H1N1 & Respiratory Protection

1. H1N1 & Respiratory Protection Preparing and Protecting EMS Responders

2. Course Objectives • Review information on H1N1 • Describe disease impact on EMS system • Discuss & describe ways to protect EMS providers and system • Describe the OSHA 1910.134 requirements • Discuss methods agencies can use to comply • Discuss & describe ways to reduce infection to EMS provider and family

3. Course Objectives (con’t) • Describe strategies to continue service delivery • Provide orientation to Respiratory Protection planning and compliance • Demonstrate the Fit testing procedures for disposable respirator masks • Provide additional resources

4. What’s this program about? • EMS doesn’t always adequately protect itself when it provides attention to others • Remember SARS in Canada • Remember when: • We would do “Mouth to Mouth” • Didn’t wear gloves - “Gloves, I can’t start a line with gloves!” • Then came HIV/AIDs & TB • Exposures • Ryan White Act • Right to know your exposure

5. What’s this program about? • We started to change our approach to patients, BUT… • Are we always well protected, or do we take risks? • But, I’m a volunteer… • But, I’ve been doing this for ## years… • But, I’ve never gotten anything… • But, but, but…

6. What’s this program about? • Trying to protect you and your family! • OSHA / PESH – the bad guy or is it? • OSHA – Occupational Health & Safety Administration • Federal Department of Labor • PESH – Public Employees Safety & Health • State Department of Labor • Why do they exist? • They try to protect you and your ability to do your job

7. Disclaimer • Information on H1N1 reflects conditions at time of presentation development. Conditions are changing. Our purpose is to encourage urgency of action and compliance. • We will not be developing your Agency's Respiratory Protection Program. • Compliance with the Federal Regulations are your Agency's responsibility. • We’re here to explain what are the elements of an Agency Respiratory Protection Program. • We’re identifying sources of additional information and further assistance.

8. What is program is not… • Forcing you to comply – We encourage you to protect your EMS employees - • These are Federal regulations - • Doing it for you - • We not here to develop, review or approve your plan. • You develop your plan for compliance with OSHA • We are providing resources and templates for you to consider.

9. Why all the concern? H1N1 vs. Seasonal Flu • What’s different? • Typical flu cycle – Season starts in late fall and ends in Spring • H1N1 Started in April and hasn’t left • We have flu every year, so…

10. H1N1 Symptoms • Can’t distinguish between seasonal influenza, novel influenza and infections with other respiratory viruses based solely on patient’s clinical presentation • Initial patient management decisions need to be based on: • Current levels of seasonal and novel influenza activity in the community • Severity of patient’s illness • Presence of any underlying conditions (including young/old age and pregnancy) that places the patient at higher risk for complications

11. Human Infection with Novel Influenza A (H1N1) • Symptoms • Influenza-like illness (ILI • Fever ≥100º F and cough or sore throat • Other Symptoms • Chills, myalgia, headache, fatigue, runny nose, shortness of breath, vomiting, diarrhea • Similar to infection with seasonal influenza virus • Incubation period = 1-7 days, more like 1-4 days • Viral shedding can begin 1 day prior to illness onset • Spread by respiratory droplets and indirect transmission

12. It’s Everywhere!

13. WHO IS H1N1 AFFECTING? 7/14/09

14. Flu-like Illness in NYS Hospital Emergency Departments (3 month snapshot) It’s been rising even before the typical season started!

15. Hospitalized Flu Patients, Current and Prior Flu Seasons Oct. Jan. Feb. Mar. …

16. Impact on EMS System • Overwhelm 911 • Overwhelm Hospitals and EDs • Reduction in available EMS staff • Changes in transport destinations • Extended waits at healthcare facilities • Alteration/modification of standards of care • Potential for triaging calls prior to response

17. How to protect EMS? • Remember when… • Mouth to mouth • Direct pressure with ungloved hands • Nylon jackets protected us at car wrecks? • All you did was change the sheets on the cot between patients. • Why did we change? • Disease Transmission, standards, policies, etc. • Cleaning & decontamination procedures resources offered later in presentation

18. Protecting yourself • On the patient – • Use a surgical mask if tolerated • On you – • Non-invasive care – • Use a surgical mask, and gloves • Dispose of PPE when care has been completed or when cleaning the ambulance • Avoid contaminating the other areas of the ambulance.

19. Protecting yourself • Fit Tested Respirator Mask on you for: • Invasive care – Aerosol generating procedures such as Suctioning & Intubation • Procedures that may cause patient to cough • Use a N 95 mask, goggles/ face shield and gloves and gown. • Dispose of PPE when care has been completed or when cleaning the ambulance • Avoid contaminating the other areas of the ambulance.

20. Protecting yourself • Keep up to date – Inform yourself from appropriate resources • Guidance/recommendations will change as more is learned • It might get tighter or looser as time goes on

21. Protecting your family & loved ones • If you are Sick – STAY HOME • If your Child is sick – KEEP THEM HOME • WASH YOUR HANDS – OFTEN • Keep your work, at work… • Your clothing, your gear

22. Maintaining Service Continuity of Operations • If you routinely partner with a driver and a medic, what will happen when your driver or the medic are out sick? • What if 25 % of the staff is either sick or taking care of someone who is sick? • What if the call taker, dispatcher, mechanic, billing clerk, accounting office, etc. are sick?

23. Planning - Agency • What has your agency done to prepare for: • Insufficient staff to field normal number of rigs • Contract obligations – to community, facilities, etc. • Delayed dispatch or missed call – Are YOU liable? • What are your “clients” expectations?

24. Actions your agency can take to keep your employees protected and working • Agency Illness policies • Enclosed (in-vehicle) space (social) distancing • Vehicle ventilation – “Does the fan work?” • Waterless hand cleaners • PPE training & availability • Patient masking, if tolerated

25. What can your agency do? • Provide employee education • Develop written policies & procedures • Offer Flu shots • Medical prescreening • Fit Testing • Cleaning & decontamination procedures • Staffing & resource sharing

26. Cleaning & decontamination • “Turn and shake out ambulance”… • Cleaning and decontaminating vehicle and equipment • Additional guidance at: www.cdc.gov/h1n1flu/guidance_ems.htm#b

27. OSHA 1910.134 requirements • What does it say? • How do you comply? • Record keeping requirements • Follow ups • What about someone who can’t pass fit testing? – Retesting procedures.

28. Components of a Respiratory Protection Program OSHA 1910.134 • Risk Assessment • Identify the jobs needing respiratory protection • Determine the level of protection needed • Selection of Respirators – Written Policies & Procedures • Medical Screening • Medical questionnaire • Medical review by Physician • Training • When to use, how to use, storage, replacement, testing, etc. • Fit testing • Maintenance of Program • Recordkeeping – Written Program – Program Administrator • Evaluation of Program

29. RESPIRATORY PROTECTION FROM AIRBORNE INFECTIOUS AGENTS • Use of N-95 Disposable Particulate Respirators

30. TRAINING OBJECTIVES • Explain what N-95 disposable particulate respirators are and why they are recommended • Discuss their capabilities and limitations • Demonstrate proper use • Describe the proper maintenance and storage of N-95 respirators

31. WHY USE A RESPIRATOR? • To protect you from infectious microorganisms, such as Influenza, tuberculosis, SARS • As a supplement to engineering controls, such as barriers between you and the patient, and proper ventilation • As a supplement to administrative controls, such as distance, and early identification and separation of ill patients • Preferred methods of controls are engineering and administrative controls • Respirators are the last line of defense when no other means of protection is sufficient to limit exposure

32. What is an N-95 disposable particulate respirator? • Filtering facepiece or air-purifying respirators • Negative pressure respirator - when inhaling, the pressure inside the respirator is less than outside the respirator • One of 9 types of filter classes • Over 300 different models of N-95 respirators approved by NIOSH

33. Why is an N-95 disposable particulate respirator recommended? • Protects by filtering out infectious particles from the air that you breathe • Protects public health workers on the front lines if a respiratory hazard is present

34. What does “N-95” mean? • The respirator is made with N-series filter material that is at least 95% efficient in removing particles of 0.3 microns • N= Not resistant to oils (industrial)

35. N-95 Disposable Particulate Respirators with or without an Exhalation Valve • May have or not have an exhalation valve. An exhalation valve can: • reduce breathing resistance • reduce moisture buildup inside the respirator • increase work tolerance and comfort • DO NOT use a respirator with an exhalation valve when there is a need to protect others from possible contamination by the respirator wearer (e.g. with a TB patient).

36. Advantages of N-95 Disposable Particulate Respirators • Lightweight compared to elastomeric • Fairly comfortable to wear for short periods • Mobility not restricted • Disposable, low cost • Available in various sizes • Do not require cleaning

37. Limitations of N-95 Disposable Particulate Respirators • Don't protect skin or eyes from contact with pathogens • if the airborne infectious agent is also spread by skin or mucous membrane contact, also use eye protection, gloves and consider gown • May not protect from high concentrations of pathogens • higher levels of respiratory protection may be required

38. Limitations of N-95 Disposable Particulate Respirators • Don't protect from oxygen deficiency or harmful chemical gases and vapors • Do not protect workers from high levels of very toxic dusts, like asbestos or lead REMEMBER: N-95 respirators must be NIOSH approved and fit tested! N-95s used as medical devices must also be approved by the FDA.

39. Is an N-95 disposable respirator the same as a surgical mask? NO! A typical surgical mask is not a respirator. Because some disposable N-95 respirators resemble surgical masks, it is important to understand the difference between them.

40. Is an N-95 disposable respirator the same as a surgical mask? • Surgical masks are designed to protect the patient from your secretions. • Most surgical masks do not adequately remove small particles from the air and do NOT prevent leakage around the edge of the mask when the user inhales. BUT............... • A surgical mask on a PATIENT helps to prevent the spread of respiratory secretions.

41. OSHA's Respiratory Standard • If N-95 respirators are issued, employers must follow OSHA standard (1910.134) • Written respiratory program with an assigned program administrator • Proper selection of respirators • Training about hazards and proper use • Medical clearance • Fit testing • Evaluation of program effectiveness annually

42. Proper Use of N-95 Disposable Respirators • Review manufacturer's instructions for proper donning (putting on), seal check, removal and use. • No facial hair that interferes with face to facepiece seal • If shape of the N-95 is compromised, it may not fit properly • If respirator is damaged, soiled or breathing becomes difficult, leave the contaminated area and replace the respirator • Dispose after each use in regular trash

43. Medical Clearance • N-95 use requires medical evaluation and clearance before use. Medical evaluation may use a confidential questionnaire that is reviewed by a licensed health care professional (LHCP) • Evaluation is repeated if a change occurs that might affect ability to use a respirator safely. • Medical provider sends written clearance to employer stating that employee can or cannot wear a specific respirator.

44. Fit Testing OSHA requires fit testing prior to initial use and annually thereafter. If a respirator does not form a tight seal around the face, contaminated air may leak around the edges of the face seal. The only way to determine if a respirator fits and is capable of protecting properly is to fit-test the respirator.

45. Quantitative Fit Testing (QNFT) Computerized means of detecting face seal leakage A PORTACOUNT measures particles inside the respirator and compares to particles in the room A number value is determined to measure how well the respirator fits the individual.

46. Qualitative Fit Testing (QLFT) • Simple “pass” or “fail” test. • Relies on the wearer's subjective response to tasting or smelling the test agent • If the subject can taste or smell the substance the fit is not acceptable - “fail” • If the subject can not taste or smell the substance during the test - “pass” • Test agent is usually saccharin (sweet) or Bitrex (bitter).

47. Fit Testing Precautions • User must put the respirator on themselves without the help of the trainer • If user can not be fit tested after 2 attempts try another make, model or size • Tester should never manipulate the respirator to obtain a fit, rather they should instruct the wearer what to do so they can perform it themselves • Never make special modifications to the respirator, e.g. tying a knot in the straps to make it fit, adjustment for glasses, etc. • Do not pinch a metal nose piece. Start with 2 index fingers touching each other at the middle of the nose piece and work outward on the bridge while pressing (form it to nose shape)

48. Demonstration of FIT TESTING

49. Respiratory Protection Effectiveness Employer must evaluate program annually Employee must select the correct respirator Respirator must be available when needed Employee must know when and how to put on/take off Must store and maintain per manufacturer's instructions

50. Key Points About Using N95 • Put on BEFORE contact with the patient, generally before entering the room • After use, avoid touching the outside of the device to help prevent contamination of the hands • Remove and discard either at the doorway or immediately outside patient room • Immediately perform hand hygiene