Reducing airborne transmissible diseases in perioperative environments.

The COVID-19 pandemic has transformed our understanding of aerosol transmissible disease and the measures required to minimise transmission. Anaesthesia providers are often in close proximity to patients and other hospital staff for prolonged periods while working in operating and procedure rooms. Although enhanced ventilation provides some protection from aerosol transmissible disease in these work areas, close proximity and long duration of exposure have the opposite effect. Surgical masks provide only minimal additional protection. Surgical patients are also at risk from viral and bacterial aerosols. Despite having recently experienced the most significant pandemic in 100 yr, we continue to lack adequate understanding of the true risks encountered from aerosol transmissible diseases in the operating room, and the best course of action to protect patients and healthcare workers from them in the future. Nevertheless, hospitals can take specific actions now by providing respirators for routine use, encouraging staff to utilise respirators routinely, establishing triggers for situations that require respirator use, educating staff concerning the prevention of aerosol transmissible diseases, and providing portable air purifiers for perioperative spaces with low levels of ventilation.

Simulated workplace protection factor study of a quarter-facepiece elastomeric respirator.

The assigned protection factor (APF) for quarter-facepiece respirators is currently 5, based on fit test data from the 1970s with models no longer commercially available. The goal of this project was to evaluate the respirator fit capability of a NIOSH-approved N95 quarter-facepiece elastomeric respirator with a gel-based facial seal design (Envo Mask by Sleepnet Corporation). Human subjects were recruited from healthcare and the general population to satisfy a 25-member NIOSH bivariate panel. Subjects were fit tested with a fast fit protocol using a TSI Portacount Model 8038 in the N95 mode. Second-by-second measures of fit were then collected while subjects performed a 30-min series of simulated healthcare activities. Subjects completed a short comfort questionnaire. The median (5th, 95th percentile) fit factor was 188 (48, 201). Simulated workplace protection factors (SWPFs) had a median (5th, 95th percentile) of 181 (94, 199) (data truncated at 200) and 570 (153, 1508) (non-truncated data). Subjects ranked inhalation and exhalation as "easy" with average scores of 5.0/6.0 and 5.2/6.0, respectively. The facepiece was ranked between slightly comfortable and comfortable (4.8/6.0) and the harness as comfortable (5.0/6.0). Most users agreed (5.2/6.0) that the mask was stable on their faces. The 5th percentile SWPF of 95 supports an APF of at least 10 for this quarter-facepiece elastomeric respirator, similar to the APF for half-facepiece respirators. This study supports increasing the APF for quarter-facepiece respirators, a class that has been largely ignored by manufacturers for the past 40 years. A lightweight, low profile, reusable quarter-facepiece respirator is an effective option for healthcare and other worker protection during a pandemic and similar situations.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Dose, Infection, and Disease Outcomes for Coronavirus Disease 2019 (COVID-19): A Review.

The relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) dose, infection, and coronavirus disease 2019 (COVID-19) outcomes remains poorly understood. This review summarizes the existing literature regarding this issue, identifies gaps in current knowledge, and suggests opportunities for future research. In humans, host characteristics, including age, sex, comorbidities, smoking, and pregnancy, are associated with severe COVID-19. Similarly, in animals, host factors are strong determinants of disease severity, although most animal infection models manifest clinically with mild to moderate respiratory disease. The influence of variants of concern as it relates to infectious dose, consequence of overall pathogenicity, and disease outcome in dose-response remains unknown. Epidemiologic data suggest a dose-response relationship for infection contrasting with limited and inconsistent surrogate-based evidence between dose and disease severity. Recommendations include the design of future infection studies in animal models to investigate inoculating dose on outcomes and the use of better proxies for dose in human epidemiology studies.

Utilizing the focused conversation method in qualitative public health research: a team-based approach.

BACKGROUND: Qualitative research studies are becoming increasingly necessary to understand the complex challenges in the healthcare setting. Successfully integrating interdisciplinary teams of investigators can be challenging, as investigators inherently view data through their disciplinary lens. Thus, new methods, such as focused conservation, are needed to facilitate qualitative data analysis by interdisciplinary teams. The purpose of this manuscript is to provide a clear description of how we implemented the focused conversation method to facilitate an organized data-driven discussion that responded to our study objectives and ensured participation of our interdisciplinary team. The focused conversation method has not, to our knowledge, been utilized for this purpose to date. METHODS: To better understand the experience of healthcare personnel (HCP) during preparations for the 2014-2015 Ebola Virus Disease (EVD) outbreak, we interviewed HCP who participated in decision making about EVD preparations and training of workers in the use of enhanced personal protective equipment ensembles in the metropolitan Chicagoland area of Illinois to attain a priori research objectives. We identified a systematic method - the focused conversation method - that enabled our interdisciplinary team to interactively contribute to the framing, analysis and interpretation of the data that would enable us to focus on our research objectives. RESULTS: The focused conversation developed to support our a priori research objective about the training of HCP in preparations included objective, reflective, interpretive and decisional questions. These questions grounded the conversation in the data, while leveraging discipline-specific lenses and professional experience in the analysis and interpretation. Insights from the conversation were reviewed later against interview transcripts to ensure validity. The conversation identified areas for future research directions and deficiencies in the interview instrument. CONCLUSIONS: The focused conversation is an efficient, organized method for analysis of qualitative data by an interdisciplinary team.

Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015.

During the 2014-2015 Ebola Virus Disease (EVD) outbreak, hospitals in the United States selected personal protective equipment (PPE) and trained healthcare personnel (HCP) in anticipation of receiving EVD patients. To improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected PPE selection and training in the context of the EVD outbreak. Semistructured interviews were conducted with HCP involved with decision-making during EVD preparations at acute care hospitals in the Chicago, IL area to gather information about the PPE selection and training process. HCP who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. A total of 28 HCP from 15 hospitals were interviewed, and 55 HCP completed the survey. Factors affecting PPE selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for HCP. Cost did not affect selection. PPE acquisition challenges were mitigated by: sharing within hospital networks, reusing PPE during training, and improvising with existing PPE stock. Selected PPE ensembles were similar across sites. Training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase HCP confidence. Many felt refresher training would be helpful. Hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. Lacking confidence in the CDC guidance, interviewed trainers described turning to other sources of information and developing independent PPE evaluation and selection. Response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for PPE selection and training that addresses protection level, ease of use, ensembles, and availability.

Are quantitative fit factors predictive of respirator fit during simulated healthcare activities?

An annual OSHA fit test is required for all U.S. employees required to wear a respirator during work, but there are limited data demonstrating a link between fit test results and respirator fit during work. The goal of this research is to determine if the fit factor (FF) achieved during an abbreviated ambient aerosol condensation particle counter (CPC) quantitative fit test is predictive of fit achieved during a simulated workplace protection factor (SWPF) scenario that includes realistic healthcare activities. Fifteen subjects (7 male; 8 female) were recruited for a range of facial sizes. Each subject donned an N95 filtering facepiece respirator and performed a single 29-min routine consisting of initial and final 2.5 min fast fit tests (five 30-sec exercises: normal breathing, head side to side, head up and down, talking, and bending over) and three repetitions of three 6-min simulated healthcare activities (CPR, ultrasound, and making a hospital bed). Two CPC instruments simultaneously collected second-by-second measures of particle concentration inside and outside of the respirator facepiece. FFs or SWPFs were calculated by dividing outside by inside facepiece concentrations. Overall FFs and SWPFs were highly correlated. Each exercise FF was highly correlated with the overall SWPF. Normal breathing, head up and down, and talking were most predictive of overall SWPF. Normal breathing and talking together were predictive of each of the three simulated healthcare activities. For CPR and bed making activities, head movement exercises were also found to be predictive. A quantitative fit test using a small set of exercises is highly predictive of an individual's fit during simulated work activities. Some exercises (e.g., talking and head movements) are predictive of fit during simulated workplace activities. Limitations include only one respirator model, a small subject pool not representative of the full range of face sizes. This article uses an innovative second-by-second assessment method that collects information about in- and outside-facepiece concentrations throughout the test period.

Analysis of workers' compensation claims data for machine-related injuries in metal fabrication businesses.

BACKGROUND: Metal fabrication workers are at high risk for machine-related injury. Apart from amputations, data on factors contributing to this problem are generally absent. METHODS: Narrative text analysis was performed on workers' compensation claims in order to identify machine-related injuries and determine work tasks involved. Data were further evaluated on the basis of cost per claim, nature of injury, and part of body. RESULTS: From an initial set of 4,268 claims, 1,053 were classified as machine-related. Frequently identified tasks included machine operation (31%), workpiece handling (20%), setup/adjustment (15%), and removing chips (12%). Lacerations to finger(s), hand, or thumb comprised 38% of machine-related injuries; foreign body in the eye accounted for 20%. Amputations were relatively rare but had highest costs per claim (mean $21,059; median $11,998). CONCLUSIONS: Despite limitations, workers' compensation data were useful in characterizing machine-related injuries. Improving the quality of data collected by insurers would enhance occupational injury surveillance and prevention efforts. Am. J. Ind. Med. 59:656-664, 2016. © 2016 Wiley Periodicals, Inc.

Comparison of two quantitative fit-test methods using N95 filtering facepiece respirators.

Current regulations require annual fit testing before an employee can wear a respirator during work activities. The goal of this research is to determine whether respirator fit measured with two TSI Portacount instruments simultaneously sampling ambient particle concentrations inside and outside of the respirator facepiece is similar to fit measured during an ambient aerosol condensation nuclei counter quantitative fit test. Sixteen subjects (ten female; six male) were recruited for a range of facial sizes. Each subject donned an N95 filtering facepiece respirator, completed two fit tests in random order (ambient aerosol condensation nuclei counter quantitative fit test and two-instrument real-time fit test) without removing or adjusting the respirator between tests. Fit tests were compared using Spearman's rank correlation coefficients. The real-time two-instrument method fit factors were similar to those measured with the single-instrument quantitative fit test. The first four exercises were highly correlated (r > 0.7) between the two protocols. Respirator fit was altered during the talking or grimace exercise, both of which involve facial movements that could dislodge the facepiece. Our analyses suggest that the new real-time two-instrument methodology can be used in future studies to evaluate fit before and during work activities.

Two-year follow-up of the Collision Auto Repair Safety Study (CARSS).

This paper presents an evaluation of the sustainability of health and safety improvements in small auto collision shops 1 year after the implementation of a year-long targeted intervention. During the first year (active phase), owners received quarterly phone calls, written reminders, safety newsletters, and access to online services and in-person assistance with creating safety programs and respirator fit testing. During the second year (passive phase), owners received up to three postcard reminders regarding the availability of free health and safety resources. Forty-five shops received an evaluation at baseline and at the end of the first year (Y1). Of these, 33 were evaluated at the end of the second year (Y2), using the same 92-item assessment tool. At Y1, investigators found that between 70 and 81% of the evaluated items were adequate in each business (mean = 73% items, SD = 11%). At Y2, between 63 and 89% of items were deemed adequate (mean = 73% items, SD = 9.5%). Three safety areas demonstrated statistically significant (P < 0.05) changes: compressed gasses (8% improvement), personal protective equipment (7% improvement), and respiratory protection (6% decline). The number of postcard reminders sent to each business did not affect the degree to which shops maintained safety improvements made during the first year of the intervention. However, businesses that received more postcards were more likely to request assistance services than those receiving fewer.

The Collision Auto Repair Safety Study (CARSS): a health and safety intervention.

BACKGROUND: Collision repair employs approximately 205,500 people in 33,400 shops. Workers are exposed to a diverse array of chemical, physical, and ergonomic hazards. METHODS: CARSS was based on a random and purposeful sample. Baseline and one baseline and one-year evaluations consisted of 92 questions addressing issues, such as Right-to-Know, fire protection, painting-related hazards, ergonomics, electrical safety, and personal protective equipment. Owners received a report and selected at least 30% of items found deficient for remediation. In-person and web-based services were provided. RESULTS: Forty-nine shops were evaluated at baseline and 45 at follow-up. At baseline, 54% of items were present. This improved to 71% at follow-up (P < 0.0001). Respiratory protection improved 37% (P < 0.0001) and Right-to-Know training increased 30% (P < 0.0001). Owners completed 61% of items they selected for remediation. CONCLUSIONS: Small businesses' interventions should address the lack of personnel and administrative infrastructure. Tailored information regarding hazards and easy-to-use training and administrative programs overcome many barriers to improvement.

National Machine Guarding Program: Part 1. Machine safeguarding practices in small metal fabrication businesses.

BACKGROUND: Metal fabrication workers experience high rates of traumatic occupational injuries. Machine operators in particular face high risks, often stemming from the absence or improper use of machine safeguarding or the failure to implement lockout procedures. METHODS: The National Machine Guarding Program (NMGP) was a translational research initiative implemented in conjunction with two workers' compensation insures. Insurance safety consultants trained in machine guarding used standardized checklists to conduct a baseline inspection of machine-related hazards in 221 business. RESULTS: Safeguards at the point of operation were missing or inadequate on 33% of machines. Safeguards for other mechanical hazards were missing on 28% of machines. Older machines were both widely used and less likely than newer machines to be properly guarded. Lockout/tagout procedures were posted at only 9% of machine workstations. CONCLUSIONS: The NMGP demonstrates a need for improvement in many aspects of machine safety and lockout in small metal fabrication businesses.

National Machine Guarding Program: Part 2. Safety management in small metal fabrication enterprises.

BACKGROUND: Small manufacturing businesses often lack important safety programs. Many reasons have been set forth on why this has remained a persistent problem. METHODS: The National Machine Guarding Program (NMGP) was a nationwide intervention conducted in partnership with two workers' compensation insurers. Insurance safety consultants collected baseline data in 221 business using a 33-question safety management audit. Audits were completed during an interview with the business owner or manager. RESULTS: Most measures of safety management improved with an increasing number of employees. This trend was particularly strong for lockout/tagout. However, size was only significant for businesses without a safety committee. Establishments with a safety committee scored higher (55% vs. 36%) on the safety management audit compared with those lacking a committee (P < 0.0001). CONCLUSIONS: Critical safety management programs were frequently absent. A safety committee appears to be a more important factor than business size in accounting for differences in outcome measures.

Smoking patterns, quit behaviors, and smoking environment of workers in small manufacturing companies.

BACKGROUND: This study describes smokers employed at 47 small manufacturing companies in Minnesota, USA. METHODS: Smokers (n = 713) participating in a group-randomized trial completed a baseline survey on their smoking patterns, quit behaviors, smoking environment, workplace attitudes about smoking, and correlates of smoking. These characteristics were examined by job type and a latent class analysis (LCA) was performed to group workers with similar characteristics. RESULTS: Production workers had the highest prevalence of daily smoking (88% vs. 68% among managers), and addiction (61% vs. 26% among managers), and the highest mean level of perceived stress (6.4 vs. 4.9 among managers). The LCA identified three subgroups of smokers that differed in levels of barriers to cessation. Production workers were most likely to be in the group with greater barriers (P = 0.01). CONCLUSIONS: These results underscore the importance of targeting interventions to production workers and those who exhibit the greatest barriers to cessation.

Comparing written programs and self-reported respiratory protection practices in acute care hospitals.

Airborne biological hazards in hospitals require the use of respiratory protection. A well-implemented respiratory protection program can protect health care workers from these exposures. This study examines the relationship between written respiratory programs and reported practices in health care settings. Twenty-eight hospitals in Illinois and Minnesota were recruited to a study of respiratory protection programs and practices in acute care settings. Interviews were conducted with hospital managers, unit managers, and health care workers from departments where respirators are commonly required. Each hospital's written respiratory protection program was scored for the 11 elements required by the Occupational Safety and Health Administration (OSHA), using a standardized tool, for a maximum possible score of 22 (2 pts. per element). Twenty interview questions associated with program practices were also scored by percent correct responses. Written program scores ranged from 2-17 with an average of 9.2. Hospital and unit managers scored on average 82% and 81%, respectively, when compared to the OSHA standard; health care workers scored significantly lower, 71% (p < 0.001). Minnesota written program scores were not significantly higher than Illinois hospitals (p = 0.16), while all Illinois survey respondents scored higher than those in Minnesota (p < 0.001). There was no trend between written programs and interview responses. Written respiratory protection programs in the study sites did not provide the level of detail required OSHA. Interview responses representing hospital practices surrounding respiratory protection indicated that hospitals were aware of and following regulatory guidelines.

Evaluation of Minnesota and Illinois hospital respiratory protection programs and health care worker respirator use.

The objective of this study was to assess respiratory protection programs for aerosol-transmissible diseases in acute care hospitals for conformance with regulatory requirements and public health guidelines. Twenty-eight representative hospitals were selected by size, location, and ownership in Minnesota and Illinois. Interviews were conducted with 363 health care workers and 171 managers from high-risk departments. Written programs from each hospital were reviewed for required elements. Seventy-seven health care workers were observed donning and doffing a FFR. The most serious deficiency in many written programs was failure to identify a program administrator. Most written programs lacked adequate details about medical evaluation, fit-testing, and training and did not include a comprehensive risk assessment for aerosol transmissible diseases; tuberculosis was often the only pathogen addressed. Employees with the highest probability of tuberculosis exposure were most likely to pick a respirator for close contact, but higher levels of respiratory protection were rarely selected for aerosol-generating procedures. Surgical masks were most commonly selected for close contact with droplet disease- or influenza-infected patients; better protection (e.g., respirator) was rarely selected for higher-risk exposures. Most of the observed health care workers had access to a NIOSH-certified N95 FFR, properly positioned the facepiece, and formed the nose clip. The most frequent deficiencies were failure to correctly place straps, perform a user seal check, and remove the respirator using straps.

Understanding safety climate in small automobile collision repair shops.

BACKGROUND: In the United States, approximately 236,000 people work in 37,600 auto collision-repair businesses. Workers in the collision-repair industry may be exposed to a wide range of physical and chemical hazards. METHODS: This manuscript examines the relationship of safety climate as reported by collision repair shop workers and owners to: (1) an independent business safety assessment, and (2) employee self-reported work practices. The study was conducted in the Twin Cities metropolitan area. RESULTS: A total of 199 workers from 49 collision shops completed a survey of self-reported work practices and safety climate. Surveys were completed by an owner or manager in all but three shops. In general, self-reported work practices were poor. Workers' scores on safety climate were uniformly lower than those of owners. For workers, there was no correlation between how well the business scored on an independent audit of business safety practices and the safety climate measures they reported. For owners, however, there was a positive correlation between safety climate scores and the business safety assessment. For workers, safety rules and procedures were associated with improved work practices for those engaged in both painting-related and body technician-related activities. CONCLUSIONS: The enforcement of safety rules and procedures emerged as a strong factor positively affecting self-reported work practices. These findings identify a simple, cost effective path to reducing hazards in small workplaces.

Criticism of Workplace Protection Barrier Face Covering Article Mischaracterizes ASTM Standard and its Potential Utility.

Editor's Note: This is a response to "Why a Workplace Barrier Face Covering is a Bad Idea" by Mark Nicas. DOI: 10.1177/10482911231193771.