PANDEMIC PLANNING
Engineering, Administrative Controls, and Personal Protective Equipment for Healthcare Personnel
Options for Reducing Exposures when Caring for Confirmed Cases, Probable Cases, and Cases Under Investigation for Infection with Novel Influenza A Viruses Associated with Severe Disease
Overview
Controlling exposures to occupational hazards is a fundamental way to protect personnel. CDC has provided recommendations for initial infection control in healthcare settings for patients who may be infected with a novel influenza A virus associated with severe disease . This website expands on those elements to prevent transmission including engineering and administrative controls.
Traditionally, a hierarchy of controls has been used to achieve feasible and effective control and has some overlap. Some of the control measures may fall into multiple categories. It should also be emphasized that multiple control strategies can be implemented currently. This hierarchy can be represented as follows:
- Elimination
- Substitution
- Engineering Controls
- Administrative Controls
- Personal Protective Equipment
To prevent infectious disease transmission, elimination and substitution are not typically options for the healthcare setting. However, exposures to transmissible respiratory pathogens in health care facilities can often be reduced or possibly avoided through engineering and administrative controls and personal protective equipment (PPE).
N95 respirators (i.e., filtering facepiece respirators) are the PPE most often used to control exposures to airborne transmissible respiratory infections, though their effectiveness is highly dependent upon proper fit and use. Planners estimate that in a severe pandemic, more N95 respirators would be needed than industry can supply—shortages of N95 respirators were observed during the 2009 H1N1 pandemic influenza season. However, it is important to recognize that the optimal way to prevent transmission of airborne transmissible respiratory infections in healthcare facilities is to use a combination of interventions from across the hierarchy of controls, not just PPE alone. Applying a combination of controls can provide a degree of protection, even if one intervention fails or is not available.
This website provides interventions from across the hierarchy of controls that can be used in combination to reduce pathogen transmission even if one intervention, such as N95 respirators, becomes unavailable during a pandemic. These controls were originally recommended for controlling influenza exposures in the workplace; however, the principles may be applicable to other transmissible respiratory pathogens. The Occupational Safety and Health Administration also provides resources about preparing workplaces for an influenza pandemic on their website (need updated link, original does not work). This guidance may change based on the specific transmissible respiratory disease characteristics.
Engineering Control Solutions
Engineering controls reduce exposures for employees by removing the hazard from the process or placing a barrier between the hazard and the employee. Engineering controls can be very effective as part of a suite of strategies to protect employees without placing primary responsibility of implementation on the employee. NIOSH offers the following engineering control solutions that aim to reduce airborne respiratory infection transmission potential within healthcare settings.
Barriers such as glass/plastic windows can be an effective solution for isolating healthcare personnel from the ill patients and the public.
The ventilated headboard is an effective solution for surge isolation capacity (i.e. for those scenarios where existing engineered isolation capacity is overwhelmed or otherwise not available) and alternative environment (i.e. emergency medical shelter) isolation that isolates patients while protecting healthcare personnel during a pandemic outbreak.
Ultraviolet germicidal irradiation (UVGI) uses ultraviolet light to break down and inactivate infectious organisms such as TB bacteria. UVGI systems have been known to have a destructive effect upon pathogenic organisms since the late 1800’s. The design, implementation and maintenance of UVGI devices can be a challenge but when done correctly, UVGI which is still being researched maycan help to reduce the transmission of certain transmissible respiratory infections.
Science, engineering and medicine continue to be rapidly evolving fields. Researchers continue to work on evolving technologies intended to make healthcare environments safer for their occupants. The absence of discussion of a particular engineering control or technology on this website should not necessarily be interpreted as a negative endorsement. However, end users considering the adoption of an evolving technology are encouraged to carefully evaluate the literature supporting its efficacy and to consider the following questions: Are there independent studies that prove the desired performance efficacy of the technology? Was the supporting research conducted in realistic test environments? Have the performance results been published in a respected peer-reviewed scientific and/or medical journal? Was the evolving technology evaluated for any potential adverse impact or occupational exposures? Where has the technology already been deployed? Are there independent points of contact at those locations for you to discuss the technology?
Expedient patient isolation rooms are an effective solution for surge isolation capacity by converting traditional patient rooms into patient care areas that offer patient isolation through containing and cleaning air near the infected patient’s bed within a larger ventilated zone.
Administrative Control Solutions
The term administrative controls refer to employer-developed work practices and policies that may reduce or prevent hazardous exposures. Their effectiveness depends on employer commitment and employee acceptance, patient compliance and consistent use of the strategies. Regular monitoring and reinforcement are necessary to ensure that policies and procedures are followed consistently. NIOSH offers the following administrative control solutions that aim to reduce respiratory infection transmission potential within occupational healthcare settings.
Vaccination of healthcare personnel will substantially reduce the risk of becoming infected with influenza and spreading pandemic influenza to others.
Cough etiquette and hand hygiene will help limit the spread of the flu directly through infectious droplets in the air and contaminated surfaces.
During an influenza pandemic, healthcare personnel may be assigned to a group or cohort of patients. Grouping of infected patients or staff assigned to patients who are ill will help limit the number of well people who are exposed to the flu. Cohorting may also reduce the number of personnel caring for these ill patients and therefore, reduce the number of respiratory devices needed.
Social distancing increases the physical space between people and reduces the frequency of contact between well and potentially ill people.
Employees can be instructed to monitor themselves for the signs of illness during a pandemic influenza outbreak, and if certain symptoms are noted, to communicate with their supervisor. In addition, in triage or pre-triage areas, patients can be screened to help keep sick people away from well people by identifying those who are ill. Patients with potentially-infectious symptoms can also be pre-identified prior to being seen by a healthcare provider, thus allowing opportunity for interventions (e.g., patient masks, special room placement) as well as reducing potential for inadvertent exposures to healthcare workers.
Non-punitive sick leave is one way to reduce the spread of the flu by keeping sick employees away from patients and well employees.
Training on the hazards associated with influenza helps to ensure personnel are aware of the hazards of influenza and may increase the likelihood that they will follow proper infection control policies.
Limiting visitors to those necessary will help limit the number of well people who are exposed to influenza.
Personal Protective Equipment Solutions
While engineering and administrative controls should be considered first when selecting controls, the use of PPE should also be part of a suite of strategies used to protect personnel. Employing multiple strategies simultaneously including engineering and administrative controls and PPE offers the optimal environment to reduce transmission of respiratory diseases, such as novel influenza A viruses, in healthcare settings. More information about PPE options is available on the NIOSH Respirator Trusted-Source Information webpage.