Hospital and institutional protocol for reusable respirators: Getting ready for the coming wave of shortages
Acknowledgements: Dr. Alex Pavlosky researched the proposal presented here with the help of Jake Bender. Dr. Sydney Todorovich wrote a separate analysis. This article is based on their work.
Full text of protocol: An Institutional Protocol for Collecting, Decontaminating, and Reservicing Reusable Respirators and Filters. Refer to the following article for more: Health care workers must move to reusable respirators now: Here’s how
Hospitals and health institutions are struggling to meet their mandates in the complex environment of the COVID-19 pandemic. Shortages in personal protective equipment (PPE) have been exacerbated by an absence of non-disposable options.
Since our group highlighted the need to move to reusable equipment urgently, others in Canada and internationally have moved toward understanding how our recommendations could be implemented on an institutional level. The need for these efforts has been exacerbated by worsening shortages of PPE at almost every institution internationally, coupled with significant and continuing supply chain issues. Almost every health authority has reported serious or critical shortages of PPE, and many have implemented extended use, reuse and conservation protocols.
Helping institutions change old policies
We have consulted for several ministries, health authorities, hospitals and clinics on this issue. It is clear that these institutions wish to implement changes but do not have clear direction on how to do this. Glia has researched and published an institutional protocol for use by ministries, health authorities, hospitals and clinics switching to reusable N95 respirators. We present some of the highlights of our experiences below.
Barriers to individual and institutional acceptance
Having worn reusable N95 respirators during emergency shifts for the past two weeks, members of Glia report difficulties with being understood while speaking. This is especially problematic during critical emergencies in which communication is essential, such as patients with vital signs absent or in which a cardiac or respiratory arrest code is being run. Masks can also cause feelings of claustrophobia. Most physicians and allied health workers we spoke to who wore reusable N95 respirators for an extended period believed that these respirators would take time to become familiar to health care workers and would ultimately be limited in their penetration to 50–75% of all health care workers.
“Ministries and health authorities must clearly signal to hospitals that reusable N95 respirators are a primary part of the PPE strategy.”
Glia has received numerous reports of health care workers in Canada and internationally being challenged, intimidated or threatened by colleagues and administrators over their use of reusable respirators. Most of these concerns are on the basis of optics — the fear of inciting panic among patients and fellow health care workers — and a lack of familiarity causing concerns about worker safety.
Institutions that wish to implement reusable respirators struggle to implement protocols related to their use and maintenance. Internal administrative disagreements about the severity of PPE shortages appear to also play a role, with several institutions wishing to implement reusable respirators as a “Plan D”, rather than considering them as part of their “Plan A”.
Three moments of institutional support for reusable respirators
There are three moments in which institutional support is required: Authorizing and fitting health care workers to use reusable respirators; Collecting and cleaning reusable respirators; Redistributing respirators.
Laying the groundwork
Ministries and health authorities must clearly signal to hospitals that reusable N95 respirators are a primary part of the PPE strategy. For their part, hospitals and clinics should adopt policies that guarantee the rights of workers who wear reusable respirators so long as they are approved by that country’s authorities.
Policies about the use of reusables must include the following points:
- Fit testing
- Donning and doffing of reusable respirators
- Proper maintenance and decontamination
- Policies protecting sick time and worker rights, even if mistakes are made in the implementation of reusable respirators during use
Collection and cleaning of reusable respirators
In our detailed paper on the subject , we propose a well-tested and widely-endorsed method for disinfecting reusable respirators: The use of 5000 ppm free chlorine solution for one minute. Creating a 5000ppm solution can be aided using our Chlorine Calculator for both sodium and calcium hypochlorite.
We propose a vapor-phase hydrogen peroxide (VPHP) method for sterilizing filters. Other groups have proposed a simple disinfectant wipe on the filters instead.
Redistribution of respirators
Reusable respirators can be redistributed to health care workers in many ways. We propose their redistribution in sealed plastic bags similar to those used for surgical tools.
The time is now
We have all systematically and repeatedly underestimated the impact of the COVID-19 pandemic. It is likely that disposable respirators will continue to be in short supply despite CDC recommendations recommending reusable N95 respirators where feasible, and so we propose an institutional protocol to be implemented immediately in hospitals in preparation for this. To study and implement protocols now will allow for an orderly transition instead of a rushed and uncontrolled one that may compromise health care worker safety.
