The COVID-19 pandemic has highlighted the importance of respiratory protection when developing and incorporating infection prevention procedures into daily tasks for employees. Hospitals and larger healthcare facilities have had prior experience applying OSHA’s Respiratory Protection Standard (29 CFR 1910.134) while addressing previously encountered airborne biological hazards, such as Tuberculosis (TB) and measles. Many smaller healthcare facilities, such as long-term care and skilled nursing facilities, which did not require respiratory protection for staff before COVID-19 emerged and have now implemented Respiratory Protection Programs over the past two years. During that time, facilities have experienced frequently evolving CDC guidelines and OSHA requirements as additional research has evolved, validating that the spread of COVID-19 is airborne by nature. Throughout these changes, respiratory protection has remained a constant necessity for employees anticipated to be in close contact with unvaccinated staff and patients, as well as those suspected or confirmed with COVID-19. Even with the recent withdrawal of the non-recordkeeping provisions of OSHA’s Healthcare Emergency Temporary Standard (ETS), the agency has pledged to continue to enforce safety standards through the “general duty” clause and specifically warns of enforcement of the Personal Protective Equipment (PPE) and Respiratory Protection Standards.
Since the launch of OSHA’s National Emphasis Program almost a year ago (March 2021), OSHA has issued more than 700 COVID-related citations with the Respiratory Protection Standard being the most commonly cited regulation. For example, in August 2021, Lakewood Resource and Referral Center — operating as the Center for Health, Education, Medicine and Dentistry (CHEMED) — received two willful violations and a fine of $273,064, for not providing medical evaluations and fit testing to temporary workers that were issued N95 respirators. According to these citations, healthcare entities and temporary agencies who employ staff required to wear respirators, may both be subject to willful citations. Therefore, all employers that issue any type of respirator must develop a robust written program that includes “proper training, fit testing, availability of appropriate medical evaluations and monitoring, cleaning, and oversight by a knowledgeable staff member”.
Medical evaluations are performed to ensure that an employee is physically capable of wearing a respirator during normal work activities and must be completed before fit testing any issued respirator(s). The evaluation can be provided as a questionnaire to be reviewed onsite by a licensed healthcare practitioners (LHCP) or outsourced to a third-party provider. Fit testing is conducted for each type of respirator issued to verify that the seal conforms to each employee’s unique facial structure and provides adequate protection. As supply availability fluctuates, and different respirators may be issued throughout the year, it is critical to fit test each different make, model and size respirator issued, in order to comply with the regulatory requirements and provide the necessary protection.
Facilities fortunate enough to have powered air-purifying respirators (PAPRs) with loose fitting hoods in supply can bypass the fit testing requirement for negatively pressurized respirators, which need a tight seal to provide protection. A PAPR is an air-purifying respirator that uses a blower to force air through filter cartridges or canisters and into the breathing zone of the user to create an air flow inside the hood or helmet. This positive pressure differential provides a higher assigned protection factor (APF) than disposable N95 or reusable non-powered air-purifying half facepiece respirators. A PAPR with a loose-fitting hood provides filtered air that is positively pressurized inside the hood; therefore, it does not function with a tight seal that needs to be fit tested. This may be beneficial to have for the use of employees with beards and hard to fit facial structures. Medical evaluations must still be performed before issuing a PAPR to screen for any possible complications during use.
Due to the heightened concern for infection prevention in healthcare settings, it is also common to observe employees providing and voluntarily wearing respirators in areas where airborne hazards are not present. This extra protection may provide an added level of comfort and may not be discouraged by employers. In these instances, employers are not required to perform medical evaluations and fit testing for employees supplying their own respirator as addressed in the voluntary use section of OSHA’s Respiratory Protection Standard. However, they must provide a notification that states, “if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker”.
Healthcare facilities allowing voluntary use must also ensure that staff that provide their own respirator(s):
- Read and follow all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator’s limitations.
- Keep track of their respirator to not mistakenly use another employee’s respirator.
- Not wear a self-provided respirator where other workplace hazards (e.g., biological or chemical exposures) require use of a respirator. In these cases, the employer must provide a respirator that is used in accordance with OSHA’s standard.
In healthcare settings, requirements for respiratory protection are modified as transmission-based precautions change. During outbreak status, when airborne precautions are in place and respiratory protections are required, voluntary use is not allowed. Employees must be medically evaluated, issued NIOSH approved respirators that have been fit tested, and received training on their use. When droplet precautions are in place, and no airborne hazards are present, the use of respiratory protection is not required and staff can wear surgical masks to comply with source control requirements.
Despite the importance of a well-structured Respiratory Protection Program, it continues to be one of the most cited annual OSHA violations across all industries. Healthcare facilities, in particular, may be aware of fit testing procedures but often fail to develop a written program, as required by regulation, which ensures the annual components of OSHA’s standard are fulfilled and documented accordingly. Such annual requirements include, employee training, fit testing and annual program review. Take time to review your Respiratory Protection Program to ensure and document annual compliance now, before OSHA comes knocking at your door.
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