OSHA makes respirator fit-testing more difficult

Another protocol added

Recent changes to OSHA requirements related to tuberculosis and respirator fit testing have prompted concern from many health care professionals who are responsible for the health and safety, including fit testing, of health care facility employees, a recent survey of occupational health nurses reveals.

And in August, OSHA announced an additional requirement to its quantitative fit-testing procedure. The new fit-testing protocol, referred to as the Controlled Negative Pressure (CNP) REDON protocol, requires three different test exercises followed by two redonnings of the respirator.


In 1998, OSHA updated the 1971 Respiratory Protection, requiring workers who need respirators when they are exposed to hazardous airborne biological or chemical agents to be fit tested annually to ensure a proper facial seal. Tuberculosis was excluded because OSHA was planning to issue a tuberculosis standard that would include rules for respirator use. In January 2004, OSHA announced that because the proposed tuberculosis standard was deemed unnecessary, respirator use for tuberculosis would instead be covered under the 1998 Respiratory Protection Standard. Enforcement of the new standard became effective in July.

The number of cases of tuberculosis in the United States has dropped by 40% in the last 11 years, according to data from the CDC.1 The most recent high number of reported cases was 26,673 in 1992; the number of reported cases in 2003 was 14,874. OSHA cited the dramatic drop as one reason it elected to drop the tuberculosis standard.

To meet the OSHA standard, facilities must revise their respiratory protection programs to comply with the OSHA standard, conduct annual respiratory fit-testing, and perform a medical evaluation and annual training for employees using respirators. The AAOHN survey indicates that the majority of the work required to bring facilities into compliance will fall on employee health staff.

AAOHN and the Association of Occupational Health Professionals (AOHP) called for a new respirator standard that takes into account the unique needs of employees in the health care industry, citing the difficulty a large hospital would have fit-testing potentially hundreds of employees every year. Also, the groups said, airborne exposures in hospitals are less likely to be tuberculosis, and more likely to be infectious microbes. Besides hospitals, other health care facilities affected include nursing homes, correctional facilities, and substance abuse clinics.

The United American Nurses union spoke out in favor of the new protocol, despite the cost in time and dollars, because of the expected protection it could extend to health care workers. OSHA has estimated that the national total cost of compliance will be more than $11 million, with 90% of that cost going toward fit-testing and training on the respirators.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires accredited facilities to adhere to OSHA standards, and recently entered into an alliance with OSHA to concentrate efforts on reducing health care workers’ exposure to airborne pathogens.

In response to member complaints about the new regulations, the AAOHN surveyed occupational and environmental health nurses and infection control professionals in hospital settings to gain information about compliance practices related to the new OSHA requirements.

According to the survey, 69% of respondents reported a high level of difficulty complying with the new OSHA requirement. Of these, a majority (75%) work in nongovernment not-for-profit hospitals, are responsible for fit-testing between 500 and 5,000 individuals (61%), and have an employee health staff of three or smaller (69%).

"AAOHN had heard from its members, particularly those in health care facilities, about their concerns related to compliance with the new general respirator requirement," says Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, AAOHN president.

Participants were asked to provide information about their compliance practices as they relate to the types of hospitals in which they work, the number of employees for whom they are responsible, the size of their employee health staff and who administers their respirator fit tests. Answers to these questions were evaluated and compared to analyze whether or not these factors contribute to a high level of difficulty with compliance.

According to AAOHN’s survey, respirator fit testing is typically handled internally; Eighty percent of respondents indicated that employee health services, or employee health services in combination with other hospital departments, administers its facility’s respirator program, compared to 7% whose facilities use outside vendors.

OSHA standards directors announced earlier this year that fit-testing — on average, a 10- to 15-minute process per person — will be expected to be an annual event to ensure respirators continue to fit workers as they age and gain or lose weight.

In the AAOHN survey, respondents in employee health programs responsible for 1,000-5,000 employees indicated they have the most challenging time with fit testing, averaging 7.4 on a difficulty scale of 1-10, with 10 being extremely difficult. By contrast, respondents with fewer than 100 employees indicated the least difficulty with fit testing, with an average difficulty rating of 5.6. Those nurses operating with 3 or fewer employee health staff indicate they have the most challenging time with fit testing, averaging 7.4 on the difficulty scale. In most of these cases (53%), the employee health staff are solely responsible for fit testing.

As far as which model is most used for assessing tuberculosis risk, according to the survey, in all facility types except investor-owned, for-profit hospitals, CDC’s 1994 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities is used more than any other risk-assessment model (43% of federal government, 67% of long-term care facilities, 56% of nongovernment, not-for-profit, and 49% of state/local government facilities use CDC guidelines). In investor- owned, for-profit hospitals; however, 57% of respondents use OSHA’s risk-assessment model.

To read the OSHA protocol for CNP REDON respirator fit test, go to www.osha.gov; click on "Federal Register," then "Date of publication," then "2004." Under August 4, 2004, see "Controlled Negative Pressure REDON Fit Testing Protocol [1910]."


1. Centers for Disease Control and Prevention Surveillance Reports. Reported Tuberculosis in the United States, 2003. Atlanta: U.S. Department of Health and Human Services; September 2004. Accessed at www.cdc.gov/nchstp/tb/surv/surv2003/default.htm.

For more information, contact:

Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, President, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Phone: (770) 455-7757. Web: www.aaohn.org.