Improving Respiratory Protection Programs in Healthcare to Reduce and Control Infection

By Brent Doney, Mark Greskevitch, Dennis Groce, Girija Syamlal, Ki Moon B and Jacek Mazurek

The risk of developing respiratory infection can be reduced by either wearing respiratory protection under the guidance of an effective respiratory protection program or using controls. In 2001, the Survey of Respirator Use and Practices gathered information on the types of respirators used, respirator use practices, and the respirator program characteristics from 40,002 randomly selected U.S. establishments. This report presents findings of the survey for the health services industry and compares them with National Institute for Occupational Safety and Health (NIOSH) recommendations.

Approximately 3.2 percent of all health services establishments required respirator use. Of the health services establishments that required respirator use:

• 82 percent of respirator-using establishments using gas/vapor filters did not have a written change-out schedule

• 70 percent did not provide the assessment or didn’t know if such an assessment was conducted

• 64 percent of establishments using airline respirators did not require such use of instructions or labels or didn’t know how airflow was adjusted

• 64 percent of airline respirator-using establishments did not assure the incompatibility of respirator couplings incompatible with other gas systems at the establishment; employees were not assessed or it wasn’t known if the employees were assessed in 70.4 percent for medical fitness to wear a respirator

• 60 percent did not include procedures for maintaining respirators or didn’t know if any procedures were included

• 58 percent had at least three indicators of a potentially inadequate respiratory protection program.

The high rates of indicators of potential inadequacies suggest widespread problems with respiratory protection programs in the health services industry, indicating a potential for improvement.

Objective

Healthcare workers have elevated mortality rates to respiratory infection. The risk of developing respiratory infection and other diseases for healthcare workers should be reduced by either wearing respiratory protection under the guidance of an effective respiratory protection program (RPP) or using controls. Of the health services establishments using respirators, more than half (58 percent), or an estimated 8,200 establishments, had three or more indicators of a potentially inadequate RPP. This report provides suggestions to correct inadequacies in RPPs to improve protection of healthcare workers to respiratory infections.

Introduction and Methods

In 2001, NIOSH and the Bureau of Labor Statistics (BLS) surveyed 40,002 randomly selected U.S. private industry establishments.1 The survey questionnaire was mailed by the BLS to the selected establishments during August 2001 through February 2002 and collected information on the types of respiratory protection used by workers at an establishment, assessment of medical fitness to wear respirators, types of respirator fit tests performed, and presence of substances that prompted the decision to use respiratory protection.¹

The findings of the survey raised questions regarding respirator usage practices and how these practices compare with Occupational Safety and Health Administration (OSHA) regulations² and NIOSH recommendations.³

This report focuses on information from the respirator use and practices survey collected from establishments in health services industry. This industry is comprised of offices and clinics of medical doctors and dentists, hospitals, medical and dental laboratories, home healthcare services, kidney dialysis centers and specialty outpatient facilities (Standard Industrial Classification 80).⁴

Findings and Discussion

The offices and clinics of health practitioners industry (Census Industry Code 830) had the highest proportionate mortality rate (PMR = 2.9) of respiratory tuberculosis among all industries from 1990 to 1999 and hospitals (Census Industry Code 831) had a PMR of 1.2 with 238 deaths causes by respiratory tuberculosis.¹ The Clinical laboratory technologists and technicians occupation (Census Occupation Code 203)” had the fifth highest proportionate mortality rate (PMR = 1.9) of respiratory tuberculosis among all occupations from 1990 to 1999.1

Approximately 3.2 percent or an estimated 14,128 establishments in health services used respirators for required purposes in 2001. This percentage (3.2 percent) was slightly lower than the percentage of establishments with respirator use in all private industry (4.5 percent). Employees in health services used respirators in greater proportions than employees in all private industry as a whole (6.3 percent versus 3.1 percent). Disposable dust masks were used in 88.7 percent of health services respirator-using establishments (12,533 of 14,128) compared to 71.3 percent (200,995 of 281,776) of all private industry establishments.¹

While the survey did not allow determination of particular substances that prompted respirator use within health services, it did provide such information for its parent industry, services. However, more than half of the employees within the services industry using respirators were in health services. Dust, paint vapors, solvents, welding fumes, and biologicals (i.e., TB and HIV) were the substances for which respirators were most frequently used in the services industry.

The services industry had the highest percent of establishments which used air-purifying respirators to protect against biologicals (17.4 percent and 15,038 establishments). Exposures to airborne contaminants and agents can cause various respiratory conditions. For example, healthcare workers exposed to Mycobacterium tuberculosis may develop tuberculosis; clinical laboratory workers, maintenance workers and nurses may be exposed to poor air quality, latex, glutaraldehyde, solvents and formaldehyde, all of which may result in the development of asthma; and maintenance workers may be exposed to welding fumes which may lead to metal fume fever and other respiratory impairments.^5-11 A NIOSH exposure survey from 1981 to 1983 estimated that 184,000 health services workers were potentially exposed to silica dust and 109,000 were potentially exposed to the solvent xylene.¹²

Respiratory Protection Program Quality Indicators – Survey Results

Each of the questions listed below (developed on the basis of OSHA requirements² and NIOSH recommendations³) examines an important part of an effective respirator program. The percentages of respirator-using establishments in the health services industry with indication of a potentially inadequate respiratory protection program are listed along with suggestions to improve respirator programs.

Is there a written change-out schedule for air-purifying gas/vapor filters?

Survey results: Of respirator-using establishments using gas/vapor filters, 82 percent did not have a written change-out schedule.

Suggestions: Many substances have poor warning properties (e.g., isocyanates in paint) so a change-out schedule to replace spent cartridges is needed. Filtering elements need to be changed often enough to prevent saturation with chemicals or clogging with dust. Cartridge change-out schedules are available from OSHA at http://www.osha.gov/SLTC/etools/respiratory/change_schedule.html and NIOSH at http://www.cdc.gov/niosh/npptl/multivapor/multivapor.html

Are employees assessed for medical fitness to wear respirators?

Survey results: Of respirator-using establishments, 70 percent did not provide the assessment or didn’t know if such an assessment was conducted.

Suggestions: Respirators may overly burden susceptible workers. The employer must obtain a written determination from a physician or other licensed healthcare provider regarding the worker’s ability to use a respirator. The physician or other licensed healthcare provider determination may be based upon responses to the OSHA screening questionnaire, and, if necessary, a medical examination.²

Does the program require use of the manufacturer user’s instructions or NIOSH certification labels to adjust the airflow for airline respirators?

Survey results: Of establishments using airline respirators, 64 percent did not require such use of instructions or labels or didn’t know how airflow was adjusted.

Suggestions: Air flow must be properly adjusted for the airline respirator to ensure adequate flow to the user and prevent infiltration of dusts and chemicals. In addition, the length of air hoses is limited by NIOSH certification to assure sufficient air flow.

Are airline respirator couplings incompatible with other gas systems at the establishment?

Survey results: Of airline respirator-using establishments, 64 percent did not assure the incompatibility.

Suggestions: If respirator hose couplings can be connected to a source that may contain nitrogen, argon, or another asphyxiant, a fatality could result.

Does the program include written procedures for maintaining respirators?

Survey results: Of respirator-using establishments, 60 percent did not include such procedures or didn’t know if any procedures were included.

Suggestions: Respirators must be cleaned after each day’s use and stored properly to prevent skin rashes. Respirators must be periodically inspected for degradation of straps, facepieces and valves, with repairs or replacements made as needed. Respirators used in routine situations must be inspected before each use and during cleaning, respirators maintained for emergency situations must be inspected at least monthly and checked for proper function before and after each use, and emergency escape-only respirators must be inspected before being carried into the workplace for use.

Do written procedures include regularly scheduled evaluations of the effectiveness of respirators used at the establishment?

Survey results: Of respirator-using establishments, 57 percent did not include such an evaluation or were unaware if evaluations had been conducted.

Suggestions: The employer should conduct an evaluation to determine if the proper respirators are being used for changing conditions, and feedback from workers should be obtained to see if respirators are interfering with work performance.

Has management adopted a written respirator program that determines how respirators are used?

Survey results: Of respirator-using establishments, 50 percent had not adopted a written program.

Suggestions: OSHA requires a written program with work-site specific procedures for: selecting respirators; using respirators; evaluating the respirator program; fit testing; maintaining and storing respirators; medically evaluating workers; training workers about respiratory hazards and respirator use and limitations, maintaining respirators; and ensuring adequate quality, quantity, and flow of air for air-supplying respirators.

Does the program provide training regarding the need, use, limitations, and capabilities of respirators?

Survey results: Of respirator-using establishments, 32 percent did not provide such training.

Suggestions: Worker training is needed to ensure that workers wear respirators properly, use the right type of respirator for the job, know the limitations of the respirator, and understand the health effects of dusts and chemicals.

Are dust masks (filtering-facepiece respirators) used to protect only against dusts, but not gases or vapors?

Survey results: Of respirator-using establishments, 20 percent did not use dust masks only against dust.

Suggestions: Dust masks should be used only for dusts. If gases or vapors are a hazard, respirators with chemical filtering cartridges or air-supplied respirators may be needed.

Are wearers of tight-fitting respirators fit tested?

Survey results: Of respirator-using establishments with tight-fitting respirators, 14 percent did not provide fit testing or didn’t know if fit testing was conducted.

Suggestions: A fit test (as described by OSHA2) such as those using banana oil, saccharine or Bitrex, or quantitative techniques must be conducted to determine that a selected respirator fits and can be adjusted to prevent leaks.

Is the respirator program administered by a trained person?

Survey results: Of respirator-using establishments, 10 percent did not have a trained program administrator.

Suggestions: A trained respirator program administrator is needed to oversee the program for that company or site. The amount and type of training needed depends on the complexity of the respirators used and hazards encountered.

Of the health services establishments using respirators, more than half (58 percent), or an estimated 8,200 establishments, had three or more indicators of a potentially inadequate respiratory protection program as measured against OSHA respirator program requirements and NIOSH recommendations listed in the previous section.

The survey findings are subject to some limitations. Public sector, self-employed and agriculture establishments with less than 11 workers were not included in the survey. Although the instructions stated that the person most familiar with respiratory protection should complete the questionnaire, this may not have always happened. In spite of the cognitive and field testing of the survey at small, medium, and large establishments prior to its mailing, recipients may have misinterpreted the written questions. The survey was not designed to collect exposure information specifically for health services. However, the operations and types of exposure are included in the broader industry category of services.

Respiratory Protection Program Consultation Service

Employers who suspect their respiratory protection program is in need of improvement should consider contacting OSHA’s free confidential consultation service available for small businesses in every state. OSHA also has a Small Entity Compliance Guide for the Respiratory Protection Standard available at http://www.osha.gov/Publications/secgrev-current.pdf. Another resource is the American Industrial Hygiene Association list of consultants at http://www.aiha.org/Content/AccessInfo/consult/consultlisting.htm.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Institute for Occupational Safety and Health.

Brent Doney, Mark Greskevitch, Girija Syamlal, Ki Moon Bang and Jacek Mazurek are with the National Institute for Occupational Safety and Health (NIOSH), Division of Respiratory Disease Studies in Morgantown, West Va. Dennis Groce is with EG&G Technical Services, Inc. in Pittsburgh, Pa. Charles Oke is with NIOSH, National Personal Protective Technology Laboratory in Pittsburgh, Pa.

References:

1. Bureau of Labor Statistics (BLS)/National Institute for Occupational Safety and Health (NIOSH). Respirator Usage in Private Sec-tor Firms, 2001. September 2003. Available at http://www.cdc.gov/niosh/docs/respsurv/ (Accessed May 4, 2009).

2. OSHA [1998]. Respiratory Protection Standard, 29 CFR 1910.134. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716 (Accessed May 4, 2009).

3. NIOSH [2005]. National Institute for Occupational Safety and Health (NIOSH). U.S. Department of Health and Human Services, NIOSH Respirator Selection Logic 2004. DHHS NIOSH Publication No. 2005-100, Cincinnati. 2005. Available at http://www.cdc.gov/niosh/docs/2005-100/ (Accessed May 4, 2009).

4. Office of Management and Budget [1987]. Standard Industrial Classification Manual. Washington, DC: U.S. Government Printing Office.

5. NIOSH [2008]. Work-related Lung Disease Surveillance Report 2007. Cincinnati, OH: U.S. Department of Health and Human Ser-vices, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2008-143a. Available at http://www.cdc.gov/niosh/docs/2008-143/ (Accessed May 4, 2009).

6. CDC [2004]. Silicosis in Dental Laboratory Technicians — Five States, 1994-2000. MMWR Morb Mortal Wkly Rep 53:195–7. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5309a3.htm (Accessed May 4, 2009).

7. Stellman JM, ed. [1998]. Encyclopaedia of Occupational Health and Safety. 4th ed. Geneva: International Labour Office.

8. CDC [2006]. MMWR Morb Mortal Wkly Rep 55:305-8. Reported Tuberculosis in the United States, 2005. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5511a3.htm (Accessed May 4, 2009).

9. Sepkowitz, K.A. [1994]. Tuberculosis and the Health Care Worker: A Historical Perspective. Ann Intern Med 120:71–9.

10. CDC [2005]. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Morb Mortal Wkly Rep 54:1–141. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm (Accessed May 4, 2009).

11. Pechter E, Davis LK, Tumpowsky C, et al. [2005]. Work-related asthma among health care workers: surveillance data from Cali-fornia, Massachusetts, Michigan, and New Jersey, 1993-1997. Am J Ind Med 47:265-75.

12. NIOSH [2007]. National Occupational Exposure Survey (1981-1983). Available at http://www.cdc.gov/noes/noes1/m0930sic.html and http://www.cdc.gov/noes/noes1/m3191sic.html (Accessed May 4, 2009).