Breathe easy with fit-test programs that work

Link program with emergency preparedness

(Editor’s note: For many hospitals, annual respirator fit-testing represents a costly and time-consuming burden. But these two hospitals found a way to manage fit-testing — one by emphasizing just-in-time readiness, the other by expanding fit-testing into hospitalwide emergency preparedness. They shared their approach with Hospital Employee Health.)

Ever since Sept. 11, when the first victims of the World Trade Center tragedy came across the river to Long Island College Hospital in Brooklyn, NY, Lewis Kohl, DO, chairman of emergency medicine and emergency preparedness, has been even more acutely aware of the hazards posed to health care workers.

It could be severe acute respiratory syndrome (SARS), avian influenza, or smallpox. It could be an act of terrorism. It could be some newly emerging infectious disease. Employees need to know how to respond — and how to protect themselves. And respirator fit-testing is a part of that, he says. "Our perspective here was we really need to fit-test everybody if it’s at all possible," Kohl adds, noting that his hospital has 2,500 on-site employees. "You stop and say, That’s impossible.’ Everyone’s going to say you just don’t have the resources."

He says he found the resources by combining fit-testing with a comprehensive emergency preparedness program. The hospital teamed up with the Service Employees International Union (SEIU), which had funds and trainers to provide an eight-hour course — including money to provide backup for employees who were pulled off their shifts for the training.

The SEIU received a hazardous materials training grant from the National Institute of Environmental Science, which is part of the National Institutes of Health.

For some hospitals, training funds may be available from the National Bioterrorism Hospital Preparedness Program, which is part of the Health Resources and Services Administration. (Those funds may be distributed by state health departments. More information is available at

The eight-hour, one-day course covers a variety of topics, including hazardous materials, MSDS sheets, when to use a respirator and how to put it on and take it off safely, and the hospital’s emergency response plan. During the day, employees are pulled out for their respirator fit-testing.

There are 15 to 25 employees in each class. So far, the hospital has trained more than 1,300 employees in various departments and job titles.

"It has worked as a seamless flow," says Steve Schrag, eastern region hazmat program coordinator for the SEIU, which assists with the training. "People learn about what they’re exposed to, and they learn how to protect themselves. They get an opportunity to wear a respirator and learn how to put it on properly."

The training has raised awareness in a number of areas, Kohl adds. For example, trainers discuss the hazards of blood and body fluids and of the respiratory secretions of coughing patients. That improves employee compliance with using personal protective equipment and following respiratory hygiene, such as asking patients with a cough and a fever to wear a mask.

As part of the program, the hospital now has 50 employees trained to conduct fit-testing. The fit-testing showed that more choices were needed to accommodate different facial structures, and the hospital now provides three different styles as well as different sizes of N95 filtering facepiece respirators. The hospital also was able to set up as many as six fit-testing stations at a time — as long as it used a spacious room that would not become saturated with the saccharin smell, he notes.

The SEIU may provide a four-hour refresher course. But Kohl says he’s confident follow-up fit-testing and training updates will be feasible. Meanwhile, with the training, employees know where to go and what to do if disaster strikes. The class uses group activities to help employees walk through scenarios, from a hazardous materials spill to an unknown infectious disease. "My obligation is to make sure everyone in the hospital knows what the disaster plan is," he explains.

Flexibility is key ingredient

Flexibility is the watchword for the respiratory protection program at Dartmouth-Hitchcock Medical Center in Lebanon, NH. "The crux of our program is that if suddenly we had avian flu outbreak and needed to go from our 450 trained [fit-tested] staff to 5,000 trained practitioners, we would have the ability to do that in a day or two," says Lindsey C. Waterhouse, manager of safety and environmental programs. That feat is possible because of clinical respiratory program administrators, who are trained in each unit and available on each shift. "[They] maintain their own program under our guidance," he says.

Some units, such as the emergency department and intensive care unit, opted to fit-test all of their staff because of their greater risk of exposure to tuberculosis or other airborne infectious diseases. Most units, however, fit-test a core group of employees and rely on the readiness plans. The medical center includes the Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic.

The program has been touted by the U.S. Occupational Safety and Health Administration (OSHA) as a model for other hospitals. Donald Wright, MD, MPH, OSHA’s director of the office of occupational medicine, notes that Dartmouth looked beyond tuberculosis in designing its program — and yet still minimized annual fit-testing. "You can develop a comprehensive program and preserve valuable financial resources in the hospital," he says. "I think the key to this program is they’ve empowered the local departments."

The hospital began evaluating its fit-testing after the SARS outbreak in Toronto. The SARS Working Group later evolved into the Readiness Working Group, which focuses on respiratory diseases. It includes the directors of infection control and safety, occupational medical physician, vice president of clinical services, nursing and nursing education, and public affairs.

The working group reviewed risk assessments of the departments and implemented the respiratory protection program in the high-risk units immediately, says Waterhouse. The working group then identified affected departments that needed to develop the program.

The Safety and Environmental Programs office conducts periodic audits of the respiratory protection program. For example, Waterhouse may visit a unit and ask to speak to an employee who is respirator qualified. He then checks that person’s knowledge about what model and size they wear, and asks other questions about respirator use.

Meanwhile, the hospital also maintains a "protected Code Blue" cart for patients with a respiratory infectious disease who code. Those carts contain powered air-purifying respirators, which provide more protection and do not require fit-testing.

The readiness concept works, says Waterhouse. In one case, the emergency department notified a new unit that a patient would soon be admitted to a negative pressure isolation room. Before the patient arrived on the unit, a nurse educator (the clinical respiratory program administrator) was able to fit-test staff.

It isn’t necessary to maintain the annual fit-testing for all clinical staff, he says. "In one of our worst years, we had six TB cases," Waterhouse notes. "To fit-test everybody for six TB patients is kind of ridiculous."

OSHA expects hospitals to tailor their respiratory protection programs to the risk of exposure, concurs Wright. "Every institution, whether it is a TB clinic, medical clinic, or hospital emergency room, has to do a hazard assessment to determine what their particular risk is and make appropriate decisions based on that," he says.