OSHA will consider 'good-faith' efforts on N95 compliance
Enforcement apparently goes beyond hospital
Particulate respirators — a controversial step beyond common surgical masks — are now mandated by the Occupational Safety and Health Administration to protect health care workers from acquiring H1N1 pandemic influenza A from patients. With respirator shortages feared, "good-faith efforts" by health care employers will be recognized by OSHA, which nevertheless is warning that citations and fines may result from inspections that will be primarily prompted by employee complaints.
"Employers should do everything possible to protect their employees," said Jordan Barab, acting Assistant Secretary of Labor. He emphasized, however, that where respirators are not commercially available, an employer will be considered to be in compliance if the employer made every effort to acquire respirators. Health care employers will need to be able to show documentation of orders that have been placed or statements from a manufacturer that the respirators are on back order. N95 respirators — already used by many hospitals for the treatment of tuberculosis patients — are the minimum level acceptable for H1N1. "We're looking for some evidence that the employer has attempted to purchase N95 respirators," Barab said. "We're looking for a good-faith effort."
OSHA is issuing a compliance directive to enforce the Centers for Disease Control and Prevention's recently issued "Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel." (Available at http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm.)
The CDC disappointed infection preventionists in the guidance by reaffirming its stance that surgical masks are not sufficient to protect workers from H1N1 patients. The CDC recommends the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for health care personnel who are in close contact (within 6 feet) with patients with suspected or confirmed 2009 H1N1 influenza.
OSHA inspectors will ensure that health care employers implement a hierarchy of controls, including source control, engineering, and administrative measures, encourage vaccination and other work practices recommended by the CDC. Where respirators are required to be used, the OSHA Respiratory Protection standard must be followed, including worker training and fit testing. While the ruling clearly applies to hospitals, as this report was filed OSHA had not responded to a written request for clarification regarding other medical settings. Employee complaints from clinics and physician offices could potentially result in an inspection because OSHA's respiratory protection standards also apply to small businesses.
"I would think that it would," says Stephen Streed, MS, CIC, a member of the national board of directors of the Association for Professionals in Infection Control and Epidemiology (APIC). My impression is that they are going to be responding to virtually any complaint."
The CDC clarified that the scope of its guidance includes a wide range of medical settings: "This guidance provides general recommendations for health care personnel in all health care facilities," the CDC stated. "For the purposes of this guidance, health care personnel are defined as all persons whose occupational activities involve contact with patients or contaminated material in a health care, home health care, or clinical laboratory setting."
Since a shortage of disposable N95 respirators is possible, employers are advised to monitor their supply, prioritize their use of disposable N95 respirators according to guidance provided by CDC, and to consider the use of reusable elastomeric respirators and facemasks if severe shortages occur, OSHA advised. Health care workers performing high-hazard, aerosol-generating procedures (e.g., bronchoscopy, open suctioning of airways, etc.) on a suspected or confirmed H1N1 patient always must use respirators at least as protective as a fit-tested N95, even where a respirator shortage exists. In addition, an employer must prioritize use of respirators to ensure that sufficient respirators are available for providing close-contact care for patients with aerosol- transmitted diseases such as tuberculosis.
Where OSHA inspectors determine that a facility has not violated any OSHA requirements but that additional measures could enhance the protection of employees, OSHA may provide the employer with a Hazard Alert Letter. OSHA will inspect health care facilities under the Respiratory Protection Standard "to ensure that health care workers are protected and that protection is in line with CDC [guidance]," Barab said.
The CDC guidance to use respirators has been controversial and hotly debated almost since the onset of H1N1 last spring. Many infection preventionists argue that H1N1 is comparable to seasonal influenza in its virulence and transmission routes, and that droplet precautions (e.g., surgical masks) are sufficient. But an Institute of Medicine panel charged with reviewing the available science concluded that surgical masks would not protect workers from airborne influenza particles.
Still, CDC is providing some flexibility to hospitals. That means in some circumstances, health care workers may reuse respirators, continue to wear them while caring for more than one patient, or may even wear surgical masks as a last-resort option. CDC states that extended use (in which the respirator is not removed while the health care worker cares for more than one patient) is preferred over reuse. "We recognize that there may be shortage situations," said CDC director Thomas Frieden, MD. "The need is for us not just to provide respiratory protection now, but the flu season lasts through May. We need to ensure we have a reliable supply."
The CDC guidance states, "when in prioritized respirator use mode, respirator use may be temporarily discontinued for employees at lower risk of exposure to 2009 H1N1 influenza or lower risk of complicated infection."
Though a national debate rages about the N95 edict, infection preventionists should make every effort to comply, advises Streed, system director of epidemiology at Lee Memorial Healthcare System at Fort Myers, FL.
"Though there is a lot of confusion about which direction should have been taken by the IOM, the CDC and others, we probably don't have much choice but to do what we can to make sure we provide the appropriate PPE for our staff — both scientifically appropriate and appropriate for regulatory purposes, he says.
Part of that is documenting good-faith efforts to procure sufficient supplies of the N95 respirators, with infection preventionists working closely with their materials management colleagues, he says. "My group here sends me an update every week as to what we have on hand, what has been ordered and what is on back order," he says. "So the first thing is just figuring out exactly what we have, trying to make projections of what we are going to need, and if there is going to be a shortfall in that. Also, determine whether you are going to use a disposable or nondisposable respirator."
Some hospitals are going to the aforementioned elastomeric nondisposals respirators, which are an acceptable alternative to N95s, he notes. "You can buy them for an individual and once fit-tested they can be used indefinitely," Streed says. "They have cleanable surfaces that can be wiped down with a normal hospital-grade disinfectant or even just alcohol would probably be sufficient. They come with their own set of headaches. Individuals have to maintain them and the date of [monthly] change out of filters has to be carefully adhered to."
Overall, clear communication to workers about the situation is critical, particularly since OSHA will apparently base inspections solely on worker complaints.
"Explain [to workers] the sort of stepwise proceeds you have gone through to provide the appropriate protection," Streed says. "We also are educating our staff that protection from influenza is not just one thing. PPE alone is not going to be sufficient for you to be protected."
Indeed, H1N1 vaccination of workers is proceeding smoothly, with immunization levels nearing two-thirds of the staff, he says. "They are being very receptive — especially those on the front lines."
Particulate respirators a controversial step beyond common surgical masks are now mandated by the Occupational Safety and Health Administration to protect health care workers from acquiring H1N1 pandemic influenza A from patients.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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