Michael J. Hodgson

Respirator tolerance in health care workers.

past 5 years, the following authors have received financial support and maintained affiliations as follows: Dr Lu-Yao has received clinical research funding from the New Jersey Commission on Cancer Research and the Agency for Healthcare Research and Quality and employment with HealthStat; Dr Peter Albertson has received clinical research funding from Sanofi-Aventis and consultation fees from Blue Cross/Blue Shield; and Dr Weichung Shih has received clinical research funding from Myriad. None of these entities contributed funding or played any role whatsoever in the design, interpretation, or drafting of our study or manuscript. We regret any misunderstanding that resulted from the omission of these disclosures.

Discomfort and Exertion Associated with Prolonged Wear of Respiratory Protection in a Health Care Setting

The nature of discomfort and level of exertion associated with wearing respiratory protection in the health care workplace are not well understood. Although a few studies have assessed these topics in a laboratory setting, little is known about the magnitude of discomfort and the level of exertion experienced by workers while they deliver health care to patients for prolonged periods. The purpose of this study was to determine the magnitude of discomfort and level of exertion experienced by health care workers while wearing respiratory protection for periods up to 8 hr when performing their typical occupational duties. This project was a multiple cross-over field trial of 27 health care workers, aged 24–65, performing their typical, hospital-based occupational duties. Each participant served as his/her own control and wore one of seven respirators or a medical mask for 8 hr (or as long as tolerable) with interposed doffing periods every 2 hr. Self-perceived discomfort and exertion were quantified before each doffing: self-perceived level of discomfort using a visual analog scale, and self-perceived level of exertion using a Borg scale. Overall, and as would be expected, discomfort increased over time with continual respirator use over an 8-hr period. Interestingly, exertion increased only marginally over the same time period. The relatively low level of exertion associated with eight respiratory protective devices, including models commonly used in the U.S. health care workplace, is not likely to substantially influence workers’ tolerability or occupational productivity. However, the magnitude of discomfort does appear to increase significantly over time with prolonged wear. These results suggest that respirator-related discomfort, but not exertion, negatively influences respirator tolerance over prolonged periods. Discomfort may also interfere with the occupational duties of workers.

The Assessment of Irritation Using Clinical Methods and Questionnaires

Sensory irritant responses to chemical exposures are measured by a variety of methods; however, studies can be influenced from biases associated with study design and subject responses. This article reviews the different methods used to quantitate irritation. These methods primarily focus on eye and nasal mucosal irritation. Although methods to evaluate mouth, throat mucosal, and dermal irritation are also relevant, they are seldom used in actual practice. Measurements for eye irritation include tear film stability, epithelial damage, foam formation, blinking frequency, tear flow, inflammation, and hyperemia. Methods for detecting nasal mucosa irritation include measuring swelling of the nasal mucosa, peak airflows through the nose, acoustic rhinometry, and rhinostereometry, which measures thickness of the anterior nasal turbinate. Questionnaires are useful for defining a set of symptoms in an attempt to characterize dose-response relationships from controlled exposure studies or field studies, to compare rates of events in field studies, or to screen for disease. However, it is important to consider carefully the study design, goal of utilization, and constraints surrounding their application. Whichever method is used in medical surveillance or to evaluate effectiveness of industrial hygiene or engineering controls in preventing irritation effects from chemical exposure, the sensitivity, specificity, and predictive value of the irritation measurements are important factors in interpreting the results. This article reviews these various issues and offers some advice.

Pulmonary Disease Associated with Cafeteria Flooding

An illness among office workers, consisting of cough, fever, chills, muscle aches, and chest tightness was associated with water leaks from a cafeteria. Mean single breath carbon-monoxide diffusing capacity (DLCO) of cases differed significantly from that of non-cases. There was a significant decrease in the percent of predicted DLCO with increasing number of symptoms. Testing for precipitating antibodies to microbial agents found in the building revealed no differences between cases and non-cases. DLCO is an appropriate cross-sectional instrument for field investigations of building-associated respiratory disease.

Seasonal Influenza Vaccination of Healthcare Employees: Results of a 4-Year Campaign

OBJECTIVE To document successful substantial increases in healthcare worker influenza vaccination rates and to identify reasons for success and failure. DESIGN (1) Four-year longitudinal characterization of facility vaccination rates, (2) Web-based facility-level questionnaire for influenza coordinators to identify success factors in year 3, and (3) semistructured telephone interviews of influenza coordinators at facilities with substantial increases or declines in year 4. SETTING National single-payer hospital (healthcare) system with 153 hospitals in 5 levels of complexity. PATIENTS Facility leadership staff. METHODS (1) Vaccination data collected from management sources (doses from pharmacies, denominator data from payrolls); (2) a Web-based survey aligned with a previously administered instrument (Wisconsin Health Department), piloted in-house, modified to reflect national strategies and improvements; and (3) semistructured telephone interviews with influenza coordinators at facilities that improved or worsened by more than 20% between the 2007-2008 and 2008-2009 influenza seasons. RESULTS Vaccination acceptance rates improved from 45% of healthcare workers in 2005-2006 to 66.5% in 2008-2009. Facilities with lower complexity had higher vaccination rates. No individual factors were associated with improved performance. CONCLUSIONS Sustained management attention can lead to improvements in healthcare worker influenza vaccination rates. Wavering of attention, though, may lead to rapid loss of effectiveness. Declination statements in this system did not contribute to vaccine acceptance.

Latex hypersensitivity in Department of Veterans Affairs health care workers: glove use, symptoms, and sensitization

BACKGROUND This report of the prevalence of latex glove allergy in 3 Department of Veterans Affairs (VA) medical centers was a collaboration of the VA, the Centers for Disease Control and Prevention, and the National Institute for Occupational Safety and Health. OBJECTIVE To enroll and evaluate personnel from across the entire hospital workforce for latex hypersensitivity and to determine the type and extent of latex glove use. METHODS A questionnaire was administered that covered demographics, job category, latex glove use, and current latex glove allergic symptoms. Skin testing to aeroallergens was performed to evaluate the presence of atopy. Blood was drawn for analyses of serum antilatex IgE antibody by CAP assay. RESULTS Of 1,959 subjects, 158 (8.1%) had latex glove-allergic symptoms, a positive latex CAP assay result, or both. In 1,003 subjects who reported latex glove use, 915 (91.4%) used nonpowdered gloves. A total of 133 subjects reported latex glove allergic symptoms, and 36 subjects had positive CAP assay results. Latex sensitization was correlated with atopy, race, and latex glove exposure. Latex symptoms were correlated with atopy, a positive CAP assay result, and latex glove exposure. Of the 133 subjects with latex glove allergic symptoms, only 11 had positive CAP assay results, giving a prevalence of confirmed latex glove allergy of 0.6%. CONCLUSIONS Symptoms attributed to latex gloves and/or latex sensitization occurred in 8.1% of the employee population, with exposure, race, and atopy being the major risk factors. Few symptomatic individuals were sensitized to latex (0.6%). This low rate of confirmed latex glove allergy may have been related to nonpowdered glove use.

Comprehensive survey of hand hygiene measurement and improvement practices in the Veterans Health Administration

BACKGROUND Veterans Health Administration (VHA) is a national health care system with variation in hand hygiene (HH) measurement and improvement practices across its facilities. The objective of this national survey was to characterize this variability and identify opportunities for standardization. METHODS Survey covered 3 major areas of HH: (1) methods of measuring HH compliance, (2) interventions to improve HH compliance, and (3) site-specific targets for HH compliance. RESULTS One hundred forty-one (100%) VHA medical centers returned the survey. A majority (98.6%) of the medical centers conduct direct observations to measure HH compliance rates. Fewer than half (45.3%) validate the observer process at the onset, and fewer still (39.6%) continue to validate observers. Main behaviors that are considered HH opportunities are room entry (69.1%) and exit (71.9%). Improvement interventions include posters (97.2%), feedback (eg, 98.6% to leadership), and improved access to HH products (eg, 90.6% provide individual hand sanitizers to staff). Mandatory education programs for clinical staff are conducted in 88.5% of the medical centers. The majority of the medical centers (77.3%) set their HH compliance target over 90%. CONCLUSION Although HH improvement interventions are relatively similar across VHA medical centers, variation exists in compliance monitoring. Findings will assist in standardizing surveillance and next steps in hand hygiene policy in VHA.

Managing disruptive patients in health care: Necessary solutions to a difficult problem

BACKGROUND We sought to describe the components and processes in a violence risk assessment and management system, including electronic record requirements in the Veterans Health Administration (VA). We present information on system-level variation among program elements and their association with perceived and measured effectiveness. METHODS We conducted a cross-sectional survey of Chiefs of Staff (COS) at 140 VA hospitals across the United States about specific disruptive behavior program elements, such as committee processes, patient referrals, and outcome patterns. We assessed COS perceived effectiveness of the processes. We compared COS perceptions with employee-reported assault-related incident rates and workers compensation lost time claim rates for assault-related injuries for 2009 and 2010. RESULTS We found the violence risk assessment and management system is heavily used, often with guidance to provide police protection for providers. COS respondents were generally satisfied with design and performance of the system. Committee processes and perceptions of effectiveness were associated with reduction in assault-related incident rates. CONCLUSIONS VAs system was considered effective by system owners and users may be effective at reducing assaulted-related injuries.

Occupational Tuberculosis Among Deputy Sheriffs in Connecticut: A Risk Model of Transmission

OBJECTIVES The purpose of this study was to identify risk factors for tuberculin skin test conversions among non-infected deputy sheriffs in Connecticut and during an out-break in an urban lock-up. METHODS 377 tuberculin skin-test negative sheriffs statewide in 1994-1995 and 37 sheriffs in the lock-up in 1995 were screened and questionnaires administered. Cellblock volumetric air flow was measured. The Wells-Riley model of airborne transmission [C = S(1-e-Iqpt/Q)] was applied to the epidemiologic and ventilation data. RESULTS Statewide, of 377 sheriffs screened, 22 (5.8%) had positive skin tests. Risk factors included older age (p < .0075) and longer tenure (p < .036). In the lock-up, of 37 sheriffs screened, 4 (10.8%) had positive skin tests. Measured mean outside air flow per occupant (8.0 cfm; S.D. = 2.2) was below design (15 cfm) and recommended (20 cfm) standards. Mathematical modeling estimated that TB transmission would be reduced by 62.5 percent with ventilation at design specifications. CONCLUSIONS Inadequate ventilation may increase the risk for occupational transmission of tuberculosis. Since lock-ups do not have the time to conduct inmate TB screenings, supplemental engineering controls may be required.