Guidance on use of N95 mask

We continue to receive messages from RNs who, in their judgment, require the use of N95 and are denied their use. The guidance, given the shortage of N95, is that they are specifically allocated for use in ICUs and mainly for aerosolized procedures. However, exceptions to this guidance should be recognized.

An RN reports working in a hemodialysis unit with chronic renal patients that often have difficulty breathing, with cough symptoms that could mask real Covid-19 symptoms. Nurses may provide oxygen to ease up breathing while preparing for the hemodialysis. This poses a real threat to the health and workload of the staff. Even with surgical mask and gown, the constant coughing of the patient, as well as the oxygen flow, could potentially be seen as aerosolized actions. Even for renal nurses doing the hemodialysis of COVID-19 patients in the ICU, the guidance in this particular hospital is still not to use N95. She reports that a number of staff in the hemodialysis unit have already tested Covid+. 

According to the Ontario Chief Medical Officer of Health’s directive,

• A point-of-care risk assessment (PCRA) must be performed by every health care worker (“worker”) before every patient interaction in a public hospital.
• If a worker determines, based on the PCRA, and based on their professional and clinical judgement, that health and safety measures may be required in the delivery of care to the patient, then the public hospital must provide that worker with access to the appropriate health and safety control measures, including an N95 respirator. The public hospital will not unreasonably deny access to the appropriate PPE.
• At a minimum, contact and droplet precautions must be used by workers for all interactions with suspected, presumed or confirmed COVID-19 patients. Contact and droplet precautions includes gloves, face shields or goggles, gowns, and surgical/procedure masks.
• All workers who are within two metres of suspected, presumed or confirmed COVID-19 patients shall have access to appropriate PPE. This will include access to: surgical/procedure masks, fit tested NIOSH-approved N-95 respirators or approved equivalent or better protection, gloves, face shields with side protection (or goggles), impermeable or, at least, fluid resistant gowns.
• The PCRA should include the frequency and probability of routine or emergent Aerosol Generating Medical Procedures (AGMPs) being required. N95 respirators, or approved equivalent or better protection, must be used by all health care workers in the room where AGMPs are being performed, are frequent or probable, or with any intubated patients. AGMPs include but are not limited to; Intubation and related procedures (e.g. manual ventilation, open endotracheal suctioning), cardio pulmonary resuscitation, bronchoscopy, sputum induction, non-invasive ventilation (i.e. BiPAP), open respiratory/airway suctioning, high frequency oscillatory ventilation, tracheostomy care, nebulized therapy/aerosolized medication administration, high flow heated oxygen therapy devices (e.g. ARVO, optiflow) and autopsy.

RNAO’s view is that the list of specific procedures in the last item should not be seen as exhaustive. The evidence-based judgment of the RN, when performing the point-of-care risk assessment (PCRA), must prevail.

We understand the enormous pressure on hospital administrators to conserve PPE when they do not have assured supplies coming in and the stocks are dwindling. This conservation, however, must be done responsibly, in consultation with the health providers themselves, using an evidence-based approach, and applying a precautionary principle – better safe than sorry.