Stressed over fit-testing? Are you doing too much?

Some hospitals don’t need a respiratory program

Industrial hygienists insist annual fit-testing is essential to the proper use of respirators.

Infection control practitioners argue tuberculosis patients, once identified and isolated, pose little risk to health care workers.

But perhaps they agree on one point: Hospitals are doing too much fit-testing.

Two issues emerged from the recent workshop on respiratory protection and infectious diseases sponsored by the Centers for Disease Control and Prevention (CDC):

  • If you determine there is no hazard from TB and the wearing of respirators is voluntary, you don’t need a respiratory protection program.

You must conduct a hazard assessment to determine whether health care workers are exposed to TB and whether they need respiratory protection. But if there is no hazard, there is no need for personal protective equipment.

That is the position of the U.S. Occupational Safety and Health Administration (OSHA), as stated in a July 23 letter of interpretation.

The agency addressed a question posed by the American Health Care Association about long-term care facilities that do not accept TB patients.

If the facility is at minimal risk for TB because it admits no TB patients and is in a community in which no TB cases have been reported in the past year, then fit-testing and other measures are not required, wrote Richard Fairfax, OSHA director of enforcement programs.

"If the risk assessment determines that there is no hazard, employees would have no requirement to wear a respirator and there would be no need to create a respiratory protection program," he said.

In a very-low-risk facility — one that does not admit any patients with active TB and has not examined any such patients in the outpatient area in the past year — only health care workers who might be involved in assessment or transport of patients may need to be included in a respiratory protection program.

What about hospitals that treat TB patients but have no nosocomial transmission?

This issue arose at the workshop when Mazae Kawamura, MD, TB controller with the California Department of Health at San Francisco General Hospital, noted that she and her staff don’t even wear masks when treating TB patients in the clinic.

"TB is not that easy to get," she said. "I’ve been working with very infectious patients for 15 years and never wore a mask."

Kawamura said the clinic uses a HEPA filter to filter the air, and TB patients are given surgical masks. "It’s really source control that’s the key."

Respiratory protection experts responded that if respiratory use is voluntary because of a low risk of exposure, the hospital does not need a respiratory protection program. However, without specific OSHA guidance on this and a lack of data about how much protection is provided by administrative and engineering controls, hospitals may find that hard to justify.

"I don’t think our administration will allow us to be exempt from the respiratory protection program," Kawamura pointed out.

Draft TB guidelines from CDC state that the "periodicity" of fit-testing should be determined by risk assessment, but they also note that OSHA requires annual fit-testing.

  • You only need to fit-test employees who are actually exposed to TB or other airborne infectious diseases.

Annual fit-testing is a burden because hospitals are fit-testing too many employees, industrial hygienists argue. Instead, you can focus on training fit-testers who maintain a core of employees in at-risk departments, such as the emergency department and the intensive care unit. Those fit-testers can conduct additional fit-tests on an as-needed basis.

Donald Wright, MD, MPH, director of the OSHA’s Office of Occupational Medicine, cited a program at Dartmouth-Hitchcock Medical Center in Lebanon, NH, where only 8% of employees receive annual fit-testing. The hospital has an Infectious Disease Readiness Committee, a contingency plan to convert a wing into a respiratory isolation unit, and employees trained on each unit for each shift to conduct fit-testing.

A respiratory response cart has two powered air-purifying respirators for use in an emergency. They do not require fit-testing.

"They truly are capable of ramping up their program very rapidly should they become the next site of an infectious outbreak," Wright added.