Lessons learned: Use PAPRs to avoid fit-tests

Washington hospitals have years of experience

While much of the country struggles to comply with the new requirement for annual fit-testing of N95 filtering facepiece respirators used to protect against tuberculosis, hospitals in Washington state have some advice:

Powered air-purifying respirators (PAPRs) are an important tool in decreasing the burden of fit-testing, employee health and safety professionals say. They have had many years to learn that lesson. Based on a rule of the Washington State Department of Labor and Industries in Olympia, they have conducted annual fit-tests since 1995.

When the U.S. Occupational Safety and Health Administration (OSHA) revoked its proposed tuberculosis standard Dec. 31, 2003, it placed hospitals and other health care employers under the General Industry Respiratory Protection Standard, which requires the fit-tests. Although OSHA was expected to further delay enforcement of the fit-testing rule, as of press time, hospitals and other health care facilities were still required to comply by July 1, 2004.

"When we first introduced this, we were able to get the [respirator] vendors to assist us with the fit-testing procedure," recalls Patti Newsted, HEM, safety manager at St. Joseph Hospital in Bellingham, WA.

It was a daunting task to fit-test 450 employees, she says. But even more troubling were some of the difficulties that arose with the fit-testing itself. Some men did not want to shave their beards, a requirement to allow the respirators to fit properly. "This went all the way up to our administrative levels," Newsted says. "They agreed we are not going to make an exception because someone is wearing a beard [for aesthetic reasons]. They have a job to do and the job requires them to work with TB patients."

The hospital decided to allow those employees to wear PAPRs — if they purchased the units themselves. At the time, they cost about $300 each.

Meanwhile, some employees seemed unable to obtain a proper fit with the two brands of N95 respirators the hospital had purchased. Some health care workers complained that the N95s made them feel hot or uncomfortable.

"That’s when we started looking at these PAPRs more seriously," Newsted says. "We justified the cost by looking at the time involved for all the fit-testing and the advantages the PAPR had over the N95."

St. Joseph Hospital now relies on a stock of PAPRs — about two or three per inpatient floor. Employees use disposable hoods, which they keep for use on a single TB patient and then throw out when the patient is discharged. (The hospital treats about six TB patients a year, and has a number of other rule-outs.)

Newsted eventually learned about some drawbacks of the fit-testing process. She had used qualitative testing with saccharin, and employees later told her they had been impatient with the process.

"There were folks who really didn’t want to deal with it, and there were folks who faked their way through it and said they didn’t taste the saccharin when they really did," she says. "Then there were folks who said, I can taste it, I can taste it.’ Did they really taste it or did they just not want to wear the respirator?"

The PAPRs were readily accepted by the staff, Newsted adds. "Initially, people were joking that they looked like beekeepers. Once they wore it, they realized, It’s cool. I can see. My vision isn’t obstructed. The patient can hear me. It’s not that heavy to wear.’ We worked out all of the barriers to this and it’s actually worked quite well."

With the advent of severe acute respiratory syndrome (SARS) and the possibility of pandemic influenza, St. Joseph Hospital has purchased a stock of N95s. With those diseases, which have different transmission properties from TB, the cleaning requirements of the PAPRs would be too great, says Lori Wilkinson, RN, COHN-S/CM, occupational health nurse.

"When we first would see a SARS patient, we would go with the PAPR. You’d have to discard the hood," she says. "I think we would quickly move to N95s and would do N95 just-in-time fit-testing."

Group Health Cooperative in Seattle took a similar path in its respiratory protection program. The health system, with about 20 outpatient clinics, three specialty centers, and two hospitals, started with N95s then purchased PAPRs. Now the health system is conducting annual fit-testing for N95s.

"We currently are only fit-testing 215 staff [and physicians], which includes two hospital labs, micro lab, emergency room, urgent care, respiratory therapy, pulmonary, and selected staff in the operating room and environmental services," says Janie Garris, RN, MN, director of infection control and employee health. "These numbers may be small compared to some facilities that do not use PAPRs in addition to N95s," she adds.

The fit-testing occurs in the emergency department and med-surg unit, where employee health relies on a "train-the-trainer" model. Employee health administers the medical screening questionnaires and maintains the respirator fit-test records. Staff on the units perform the fit-tests. (See sample record form.)

Employee health simply would not have the staff to perform all the fit-tests, but instead manages the program and keeps track of which employees need the tests, Garris says.

"It’s been challenging," admits Garris, who must contact managers to alert them about employees who haven’t received their annual fit-tests.