OSHA may revise respirator, skin-test provisions in final TB standard

EHPs warned not to delay evaluation of protection programs

With the comment period on the proposed tuberculosis standard over, U.S. Occupational Safety and Health Administration officials apparently are considering changes in some of the document’s most controversial provisions. Meanwhile, experts warn that postponing your TB protection program while OSHA hammers out a final rule could result in a regulatory disaster for your hospital.

Development of the standard has been fraught with controversy and debate. Critics have charged that a law is unnecessary due to a drop in TB cases, low worker conversion rates, and the existence of detailed CDC guidelines for preventing TB transmission in health care facilities.1 Individuals and organizations also have battled against certain provisions of the proposed standard,2 particularly the frequency of respirator fit-testing and employee skin-testing. (See Hospital Employee Health, January 1998, pp. 1-4; February 1998, pp. 13-17; and June 1998; pp. 69-72.)

The post-hearing comment period on the proposed TB standard ended in October 1998, and OSHA officials are in the process of evaluating comments, says Amanda Edens, OSHA project officer for the TB standard. "The major issues are not big surprises," she says. "What we thought was going to be a problem going in is bearing out."

Six-month requirement may change

One of the most controversial provisions in the proposed standard has been the requirement for six-month tuberculin skin-testing of health care workers. However, testimony from the U.S. Centers for Disease Control and Prevention and other commenters may have influenced OSHA to change that proposal. (See Hospital Employee Health, August 1998, pp. 93-97.)

"We’re starting to rethink that," Edens says. "We may change the requirement for anyone who enters an isolation room in low-risk settings, such as places where they see only one TB case per year. However, there may be certain situations where the six-month frequency is appropriate, so we may not eliminate it completely."

OSHA also received many comments on the proposal for annual respirator fit-testing, but Edens says no decision has been made. She points out that OSHA’s new respiratory protection standard includes a provision for annual fit-testing, "so why should TB be different? Fit is a crucial factor in making sure a respirator functions as you want it to. We hope to make all standards as consistent as possible."

Medical removal may be modified

Comments reveal "misunderstandings," as well. Regarding medical removal protection, which would require that HCWs with infectious TB be paid their full salary while off work, "many people think workers’ compensation takes care of that, and it’s not appropriate for us to get involved," Edens says.

Nevertheless, several other OSHA standards include similar provisions, she notes. While some commenters were concerned that employers would have to pay benefits to workers who might have contracted TB in the community instead of on the job, Edens says workers might be less likely to report symptoms early if they fear losing money from time off work.

Some workers’ compensation programs pay only a percentage of an employee’s full salary, and OSHA would require employers to make up the difference, but the provision might be modified. The presumption in an OSHA standard is that a condition is work-related, but the final TB rule might allow employers the option of not paying for medical removal if they can prove an employee acquired infectious TB outside of work, Edens says.

While nobody knows exactly what the final standard will require, one expert says most hospitals have little to fear.

"Hospitals won’t be doing anything much different than they’re doing already, says Gina Pugliese, RN, MS, the Chicago-based infection control consultant for the American Hospital Association. "Hospitals are doing well in TB control programs as evidenced by the drop in cases (see related story, p. 15), but many other work sites are covered by the standard, and their [worker] protections aren’t as good."

Current requirements do not call for annual respirator fit-testing, which has been an issue during the comment period, Pugliese points out, adding that it also will not be required under the final standard. Instead, protocols must be in place to evaluate periodically whether workers who have been fit-tested previously have undergone any physical changes that could cause their respirator to fit improperly. Those might include a significant weight loss or gain, a change in facial hair, or having had teeth removed.

"Hospitals need to have a way to assess those changes; otherwise, once you document a fit-test, a particular respirator, model number, and size, you’re all set," she says.

The TB standard will bring "no dramatic changes" for hospitals, Pugliese adds. Facilities that fail to comply with current fit-testing requirements can be cited now under OSHA’s general duty clause. Once a regulation is on the books, "the citation form they get will just have a different number on it; that will be the only difference."

Tweaking’ may be necessary

Respirator fit-testing is "not going to go away," but some facilities still are not doing it, says Janet Abernathy, RN, BSN, an Oakland, CA-based occupational health and safety consultation lead for 50 acute care hospitals in the Catholic Health Care West chain throughout California, Arizona and Nevada.

Like Pugliese, Abernathy says compliance with interim enforcement guidelines will help ensure that employee health professionals are placing their facilities in good stead with OSHA instead of risking a citation under the general duty clause.

"If you’re meeting the letter of those compliance guidelines, you should be in a good position," she states. "I’m not saying you won’t have to make any changes when the standard comes out, but they will be only minor changes, just a tweaking of the program."

Hospitals or EHPs that are waiting for a standard before implementing a TB protection program "show poor understanding of the process," she adds. "There is no excuse for not doing anything. I’ve heard all the excuses, but if you’re waiting, that’s a real mistake."

All of the opposition to accepting a standard in the first place has prevented many people from getting beyond being "reactive" to objectively evaluating what will be required in addition to what they’re already doing, Abernathy maintains.

"People already are doing quite a bit that they don’t take credit for because it may not be formalized," she says. "Just because people may not already have a policy in place, they may think that [a provision of the proposed standard] is outrageous. It’s a matter of being educated about the standard and realizing that it will undergo significant changes in some areas."

A final standard is not likely to be issued before the year 2000, so EHPs can use the time to assess their programs thoroughly in relation to OSHA’s current interim enforcement compliance guidelines, says Abernathy, who presented a session on the upcoming standard at the recent Association of Occupational Health Professionals in Healthcare (AOHP) annual conference.

She recommends the following areas for assessment:

New hires: Examine every aspect, "from the moment a new hire walks through your door," including initial screenings. Two-step testing should be done on populations that haven’t had skin-testing in the last year.

Educational components: Make sure you are covering required topics in orientations and re-orientations (general epidemiology; TB signs and symptoms; TB standard contents; risk of developing TB; exposure incident follow-up procedures; and the employer’s exposure control plan, respiratory protection program, and medical surveillance program).

Exposure control: Identify employees who have occupational exposure at their work setting and develop a written exposure control plan, develop procedures for providing employees with information about individuals with suspected or confirmed infectious TB, and have procedures in place for reporting exposure incidents.

Respiratory protection: Develop a program for providing respirators to employees who are exposed to individuals with suspected or confirmed infectious TB.

Medical surveillance: A program should be provided for all employees who have an exposure incident while working, even if the employee is not categorized as having occupational exposure, as well as any employee who develops infectious TB.

Record keeping: Records to be kept include OSHA illness and injury log, medical, training, and engineering control maintenance and monitoring.

References

1. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43(No. RR-13):1-132.

2. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,159-54,307 (Oct. 17, 1997).