By Shari L. Solomon

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 experience applying the Occupational Safety & Health Administration (OSHA) 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, did not require respiratory protection for staff before COVID-19 emerged and now have implemented respiratory protection programs over the past two years. During that time, facilities have experienced frequently evolving U.S. Centers for Disease Control and Prevention guidelines and OSHA requirements as 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 for 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. 

Eye on enforcement  

Since the launch of OSHA’s national emphasis program in 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 — received two willful violations and a fine of $273,064 for not providing medical evaluations and fit testing to temporary workers who were issued N95 respirators. According to these citations, healthcare entities and temporary agencies who employ staff required to wear respirators both might 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 respirators. The evaluation can be provided as a questionnaire to be reviewed onsite by a licensed healthcare practitioner 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 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. As a result, it does not function with a tight seal that needs to be fit tested. This respirator might be beneficial to have for the use of employees with beards and hard-to-fit facial structures. Medical evaluations still must be performed before issuing a PAPR to screen for possible complications during use.  

Voluntary use  

Due to the heightened concern for infection prevention in healthcare facilities, it is also common to observe employees providing and voluntarily wearing respirators in areas where airborne hazards are not present. This extra protection might provide an added level of comfort and might 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. But 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 also must ensure that staff who provide their own respirators:  

• 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 
• avoid wearing a self-provided respirator where other workplace hazards — e.g., biological or chemical exposures — require the use of a respirator. In these cases, the employer must provide a respirator that is used in accordance with OSHA’s standard. 

In healthcare facilities, requirements for respiratory protection are modified as transmission-based precautions change. During outbreak status when airborne precautions are in place and respiratory protection is 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 might be aware of fit testing procedures but 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. Managers must take time to review their respiratory protection programs to ensure and document annual compliance now, before OSHA comes knocking. 

Shari L. Solomon, Esq. is president and founder of CleanHealth Environmental, LLC. CleanHealth provides infection prevention and industrial hygiene training and consulting services geared toward facility personnel and vendors responsible for infection prevention, cleaning and disinfection, and facility operations and maintenance practices. Solomon possesses more than 20 years of environmental consulting and federal regulatory experience. An attorney by trade, combined with her experience in the industrial hygiene field with a focus on healthcare, Solomon holds a unique expertise and understanding of liability prevention techniques, offering clients practical and valuable risk management solutions.