Beware of the N95s: Fit-testing is fair game for OSHA inspectors

Hospitals find it hard to pare numbers

Is your respiratory program ready for an Occupational Safety and Health Administration (OSHA) inspection? As of July 2, an OSHA inspector can ask about your use of respirators to protect against tuberculosis and when you last fit-tested health care workers who are caring for TB patients.

Some states that operate their own health and safety programs (state-plan states) granted hospitals extra time to comply, but federal enforcement has begun for the requirement to conduct annual fit-testing of filtering face-piece respirators (N95s) to protect against tuberculosis.

And although OSHA announced that all citations will be reviewed by the national office, that isn’t an effort to deter citations, says Craig Moulton, senior industrial hygienist. "We usually want to have uniform enforcement throughout the country," he says. A similar policy temporarily followed the revision of the bloodborne pathogen standard, Moulton notes.

An OSHA inspector would first look for the basic respirator program, which includes medical evaluations of employees wearing respirators, annual training, and record keeping, he adds.

Annual fit-testing is required for employees who are using the respirators. So an OSHA inspector would be concerned about protections for employees who are currently caring for a TB patient in an isolation room — not employees who might have an exposure at some future date, notes Moulton. (For more on regulations, see insert.)

"They should fit-test those who are actually wearing the respirators, as opposed to those who might wear a respirator at some point," he says. "We would be looking to see if those wearing the respirators have been fit-tested in the past year."

The inspector would identify those people using respirators by talking to employees, Moulton explains. "There is no paperwork that says, Janet Smith wore a respirator on such-and-such a date.’ We don’t require them to document the date a respirator is worn."

He notes that hospitals have been required to comply with the respiratory protection rule for TB since Dec. 31, 2003, when the agency revoked its TB-specific respiratory protection standard along with the proposed tuberculosis rule. With that action, OSHA stated that hospitals must follow the General Industry Respiratory Protection Standard for tuberculosis.

A six-month delay in enforcement gave hospitals time to ramp up their programs and bring their fit-testing up to date, Moulton says. When the standard was released in 1998 for general industry, employers only had three months to come into compliance, he adds.

Fit-testing has turned into a major headache for many hospitals around the country, as they are fit-testing hundreds of employees. According to Moulton, hospitals shouldn’t fit-test employees who don’t wear respirators. But paring down the list of fit-tested employees has been a challenge for many employee health professionals.

"The smaller the respirator program, the more effectively it will be maintained," he says. "You can always expand that if you need to."

In the past, hospitals often conducted an initial fit-test of virtually all clinical employees during their pre-placement exam. It actually was easier to fit-test everyone than to figure out who would be entering an isolation room. But when employee health professionals asked managers to designate employees who needed annual fit-testing, they often still wanted to include all their clinical staff.

"The consensus is that most of the department managers don’t want to worry about the scheduling nightmare of [always] scheduling someone on [a shift] who is fit-tested," says Deborah A. Spooner, PA-C, physician assistant for employee occupational health services at North Arundel Hospital in Glen Burnie, MD. "If you only have a few, then you have to [schedule someone who is fit-tested] on every shift."

So Spooner and the hospital’s infection control nurse looked at the list by job title. They tried to exclude people who weren’t likely to enter an isolation room, but that didn’t always work, either. For example, the manager of home health services pointed out that someone might have to visit the home of a TB patient who wasn’t yet removed from airborne precautions, she says.

North Arundel Hospital plans to fit-test about 1,600 of 2,500 employees. The respirator vendor trained about 50 fit-test trainers. Managers will be responsible for maintaining the annual fit-tests of their own employees, Spooner says. The hospital treats about five TB patients a year, but has about 30 patients a year who spend time in an isolation room while TB is being ruled out.

At Vassar Brothers Medical Center in Poughkeepsie, NY, staffing issues also make it difficult to limit fit-testing. "The concern of the managers was that because we have negative-pressure rooms in a variety of places in our hospital, there’s no guarantee that if we limit the number of people we’re testing, that those people will be on [duty] when we get a person in that room," says Pat Sullivan, RN, MSN, coordinator of employee health.

For instance, there’s an isolation room on the oncology floor. Recently, a TB patient was temporarily placed in that room because it was the only available negative-pressure room. Vassar Brothers plans to fit-test about 1,000 of 1,600 employees.

For James Garb, MD, director of occupational health and safety at Baystate Health System in Springfield, MA, the issue is broader than just TB. Severe acute respiratory syndrome (SARS) redefined the need for fit-testing, he points out. "I wouldn’t want to be on the just-in-time [fit-testing plan] for that if it did come back in a serious way."

By hiring a temporary employee just to conduct fit-tests and training 50 staff members to perform the tests in their units, Baystate was able to fit-test about 2,800 employees. Turning another part-time employee into full time will enable him to maintain the program, he says.

Baystate gives employees a wallet-sized card with their respirator brand and size and instructs them not to use a respirator that they weren’t fit-tested for. That warning isn’t always heeded.

"It’s a little disconcerting to me how many people didn’t know what size they were fit-tested for before [on their initial fit-test]," Garb says. "They probably grab a 3M medium, which is the most common one we use, and hope for the best."

Melanie Swift, MD, medical director of Vanderbilt Occupational Health Clinic in Nashville, TN, agrees that SARS forever changed her approach to respiratory protection. Vanderbilt will fit-test 5,000 of its 14,000 medical center personnel.

"When you consider that this is the mask we would use for anyone on airborne precautions, not just TB, there’s only so much you can do to limit the list [of those fit-tested]," she says.