Wicker amendment brings confusion — and relief

Some hospitals postponed fit-testing

A reprieve from federal enforcement of annual fit-testing was greeted by some hospitals like a holiday present from Congress, but it has scarcely registered at other facilities.

Response was mixed to the "Wicker amendment," a provision added by Rep. Roger Wicker (R-MS) to the recent federal spending bill, which prohibits the U.S. Occupational Safety and Health Administration (OSHA) from spending federal money to enforce the annual fit-testing rule as it relates to tuberculosis.

The rule remains in force. State plan states may continue to spend state money to enforce it, and the Joint Commission on Accreditation of Healthcare Organizations may continue to require compliance. The prohibition on enforcement lasts until October 2005.

For example, in California, hospitals were required to complete their updated fit-testing of staff by Jan. 18.

That deadline remained in place. Twenty-six states have state-run and OSHA-approved occupational safety and health programs.

Many hospitals in federal OSHA states adopted a cautious approach.

"Institutions that have begun a process to thoroughly implement [annual fit-testing] are likely not to make much change," says Judene Bartley, MS, MPH, CIC, vice president of Epidemiology Consulting Services in Beverly Hills, MI.

Bartley also is on the public policy committee for the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America.

"Other places that have been trying to determine the best way to approach this or are in the process of looking at who should really be fit-tested or not — I suspect some of them may say, This buys us some time,’" she adds.

Hospitals see little risk

Some hospitals saw the provision as a welcome move toward a looser policy on fit-testing.

Tampa (FL) General Hospital looked at the recent draft guidelines from the Centers for Disease Control and Prevention (CDC) and reviewed its TB conversion rates and decided to hold off on annual fit-testing.

JoAnn Shea, MSN, ARNP, director of employee health and wellness, notes that CDC’s draft TB guidelines refer to "periodic" testing. The draft guidelines state: "Perform fit-testing during the initial respiratory protection program training and periodically thereafter [based on the risk assessment for the setting], and in accordance with applicable regulations. . . . There are insufficient evidence-based data to make a recommendation on the periodicity of fit-testing."

Last year, Tampa General treated about 40 TB patients. Among about 5,000 employees, the hospital had two conversions, a rate of 0.3% of those tested. Neither conversion involved a hospital-based exposure to TB, Shea explains. Two employees were exposed to TB patients, but neither case resulted in conversions.

Tampa General conducts annual screenings and user fit checks with every employee assigned to wear a respirator. They also receive a TB questionnaire to determine if they need a new fit-test. (See sample questionnaire.)

It’s hard to imagine that annual fit-testing would result in lower conversion rates, she adds.

"I think OSHA would be hard-pressed to come in and say your employees are at higher risk than other hospitals," Shea says. "If we started to notice a jump in our conversion rates and other problems, that would be another story."

That language in the CDC draft guidelines, coupled with the halt on enforcement, also influenced Shands Healthcare in Gainesville, FL, to postpone annual fit-testing.

The hospital system had planned to delegate the fit-testing task to individual departments. "It would be so labor-intensive," says Trina Girimont, ARNP, COHN-S, director of Occupational Health Services. "We figured we’d have to fit-test probably 6,000 employees. The expense with that is enormous."

Girimont acknowledges that she would have tried to reduce the number of employees designated for annual fit-testing. But the program still would have been large and difficult to maintain, without a clear benefit, she says.

Shands has a TB conversion rate of 0.26%, she says. The conversions were not linked to hospital-based exposures. "I’ve never had an employee contract TB on the job in the time I’ve been here," Girimont adds.

Search for clarity on fit-testing

Baystate Health System in Springfield, MA, mounted a major effort last year and fit-tested 2,800 employees. The three-hospital system hired an outside contractor and also used a train-the-trainer approach to update the fit-testing.

The future of that program is uncertain, but James Garb, MD, director of occupational health and safety, notes the fit-testing rule still is in place.

"The occupational medicine and infectious disease community is still very divided on this," he explains. "There are some people who think you should do it, and others who think it’s not necessary."

The fit-testing had some benefits, notes Garb. The hospital now has a record of the dates employees were fit-tested, and the brand and size of the mask; and there was an educational component.

"We did find that a lot of [employees] in areas that didn’t use them that much didn’t even know which ones they were fit-tested for," he says.

Meanwhile, Garb and his colleagues are hoping for clarification on the fit-testing issue — and more generally on how to protect workers from the hazards of airborne infectious diseases.

What diseases are truly airborne? How do you determine the level of hazard? What is the role of respirators?

"We all need a sense that there’s a single position by CDC on how they approach respiratory protection for agents that are known and how they approach the unknown," Bartley adds.