Training method may not affect fit-testing success

Hospital studies types of respirator instruction

While training in the proper use of respirators for protection from tuberculosis infection is important, the method of training may not be significant to a health care worker’s (HCW’s) ability to pass a qualitative fit test, according to a recent study conducted at a 775-bed veteran’s affairs hospital.1

Federal law requires hospitals to fit-test respirators on workers who must use them for TB protection against tuberculosis infection, plunging employee health and infection control practitioners into what they often describe as a time-consuming and costly task.

The U.S. Occupational Safety and Health Administration’s (OSHA) tuberculosis standard will clarify concerns about the need for fit-testing. The proposed standard has been held up by the Office of Management and Budget but should be published for comment in May in the Federal Register, says OSHA spokesman Frank Kane.

Meanwhile, current compliance rules require HCWs who fall into three job categories to wear respirators and, therefore, be fit-tested: those who enter isolation rooms that house TB patients, those who perform a procedure considered high-risk for TB exposure, and those who transport TB patients.

At McGuire Veterans’ Affairs Medical Center in Richmond, VA, that amounted to 1,200 of the facility’s 2,100 full-time employees. According to the federal Centers for Disease Control and Prevention’s risk assessment classification,2 the hospital was in an intermediate risk category for TB protection. In May 1993, workers began using high-efficiency particulate air (HEPA) respirators as part of the respiratory protection program, which included individual training by an industrial hygienist on how to inspect and put on respirators. HCWs then were tested formally by a qualitative fit test. Due to the time-consuming nature of the one-on-one sessions, which required about 20 minutes per employee, only 200 workers had been trained and fit-tested six months into the program.

Researchers test training methods

"It was taking so much time from the industrial hygienist’s job that we decided to see if the method of training made a difference in [workers’] ability to pass a fit test," says Donna Hannum, RN, infection control practitioner and lead author of the study.

To determine whether different methods of training would affect the ability of HCWs to wear respirators and pass a qualitative fit test and to compare the cost of training, Hannum and associates recruited 179 employees for a study. Most worked in clinical wards and laboratory services.

Hannum says the study was designed to address three main issues:

• Is respirator training important, and, if so, which method is best for teaching workers to wear a respirator correctly?

• Does fit-testing contribute to a worker’s ability to wear a respirator correctly?

• What is the difference in cost for these training methods?

The workers were stratified into three groups based on the type of respirator training they received. The 52 workers (29%) in Group A were individually trained and fit-tested by the industrial hygienist. In Group B, 64 workers (36%) were trained by infection control nurses in a classroom demonstration setting averaging six workers per class, but they were not fit-tested as part of the instruction. Group C’s 63 workers (35%) neither received training nor fit testing.

Researchers fit-tested all study participants between one and two months later.

"The results indicated that training was important," says Hannum. "However, there really was no difference between employees who were trained individually for 20 to 30 minutes and those who were trained in a group for 10 minutes."

Of employees trained and fit-tested by the industrial hygienist (Group A), 94% passed the subsequent qualitative fit test that was part of the study. Similarly, 91% of HCWs trained by classroom demonstration (Group B) passed the fit test, as well. In contrast, employees who had no formal respirator training (Group C) had a pass rate of only 79%.

However, Hannum points out that participants’ experience wearing respirators before enrollment into the study was a confounding variable. Most of the study population were nurses and other health care professionals who had worn respirators previously. Researchers found that they were more likely to pass the qualitative fit test than those who had no experience wearing respirators.

When the study groups were compared after stratifying for prior experience, no difference was found in pass rates, except when groups A and B were combined and compared with Group C.

"Indeed, when [Groups A and B] were combined, the pass rate of the combined group was significantly higher than that of Group C," the report states.

Respirator training conclusion

The researchers concluded that, for all practical purposes, the two methods of respirator training are equivalent for employees at a medical center the size of McGuire.

They also note that study results show the accuracy of fit testing as a measure of an HCW’s ability to wear a respirator correctly needs to be validated. Of the 52 Group A participants who had been fit-tested as part of their training and had passed, three failed when they were fit-tested again for the study.

"This suggests that there is some variability in results of fit testing, especially because the same individuals were retested," the report states.

In addition, the researchers note that although the study was conducted using HEPA respirators, the recent approval of N95 respirators for TB protection does not affect the mandate for fit testing. Because N95s are not as cumbersome or complicated to fit as HEPA respirators, Hannum says the more costly one-on-one training is even less warranted.

In terms of cost savings, the researchers estimated that the hospital could save approximately $19,000 per year by switching to classroom instruction and eliminating fit testing. "However, despite evidence to support this, we were reluctant to stop fit testing because OSHA regulations require hospitals issuing respirators to fit-test and fit-check their employees periodically," they state.

Medical center employees now are trained by the industrial hygienist in groups of between six and 10, followed by individual qualitative fit testing. This has cut training time in half and has achieved some, but not all, of the $19,000 in potential savings. Researchers did not calculate the precise amount saved.

OSHA: Cost should not be substantial

Because most hospitals already have respirator training programs in place for HCWs exposed to other airborne hazards such as ethylene oxide or waste anesthetic gases, the cost of training some additional workers who are exposed to TB should not be significant, says Richard Fairfax, CIH, an industrial hygienist in OSHA’s office of health compliance assistance.

"At the time we issued our compliance directive for the use of respirators for TB protection and the need to fit-test and fit-check, we were inundated with letters regarding time and training costs," he says. "But since most facilities already have training programs in place, we felt the only burden was that they might have to train some additional people, and we didn’t feel they would incur any substantial new costs."

OSHA has no requirements regarding training methods, says Fairfax, who notes that some hospitals hire "high-priced consultants" to do the job, while others show 15-minute videotapes provided by respirator suppliers in a classroom setting.

"When we do inspections, we talk to employers and find out what they do, and then we go out and observe and verify that with employees. We will often ask them where the respirators are and to show us how they put them on," he adds.

Employees should know how and when to use respirators, when disposable respirators should be discarded, and how to do a fit check, he points out.

OSHA does not specify how often fit testing should be performed, but Fairfax says presently there is no need to repeat a test unless an employee’s face size or facial features change substantially.

Responding to speculation that the TB standard currently being developed might include a requirement for more regular fit testing, Fairfax says, "I think it will. There may be an annual provision in it."


1. Hannum D, Cycan K, Jones L, et al. The effect of respirator training on the ability of healthcare workers to pass a qualitative fit test. Infect Control Hosp Epidemiol 1996; 17:636-640.

2. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR 1994; 43:1-132.