING RESISTANCE 



Human surrogate : breathing mannequin/headform (Smartman, 
ILC Dover, Frederic a, DE) attached to a Dynamic Breathing 
Machine (Warwick Technology, Ltd., Warwick, UK) that 
delivered sinusoidal breathing patterns at 25 L/min and 40 
L/min. 

• Room particle counts: 16,000 - 30,000 m 3 by aTSI Particle 



[crSTiT2rf?i i 



Respirators : N 10 SH -certified N95FFRS (3 replicates x 3 models; 
different manufacturers) were individually heat-glued to the 
mannequin and Protection Factors* (•100 @ 25 L/min) 
quantified by TSI Portacount Plus® particle optical density 
measurement. 

Breathinq resistance: Inhalation and exhalation breathinq 



resistance was measured with an m-lm 
Resistance Pressure Transducer Model DP45-24 (Validyne 
Engineering Corp, Northridge, CA) for 774 inhalations and 774 
total exhalations. 

Surgical mask overlay : a non-splash resistant, Type II surgical 
mask model (single manufacturer) was applied over the 
respirator and pressure measurements repeated and 
compared. 




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SURGICAL MASK-N95FFR COMBINATION: 
BREATHING RESISTANCE RESULTS SUMMARY 



Increases in Breathing Resistance 




N95FFR MODEL 


% inhalation resistance 
increase© 25 L/min 


% inhalation resistance 
increase @ 40 L/min 


% exhalation resistance 
increase© 25 L/min 


% exhalation resistance 
increase© 40L/min 


A 


10.09 


12.61 


12.30 


13.22 


B 


7.61 


8.99 


8.56 


9.58 


C 


4.60 


6.03 


5.79 


3.44 


Mean 


6.99 


8.70 


8.43 


9.48 




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RESPIRATOR MICROENVIRONMENT 

INTERFACE 

• OS HA workplace ambient air standard (respirator not 
factored into determination) 

- C0 2 <0.5% 

- 2 <L9.5% is considered deficient 

Mean Respirator Deadspace Gas Centrations After Treadmill Exercise X 1 hr 



espirator 




N95 FFR/EV/S 



ixed inhalati 

halation O 
oncentrati ~ 



16-63°/ 








lixed inhalatio 

exhalation CO : 
concentration 



[Z¥A 



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MOISTURE INTERFACE -AMBIENT HUMIDITY, 
SWEAT AND EXHALED MOISTURE 

• Test Procedure - Automated Breathing and Metabolic Simulator, 
and attached breathing mannequin with affixed N95 FFR, N95 
FFR/EV, and SN95 FFR (9 models, 45 respirators), programmed at 
100% humidity, 342 C exhaled air, 40 LPM breathing volume X four 
hours. Controls were the first five minutes of ABMS breathing. 
Ambient temp. 22.3 C, RH 40 - 60%. 

• Outcome measures: inhalation resistance, exhalation resistance, 

FFR moisture retention 

i 

• Results 
- mean inhalation resistance increase from -14.11 mm to -14.54 

mm H 2 pressure (increase of -0.43 mm) 
-mean exhalation resistance increase from 7.09 to 7.32 mm H 2 
pressure (increase of 0.23 mm) 

-mean moisture retention after 4 hours was 0.26 ml (-0.02% of total 
expired water vapor) 

-a significantly lower exhalation resistance was noted for N95 FFR 
compared with SN95 FFR after four hours {p=O.O0i7); otherwise, no 
significant differences were noted between FFR classes 

Roberge RJ , Bayer A, Powell J B, Coca A, Roberge MR, Benson SM: Effect of exhaled moisture on breathing 
resistance of filtering facepiece respirators. Ann Occup Hyg (under review) 



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Visit Us at: www.cdc.gov/niosh/npptl 

Disclaimer: 

The findings and conclusions in this presentation have not been 
formally disseminated by the National Institute for Occupational 
Safety and Health and should not be construed to represent any 
agency determination or policy. 



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