A new study from the UK suggests that OR nurses, CRNAs and other surgical staff might soon be free to dispense with the time-consuming Covid-19 safety procedures such as having to don (and work under) additional layers of PPE and ½-hour delays for air changes.
According to a paper just published in Anaesthesia (a journal of the Association of Anaesthetists), the use of facemask ventilation during routine surgery should not be classed as an aerosol-generating procedure and does not increase the risk of COVID-19 transmission compared with normal breathing/coughing of patients.
Concerns about SARS-CoV-2 transmission prompted the World Health Organization (WHO) to classify facemask ventilation as an ‘aerosol-generating procedure’ (AGP), and the safety guidelines have impaired efficiency and processes in surgical theaters around the world. The evidence supporting the WHO AGP classification is primarily based on a 2003 study of infections in anaesthetists during the SARS-1 epidemic.
However, authors of the Anaesthesia study state that “There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation.” In fact, this paper appears to be the first study to actually monitor and measure aerosol concentrations generated during facemask ventilation.
Following the WHO AGP designation and current pandemic guidance, anesthetists performing facemask ventilation in patients at risk of having COVID-19 have been wearing a respirator mask, eye protection and additional personal protective equipment. The guidelines apply to nearby theatre staff as well. In addition, extra time (up to half an hour per case) must be added to each operation to allow sufficient air changes in theatre to remove any of the presumed infectious aerosol. The time-consuming safety restrictions significantly reduce the number of procedures that staff can perform each day, especially those involving urgent or emergency surgery, and increase the backlog in the healthcare system.
In this new study, the authors conducted aerosol monitoring in anaesthetized patients during standard facemask ventilation, and facemask ventilation with an intentionally generated air leak – to mimic the worst-case scenario where aerosol might spread into the air. Recordings were made in ultraclean operating theatres (at Southmead Hospital, North Bristol NHS Trust, UK) and compared against the aerosol generated by each patient’s normal breathing and coughing.
Respiratory aerosol from normal breathing was reliably detected above the very low background particle concentrations with median aerosol concentration of 191 particles per liter. The average aerosol concentration detected during facemask ventilation without a leak (3 particles per liter) was 64-times less than that for breathing. When an intentional leak was introduced the aerosol count was 17 times lower than breathing (11 particles per litre).
When looking at peak particle concentrations the team found that a patient coughing produced a spike of 1260 particles per liter, compared to the peak of 60 per liter (20 times lower) for regular facemask ventilation and 120 per liter with an intentional leak introduced (10 times lower).
Dr Andrew Shrimpton, the lead author of the study, commented: “This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol.”
The authors add: “The low concentration of aerosol detected during facemask ventilation even with an intentional leak is also reassuring given that this represents a worst-case scenario. Both normal breathing and a voluntary cough generate many-fold higher quantities of aerosol than facemask ventilation… On this basis, we believe facemask ventilation should not be considered an aerosol-generating procedure. Accumulating evidence demonstrates many procedures currently defined as aerosol-generating are not intrinsically high risk for generating aerosol, and that natural patient respiratory events often generate far higher amounts.”
They conclude: “The emerging evidence from quantitative clinical aerosol studies is yet to be incorporated into clinical guidance for aerosol-generating procedures and we believe this needs urgent reassessment. Declassification of some of these anesthesia-related procedures as aerosol-generating would seem appropriate due to their lack of aerosol generation. Our findings also raise the broader question of whether the term ‘aerosol-generating procedure’ is still a useful concept for anaesthetic airway management practice in the prevention of SARS-CoV-2 or other airborne pathogens.”
Dr Mike Nathanson, President of the Association of Anaesthetists said: “This important work will allow clinicians to better understand the risks of general anesthesia in patients with Covid. As we enter another winter, and with a high prevalence of Covid, the backlog of surgical cases is increasing. Anesthetists will wish to carry on working for as many of their patients as possible. As the authors suggest, this research will inform the debate on how we can work safely.”
This study is the result of a collaboration between Anaesthetic and Aerosol research groups based in Bristol, UK and Melbourne, Australia as part of the NIHR funded AERATOR study. The results reinforce the findings of similar studies performed by the AERATOR group demonstrating many anesthetic procedures are not high risk for aerosol generation.
SILVER SPRING, MD—The American Nurses Association (ANA) advocated for and supports the Occupational Safety and Health Administration (OSHA) Emergency Temporary Standard (ETS) that requires employers to better protect nurses from COVID-19 hazards in the work environment.
This standard, published in the July 6th Federal Register, recognizes that nurses must have the most stringent levels of safety protections to provide the highest quality care to their patients. Critically, the ETS requires that employers provide better protections for nurses by developing and implementing plans to identify and control COVID-19 hazards in the workplace. Nurses who care directly for patients with confirmed or suspected COVID-19 must also be protected by approved respirators, which include single-use N95 respirators, elastomeric respirators, and powered air-purifying respirators (PAPR). Employers must also provide gloves, gowns, and eye protection. This requirement applies regardless of the nurses’ vaccination status. Employers are also required to screen health care personnel daily for COVID-19, provide COVID-19 tests at no charge to the employee, and to support employees to receive COVID-19 vaccinations.
The ETS also empowers nurses to advocate for meaningful safety improvements during the duration of the emergency standard, as well as providing whistleblower protections for employees who raise safety concerns.
“While ANA is pleased that OSHA took the rare step to issue this new emergency standard, it is long overdue as nurses have been—and continue to be—at high risk for exposure to COVID-19.” said ANA President Ernest J. Grant, PhD, RN, FAAN. “ANA has been calling for specific safety protections from COVID-19 since the start of the coronavirus pandemic and while this ETS is beneficial, it is not a replacement for a permanent standard with strong respiratory protections, which remains a necessity. According to OSHA’s own materials, by the end of May 2021 nearly 492,000 health care personnel had contracted COVID-19 and more than 1,600 had died. More must be done to protect our nation’s nurses and frontline health care workers from the ravages of this pandemic.”
A comprehensive survey in February 2021 by the American Nurses Foundation (the Foundation) found that 74% of respondents said that consistent and better executed national health policies and public intervention plans will better prepare for future crises or pandemics. Nurses understand the critical role the federal government plays in ensuring their safety. They also know that this pandemic is not over, and that the future will inevitably bring new pandemics and public health crises. Nurseslives must not be endangered because policymakers have failed to take actions to adequately prepare. ANA is committed to protecting nurses and frontline health care workers. It will engage with OSHA on the implementation and enforcement of this ETS and continue to advocate for permanent protections from infectious agents in health care delivery.
Except for a few requirements, OSHA expects employers to comply with the ETS as of July 6, 2021, and nurses are able to comment on it through July 21, 2021. ANA encourages nurses and health care personnel to learn about the new requirements and to understand how to report violations, by visiting OSHA’s website. ANA members can also access our Policy Brief on the ETS here.
Federal officials announced new measures to help get fresh, new N95 masks to health care workers and expand their use in other industries after scientists argued that the highly protective masks are essential to keep workers safe from covid-19.
The changes come as U.S. mask-makers say the demand from hospitals is so sluggish that they’ve laid off 2,000 workers and fear some new protective gear companies could collapse. Yet in a letter to lawmakers, hospitals cite ongoing concerns about scarce supplies, saying limits on which workers should get N95s must stay in place.
Among the new moves: The Food and Drug Administration plans to eventually revoke its approval of the widespread crisis-era practice of decontaminating N95 respirators and returning them to front-line workers to use again.
A Centers for Disease Control and Prevention official also announced a tweak to its guidelines, which used to say the protective N95 respirators were reserved for health workers. Now they are “prioritized” for those workers but will be OK for bulk sales to other employers — a step that should boost overall demand.
A group of prominent scientists had written to the White House in February, saying a broader swath of U.S. workers need more protection from the airborne virus. And on March 1, U.S. mask-makers wrote to President Joe Biden decrying a glut of nearly 300 million N95 or equivalent respirators that were made in this country and sitting unused in warehouses.
KHN also reported that in January federal officials approved the export of U.S. N95s amid mounting unsold inventory, a move a nurses union leader called “unconscionable.”
Lloyd Armbrust, president of the American Mask Manufacturers Association, took a career U-turn to launch Armbrust American and start making masks near Austin, Texas, last year, troubled by “cheap, flimsy” personal protective equipment coming in from overseas: “We … decided to take matters into our own hands.” He said that he was gratified to see federal officials respond to U.S. mask-makers’ concerns and that he expects to see sales rise in coming months.
But he said it’s been a shock for the upstart industry to try and fail over many months to break into the U.S. health care market — dominated by large group purchasing organizations — where the preference to buy from China is ingrained.
“Who knows how many health care workers are getting infected, maybe dying, because of a logistics problem that doesn’t exist,” he said. “That was very frustrating. As a human, that was hard for me to understand.”
Armbrust said about 50 U.S. mask-makers the association represents reported in a survey that they’ve collectively laid off about 2,000 workers in recent months amid sluggish demand. They expect some companies to fail.
Mike Bowen, vice president of Prestige Ameritech, another Texas-based N95 maker, said he has reduced production because he has 11 million masks on hand. “I am waiting to see if [the] FDA announcement will make hospitals buy more N95s,” he said by email. “If they do, we’ll make what they need. We have a lot of N95 manufacturing capacity.”
Yet even through last month, the American Hospital Association cited supply chain concerns in a letter to lawmakers and endorsed existing CDC guidelines that allow health workers to use a surgical mask unless performing an aerosol-generating procedure. (Although some experts now say a cough produces more aerosols than such procedures.)
Another change by the CDC would allow major retailers like Amazon to sell N95s in bulk to businesses outside the health care sector, said Maryann D’Alessandro, director of the CDC’s National Institute for Occupational Safety and Health lab for personal protective technology.
Researchers and journalists have noted elevated workplace risk to bus drivers, meatpacking employees, and those in manufacturing and food processing who labor in crowded conditions.
D’Alessandro said the agency also approved several models of durable “elastomeric” respirators that are meant to be reused, including one by 3M, and signed a contract to add 375,000 to the Strategic National Stockpile.
That move might serve to protect more health care workers in the case of a variant surge or new pandemic. Health care workers were two to five times more likely than the average person to get covid, studies have shown.
KHN and The Guardian counted more than 3,600 health care workers who died over the past 12 months, many of them people of color and most working outside of hospitals. In interviews with families and colleagues, dozens raised concerns about inadequate protective gear.
Throughout the pandemic, workers who used N95 respirators were routinely asked to put them in a brown paper sack so they could be disinfected by gas, UV light or other means and then returned to them to wear again. Nurses have complained that the respirators, which are designed to be used once, come back misshapen or with a chemical odor.
The FDA on Friday sent a letter to health care providers urging them to “transition away from crisis capacity conservation strategies,” including the disinfection and reuse of disposable N95s.
The letter is one step toward revoking the “emergency use authorizations” that allowed companies to disinfect and reuse N95s, said Suzanne Schwartz, director of the FDA’s Office of Strategic Partnerships and Technology Innovation.
“That was never intended to be anything other than a crisis measure,” Schwartz said in an interview. “We want to be sure health care facilities are getting themselves in a situation where they have respirators or reusables in stock.”
Surveys by National Nurses United from November and February show that about 80% of nurses reported using reprocessed respirators.
The changes are “tiny steps” in the right direction but fall short of what’s needed to fully protect nurses, said Jane Thomason, lead industrial hygienist for National Nurses United.
She said about half of more than 9,000 nurses surveyed report working in hospitals where patients are not universally screened for covid, presenting the potential for pre- or asymptomatic patients to infect staffers.
The CDC guidance updated in February advising health workers to use N95s or well-fitted masks to care for covid patients remains nonbinding, she said, allowing employers to outfit nurses and other health workers in surgical masks instead of more protective N95s.
The practice has been controversial even after the initial supply chain collapse. Doctors on Twitter reacted strongly to a recent debate held by the University of Calgary where two academics pointed to evidence that covid is airborne — meriting N95 protection for front-line health workers.
Nurses called early in the pandemic for a high level of protection against an airborne virus, but in many places have had to stage protests to get it or go without.
Since last summer, mounting evidence has shown that health care workers in surgical masks were more likely than those in respirators to catch the coronavirus. Harvard researchers and those in Israel pinpointed specific instances when a patient or visitor in a surgical mask infected health care workers who also wore a surgical mask.
Republished courtesy of KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
After 27 years as an emergency RN and over a year as a frontline nurse in the Covid-19 pandemic, Rhode Islander Timothy Aurelio has seen a lot. But, during the height of last year’s surge, the Nurse of the Week was taken aback when the CDC told hospitals that workers should tote their (suddenly-classed-as-reusable) N95 masks in a brown paper bag. One day, as he arrived at the hospital, Aurelio says he saw “This security guard had his N95 in a brown paper bag, and it was completely crushed. His metal nose bridge was completely flat.”
Rhode Island emergency nurse, Timothy Aurelio, RN, BSN-DC.
There was some logic to the instruction, as a brown paper bag permits the free flow of air around the N95 and should help prevent bacteria from growing inside the mask. However, Aurelio quickly discovered the downside: “With a mask in this integrity, it’s not going to protect you… I saw their masks being stored in their duffel bags, and in their pocketbooks, and hanging from the hook next to the printer Anything from the air is dropping down into their mask.” As he told a local reporter, “Last July… we didn’t have a safe place to store our N95 masks and our masks were getting crushed and soiled, people were leaving them on the desk.” In fact, he added, “This is how I first developed the idea: a security guard had his N95 in a brown paper bag and it was intertwined in his belt. And I said, ‘What is that?'”
This could literally be a matter of life or death, so the RN began to think of a way to create PPE for his PPE. Aurelio’s solution? The N95 Mask Preserver. Designed with the aid of engineers at MassChallenge Rhode Island, RIHub, and Michael Katz of the University of Rhode Island, Aurelio’s PPE protector consists of a hinged case made of medical-grade plastic, which he says is “the same material that’s used for our hospital syringes. It also has an additive called WITHSTAND, which is antimicrobial, anti-fungal, anti-mold, and anti-mildew.” The Preserver also includes a 1/4″ hole so healthcare workers can clip the case to their scrubs so they always have their PPE ready to hand.
Aurelio’s N95 preserver has proved so popular that he now has a patent pending. He told ABC in Rhode Island, “The docs at the ER at my place are wearing them, our nurses are wearing them and using them, and they’re seeing such a difference in the integrity of their mask.”
As he sees it, Aurelio was acting as a nurse more than as an entrepreneur: “I saw that my colleagues were getting sick with Covid,” he said. “If I can eliminate one of those risk factors by having a safe N95 mask that’s in good integrity, that’s why I did this.”
For more on Aurelio’s N95 tote, visit his website.
Wearing PPE full-time can be trying. Acne. Rashes. Bruising. Headaches. Unrecognizable co-workers. PPE has never been comfortable, but now an unprecedented number of healthcare providers are experiencing PPE discomfort, and their misery is prolonged by working conditions related to the pandemic. Shortages and the life-or-death risk of infection often make it impossible to take a PPE break and don fresh equipment every two-to-four hours as recommended; as a result, clinicians all over the world are suffering from sad faces (and sad hands as well).
So far no one has suggested ways to make coworkers more recognizable, but there are measures you can take to help protect your skin from the effects of chafing, pressure, lack of air, and sweating while wearing PPE (spending hours in a tight-fitting N-95 is especially onerous).
1. Drink PLENTY of Water
Rule number one is, hydrate! When you’re not working, be sure to drink plenty of water throughout the day, and make sure you have a water bottle ready at the end of each shift.
2. Your Face and Hands Need Water, Too!
And rule number two is… Hydrate! Keeping your face and hands well-moisturized is always a good idea; when you’re wearing PPE this becomes a must. Use a cleanser for sensitive skin, and gently pat your face dry with a towel. Moisturizer is essential but stick with water-soluble products and avoid zinc, petroleum jelly (whether pure or in a blended ointment such as Aquaphor or Cerave), and heavy creams that can clog your pores. Products such as Aquaphor are useful for protecting your hands, though, and preventing dry hands is an essential part of hand hygiene. In addition to regular applications of skin ointment, make a habit of moisturizing your hands every time you wash them (all hospital hand hygiene stations should provide moisturizing lotions).
3. Make Your Face a Fortress
If your employers permit, experiment with protective cushioning options to prevent chafing and irritation from N-95s. Before putting on a mask and goggles, apply an alcohol-free liquid barrier to provide your face with clear, breathable protection. Thicker barriers such as dressing tapes should be avoided, as they can interfere with the proper fitting and seal of your mask.
4. Go to a Reliable Source for More Tips
For an authoritative discussion of the skin issues that can be caused by PPE and a guide to the safest, most effective methods of skin protection, see the Medscape interview with Kimberly LeBlanc PhD, RN, Step-by-Step Guide to Preventing PPE-Related Skin Damage.
