How and why to fix your respirator program

HCWs still confused about respirators

Gaps in your respiratory protection program can create unnecessary hazards for your employees. A survey of hospitals in California and the Midwest has revealed those weaknesses. For example, health care workers often receive minimal training and are confused about which respirator to use for aerosol-generating procedures.

"Wherever you use respirators, [you need to have] a full comprehensive respiratory protection program that ensures you're using them effectively," says Barbara Materna, PhD, CIH, chief of the Occupational Health Branch of the California Department of Public Health and a lead investigator in the Respirator Use Evaluation in Acute Care Hospitals (REACH) project.

The H1N1 pandemic was a watershed moment for hospitals, as they suddenly needed to use respirators to protect health care workers from a novel virus, she says. Hospitals coped with sudden demand, the need to quickly train and fit-test employees, and spot shortages.

"That whole experience really did increase awareness of the need and appropriate use of respiratory protection," says Materna. "We can't become complacent now and go backwards. We need to maintain that level of preparedness."

One bright spot: Hospitals seem to be largely in compliance with annual fit-testing. In the California survey of personnel at 15 hospitals, 87% of health care workers and 98% of unit managers said fit-testing occurred at hire and then annually.

Compliance was not as uniform in Minnesota and Illinois. "It did seem that fit-testing was generally happening annually, though that varied by hospital," says Lisa Brousseau, ScD, CIH, associate professor in the School of Public Health at the University of Minnesota in Minneapolis and principal investigator for the REACH survey in Minnesota and Illinois. At hospitals in Minnesota, 9% of health care workers said they had not been fit-tested, and 15% said a fit-test wasn't required before wearing a respirator.

In a REACH survey in Michigan, only 45% of managers and 76% of health care workers said fit-testing occurred at hire and then annually.

Not just for TB

Typically, hospitals have considered the respiratory protection program to be an element of their tuberculosis program. They may have less awareness of the need for respirators with other airborne diseases.

"Oftentimes, what they would give us was their tuberculosis plan, and they would say 'Here's our respirator plan,'" says Brousseau. "Inside the tuberculosis plan would be something related to respirators. Only rarely would you see a separate program called the respiratory protection program."

In California, the Aerosol Transmissible Disease standard clearly spells out the need for respirators to protect against novel infectious organisms and other airborne diseases. It includes a chart that delineates which diseases require airborne or droplet precautions.

Because of the ATD standard, hospitals in California are more aware of the requirements for respirators, but problems remain with the written programs, says Materna.

"A number of the components that are required were missing," she says. Most concerning: 47% had not designated a program administrator. About 40% did not address how health care workers should select the correct respirator for different types of hazards. And two-thirds didn't include any information about program evaluation.

"The respiratory protection standard [of the U.S. Occupational Safety and Health Administration] says that program evaluation needs to be done periodically and employee input needs to be included," says Materna. "A labor-management safety committee is a really good forum to have discussions about what's working and what could be improved."

Brosseau found similar problems with written programs in Minnesota and Illiniois. "Almost nobody is doing program evaluation," she says. "You're supposed to audit your program periodically and see if things are happening the way they're supposed to be happening."

Airborne and droplet confusion

Health care workers understand that they need to wear a fit-tested N95 respirator or greater protection if they are in close contact with a patient with tuberculosis. They are more confused about what they need to wear when performing an aerosol-generating procedure.

California's Aerosol Transmissible Disease standard requires the use of a powered air-purifying respirator (PAPR) during aerosol-generating procedures with patients who have TB. Some health care workers were uncertain about the use of PAPRs.

During the H1N1 pandemic, the Centers for Disease Control and Prevention (and the California Department of Public Health) advised hospitals to use N95s in patient care. When H1N1 became seasonal influenza, the N95s were only recommended for aerosol-generating procedures and surgical masks are recommended for routine care.

In California, about 20% of health care workers reported still wearing N95s with flu patients. In Minnesota, where the Department of Health still allowed hospitals to use surgical masks with pandemic H1N1, there is even more confusion, says Brousseau.

"There's a general lack of understanding about what's an airborne disease and what's a droplet disease," says Brousseau. "Where does seasonal influenza fall? It seems it sort of falls in between. It's sort of a droplet disease when it's close contact. It's sort of airborne when it's an aerosol-generating procedure. I can see why people are very confused about it."

Is there a program administrator?

Some other suggestions for improvement from Materna and Brousseau:

Assign a program administrator for your respiratory protection program. "In large hospitals, respiratory programs are often divided up. Employee health and safety does some things, infection control does some things, unit managers are expected to do some things and those groups are not always working together," says Brouseau.

Conduct a risk assessment. That's the only way to know who may need to wear a respirator, says Brousseau.

Make sure your annual training is adequate. In the California survey, about 40% of health care workers said their training lasted only 1 to 15 minutes. Many respirator wearers failed to do a user fit check when they donned the respirator, possibly because they hadn't received proper training, says Brousseau.

Give employees a written card or a sticker for their badges with their respirator model and size. In California, 24% of workers only received a verbal instruction about which N95 they should wear.

Still, Brousseau found some bright spots in the surveys.

"We didn't run into any hospital where they hadn't heard of respirators," she says. "That's a step up from 10 or 15 years ago.

"But we did have some hospitals say to us, 'We never see anybody that requires us to wear a respirator.' They were sure an exposure was never going to happen. That made us worry a little bit because tuberculosis can happen anywhere, and so can measles and pandemic influenza," she says

[Editor's note: Inserted in this issue is a respiratory protection checklist created by health officials in California that can be used to evaluate your program.]