March of 2020 marked the beginning of a new era in public health. Healthcare workers and compliance experts in infection prevention and control have been busy keeping up with everything there is to learn about the novel SARS-CoV-2 virus, and the corresponding changes needed to provide safe health care such as proper respiratory protection.
Wearing surgical masks has always been a part of the routine for healthcare workers. This standard precaution provides the protection needed against certain illnesses, but coronavirus requires a higher level of protection referred to as transmission-based precautions and in particular, airborne precautions. There is evidence that this virus may be spread in an airborne manner, especially during aerosol-generating procedures (AGP). Microorganisms spread in an airborne manner are very tiny and can remain in the air for extended periods of time. Due to the size of the virus, a surgical mask does not provide the highest level of protection against the inhalation of the organism. The designated level of protection, especially for AGPs, by both the CDC and OSHA is the N95 respirator or higher.
Once it is determined through a hazard assessment that respirator use will be implemented to reduce exposure to airborne pathogens the Respiratory Protection Standard 1910.134 comes in to play and several items are required:
- Written respiratory protection plan
- Medical evaluation for employees who will use the respirator
- Initial and annual fit testing
The use of respirators, while providing a higher level of protection, has brought many challenges, with the two greatest being adequate supplies of the respirators and access to either fit testing supplies or the ability to have fit testing completed on impacted employees. Just recently a dental practice was cited by OSHA and a $9,500 financial penalty was proposed. While the practice did have other compliance issues, the citation leads to issues related to the use of respirators.
OSHA cited the dental practice for failing to provide medical evaluations and fit testing for employees required to wear N-95 respirators as protection against coronavirus; lack of written programs related to respiratory protection, bloodborne pathogen exposure control and chemical hazard communication; insufficient bloodborne pathogen training and controls; and inadequate eyewash stations.
Faced with the listed challenges, just how do practices implement the use of respirators if needed and also comply with the recommended standards? Recently OSHA published a document, Understanding Compliance with OSHA’s Respiratory Protection Standard During the Coronavirus Disease 2019 (COVID-19) Pandemic. There is helpful information about compliance and how to document and demonstrate compliance efforts. Part of the introductory paragraph acknowledges that OSHA does understand the challenge healthcare providers are facing:
“Shortages (either intermittent or extended) of both N95 filtering facepiece respirators (FFRs) and fit-testing supplies have posed tremendous challenges. In order to allow essential operations to continue, many employers have had to utilize contingency and crisis strategies that are ordinarily not compliant with OSHA’s Respiratory Protection standard.”
While recognizing the challenges the document goes on to explain that in order to assist employers, several temporary enforcement guidance memoranda have been released. It is important and OSHA reminds that these are not permanent solutions and will end once shortages related to the pandemic have been resolved. The statement below is very clear that no waivers or exemptions have been issued for compliance. They do allow for enforcement discretion during the pandemic ONLY in circumstances when the employer can demonstrate that attempts were made to obtain supplies of respirators and fit testing supplies.
“It is important for employers to understand that these temporary enforcement guidance memoranda do not offer blanket waivers or exemptions for complying with any OSHA standards or provisions of such standards, including the Respiratory Protection standard (e.g., annual fit-testing requirements).”
To benefit from the enforcement discretion, it will be very important to have documentation to support your efforts to protect employees from exposure to this virus. Assuming the practice hazard assessment identifies high-risk activities to include caring for a suspected or known COVID–19 patient or aerosol-generating procedures and respirators are used consider the following items:
- Written Respiratory Protection Plan in all other regards that outlines the process for procedures for medical evaluation of employees, fit testing, respirator maintenance, and care, and employee training.
- Strategies to prioritize and conserve the use of N95s if supplies are short according to CDC PPE Optimization Strategies: N-95 and Other Respirators.
- Documentation of engineering controls to reduce the exposure risk. Some examples are working with an HVAC specialist to improve air circulation, high volume evacuation (suction) during aerosol-generating procedures when possible, and the use of Airborne Infection Isolation Rooms (AIIR) when indicated.
- Estimate respirator supply needs and make reasonable efforts to obtain NIOSH approved respirators. If unable to obtain N95 NIOSH approved respirators investigate other types of respirators such as elastomeric, powered air-purifying respirators, and foreign respirators that are on the approved list which is Appendix A on the FDA website. It is always best to document these attempts as evidence of attempted compliance.
- Document all attempts to complete the fit testing process which may be attempting to obtain supplies or locations of an individual/business who can perform the test.
Remember Flu Season
It is October and the influenza season is upon us, in addition to this ongoing pandemic. Respirator protection remains a priority in every healthcare environment. Ensure you have performed a hazard assessment to identify risks for all employees and implement the highest levels of protection to ensure their safety.
TMC has a respiratory protection live webinar coming up on November 18, 2020. It is complimentary for TMC Clients if you would like additional information on this topic. We have also created a Written Respiratory Protection Plan to help your practice be compliant.
Pandemic Preparedness Plan
TMC is pleased to announce an updated, more robust Pandemic Preparedness Plan. Every healthcare facility should have a written plan which clearly outlines how both patients, visitors, and employees will be protected while in the office. This written plan which is customizable includes a very thorough hazard assessment, screening tools for patients, workers, and visitors, PPE posters, and more.
TMC clients receive this as a value-added service and can find this document in the Client Portal. For all others, the plan is available for purchase in the Online Store on the TMC website.