The Use of PAPR: An Institutional Experience Trish M. Perl, MD, MSc Professor of Medicine Senior Epidemiologist The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Thanks and Disclosures Thanks to Anita Stone and Edward Bernacki for providing input into the program at JHU Research Funding: CDC and VA to fund a study comparing the efficiency of N-95 versus medical masks for the prevention of respiratory diseases (RESPECT study) Merck (C. difficile RCT) Medimmune (Epidemiology of S. aureus and P. aeruginosa) Advisory Boards: Merck (C. difficile) Pfizer (S. aureus) 2
Respiratory Protection Program: JHM 6 Hospitals serves Baltimore and west Florida with an urban, tertiary care, and large international patient population In 2003, established a two tiered respiratory protection program using both the N 95 and the PAPR respirators. An assessment is made to determine those individuals who have high risk of exposure. Staff working in low risk areas will be trained and fit tested with N 95 respirators. 3
Respiratory Protection Program Staff working in high risk areas will be trained in PAPR and trained and fit tested with N 95 respirators in the event that there is a problem with the PAPR. Health Safety and Environment Performs fit testing Manages the PAPR maintenance program 4
Respiratory Protection Program Requires staff to pass medical screening process before being used; to be trained on respiratory protection regulations and usage; To use when caring for patients on airborne precautions; when performing aerosol generating procedures on high risk patients and when administering aerosolized hazardous drugs 5
Respiratory Protection Program PAPRS Use 3M Air Mate-99.97% filtration efficiency No latex (we are a latex free institution) Preferentially used for those with facial hair, who work in a high risk area or with high risk patients No need for annual fit testing 6
Obtaining PAPRs Is Complicated Many units maintain PAPR devices at all times Call Central Stores to obtain additional headpieces as needed. Unit without on-site PAPRs can call Central Stores to request PAPRs on an as-needed basis. Central Stores will send a bin containing five base units and tubing and six headpieces (unless the unit requests otherwise), along with a charger. 7
What a HCP Needs to Know About a PAPR Headpiece (or hood) single-person use only Connecting tubing multi-person use Base unit (blower/filter unit/battery pack) multiperson use Battery charger Except with certain patients (or other organisms [e.g. SARS, MERS CoV] as determined by infection prevention) the headpieces can be reused (by the same individual) many times. 8
What a HCP Needs to Know About a PAPR In the case of certain infections, the headpiece must be discarded after each use. The tubing and base unit are cleaned after use and can be re-used until cracked or damaged 9
What a HCP Needs to Know About a PAPR In the case of certain infections, the headpiece must be discarded after each use. The tubing and base unit are cleaned after use and can be re-used until cracked or damaged 10
PAPR: Instructions For Use Inspect the headpiece for damage. Discard if it is torn, soiled, or the elastic is no longer taut. Connect breathing tube to base unit & check air flow. Push the slotted end of the breathing tube into the connector in the rear of the headpiece until it snaps into place. Turn the unit on & air is flowing before entering the isolation area. Pull the headpiece over your head and adjust it so the headband wraps around your head. Pull the elasticized edge of the face seal under your chin and in front of ears. 11
PAPR: Cleaning An approved disinfectant must be used to wipe off the headpiece, tubing and base unit after each use. (Refer to Cleaning and Disinfection Policy) Place headpiece in a plastic drawstring bag, labeled with the user name, and place in designated area on the unit. Return base unit and tubing to designated area on the unit. Plug base unit into charger. 12
How Do HCP Perform In Emergencies? Simulation for pediatric resuscitation during H1N1-19% of HCP did not wear any type of respirator; only 6% used a PAPR and 75% used a N95 Watson et al. Jt Comm J Qual Patient Safety 2011: 37;515 13
PAPR: Trouble Shooting/Maintenance If there are problem with the battery, filter, or base unit motor, the device should not be used until it can be checked by HSE. Contact HSE at XXX. After hours, HSE can be contacted through the paging operator. With low airflow, check the connecting tubing to be sure that it is not kinked or damaged and replace as needed. Units that do not maintain a permanent supply of PAPR devices must return all base units and tubing to Central Stores once they are no longer needed for patient care. 14
Respiratory Protection Program: Maintenance and Costs PAPR s are inspected by HSE staff twice monthly when circulating and every 6 months in storage Costs: Staff to maintain all the PAPRs Replacement batteries/face shields/hoods 15
Respiratory Protection Program: What Do We Hear? Feel safe Cannot hear the patients or do clinical tasks They wander Don t know how to check it Don t know how to clean them Can t get one when I need one 16
Summary: Pro s Safety: PAPRs offer 2.5 x more protection (NIOSH APF) Built in splash protection Speaking has little negative impact on protection provided No fit-test required User does not have to draw breathing air via filtering face piece Convenience: Accommodates people with facial anomalies and men with facial hair Reusable One size fits all PAPR s are cool 17
Summary: Con s Policy and Education: Must decontaminate between uses Difficult to train all HCP s on safe use Maintenance: are resource and time intensive HCP Comfort: Cumbersome Patient Safety: Requires more time to don and doff Noise from motor can inhibit communication Less patient friendly in terms that it might be possibly intimidating 18
Summary: Con s Availability and Costs: There may not be enough units available or accessories such as hoods/hoses Battery may not be charged Expensive! A PAPR battery alone costs around $130. The entire pkg (all accessories & battery charger is ~ $900. 10 unit chargers ~ $1700-$2000. 19
Top 3 Barriers to, or Opportunities to Improve, Effective Usage of PAPRs Decrease noise so that HCP feel they can assess patients Simplify cleaning and storage requirements Improve battery life requirements 20
Top 3 Ideas to Improve NPPTL Certification 1) Important knowledge gaps? Cleaning how much, what, when Translation of filtration efficacy into clinical efficacy 2) Approach or content of certification standards? Simplify Focus on cost effectiveness Use patient safety approach with design enhancements