Cost-saving question: Who should you fit test?

Hospitals are buying powered air purifying respirators (PAPRs) and trimming the ranks of employees who potentially would use respirators as a way to cut down on fit-testing.

Some had taken those steps in the wake of severe acute respiratory syndrome (SARS) and concerns about respirator fit. Other hospitals began reevaluating their programs in response to the announcement by Occupational Safety and Health Administration (OSHA) that fit-testing of N95 half-mask filtering face-piece respirators would be required every year.

The Veterans Health Administration (VHA), which has 170 facilities, is buying 30 PAPRs per facility and will beef up its training and fit-testing efforts, says Michael Hodgson, MD, MPH, director of the occupational health program at the VHA in Washington, DC. "We’re trying to develop a far more substantial respiratory protection training program and infrastructure that will provide greater flexibility at the facility level," he says. "Still, justifying and funding the increased staffing is difficult, especially in a tight budget year."

In its Federal Register notice announcing the withdrawal of the TB-specific respiratory standard, OSHA estimated that annual fit-testing would cost employers a total of $10.7 million a year. Hospital-based employee health professionals say the actual costs — including personnel to conduct the fit tests — will be much higher.

"They’re only estimating somewhere around 100 employees per facility that would be affected. It’s more like 10 times that," says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety, Marshfield (WI) Clinic.

Many hospitals have a long way to go to beef up their respiratory protection programs to meet the requirements. In an informal, on-line survey through an occupational health e-mail list, Cunha collected information from 23 hospitals. Only two had done annual fit-testing. One had conducted no fit-testing at all, and 20 had performed initial but not annual fit-testing. One facility reported an employee who had worn a respirator while caring for a TB patient later had a positive tuberculin skin test on annual testing. That was considered a possible exposure, despite the use of the respirator. "I think it should be opened up for more study," Cunha says.

"I think coming up with an infectious disease standard would be a better approach," he explains. "If we’re talking about the safety of employees, I think there needs to be more data."

Meanwhile, hospitals are complying by scrutinizing the number of employees who might come into contact with a TB patient — especially if the hospital is in an area of very low incidence of TB.

"When we established our TB protection program, we went as broad as we could," Cunha adds. "I think we’re going to need to look long and hard, and re-categorize some people based on some real science of who is at risk."

Geoff Kelafant, MD, MSPH, FACOEM, medical director for occupational health and employee health at McLeod Regional Medical Center in Florence, SC, already has reevaluated the number of employees who need annual purified protein derivative (PPD) skin tests. The hospital had conducted skin tests on all employees — almost 5,000. Kelafant and his colleagues removed those unlikely to have contact with TB patients, such as billing and clerical staff and employees in the health and fitness center. The list dropped to about 2,500. "Now that we’ve identified the people we think could actually get TB, those are the people who should probably actually have fit testing done. We’re going to tie fit-testing, PPD, and education into one encounter," he continues, noting that the sessions will cover respirator use and care as well as SARS preparedness.

The OSF Saint Francis Medical Center in Peoria, IL, found it was difficult to cut back on the number of employees cleared for possible respirator use — even before this latest edict. Rather than designate a core group of health care workers who would care for TB patients, the units wanted everyone fit-tested, says Denise Strode, RN BSN COHN-S/CM, clinical case manager at the Center for Occupational Health.

The hospital bought its first PAPR for an employee who could not be cleared medically to wear an N95 filtering face piece to work in spaces that involved possible asbestos exposure. Now the hospital has 50 PAPRs, including seven for the emergency department, five in the unit that cares for TB patients, and two in every other nursing unit.

The PAPRs have been well accepted, Strode says. There have been no problems with patient reaction to health care workers in the hooded respirators or with reprocessing of the hoods, she says. And in the past two years, the hospital has had no TB conversions among staff.