Good respirator programs offer different brands
NIOSH document will help meet OSHA standard
If the mask doesn’t fit, it’s better to have one or two other brands on hand rather than expose health care workers to the risk of wearing ineffective respirators, say officials at the National Institute of Occupational Safety and Health (NIOSH) in Washington, DC.
That bit of advice is one of many that will be published later this year when NIOSH completes a comprehensive guideline for respirator programs for tuberculosis control. Since the federal agency updated its respirator testing and certification requirements two years ago, health care facilities have been slow in establishing policies and protocols for respirator fit testing, says Walter Ruch, PhD, CSP, a senior industrial hygienist at NIOSH. The guidelines should help facilities meet the new TB standard promulgated by the Occupational Safety and Health Agency (OSHA) in Washington, DC. Although the proposed OSHA standard was due for publication in the Federal Register in June, the date has been delayed again, says OSHA spokesman Frank Kane.
Until the standard is adopted, respirator fit-testing is required under OSHA’s general duty clause, and facilities that don’t have testing as part of their respirator program are being cited for violations. Nonetheless, hospital administrators have complained that routine respirator fit-tests are time-consuming, expensive, and unnecessary, Ruch tells TB Monitor.
"They sound like they would rather place a big barrel out front, and you can pick one and go do your thing," he says. "If they don’t fit-test and OSHA comes in and does an inspection, they are on their own because everyone knows NIOSH guidelines are out there." (See TB Monitor, November 1995, pp. 121-123; July 1995, pp. 73-75.) The guidelines, which will be incorporated into the OSHA standards, require employees to be fit-tested once a year. In addition, an employee should fit-check the mask each time it is put on.
Have several brands on hand
Ruch does not know whether OSHA will require annual fit-testing. Many TB program managers are hoping it won’t, arguing that after the initial fit-test, an annual education component with a possible demonstration is sufficient.
A non-OSHA facility, Miami’s Jackson Memorial Hospital began routine fit testing last fall. Previously, the hospital provided annual respirator education with a fit-test demonstration, says Joan Otten, RN, MPH, director of the hospital’s TB program. Fit tests were available for employees who felt they needed them. Workers who lost or gained excessive weight also were encouraged to seek another fit test, she adds. The current policy requires fit testing for all new hires and a one-time fit-test for all in-house staff. Annual fit testing for such a large facility would not be cost-effective, she adds.
While many facilities are fit-testing employees for the new respirators, they may not be as stringent about fit-checking, which ensures that the respirator has been properly adjusted and its integrity has not been compromised, he explains. While a fit-test tells a worker which size and make is best for his or her face, a fit-check, which takes less than five minutes, ensures that the straps have been placed correctly, and the tightness is right. Moreover, the fit-check will detect those 5% to 10% of respirators that are inherently leaky because of manufacturing defects, Ruch adds.
"Every time they put one on, they should do a positive and negative pressure test put their hands over it, and blow into it or suck it," Ruch says. "If it claps against your face or balloons out, you have a good chance of being fit."
A fit-check should include the following steps:
• Adjust the straps so that they hold the mask against your face but not so tightly that you get wrinkles.
• Perform a negative or positive pressure check. This step cannot be done on disposable masks.
• Get into the "chamber" a small plastic bag and place a small amount of the test substance (saccharin usually) inside the chamber and begin breathing.
• Exercise, talk, move your head up and down. If you taste or smell nothing, then your respirator fits properly.
The best-fitting respirator may not be the most comfortable one, and if a respirator is uncomfortable, an employee is more reluctant to wear it, says Ruch. With more than a dozen N95 respirators now approved and most offering two or three different sizes, facilities now have a wider choice and should have masks from at least two manufacturers on hand to find the one that fits best and is most comfortable, he says.
"No matter how you look at it, respirators aren’t comfortable, but some are more comfortable than others," he explains. "People should be able to choose from two or three brands and see which one is more comfortable because better comfort gives you a better chance for them to keep wearing respirators like they are supposed to be worn."
Rather than incur the added expense of having two different brands, Jackson Memorial Hospital’s TB program wrote into its bid contracts that the manufacturer would provide an alternative particulate respirator for workers who were not comfortable with the chosen N95, says Otten. "They will provide them at no extra charge, " she says. "If you start going to another company vs. staying with the same company and writing it into the contract, it will probably cost you more."
By putting out bids for the respirators, facilities can get better prices. Also, because the respirators vary so much in design and comfort, it is best to test all of them before making a selection, she adds.
N95 replaces HEPArespirators
Lighter, cheaper, and more efficient, the N95 masks are a welcomed relief from the imposing and bulky high-efficiency particulate air (HEPA) filter respirators that were required before NIOSH revised its certification standard in 1995. (For a list of N95 respirators approved by NIOSH, see chart, p. 77.)
"There is no comparison to the [HEPA filters]," says Anna Elarth, RN, nursing supervisor for the TB clinic at the Seattle-King County Department of Public Health. "If one wears [N95 masks] in front of patients, they are much more acceptable than the array of other masks that were available."
With the majority of N95 masks costing less than a dollar, many facilities are disposing of them after a single use. The NIOSH guidelines will allow multiple use of the "disposable" mask if it has not been soiled or abraded, or the filter medium has not been compromised in any other way, Ruch says.
The policy at Jackson Memorial is to allow workers to use the mask throughout their shift unless the mask has become damaged or excessively moist, Otten says. The masks could be used longer, but the clinic has no storage place for them, she added.
Companies are still submitting N95 masks for certification, and NIOSH is still about six months behind in approving them, he reported. The agency has received reports in which several brands have caused difficulty when fit-testing with irritant smoke and is looking into the problem, Ruch said, adding that the reports were few in number.
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