RESPIRATORY MASK FIT TESTING

Transcription

1 Title: RESPIRATORY MASK FIT TESTING Ref No: 2079 Version 1 Classification: Policy Directorate: Infection Control Due for Review: Responsible for review: Infection Control Department Document Control Ratified by: Infection Prevention and Control Committee Applicability: All staff Contents 1. Purpose and Scope 1 2. Policy Aims 2 3. Responsibilities and Organisational Arrangement 2 4. Monitoring 4 5. Equality and Diversity 4 6. References 4 Appendices 1. Areas of Risk 5 2. Information for Person Conducting Fit Test 6 3. Fit Test Procedure 8 4. Memory Jogger Fit Test Record General Questions Information for the Face Mask Wearer Failures Fitting and Cleaning a 3M 7500 Series Reusable Respirator and Filter PURPOSE AND SCOPE This Policy will apply to all Torbay and South Devon NHS Foundation Trust staff who either manage staff or are those staff who require to wear a tight fit respiratory mask (Appendix 1). The purpose being to provide guidance to all staff and managers of the organisational arrangements in relation to respiratory face fit mask testing. The scope of this policy is Board wide. LEGISLATIVE FRAMEWORK The Trust as an employer has a legal responsibility under the Control of Substances Hazardous to Health Regulations 2002 (COSHH) to control substances hazardous to health in our workplace and to prevent or adequately control our employee s exposure to those substances. Under the law, Respiratory protective equipment (RPE) is a line of protection. Where respiratory protective equipment (RPE) has to be used as a control measure, it is vital that the selected RPE is adequate and suitable. To ensure that the selected RPE has the potential to provide adequate protection for the individual wearer they must undergo face fit training/testing. Aerosol Generating Procedures (AGPs) AGPs can produce droplets < 5 microns in size which may cause infection if they are inhaled. These small droplets can remain in the air, travel over a distance and still be infectious. A list of AGPs follows: Endotracheal intubation and related procedures, for example manual ventilation and airway suctioning Cardiopulmonary resuscitation Diagnostic sputum induction Respiratory Mask Fit Testing Version 1 (October 2016) Page 1 of 4

2 Bronchoscopy Positive pressure ventilation via face mask (e.g. BiPAP, CPAP) Procedures involving the use of high speed devices such as power saws used in postmortem Nebulisers This list is not exhaustive. In general, the WHO has concluded that the risk associated with many aerosol generating procedures is not yet well defined and that further study is required to gain understanding of this particular subject area. The WHO class nebulisation as a controversial/possible increase in risk of respiratory pathogen transmission, as the evidence regarding this transmission route is of low number and quality. However this trust will err on the side of precaution and treat nebulisation as a risk of transmission, and use FFP3 masks as appropriate. 2. POLICY AIMS This policy aims: To reduce/prevent the risk of respiratory infection/transfer between patients and staff To identify and ensure that the relevant staff and managers understand their responsibilities To provide staff with the necessary guidance and support in relation to RPE selection To support Torbay and South Devon NHS Foundation Trust policies in relation to respiratory disease or infection i.e. TB, SARS, Flu To provide staff with guidance on completion of fit testing procedures. 2.1 DEFINITIONS Face fit testing is a method of checking that a tight-fitting face piece matches the wearer s facial features and seals adequately to their face. It will also help to identify unsuitable face pieces that should not be used. A tight fit mask is a full face mask, a half mask or a filtering face piece (commonly referred to FFP3 masks). The performance of these types of face pieces relies on the quality of fit to the wearer s face. Please note the selection and use of any respiratory mask should be in accordance to local risk assessment and guidance and protocols in the relevant Infection Control policies. 3. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS Chief Executive The Chief Executive has overall strategic responsibility for ensuring that Board Policies comply with all legal, statutory and good practice guidance requirements. Executive Directors, Associate Directors, General/Nurse Managers, Associate Directors of Nursing, Service Delivery Unit managers, Clinical Directors, Matrons, Allied Health Professionals Manager. are responsible for: Ensuring that all staff for which they have line management/clinical responsibility are appropriately informed, instructed, trained and supervised in compliance with this policy Ensuring the provision of the necessary face masks in liaison with line management. Respiratory Mask Fit Testing Version 1 (October 2016 Page 2 of 4

3 Line Managers including all disciplines (Ward Manager, Physio Lead, Radiography Lead etc) Are responsible for: Identifying those staff who may be required to use a tight fit face mask Ensuring they are fit tested - if not fit tested exclude from the relevant patient contact. Ensuring that there is always at least one, ideally two, competent fit mask testers in their area of responsibility. Ensuring fit mask testers have adequate initial and annual refresher training, including use, donning, cleaning, storage, maintenance and checks of any RPE. Maintaining records of fit testing and any training, ensuring that staff have access to these records and that Health and Safety is provided with a copy of the fit test report. Ensuring the provision of the necessary face masks as per local risk assessment policies and procedures. Staff including all disciplines Having been provided with the necessary information, instruction, training and having been mask fit tested will be responsible for: Ensuring the appropriate selection and use of the respiratory mask they have been fit tested for. To reduce/prevent the risk of respiratory infection/transfer between patients and staff. Ensuring the correct use, cleaning, storage, maintenance and checks are completed for their RPE Ensuring the correct and safe fitting, removal and disposal of RPE. Ensuring they report any faults or inadequacies with their RPE to their line manager. Ensuring they report any significant changes to their manager/designated fit tester i.e. significant weight loss/gain, significant dental work or any facial changes around the mask face seal area. Ensure they have their annual mask fit test. Fit Mask Testers Are responsible for: Ensuring all staff in their area are mask fit tested on induction, including training on use, fitting, removal, disposal, cleaning, maintenance and storage of mask. Ensuring completion of fit test report and copy given to manager, which employee will have access to, and copy sent to Occupational Health Ensuring any staff who report any changes, i.e. significant weight loss/gain, has substantial dental work undertaken or develops any facial changes (scars or moles) around the face seal area are re fit tested. Ensuring that they attend annual refresher training. The Training Department Is responsible for: Maintaining a database of all Torbay and South Devon NHS Foundation Trust staff who have been fit tested. Co-ordinating and maintaining record of fit test competent persons initial training and annual refresher training, providing a copy of record to the manager. Infection Control Is responsible for: Ensuring relevant National Policy is accessible to staff via Infection Control Manual - intranet Providing advice and guidance to all parties on the appropriate provision, use, decontamination, disposal and storage of face fit masks, guided by Public Health England Respiratory Mask Testing Version 1 (October 2016) Page 3 of 4

4 and local Standard Infection Control Precautions (SICPs) and Transmission Based Precautions (TBPs), Providing guidance and support to all parties in the development of local risk assessments, where appropriate 4. MONITORING Responsibility for monitoring the application of this policy will rest with the Health and Safety, assisted by the Infection Control Team. The Policy will be reviewed a minimum of every 2 years by Occupational Health. On-going audit will be conducted by Health and Safety at site visits to assess compliance throughout the organisation. Any changes will be made in consultation with the relevant staff. Revised versions of this policy will be approved by The Infection Control Committee prior to dissemination and implementation. 5. EQUALITY AND DIVERSITY Torbay and South Devon NHS Foundation Trust are committed to equality and diversity in respect of the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. A rapid impact assessment has been carried out on this policy. The issues identified were: Some individual staff members may be unable to be successfully fit tested with a FFP3/ tight fit mask. In most cases the provision of a full face respirator or temporary redeployment can be accommodated. Staff wearing masks may cause additional communication problems especially to those patients with existing communication/language difficulties. The wearing of RPE for long periods may result in additional anxiety for some patients. 6. REFERENCES HSE Operational Circular OC 282/28 ( ) Respiratory protective equipment at work HSG53 The Control of Substances Hazardous to Health Regulations 2002 COSHH 2002 OSHA App A (2004): Fit Testing Procedures (mandatory) BSEN 12942:2001 Respiratory Protective Devices: Power assisted fitting devices incorporating full face pieces, half face pieces, half or quarter face pieces requirements, testing, makings BSEN 136:1998 Respiratory protective devices: full face piece requirements, testing, markings BSEN 140:1998 Respiratory Protection Devices: half face pieces and quarter face pieces requirements, testing, markings General Information & Infection Control Precautions to Minimise Transmission of Respiratory Tract Infection in Healthcare Settings, Health Protection Scotland, Infection Control Precautions During the Assessment of Patients Presenting with Respiratory Illness in A&E/Acute Admission Department, Health Protection Scotland, WHO, Infection prevention and control of epidemic - and pandemic - prone acute respiratory disease in health care, Respiratory Mask Fit Testing Version 1 (October 2016 Page 4 of 4

5 Areas of Risk The following areas and groups of staff have been deemed by Infection Prevention and Control Committee and Public Health as 2high risk. Midgley EAU3 EAU4 Maternity Louisa Cary Radiography Physiotherapists Anaesthetics Theatre Staff Emergency Department Medical Staff permanent / rotation Respiratory Specialist Practitioners Mortuary Staff (There are other designated flu areas but it is unlikely that staff will be performing aerosol generating procedures in these areas). Appendix 1 In each of these areas there must always be at least one, ideally two, competent fit mask testers or more, as per local risk assessment identifies. Others areas and group of staff may be identified, depending on hazard i.e. droplet borne infection. Advice will be provided by Infection Prevention and Control. G2087 Appendix 1 Areas of Risk Version 1 (October 2016) Page 1 of 1

6 Appendix 2 Information for Person Conducting Fit Test 1. You should explain to the wearer the purpose of the test, what they will have to do and the meaning of the fit test results. 2. You should check that the fit testing equipment is properly set up and checked prior to conducting the fit test. 3. You should ensure that any sampling adapters and probes are working properly, fitted correctly and that any sampling lines, nebulisers, etc., where applicable, are not blocked. 4. You should use the wearer s own face piece. Where this is not practical, then a test face piece that exactly matches the wearer s face piece should be used. 5. You should visually examine the face piece (used for fit testing) prior to carrying out a fit test. The examination should include the condition of the face piece, especially around the face seal and face piece connectors, the exhalation valve(s) and the head harness. Test face pieces should be properly inspected and maintained in accordance with the manufacturer s instructions. 6. You should ensure that test face pieces are cleaned and disinfected before being used by different individuals. Test face pieces that cannot be adequately disinfected (e.g. filtering face pieces) should not be used by more than one individual. 7. You should instruct the wearer in the test exercises. 8. You are advised to ascertain that the wearer is medically fit to wear RPE and, where appropriate, be able to undertake the recommended test exercises (as described in paragraphs 13-15). 9. The wearer should don the face piece in accordance with their received training and the manufacturer s instructions. If it is necessary for you to help (or intervene) this should be noted and recommendations should be made for further training. The use of a mirror will assist the wearer to fit the face piece correctly. 10. The wearer should be instructed to wear the face piece for at least five minutes before the start of the fit test. This allows time for the wearer to determine if the face piece is comfortable and to make any adjustments to the fit before commencing the fit test. 11. The wearer should have received training in correctly donning the face piece before the fit test. However, if you are helping in the face piece selection process you should show the wearer how to put on a face piece, how it should be positioned on the face, how to set strap tension and how to determine an acceptable fit. A mirror should be available to assist the wearer in evaluating the fit and positioning of the face piece. 12. If the wearer will need to use in face piece spectacles then these (or unglazed frames) should be worn during the fit test. If other types of personal protection are worn with the RPE (e.g. hard hat, goggles etc) and have the potential to interfere with the seal of the face piece, then they should be worn during the fit test. However, if the other items of PPE prevent the RPE from being fitted correctly, a proper fit test cannot be carried out. Personal protective equipment should be compatible with the RPE. 13. You should not conduct the fit test if there is any hair growth between the skin and the face piece sealing surface, such as stubble beard growth, beard, moustache, sideburns or low hairline which cross the respiratory sealing surface. You should ensure that any type of non PPE apparel or adornment (e.g. piercing) does not interfere with the fit of the face piece. G2087 Appendix 2 Information for Person Conducting Fit Test Version 1 (October 2016) Page 1 of 2

7 14. You should observe the wearer throughout the fit test to watch for facial/head movements that may cause face seal leakage and also to ensure the safety of the wearer this is important if the wearer is walking on a treadmill or stepping during the fit test. If the wearer sneezes or coughs during the fit test this can have an affect on the fit test result and the fit test may have to be repeated. 15. If the test fails, you must determine the appropriate action to take. This is where the fit test operator s experience is important. Further guidance on troubleshooting is given in Appendix 8. In any case, the fit test should be repeated in its entirety ideally on a separate day. 16. You should inform the wearer of the fit test result i.e. a pass or fail. You should be cautions if providing information on numerical fit factor results. Informing a wearer that a high fit factor has been achieved may give the wearer false confidence in the RPE and may cause the wearer to be less careful when donning and using the RPE in the workplace. It should be stressed to the users that practical experience in the workplace has shown that the protection level obtained can be less than that achieved in the fit test. 17. You should also be aware of the sensitive nature of a fit test failure, especially on a wearer who may have been wearing the particular type of respirator in the asbestos or similarly hazardous industry for a period of time. A procedure for consultation with the employer should be developed in advance to deal with such cases. Where the failure results from a type of face piece already worn for a period of time in the workplace, you should inform the employer. They in turn should note this fact on the individual s health record and may wish to make arrangements for medical advice. 18. As part of the fit test it is encouraged, where possible, that you check the condition of the wearer s own RPE. This is vital if the fit test is going to be performed on the wearer s own face piece. The condition of the RPE can form part of the test report. G2087 Appendix 2 Information for Person Conducting Fit Test Version 1 (October 2016) Page 2 of 2

8 Appendix 3 Fit Test Procedure Qualitative Method Always check your fit test equipment before use: The nebulisers should be checked during each test for correct functioning Make sure you use the correct solution for the fit test Is the wearer trying to smell the aerosol, rather than taste it? You may have to keep reminding the wearer to breathe through their mouth, not their nose. Make sure the wearer does not eat, drink or smoke for at least 30 minutes before the test, otherwise their sense of taste may be affected. Test Environment Well-ventilated, private, need a clock/watch with a second hand and table with room for kit and instructions. Delegates Must have a clean palate and had nothing strong to eat or drink for at least half an hour beforehand. Smokers tend to have a less sensitive palate than non. A heavy cold can lead to reduced sensitivity. Must be clean shaven stubble from heavy growth can influence fit. No coffee, no mints, no curry, no mouthwash etc beforehand. Ideally leave 30 minutes if possible and ventilate room between sensitivity and fit test. Retesting is required if a different model or size of RPE is specified or there is a significant change to the face eg dental work weight loss/gain Sensitivity Test Done without the mask. The person must breathe through their mouth with tongue slightly out (taste not smell test remember). Easiest if you and the delegate are standing up. Ensure the nebuliser is upright (bulb at bottom) and point to side of the person s face so not so intimidating for them and right in their face. Squeeze the nebuliser at even intervals, slowly about 1 per second during the sensitivity test. Maximum of 30 scooshes. (If do get to 30 double-check the person has not had a piece of chewing gum or something recently). Then move onto the alternative solution (sweet or bitter better response rate to bitter). If retesting is necessary after 2 attempts, please contact Occupational Health for assistance. Correlation between sensitivity and fit tests in terms of scooshes: Puffs of solution until taste Puffs on fit test detected to 5 to 5 to to 10 to 10 to to 15 to 15 to 15 Get the person to put their hand up when they taste the solution. Once finished get them to wash their face and have a drink of water to get rid of the taste. Fitting Masks For all models best to take off glasses if worn for ease of fitting. Ensure hair is back off face so does not create a barrier to achieving a seal. Always start with the chin for the FFP3 masks we use and supply. G2087 Appendix 3 Fit Test Procedure Version 1 (October 2016) Page 1 of 3

9 For the folding masks e.g. 3M 1863, 1873 Gently remove from the packet and put the red straps to one side. Then get hold of the mask at the middle of the edges and tug sharply to open up into a cup shape with the straps dangling down. The adjustable edge on the mask is the top because that is where you need most adjustment to get a good fit. Put the mask on chin first and bring both straps to the back of the neck. Bring the mask up to cover the nose and then raise the top strap to the crown of the head. Make sure the chin is enclosed before fitting around the nose. Use two fingers to press down and follow the nose down both sides. Never use one hand as the fit will be to the shape of the pinched fingers rather than the face shape. Tell delegates to do a fit check every time you use a fitted mask. Put both hands over the mask to create a vacuum and breathe in and out quickly and hard. A good fit is likely if the material moves in and out a little. Fitting non foldable masks e.g. 3M 8835 Put the straps into opposite slots on the sides of the mask without crossing. Hold the mask with the straps dangling down then, holding the mask with one hand pull back the straps to bring up over your face putting your chin in first and bringing them to the back of the neck. Bring the top strap to the crown of the head and ensure your chin and nose are covered before tightening the top strap first and then the lower. Use two fingers to press down and follow the nose down both sides. Never use one hand as the fit will be to the shape of the pinched fingers rather than the face shape. Check straps are tight. Tell delegates to do a fit check every time you use a fitted mask. Fit Check If you can see the mask moving when taking several sharp breaths in/out a good fit is likely. Fit Test with Mask on The test will take around minutes depending on conditions and experience. The wearer goes through a series of exercises over 7 minutes. The delegate must be instructed not to speak until instructed to do so. Initial dose and half dose rate are based upon the sensitivity test in line with the correlation table above. Deliver the first e.g. 20 scooshes quickly. If the person tastes it immediately there is probably something obviously wrong with the way the mask has been put on. Table below to check timings and dose rate: Time Exercise Action Notes Breath normally Initial full dose based on sensitivity Squeeze quickly G2087 Appendix 3 Fit Test Procedure Version 1 (October 2016) Page 2 of 3

10 test Half dose Breathe deeply Half dose Demonstrated deep cleaning Half dose Head side to side Half dose Demonstrate slow head turning Half dose Head up and down Half dose Demonstrate head up and down slowly Half dose Bend over at waist Half dose Demonstrate Half dose Talking Half dose Rainbow passage or 100 down to Half dose Breathe normally Half dose Half dose End Few scooshes Ask person to break seal with one finger before removing hood Hopefully the delegate will pass. The final action in the table above is designed to inspire confidence in the effectiveness of the mask and its ability to protect as long as they fit correctly each time with that mask. If the delegate fails a fit test, second test can be done before looking for an alternative mask offering the same level of protection. Arrange for fit testing on an alternative model or size as soon as possible for anyone failing a fit test. Ensure the test record is complete and copied to manager and Occupational Health. Ensure delegates are instructed to do a fit check every time they use a fitted mask. G2087 Appendix 3 Fit Test Procedure Version 1 (October 2016) Page 3 of 3

11 Appendix 4 Memory Jogger Sensitivity Test Use sensitivity solution and matching atomiser Remind person to breathe through mouth with tongue at front. Say, Tell me immediately when you can taste it squeezes If not tasted, repeat squeezes If not tasted, repeat squeezes STOP if not tasted Fit Test Note down which range the taste was detected = 10, 20 or 30 Change exercises every 60 seconds Top up with atomiser every 30 seconds Repeat again, Tell me immediately when you can taste it Start During test Exercised (7) Finish 10,20 or 30 squeezes Half = 5, 10 or 15 extra squeezes every 30 seconds Breathe normally Breathe more deeply Head side to side Up and down Bending over Talking Breathe normally Ask person to break face seal with finger and take a breath through the mouth (explain what this shows). Don t forget to record the results and copy to Manager and Occupational Health! Ensure delegates are instructed to do a fit check every time they use a fitted mask. Access to website 3M intranet link training package mmes/fittestsupport G2087 Appendix 4 Memory Jogger Version 1 (October 2016) Page 1 of 1

12 Appendix 5 All documents are available on the H&S web page under Face Fit testing Qualitative Fit Test Record Name: Designation: Model / Size of Respirator: DoB: Department: Own face piece, pool or test model use? Own Pool Test Fit test kit used? FT10 (sweet) FT30 (bitter) Test conducted by (fit tester): Retest required? Yes No If yes, please state reasons: Pass achieved? Yes No Comments : Date :.. Signed: (Fit Tester) Signed: (Staff Member) As Applicable Satisfactory Comments Condition of wearer s own face YES / NO piece Competency of wearer donning and fit checking mask YES / NO Fit test records must be stored for at least 5 years by the employer. These records must be kept available for inspection. Copy to Manager and Occupational Health G2087 Respiratory Mask Fit Testing Appendix 5 Fit Test Record Version 1 (October 2016) Page 1 of 1

13 Appendix 6 How is a power assisted respirator or a breathing apparatus face piece fit tested? Please note, respirators, such as, Versaflo and Jupiter have loose fit hoods and do not require fit testing. Fit testing a power assisted respirator or a breathing apparatus face piece is carried out with the respirator temporarily converted into a negative pressure respirator by adapting the face piece to use a high efficiency filter (P3) instead of the usual air supply. Respirator manufacturers can supply special face piece adapters specifically for this purpose. Alternatively, an identical negative pressure respirator face piece, with the same sealing surfaces as the power assisted respirator or the breathing apparatus face piece, can be used. Should a fit test be carried out if the wearer s face piece is contaminated? A fit test on the wearer s face piece should only be carried out if it is clean and in good condition. Debris in the face piece can interfere with the fit of the face piece, cause the exhalation valve to leak and affect the fit test device all of which may result in a falsely low fit factor. A contaminated face piece may also expose the fit tester to hazardous substances e.g. asbestos fibres. If possible the wearer s employer should be informed about faulty or contaminated face pieces. Why is it necessary for the wearer to exercise during the fit test? The purpose of the test exercises is to generate a physical workload on the wearer that simulates working activities and work rate. This will test the fit of the face piece better than if the wearer was sat down or stood still during the fit test. What actions should be taken if the wearer is not able to put on the Face Piece correctly? If a poor fit is due to inadequate training, then a refresher course should be undertaken; the fit tester may give this training if competent to do so. The wearer s manager should also be informed G2087 Respiratory Mask Fit Testing Appendix 6 General Questions Mask Fit Testing Version 1 (October 2016) Page 1 of 1

14 Appendix 7 Linked to Patient Information Leaflet Information for the Face Mask Wearer G2087 Respiratory Mask Fit Testing - Information for the Face Mask Wearer Version 1 (October 2016) Page 1 of 1

15 Appendix 8 Failures Wearer Factors The most obvious reason for a fit test failure is that the face piece is unsuitable for the wearer and is not capable of fitting their face. Certain facial features may lead to poor fit. Watch out for: Cleft chins Scars on the face sealing area Depressions around the temple/cheekbones Unusual chin profiles (chisel feature) Unusual nose shapes Very large/small or angular faces The fit tester should inspect the fit of the face piece before beginning the fit test. Ask the wearer to move their head to look down whilst you check the fit around their nose or forehead. Similarly, ask them to move their head to look up, then to each side to check the fit all around the face piece. Obvious gaps indicate a poor fit and an alternative face piece may be needed. A fit check should be successfully carried out before beginning the fit test. It is possible that the fit test exercises will result in the face piece moving on the face, creating a leak. Note at what stage in the test the failure occurred. If it was during the head movement exercises, this could mean that the face piece could have moved on the face. Inspect the fit again for changes since the beginning of the test. Changes may be because the face piece is unsuitable for the wearer s face or could be due to other factors. Watch out for: Sweating, which can cause the face piece to slip Make-up, face creams etc. these can create sealing problems Jewellery, such as nose studs, interfering with the fit The face piece may need redonning and the straps tightening to prevent slippage, however, they should not be so tight as to make the face piece uncomfortable. Retest if the problem can be rectified or try a different face piece. Face Piece Problems If there is no obvious reason for the fit test failure, it is worth examining the face piece closely to check for defects. With reusable face pieces inspect generally and ensure that the exhalation valve is in good condition and clean. G2087 Respiratory Mask Fit Testing Appendix 8 Failures Version 1 (October 2016) Page 1 of 1

16 Appendix 9 Appendix 9 Reusable FFP3 (only to be used as directed by Infection Control) G2087 Respiratory Mask Fit Testing Appendix 9 Fitting and Cleaning Version 1 (October 2016) Page 1 of 2

17 Doffing Reusable FFP3 (7500 3M) 1. Do not remove the facepiece filters until you have vacated the contaminated area. 2. Hand hygiene is critical after removing the aprons gloves and eye protection. 3. Release the tension on the headstraps by pushing on the back side of the buckles. 4. Unhook the bottom straps 5. Carefully lift the facepiece off the face and remove the respirator by lifting up and away from the head. Decontamination of Reusable FFP3 (7500 3M) Discard the whole unit in yellow clinical waste bag if used for patients with or suspected ohf having a viral haemorrhagic fever, Avian flu, MERS CoV, TB or a new strain of pandemic flu (before data on the FF100 is available). Contact Infection Prevention and control for further advice. If the mask is used for seasonal flu the following decontamination process should be followed: 1. Only use masks as single person use per shift. 2. If staff leaves the patient area for a period of time, but plan to return, then the reusable respirator must be cleaned after removal. 3. Put on a pair of gloves 4. Clean using 5 SaniCloth wipes 5. Remove filters and headstraps from clips 6. Remove gloves and decontaminate hands 7. Put on a new pair of gloves 8. Wipe each filter with a SaniCloth. 9. Wipe each headstrap with a SaniCloth. 10. Wipe the outside of the mask with a SaniCloth 11. Wipe the inside of the mask with a SaniCloth 12. Remove gloves and decontaminate hands 13. Reassemble mask as per manufacturer s instructions 14. Wash hands. G2087 Respiratory Mask Fit Testing Appendix 9 Fitting and Cleaning Version 1 (October 2016) Page 2 of 2

18 11. Document Control Information This is a controlled document and should not be altered in any way without the express permission of the author or their representative. Please note this document is only valid from the date approved below, and checks should be made that it is the most up to date version available. If printed, this document is only valid for the day of printing. Ref No: 2079 Document title: Respiratory mask fit testing This Policy will apply to all Torbay and South Devon NHS Foundation Trust staff who either manage staff or are those staff Purpose of document: who require to wear a tight fit respiratory mask (Appendix 1). The purpose being to provide guidance to all staff and managers of the organisational arrangements in relation to respiratory face fit mask testing. Date of issue: 21 October 2016 Next review date: 21 October 2018 Version: 1 Last review date: Author: Infection Control Directorate: Infection Control Equality Impact: The guidance contained in this document is intended to be inclusive for all patients within the clinical group specified, regardless of age, disability, gender, gender identity, sexual orientation, race and ethnicity & religion or belief Committee(s) approving the Infection Prevention and Control Committee document: Date approved: 22 September 2016 Links or overlaps with other All TSDFT Trust Strategies, policies and procedure documents policies: Have you considered using Equality Impact Assessment? Does this document have implications regarding the Care Act? If yes please state: Please select Yes No Does this document have training implications? If yes please state: Does this document have financial implications? If yes please state: Is this document a direct replacement for another? If yes please state which documents are being replaced: Document Amendment History Date Version no. Amendment summary Ratified by: 21 October New Infection Prevention and Control Committee Respiratory Mask Fit Testing Document Control Information Version 1 (October 2016) Page 1 of 1

19 12. The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. Respiratory Mask Fit Testing The Mental Capacity Act 2005 Version 1 (October 2016) Page 1 of 1

20 13. Quality Impact Assessment (QIA) Please select Who may be affected by this document? Patient / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Other Statutory Agencies Others (please state): Does this document require a service redesign, or substantial amendments to an existing process? If you answer yes to this question, please complete a full Quality Impact Assessment. Are there concerns that the document could adversely impact on people and aspects of the Trust under one of the nine strands of diversity? Age Disability Gender re-assignment Pregnancy and maternity Marriage and Civil Partnership Race, including nationality and ethnicity Religion or Belief Sex Sexual orientation If you answer yes to any of these strands, please complete a full Quality Impact Assessment. If applicable, what action has been taken to mitigate any concerns? Who have you consulted with in the creation of this document? Note - It may not be sufficient to just speak to other health & social care professionals. Patients / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Details (please state): Other Statutory Agencies Respiratory Mask Fit Testing Quality Impact Assessment Version 1 (October 2016) Page 1 of 1

21 Rapid Equality Impact Assessment (for use when writing policies and procedures) Policy Title (and number) G2079 Respiratory Mask Fit Policy Version and Date Version 1 October 2016 Policy Author Infection Control An equality impact assessment (EIA) is a process designed to ensure that a policy, project or scheme does not discriminate or disadvantage people. EIAs also improve and promote equality. Consider the nature and extent of the impact, not the number of people affected. EQUALITY ANALYSIS: How well do people from protected groups fare in relation to the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Is it likely that the policy/procedure could treat people from protected groups less favorably than the general population? (see below) Age Yes No Disability Yes No Sexual Orientation Yes No Race Yes No Gender Yes No Religion/Belief Yes No (non) Gender Reassignment Yes No Pregnancy/ Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy/procedure could affect particular Inclusion Health groups less Yes No favorably than the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Are the services outlined in the policy/procedure fully accessible 6? Does the policy/procedure encourage individualised and person-centered care? Could there be an adverse impact on an individual s independence or autonomy 7? If Yes, how will you mitigate this risk to ensure fair and equal access? Yes No Yes No Yes No Yes No EXTERNAL FACTORS Is the policy/procedure a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy/procedure? What were the recommendations/suggestions? H & S Lead, Horizon Lead ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date Mask fit text staff H&S, Horizon, Matrons, Managers December 2016 AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Selina Hoque Signature Validated by (line manager) Jane Viner Signature This form should be published with the policy and a signed copy sent to your relevant organisation. Respiratory Mask Fit Testing Rapid Equality Impact Assessment Version 1 (October 2016) Page 1 of 2

22 1 Consider any additional needs of carers/ parents/ advocates etc, in addition to the service user 2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them 3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge 4 Consider how someone will be aware of (or access) a service if socially or geographically isolated 5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives 6 Consider both physical access to services and how information/ communication in available in an accessible format 7 Example: a telephone-based service may discriminate against people who are d/deaf. Whilst someone may be able to act on their behalf, this does not promote independence or autonomy Respiratory Mask Fit Testing Rapid Equality Impact Assessment Version 1 (October 2016) Page 2 of 2