The effectiveness of training and taste testing when using respirator masks

Sir,

Recent concerns about severe acute respiratory syndrome (SARS), influenza and multidrug-resistant tuberculosis have highlighted the need for the use of respirator masks of adequate design and construction. However, it is equally important to ensure that healthcare personnel are using these masks correctly. In November 2003, 12 members of staff on our respiratory ward were trained on the correct method for putting on respirator masks (Tecnol fluid N95 particulate filter, Kimberly Clark); they were asked to cascade this training on to remaining staff on the ward. In February 2004, with help from the suppliers, we returned to test the adequacy of mask fitting by staff. This involved staff putting on a mask using their normal method and then wearing a plastic hood into which a saccharin solution was aerosolized. They were then asked to read a paragraph of text and any tasting of saccharin during this time was regarded as a mask-fit failure, demonstrating to staff that this left them exposed to infectious agents. The results are shown in Table I . The majority of staff who had not been trained failed the test. Although there was a greater degree of success amongst those formally trained, they still failed to comply with the manufacturer's instructions in all aspects, which suggests that their future success may be haphazard.

Table I.

Mask fit results on a respiratory ward

Staff member	Previously trained	Ties	Nose	Pointed down	Pass/fail
Nurse	✓	✓	✓	✓	Pass
Nurse	×	✓	×	×	Fail
Nurse	✓	×	✓	✓	Pass
Doctor	×	×	✓	×	Fail
Doctor	✓	✓	✓	×	Pass
Doctor	×	✓	✓	×	Fail
Physiotherapist	×	×	✓	×	Pass
Physiotherapist	×	×	✓	×	Fail
Student nurse	×	×	✓	✓	Fail
Student nurse	✓	×	✓	✓	Fail
Student nurse	×	×	✓	×	Fail

Using the test hoods, we also looked at staff in the accident and emergency department and the intensive care unit who had not received any formal training in mask fitting but who were expected to follow the manufacturer's instructions. Only three out of 44 clinical staff passed the fit test; 30/33 nurses and all medical staff, including nine consultants, failed. Subsequently, the correct method of mask use was demonstrated followed by testing; the effectiveness of the mask was demonstrated for every individual using the hood and all passed the fit test.

This experience has highlighted several areas. In particular, it re-emphasizes that just because a piece of equipment is technically sufficient for purpose does not mean that it will provide the required protection when called upon in practice. It also suggests that training may be of limited value if the relevance to the individual is not clearly demonstrated. We have changed our practice and now recommend that staff working in high-risk areas receive training on mask fitting at induction and pass a fit test. We also recommend that staff in these areas are tested annually. We have found that these tests not only give us assurance regarding performance, but they have given every member of staff real confidence in these relatively simple masks and brought home to them what failure might represent.