OSHA hears plea for annual respirator fit-testing delay

Hospitals hope for more time to comply with new rule

Fit-testing is still on, but the timing may be off. Hospitals may take as long as a year to implement their annual fit-testing of filtering facepiece respirators used for protection against tuberculosis.

As Hospital Employee Health went to press, the U.S. Occupational Safety and Health Administration (OSHA) was expected to grant an extra six-month moratorium on enforcement to give hospitals and other health care facilities more time to comply. Some state-plan states already provided extra time. Many hospitals had planned to stagger their compliance, taking as long as a year to complete their programs and fit-test their staff.

The fit-testing rule remains a source of controversy for the agency. When OSHA revoked its tuberculosis standard Dec. 31, 2003, it also placed hospitals and other health care employers under the general industry respiratory protection standard, which requires the fit-tests as well as medical evaluations, training, and record keeping.

The Association for Professionals in Infection Control and Epidemiology (APIC) and the American Hospital Association protested the action with letters to OSHA and an appeal to supporters in Congress.

At hearings held before the House Appropriations Subcommittee on Labor, Health, and Human Services in April, APIC asked for the respiratory protection rule to be reopened and for the agency to provide an additional delay in enforcement.

In a meeting with APIC officials after the hearing, OSHA administrator John Henshaw said the agency would confer with experts at the Centers for Disease Control and Prevention (CDC) to discuss the broader issue of worker protection against biological hazards, says Jeanne Pfeiffer, RN, MPH, CIC, president of APIC. "That was a positive initiative from our perspective," she says.

OSHA also sent APIC a detailed response to its concerns about annual fit-testing, and noted that the agency has always included biologic hazards in its respiratory protection rule. (See a copy of the letter.)

Meanwhile, at hospitals around the country, many employee health professionals have already come to terms with the new reality.

"Whether or not this change had happened at OSHA, we would still have to deal with other diseases that did not fall under the TB respiratory protection standard," says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic in Nashville, TN. "I think overall it’s been beneficial because it’s laid the groundwork for us to deal with other hazards."

The fit characteristics of different N95 filtering face-piece respirators can vary significantly from one manufacturer to another. If a respirator has a high fail rate on fit-tests, it may be time to switch to another brand that has an overall better fit, says William Buchta, MD, MS, MPH, medical director of the Employee/Occupational Health Service at the Mayo Clinic in Rochester, MN.

When Mayo conducted recent fit-tests, "30% of the people who were refit actually needed a different respirator or a modification of what they had," he says. "That was a wake-up call."

Some employee health professionals have called Denise Strode, RN, COHN-S/CM, executive president of the Association of Occupational Health Professionals in Healthcare in Warrendale, PA, asking if they might get some relief from OSHA’s rule. She advises them that any change in the approach toward biologic hazards would take time and study. "I think we just need to follow the guidelines and start the process," says Strode, clinical case manager at the OSF SFMC Center for Occupational Health at Saint Francis Medical Center in Peoria, IL.

It has taken hospitals several months to review their respiratory protection programs, determine who must receive the fit-tests, and train the personnel to conduct them. By late spring, many hospitals still were establishing their new systems. State-plan states are required to implement OSHA changes within six months of their adoption, so some states gave their employers extra time.

Many hospitals plan to stagger their annual fit-tests during the year. That is OK, says OSHA industrial hygienist Craig Moulton, as long as the employees who are currently interacting with TB patients or who are at the highest risk receive their fit-tests immediately.

"They should prioritize to fit-test those people who are going to be wearing [respirators] in order to be in compliance," he says.

Hospitals that do not treat TB patients and have virtually no TB in their communities do not need to conduct fit-testing, he says. However, they should have a respiratory protection program in place that can be activated if necessary for airborne diseases such as severe acute respiratory syndrome (SARS), he says.

Hospitals are trying to integrate the annual fit-tests into existing programs. Pitt County Memorial Hospital in Greenville, NC, plans to conduct the fit-tests during annual health screens, which employees will receive during their birth month, says Pat Dalton, RN, COHN-S, occupational health project specialist at Pitt County Memorial. North Carolina OSHA granted employers an extra six months to comply — time that the hospital will use to plan and launch the staggered tests.

At that health screen visit, they will have respirator medical evaluations, an update on immunizations, TB skin test and education, vision screen, and workers’ compensation education. The hospital also plans to offer voluntary health risk appraisals and cholesterol and blood sugar tests.

Meanwhile, the hospital will try to limit the number of employees who need the fit-testing, says Dalton, who is chair of the safety subcommittee. "Optimally, that’s something OSHA likes anyway," she says. "You put the fewest people you can at risk and then you use personal protective equipment."

Vanderbilt has linked the annual fit-testing to CPR recertification and staff competency testing. "The annual retesting will begin by July 1, but it will take a while to logistically retest everyone," Swift adds.

Vanderbilt will conduct the testing on the same days new employees receive their fit-tests, she says. Swift will use the same tracking software that she uses for TB skin testing. "I think we have a good plan in place," she says. "It’s going to be fairly labor-intensive, but we can do it."

Still, the logistics are daunting. Even after reviewing the number of employees who may need to wear respirators, hospitals still have hundreds or even thousands of fit-tests to perform.

Vanderbilt previously provided initial fit-testing to everyone who had a TB skin test and would have patient contact. "Now we need to target the program to people who truly are at potential risk," Swift says. However, many units have a couple of isolation rooms. "You can’t predict who’s going to be assigned to that patient, who’s going to be on that shift," she notes.

Swift eliminated certain employees, such as those who deliver food trays, from the fit-test list. They shouldn’t be entering isolation rooms, she says. And the myelosuppression unit has positive-pressure rooms with patients who are severely immunocompromised. No TB patient would ever be placed there.

When they finished reviewing the employee lists, Swift and her colleagues reduced the fit-testing population from 5,500 to 4,500.

At Children’s Hospital of the King’s Daughters in Norfolk, VA, the list dropped from 2,000 to about 700. "For people who never ever have had to put on a respirator and probably will never have to, we just made the decision these people will not be fit-tested and they will not be going into a TB room," says Patricia Higazi, RN, COHN, occupational health manager.

Each unit will be responsible for evaluating and fit-testing employees, and Higazi has trained an additional 20 fit-testers. Occupational health will continue to fit-test about 250 employees and will provide quantitative fit-testing, when necessary, she says. "If there are any positive responses to the [medical evaluation] questionnaire, then they refer them to occupation health," she says.

Smaller hospitals are having a particularly difficult time because they don’t have extra personnel or help from an in-house occupational health physician, Strode explains.

She advises employee health professionals to partner with infection control, to use the expertise of pulmonologists, and to discuss the new mandate with administration. They also may tap into other resources at the hospital.

"Look at the people you have on modified duty, whether it be occupational or nonoccupational. It wouldn’t take very long to train somebody. It doesn’t have to be a nurse," says Strode.

Many hospitals are trying to avoid the fit-testing altogether by using powered air-purifying respirators (PAPRs). They also can be used as backup protection for employees who have beards or haven’t been fit-tested. Yet widespread use of PAPRs introduces other logistical issues, says Dalton. She sums them up with some questions: "How are you going to keep them clean, where are you going to store them, and who’s going to keep up with them?"