Strategies for Optimizing the Supply of N95 Respirators: Contingency Capacity Strategies

Contingency Capacity Strategies

In the continuum of care, the following measures can be categorized as contingency capacity, which may change daily practices but may not have any significant impact on the care delivered to the patient or the safety of the HCP.1 The following measures may be considered in the setting of a potential impending shortage of N95 respirators. The decision to implement these practices should be made on a case by case basis taking into account known characteristics of the SARS-CoV-2 and local conditions (e.g., number of disposable N95 respirators available, current respirator usage rate, success of other respirator conservation strategies, etc.).

Administrative Controls

Decrease length of hospital stay for medically stable patients with COVID-19

Currently, CDC recommends discharge of patients with confirmed COVID-19 when they are medically stable and have an appropriate home environment to which to return. CDC lists considerations for care at home in: Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19). If patients cannot be discharged to home for social rather than medical reasons, public health officials might need to identify alternative non-hospital housing where those patients can convalesce.

Personal Protective Equipment and Respiratory Protection

Use of N95 respirators beyond the manufacturer-designated shelf life for training and fit testing

In times of shortage, consideration can be made to use N95 respirators beyond the manufacturer-designated shelf life. However, expired respirators might not perform to the requirements for which they were certified. Over time, components such as the strap and material may degrade, which can affect the quality of the fit and seal. Because of this, use of expired respirators could be prioritized for situations where HCP are NOT exposed to pathogens, such as training and fit testing.  As expired respirators can still serve an important purpose, healthcare facilities should retain all N95 respirators during the early phases of this outbreak.

Extended use of N95 respirators

Practices allowing extended use of N95 respirators, when acceptable, can also be considered. The decision to implement policies that permit extended use of N95 respirators should be made by the professionals who manage the institution’s respiratory protection program, in consultation with their occupational health and infection control departments with input from the state/local public health departments. CDC has recommended guidance on implementation of extended use of N95 respirators in healthcare settings. Extended use has been recommended and widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.

Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.2 Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit). It can also be considered to be used for care of patients with tuberculosis, varicella, and measles.

Limited re-use of N95 respirators for tuberculosis

Re-use refers to the practice of using the same N95 respirator by one HCP for multiple encounters with different patients but removing it (i.e. doffing) after each encounter.2 This practice is often referred to as “limited reuse” because restrictions are in place to limit the number of times the same respirator is reused. It is important to consult with the respirator manufacturer regarding the maximum number of donnings or uses they recommend for the N95 respirator model. If no manufacturer guidance is available, data suggests limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin.3 N95 and other disposable respirators should not be shared by multiple HCP. CDC has recommended guidance on implementation of limited re-use of N95 respirators in healthcare settings.

For pathogens for which contact transmission is not a concern, routine limited reuse of single-use disposable respirators has been practiced for decades. For example, for tuberculosis prevention, a respirator classified as disposable can be reused by the same provider as long as the respirator maintains its structural and functional integrity. To extend the supply of N95 respirators during an anticipated dwindling supply, HCP could be encouraged to reuse their N95 respirators when caring for patients with tuberculosis disease.4

To maintain the integrity of the respirator, it is important for HCP to hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. It is not recommended to modify the N95 respirator by placing any material within the respirator or over the respirator. Modification may negatively affect the performance of the respirator and could void the NIOSH approval.

References

  1. Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(2 Suppl): S59-67.
  2. Fisher, Edward M., and Ronald E. Shaffer. Considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings. Journal of occupational and environmental hygiene 11, no. 8 (2014): D115-D128.
  3. Bergman MS, Viscusi DJ, Zhuang Z, Palmiero AJ, Powell JB, Shaffer RE. Impact of multiple consecutive donnings on filtering facepiece respirator fit. Am J Infect Control. 2012; 40(4):375–380.
  4. Hammond, D.R., Cecala, A.B., Colinet, J.F., Garcia, A., Mead, K.R., Echt, A., Shulman, S.A., Hein, M.J., Gressel, M.G., Blade, L.M. and Zimmer, J.A., 2015. Hospital respiratory protection program toolkit: resources for respirator program administrators.