RESPIRATORY MASK FIT TESTING POLICY Printed copies must not be considered the definitive version DOCUMENT CONTROL Policy Group: Author: Reviewer: POLICY NO. IC - 130 Occupational Health & Safety/Infection Prevention & Control Heather Aitchison Maria Taylor Heather Aitchison Maria Taylor Scope: Board wide Version no. 3.0 (Applicability) Status: REVIEW Implementation May 2018 date: Approved by: Infection Control Last review date: April 2018 Committee May 2018 APF (DATE) Impact Assessed: Yes Next review date March 2021
CONTENTS No Contents Page 1 Purpose and Scope 3 2 Policy Aims 5 3 Responsibilities and Organisational Arrangements 6 Chief Executive Executive Directors, Associate Directors, General/ Nurse Managers, Clinical Leads and Department Heads Staff Line Managers Occupational Health Infection Control Fit Mask Testers 4 Monitoring 9 5 Equality and Diversity 10 6 Document Control Sheet 11 Appendices 1 Areas of Risk 15 2 3 Fit Test Record Useful Information/Contacts 16 17 Title: Respiratory Mask Fit Testing Policy Page 2 of 17
1. PURPOSE AND SCOPE This Policy will apply to all NHS Dumfries and Galloway staff who either manage staff or are those staff who require to wear a tight fit respiratory mask (Appendix 1).The purpose being to provide guidance to all staff and managers of the organisational arrangements in relation to respiratory fit mask testing. The scope of this policy is Board wide. LEGISLATIVE FRAMEWORK Where respiratory protective equipment (RPE) is used as a control measure, under Control of Substances Hazardous to Health Regulations 2011 (COSHH), it is vital that the selected RPE is adequate and suitable. To ensure that the selected RPE has the potential to provide adequate protection for the individual wearer, the approved code of practice supporting COSHH states that tight fitting RPE must be fit tested to ensure adequate protection for individual wearers. This will ensure that inadequate RPE is not selected for use. National Services Scotland In 2015 National Services Scotland formed the National Competency Framework for RPE. The aim being to develop a national risk categorisation for Healthcare Workers under SAR HAI Project Continuation Funding (PCF) 3.31. This has been approved and is included in the National Infection Prevention and Control Manual, Chapter 2 and Appendix 11 which details when FFP3 protection is required. National Minimum Risk Categorisation for fit testing with FFP3 The risk categorisation is as follows: Level 1 Preparedness for business as usual Staff in clinical areas most likely to provide care to patients who present at healthcare facilities with an infectious pathogen spread by the airborne route; and/or undertake aerosol generating procedures i.e. ED, CCU, Paediatrics, Respiratory, Infectious diseases, Anaesthesia, Theatres, Chest physiotherapists, Special Operations Response Team (Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams and Mortuary staff involved in Post Mortem procedures (in which high speed devices are used). Title: Respiratory Mask Fit Testing Policy Page 3 of 17
Level 2 Preparedness in the event of emerging threat Staff in clinical setting likely to provide care to patients admitted to hospital in the event of an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all other ambulance transport staff. In the event of an Epidemic/Pandemic Local Board Assessment as per their preparedness plans will apply. Level 1 & 2 should be a minimum priority level for boards and anything additional should be the responsibility of local board to assess and add into their preparedness plans. All tight fitting RPE i.e FFP3 respirators must be: Single use (disposable) and fluid repellent Fit tested on all healthcare staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers guidance. Fit checked (according to the manufacturers guidance) every time a respirator is donned to ensure an adequate seal has been achieved. Compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection. Donned and removed in a safe area (e.g. outside the isolation/cohort room/area). Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website at: http://www.hse.gov.uk/respiratoryprotectiveequipment/basics.htm Beacon Workforce Teams Occupational Health and Safety Folder Respiratory Mask Information. Title: Respiratory Mask Fit Testing Policy Page 4 of 17
Air Powered Respirators Three Pool Air Powered Respirators are provided for staff who have not been previously fit tested who are caring or in contact with a patient who is known or suspected as having infection when FFP3 Respiratory Protective Equipment is required. Some areas such as CCU, Theatre and Physiotherapy have purchased their own Powered Respirators. The 3 Pool Respirators are located in the Emergency Department PPE Room A contingency stock of 1863+ and 1873V+ is also in this area for emergency use only Instructions on fitting, use and decontamination are provided. Detail of when FFP3 RPE is required is provided in the National Infection Prevention and Control Manual, Appendix 11. Please follow the link below which demonstrates checks and fitting instructions. This is also available in Beacon Teams Occ Health and Safety Respiratory Mask Information Air powered Respirator demonstration link. htpps://youtu.be/fo06zzrz9zi Title: Respiratory Mask Fit Testing Policy Page 5 of 17
2. POLICY AIMS This policy aims: To reduce/prevent the risk of respiratory infection/transfer between patients and staff To identify and ensure that the relevant staff and managers understand their responsibilities To provide staff with the necessary guidance and support in relation to RPE selection and use. To support NHS Dumfries and Galloway s policies in relation to respiratory disease or infection i.e. TB, SARS, Flu To provide staff with guidance on when mask fit testing is required. 2.1 DEFINITIONS Tight Fit Mask A tight fit mask is a full face mask, a half mask or a filtering face piece (commonly referred to FFP3 masks). The performance of these types of face pieces relies on the quality of fit to the wearer s face. Please note the selection and use of any respiratory mask should be in accordance to local risk assessment and relevant guidance in the National Infection Prevention and Control manual. Aerosol Generating Procedures (AGPs) Aerosol Generating Procedures (AGPs) can produce droplets <5 microns in size which may cause infection if they are inhaled. These small droplets, containing pathogens, can remain in the air, travel over a distance and still be infectious. AGPs procedures should only be carried out when essential. Where possible, these procedures should be carried out in well-ventilated single rooms with the doors shut. Only those healthcare workers who are needed to undertake the procedure should be present. Health Protection Scotland in the current National Infection Prevention and Control Manual define the following activities as Aerosol Generating Procedures: Intubation, extubation and related procedures, for example manual ventilation and open suctioning. Cardiopulmonary resuscitation. Bronchoscopy. Surgery and post mortem procedures in which high-speed devices are used. Some Dental procedures (e.g. drilling) - ONLY urgent Dental work would be carried out on a suspected or known infectious patient. Title: Respiratory Mask Fit Testing Policy Page 6 of 17
Non Invasive Ventilation (NIV) e.g. Bilevel Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP). High Frequency Oscillatory Ventilation (HFOV). Induction of sputum. This list is not exhaustive Nebulisation is no longer considered an AGP 2. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS See Occupational Health & Safety Intranet Beacon folder for FFP3 mask information i.e. instruction on how to fit masks correctly, fit check masks and decontamination care and maintenance of usable masks and/or respirators. The Emergency department is responsible for completing and recording the monthly checks and maintenance of 3 Pool Powered Respirators ensuring that fitting, use and decontamination information is available. Chief Executive The Chief Executive has overall strategic responsibility for ensuring that Board Policies comply with all legal, statutory and good practice guidance requirements. Executive Directors, Associate Directors, General/Nurse Managers, Clinical Leads and Department Heads Are responsible for: Ensuring that all staff for which they have line management/clinical responsibility are appropriately informed, instructed, trained and supervised in compliance with this policy Ensuring the provision of the necessary face masks in liaison with line management. Line Managers including all disciplines Are responsible for: Identifying those staff who may require to use a tight fit face mask Title: Respiratory Mask Fit Testing Policy Page 7 of 17
Ensuring all appropriate staff are fit tested - if not fit tested exclude from the relevant patient contact. Ensuring maintenance of fit test records and in case of need/emergency that staff have access to these records at all times. At all times the Manager must be able to identify the current fit test status of all staff under their management In case of need/emergency ensuring the provision and access of the necessary face masks at all times (i.e. on top up system) as per national and local risk assessment policies and procedures Ensuring staff have access to Respirators in event of not being successfully fit tested Staff including all disciplines Having been provided with the necessary information, instruction, training and having been mask fit tested will be responsible for: Ensuring they are fit tested as appropriate Ensuring that they comply with local and national infection prevention and control policy and guidance on when respiratory mask protection is required see National Infection Prevention and Control Manual, Appendix 11 and Infection Prevention and Control team and Occupational Health can be contacted for advice. Ensuring the appropriate selection and use of the respiratory mask they have been fit tested for. Ensuring the correct use, cleaning, storage, maintenance and checks are completed for their RPE Ensuring the correct and safe fitting, removal and disposal of RPE. Ensuring they report any faults or inadequacies with their RPE to their line manager Ensuring they report any significant changes to their Manager/Occupational Health that may indicate repeat mask fit testing i.e. significant weight loss/gain, significant dental work or any facial changes around the mask face seal area Any staff member who may require to use a pool respirator must first ensure they have read and understood the correct and safe fitting and use information provided with each respirator. Following use they must ensure the correct decontamination of the respirator including disposal and replacement of hood, tubing cover etc as per instructions provided. Title: Respiratory Mask Fit Testing Policy Page 8 of 17
Occupational Health Is responsible for: Completing fit testing for masks including fit check training for appropriate staff as required Ensuring record of testing copied to employee and manager Ensuring records of testing are documented in employees file and recorded on Occupational Health database including type of mask Provide training for any staff on the fitting, use and decontamination of the Powered Respirators as requested Providing advice and guidance and support to all parties where appropriate Inform staff of any changes in procedure, legislation or any other relevant information Ensuring the competence of Occupational Health staff on respiratory mask Fit testing and Fit checking via an accredited trainer. Infection Prevention and Control Is responsible for: During infection control audits assess areas management and readiness/preparedness for the provision and use of FFP3 respiratory protection Providing advice and guidance to all parties on the appropriate provision, use, decontamination, disposal and storage of face fit masks, guided by Health Protection Scotland and local Standard Infection Prevention and Control Precautions (SICPs) and Transmission Based Precautions (TBPs), Providing guidance and support to all parties where appropriate Ensuring relevant National Policy is accessible to staff via Infection Prevention and Control Manual - intranet 4. MONITORING Responsibility for monitoring the application of this policy will rest with the Occupational Health and Safety Service, assisted by the Infection Prevention & Control Team. The Policy will be reviewed a minimum of every 3 years by Occupational Health. Ongoing audit will be conducted by Occupational Health and Safety and Infection Prevention Control teams at site visits to assess compliance throughout the organisation. Any changes will be made in consultation with the relevant staff. Revised versions of this policy will be approved by The Infection Control Committee prior to dissemination and implementation. Title: Respiratory Mask Fit Testing Policy Page 9 of 17
5. EQUALITY AND DIVERSITY NHS Dumfries and Galloway are committed to equality and diversity in respect of the nine equality groups defined by Age, Disability, Gender, Gender Reassignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion and Belief and Sexual Orientation whilst also giving consideration to human rights. An impact assessment has been carried out on this procedure. Some individual staff members may be unable to be successfully fit tested with a FFP3/ tight fit mask. In most cases the provision of a full face respirator or temporary redeployment can be accommodated. Staff wearing masks may cause additional communication problems especially to those patients with existing communication/language difficulties in such cases a Powered Respirator may be beneficial as it offers full facial vision. Staff wearing RPE for long periods may result in additional anxiety for some patients. Title: Respiratory Mask Fit Testing Policy Page 10 of 17
6. DOCUMENT CONTROL SHEET 1. Document Status Title Author Approver Document reference RESPIRATORY MASK FIT TESTING POLICY Heather Aitchison, Maria Taylor Infection Prevention & Control Committee / Area Partnership Forum Version number 2. Document Amendment History Version Section(s) Reason for update 1.0 All Scheduled review and updating of the policy. 1.1 All Review and update procedure in accordance with current legislation, corporate Document Development and Approval Policy and local guidance and practice. 2.0 All Review and update procedure in accordance with current National Services Scotland risk categorisation. Change provision of fit testing to be completed by Occupational Health and removal of responsibility from current Fit Testers. Implementation of Pool of 3 Powered Respirators 3.0 All Review and update procedure in accordance with current legislation, corporate Document Development and Approval Policy and local guidance and practice. Implementation of emergency FFP3 mask stock in Emergency department. 3. Distribution Name Responsibility Version number Elaine Simpson Place on intranet. All Policies under Workforce Teams in 3.0 Occupational Health and Safety Folder Elaine Simpson Record in Workforce 3.0 Occupational Health and Safety Policy / Procedure Register Heather Aitchison Communicate to all staff via 3.0 Workforce Directorate Paper and Intranet Title: Respiratory Mask Fit Testing Policy Page 11 of 17
4. Associated documents HSE Operational Circular OC 282/28 (Version 6, 30/04/2012) COSHH 2002 National Infection Prevention and Control Manual Health Protection Scotland (HPS) Version 2.4. January 2015 OSHA 1910. 134 App A (2004): Fit Testing Procedures (mandatory) www.osha.gov BSEN 12942:1998 Respiratory Protective Devices: Power assisted fitting devices incorporating full face pieces, half face pieces, half or quarter face pieces requirements, testing, makings BSEN 136:1998 Respiratory protective devices: full face piece requirements, testing, markings BSEN 140:1998 Respiratory Protection Devices: half face pieces and quarter face pieces requirements, testing, markings General Information & Infection Control Precautions to Minimise Transmission of Respiratory Tract Infection in Healthcare Settings, Health Protection Scotland, 31.10.2010 Infection Control Precautions During the Assessment of Patients Presenting with Respiratory Illness in A&E/Acute Admission Department, Health Protection Scotland, 30.07.2009 WHO, Infection prevention and control of epidemic- and pandemicprone acute respiratory disease in health care, 2007. 5. Action Plan for Implementation Action Lead Officer Timeframe Place on Occupational Elaine Simpson Health & Safety Intranet folder Place on Occupational Elaine Simpson Health & Safety latest documents Record in Workforce Elaine Simpson Occupational Health and Safety Policy / Procedure Register Disseminate to all staff via Heather Aitchison Line Management/SCN Group Raise awareness and Heather Aitchison inform all staff via induction and intranet. Use Policy All NHS D&G employees Title: Respiratory Mask Fit Testing Policy Page 12 of 17
NHS DUMFRIES AND GALLOWAY POLICY APPROVAL CHECKLIST This checklist must be completed and forwarded with the policy to the Corporate Business Manager for Quality Assurance, prior to approval of the policy. POLICY TITLE RESPIRATORY MASK FIT TESTING POLICY EXECUTIVE LEAD POLICY NO. Why has this policy been developed? Has the policy been developed in accordance with or related to legislation? Please give details of applicable legislation. Has a risk control plan been developed? Who is the owner of the risk? Who has been involved/consulted in the development of the policy? Does the policy contain evidence of the Equality & Diversity Impact Assessment Process? Is there an implementation plan? When will the policy take effect? If the policy applies to partner agencies, please explain the reasons for this and how they will be informed of their responsibilities Is any training required? If yes, has any been arranged? To comply with Health and Safety legislation and provide guidance and information for those NHS employees who either manage or are those staff who require to wear at tight fit mask. To prevent and control the spread of an infectious pathogen by the airborne route HSE Operational Circular OC 282/28 (Version 6, 30/04/2012) COSHH 2011 Occupational Health/Infection Prevention & Control Team Occupational Health, Infection Control, Nurse Management, Associate Medical Director, Health and Safety Adviser, Public Health, Staff Side Representation. YES YES NO Ongoing Are there any cost implications? If yes, please detail costs and note source of funding. Additional funding agreed via Infection Prevention & Control Title: Respiratory Mask Fit Testing Policy Page 13 of 17
Chair and Finance Directorate If the policy has to be reviewed other than biannually please state the reasons for this and who will review the policy (please give designation). Review 3 yearly or in event of any changes. Occupational Health & Safety Name: H Aitchison Date: Title: Respiratory Mask Fit Testing Policy Page 14 of 17
Appendix 1 Areas of Risk The following areas and groups of staff have been deemed by Infection, Prevention and Control Committee and Public Health as high risk : Emergency Care Centre CCU (Critical Care) Combined Assessment Unit (CAU) Respiratory Care Women and Childrens Wing (Paediatrics) Chest Physiotherapists Theatre Anaesthetics ANP (Advanced Nurse Practitioners) Mortuary staff Ward B2 See also D&G Major Emergency Scheme Pandemic Flu Plan Other areas and groups of staff may be identified, depending on hazard i.e. droplet borne infection. Advice will be provided by Infection Prevention and Control Team. Title: Respiratory Mask Fit Testing Policy Page 15 of 17
APPENDIX 2 Name: Designation: Respiratory Mask Fit Test - Record DoB: Department: Model/Size of Respirator: Own face piece, pool or test model used? Own Pool Test Fit test kit used? FT10 (sweet) FT 30 (bitter) Test conducted by (fit tester): Retest required? Yes No If yes, please state reasons: Pass achieved? Yes No Training & competency of wearer donning and fit checking mask satisfactory?: Comments: Yes No Date: Signed: (fit tester) Signed: (staff member) As Applicable Satisfactory Comments Condition of wearer s own face Yes/No piece THE WEARER MUST KEEP THIS RECORD FOR REFERENCE Repeat fit testing required if the wearer: loses or gains significant weight, undergoes substantial dental work or develops facial changes around face seal area. Fit test records must be stored for at least 5 years by the employer. These records must be kept available for inspection. Copy to Individual, Manager and Occupational Health Title: Respiratory Mask Fit Testing Policy Page 16 of 17
APPENDIX 3 USEFUL INFORMATION For advice contact Occupational Health and Safety dg.occhealth@nhs.net: Ext 34626 and/or Infection Prevention & Control Team For advice on when FFP3 protection must be worn refer to National Infection Prevention and Control Manual, Appendix 11 See Occupational Health & Safety Beacon folder FFP3 mask information re instruction on how to fit masks correctly, fit check masks and decontaminate, care and maintain re usable masks and/or respirators. For Fit test clinic dates/times and Information on fitting and fit checks of masks see Occupational Health & Safety, Beacon folder: Respiratory Mask Information To arrange a Mask Fit Test appointment out with clinic dates / times please contact Occupational Health and Safety Department Ext 34626 Dg.occhealth@nhs.net Title: Respiratory Mask Fit Testing Policy Page 17 of 17