Many of you are probably already experiencing some increase of H1N1 cases in your community whether you work in a small outpatient facility or a large hospital.
In Omaha, NE, I have seen a number of issues arise with H1N1 including hospitalization of pediatric patients. Other hospitals are limiting visitation rights, especially children, in NICUs and ICUs, because there is such a high risk there. Many other facilities are setting up more respiratory etiquette stations and emphasizing infection control best practices among visitors.
Easily the biggest subject among healthcare facilities is the debate over whether to use N95 respirators or surgical masks for protection against H1N1. A lot of facilities aren’t waiting for the CDC to make their final decision on this matter, and going ahead with their own internal policies.
Most facilities are leaning towards droplet precautions and the use of surgical masks for protection, given the position from organizations like the American Hospital Association  or the Society for Healthcare Epidemiology of America  regarding the problem of respirator availability. A study conducted in 2008 and recently published in the Journal of the American Medical Association (JAMA)  found that surgical masks compared with N95 respirators “resulted in noninferior rates of laboratory-confirmed influenza” among healthcare workers. On the other hand, this study didn’t include H1N1 virus transmission.
The CDC’s 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings  categorizes influenza under droplet precautions. Many facilities are arguing that H1N1 is just another form of influenza, and using the CDC’s fork-tongued approach in their favor.
On the other hand, if you have mandated N95s in your facility they won’t be of any use from an infection control or worker safety standpoint if they are used improperly. I’ve seen one comment on this blog  that indicated employees are required to use N95s until visibly soiled or damaged. In other forums people have talked about spraying down an N95 with Lysol to disinfect and reuse it. From an infection control standpoint it is much safer to use surgical masks than to reuse potentially infectious N95 respirators to that extent.
Some people are also wondering if they should be wasting N95s for fit testing when there is such a shortage. I’ve received some calls asking me if that’s OK to forgo fit testing because of this. The simple answer is no, since it isn’t OSHA compliant and an N95 that hasn’t been fit tested isn’t going to protect the healthcare worker anyway.
One last consideration regarding the H1N1 virus is the difficulty some smaller facilities, and even some larger ones, have with screening and isolating potentially infectious patients. If you have the space, the most logical thing to do is set up an additional room, an outdoor tent , or section off the waiting room to separate the healthy from the ill.
However, given the space constraints for many others, this approach isn’t feasible. Some commenters  on this blog have recommended very interesting ideas, including “car waiting rooms” in which sick patients provide their cell phone number and then wait in their car until a room is ready. Another reader suggested seeing well patients in the morning and ill patients in the afternoon so that the offices can be thoroughly disinfected at the end of the day.
Do you have any suggestions for isolation procedures for smaller physician offices? Let us know in the space below.