Just say no? EHPs protest OSHA rule requiring respirator fit testing
OSHA defends requirement, warns against noncompliance
Not since the Boston Tea Party has there been such united rebellion against a law of the land. And while it might be a slight exaggeration to liken that event to the reaction against OSHA’s proposed tuberculosis respirator fit-testing rule, many employee health practitioners are firmly resolved to oppose, find a way around, or defy the requirement outright. At least some of them would like to fling boxloads of N95 respirators into the nearest harbor.
Late last year, the U.S. Occupational Safety and Health Administration issued its long-awaited proposed TB standard, designed to prevent occupational exposures.1 Hospital occupational health and infection control professionals immediately criticized the plan, calling instead for enforcement of the federal Centers for Disease Control and Prevention’s 1994 guidelines for preventing TB transmission in health care facilities.2 (See Hospital Employee Health, January 1998, pp. 1-4.)
The proposed standard generally incorporates many basic elements of the CDC guidelines, which also allow facilities to provide workers with the low-cost N95 respirators recently approved by the National Institute for Occupational Safety and Health (NIOSH). Like the CDC guidelines, OSHA requires both fit testing and fit checking of the multiple-use masks. (See "OSHA fit-testing requirements," p. 14.)
Fit testing has remained a controversial issue, with some hospitals choosing to ignore that CDC recommendation while waiting to see what OSHA would decide. (See HEH, June 1996, pp. 61-65.) Now that OSHA has proposed turning the fit-testing recommendation into law and has added two new situations requiring employees to use respirators (see "Who must wear a respirator," p. 15) practitioners are protesting due to the time and expense involved.
Many question the need for protection beyond a surgical mask. Eddie Hedrick, BS, MT (ASCP), CIC, manager of infection control and staff health at the University of Missouri Hospital and Clinics in Columbia, is one of them. He acknowledges that the N95 requirement probably will not change, but he says the time and cost of fit testing are not warranted.
"If I fit-test you right now, five minutes from now it may not fit you if you are moving around and talking," he states.
Hedrick, who also is chairman of the TB task force for the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC), says the organization favors fit checking whenever an N95 is worn instead of annual fit testing.
Jeanne Culver, RN, COHN, director of employee health services at Emory University Hospital in Atlanta, agrees with the APIC position and questions whether N95s should be considered respirators in the same sense as powered-air-purifying respirators or other models that could compromise the wearer’s lungs.
"The VW and BMW are both cars, but I doubt anyone would consider them in the same category," she says. "The N95 is a more protective mask [than a surgical mask], which necessitates health care worker education on fit checking, but it should not require fit testing or a respirator program."
Culver says Emory is considering trying a group setting for respirator training, based on a 1996 study that showed no difference in the ability to pass a qualitative fit test among workers who were trained in a group for 10 minutes compared with those who were trained individually for 30 minutes. The researchers demonstrated significant financial savings, as well as reduced training time.3 (See HEH, February 1997, 21-23.)
While Culver might have found a less costly but effective means of complying with fit-testing requirements, some health care facilities plan to turn their backs and take their chances.
"Some institutions I’ve talked to simply are not going to do it," Culver says. "They have weighed the risk-benefit for their institution and decided to take their chances of an OSHA citation. Paying a fine is cheaper. OSHA must prove that a hazard exists in the facility before that can happen. If institutions follow the CDC guidelines as written isolating suspected TB patients and using negative-pressure rooms and if workers wear any mask, they will eliminate TB transmission. I am not aware of any scientific evidence that these controls were in place and failed to protect health care workers."
While many EHPs who plan to ignore OSHA’s fit-testing requirement wish to remain anonymous for obvious reasons, Ken Woodham, RN, BSN, has no such qualms.
"We’ve been out of compliance for the last five years, so why start now?" asserts Woodham, a department of one, who manages employee health, infection control, quality assurance, and workers’ compensation, and also is medical staff coordinator at North Valley Hospital in Whitefish, MT.
Fit testing is "a waste of time and ineffective," he says. "It’s overkill. We have had only one active TB patient in the past year. To incorporate fit testing, to spend the time and the money, even on the kit itself, is not conducive to cost-effectiveness in our facility."
Noting that his many responsibilities allow him to spend only a small amount of time on employee health issues, Woodham says he will inform administrators that fit-testing of workers would require hiring full-time help, "but other than that, we’ll be out of compliance.
"The government is stepping in someplace where they don’t have any scientific data," he states. "It’s just ridiculous for bureaucrats to be making a scientific decision and enforcing a standard when they don’t have any idea how it works in the real world."
Pat Love, RN, employee health manager at Winter Haven (FL) Hospital, also says fit testing is expensive and time-consuming. She and one other nurse staff the department for 3,000 employees, and Love says administrators probably would not hire additional help for fit-testing duties.
"We’ll have to do the best that we can," she says. "It will also be very hard to get employees to be compliant. We can’t ask them not to grow a beard, or not to gain or lose weight, and then we’ll have to start [fit-testing] all over again to be sure they are wearing the right type of respirator."
OSHA: It’s consistent with our policy’
OSHA officials defend the proposed standard’s fit-testing requirement on several fronts. First, the basic concept behind the provision is that all tight-fitting negative-pressure types of respirators must be fit-tested to ensure an adequate face-mask seal that prevents leaks, says Amanda Edens, OSHA project officer for the TB standard.
Fit checking alone does not accomplish that objective, and is done only to make sure a mask still fits after it has been fit-tested.
"Respirators that rely on a face seal must be fit tested. The general industrial hygiene policy we take at OSHA is that fit testing is a necessary part of a respiratory protection program. It’s consistent with our policy," she says. "But it is a proposed standard, so if people want to show us data that say a fit check is the most reliable way to show effectiveness of a respirator face seal and they can present a convincing argument, now is the time to do it."
Second, the requirement for N95s as minimum respirator protection as opposed to using a surgical mask, for example, comes directly from the CDC guidelines, Edens points out.
"We essentially adopted the performance criteria the CDC recommends," she says. "They say the necessary protection is a respirator that filters out one-micron particles with 95% filter efficiency, and right now the only respirator that meets that criteria is an N95, and it has to be NIOSH-approved. Surgical masks are not respirators and do not have filter mechanisms in them."
In addition, the CDC guidelines also specify that respirators used for TB protection must have the capacity to be fit-tested as well as fit-checked, Edens notes.
Third, OSHA is not requiring all employees to be fit-tested every year. Under the medical sur veillance portion of the proposed rule, employees will report at least once a year for skin testing, and at that time, the licensed health care professional administering the skin test can evaluate employees for the need to be fit-tested again. Unless there has been a dramatic change in the size or shape of the employee’s face, repeat fit testing is not necessary.
While OSHA has not estimated the cost per employee for fit testing alone, the agency does estimate that implementing the entire standard will cost average-size employers approximately $46 per employee. According to OSHA figures for hospitals, a respiratory protection program represents nearly 75% of the total projected expenditure. (For cost estimates related to fit testing, see box, p. 14.)
Edens says OSHA understands that hospitals perceive fit testing as costing time (OSHA estimates about 30 minutes per employee) and money "that could be spent on something else they think is important, but our policy is that fit testing is a necessary element, and right now we think all the elements of the standard are feasible."
Edens says the agency hopes all employers will "do the right thing" and comply with the standard when it is finalized. Fines are based on degrees of violation, with intentional violators incurring greater penalties than those who make a good-faith effort but fall short. Fines also are based on the seriousness of the hazard to which employees are exposed.
"Some people might not believe that fit testing is necessary, but it is very crucial, for example, if they’re allowing workers to go into an isolation room where somebody has MDR [multidrug-resistant]-TB with a false sense of security because they’re wearing a respirator, but the respirator has a poor face seal, and they got MDR-TB because of that. That’s a pretty serious thing to do to somebody."
References
1. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,159-54,307 (Oct. 17, 1997).
2. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43 (No. RR-13):1-132.
3. Hannum D, Cycan K, Jones L, et al. The effect of respirator training on the ability of healthcare workers to pass a qualitative fit test. Infect Control Hosp Epidemiol 1996; 17:636-640.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content