Amid Shortages, Cal/OSHA Issues Updated ATD Respirator Guidance

On August 6, the California Division of Occupational Safety and Health (Cal/OSHA) released updated guidance for healthcare employers facing severe shortages of respirators during the ongoing coronavirus disease 2019 (COVID-19) pandemic. The supply chain for respirators has improved but is not yet fully restored, according to Cal/OSHA.

Healthcare facilities in California must comply with the state’s Aerosol Transmissible Diseases (ATD) Standard, which has no federal equivalent. COVID-19 is a respiratory illness caused by the SARS-CoV-2 virus. COVID-19 currently is widespread in most U.S. communities and considered a workplace hazard.

“Respirators must always be immediately available to health care workers who may be called upon to perform emergency aerosol generating procedures on suspected or confirmed COVID-19 patients,” stated a boxed warning in the guidance. A surgical mask may not be used in situations when a respirator is required.

The guidance includes recommended engineering controls and work practices to help minimize the need for respiratory protection and strategies for extended respirator use and optimizing supplies.

Engineering and work practice controls include:

• Minimizing the number of employees exposed to suspected and confirmed COVID-19 patients and infectious aerosols by using barrier enclosures that cover a patient’s head and upper body;
• Masking suspected and confirmed COVID-19 patients as a source control method whenever employees are not using a respirator;
• Training employees on additional precautions and changes to the ATD plan when respirators cannot be obtained or when there are changes to procedures such as respirator reuse or extended use; and
• Informing employees and their representatives that the changes are only in effect until respirator supplies can be restored, keeping them updated on status changes.

Employers must provide and ensure that all employees exposed to aerosol-generating procedures use powered air-purifying respirators (PAPRs) or another respirator that provides equivalent or greater protection. If PAPRs are unavailable and cannot be obtained, an N95 respirator is the minimum protection that should be used. More protective respirators like elastomeric half-mask or full-face respirators, which are more likely to seal well to the face and achieve a better fit factor, should be used if available.

Methods that may be used to extend supplies of N95 respirators include the following:

• Using reusable National Institute for Occupational Safety and Health (NIOSH)-certified respirators—elastomeric half-mask, full-facepiece respirators and PAPRs equipped with particulate filters that can be disinfected and reused multiple times—instead of disposable filtering facepiece respirators;
• Using industrial, NIOSH-certified filtering facepiece respirators recognized under the Food and Drug Administration’s Emergency Use Authorization issued on March 2;
• Allowing employees to wear their own respirators if they comply with Cal/OSHA requirements;
• Using fit-testing methods that maximize respirator supplies and fit-testing efficiency like qualitative fit testing, which does not damage the respirator so the respirator used during the test can be used on the job by the employee who was tested;
• Using certain expired NIOSH-certified filtering facepiece respirators that NIOSH has approved for use under specific conditions; and
• Extended respirator use—for a maximum of 8 to 12 hours—and storing disinfected filtering facepiece respirators for future shortages.

The ATD Standard also applies to correctional facilities, diagnostic laboratories, and police and public health services; the agency only issued guidance on August 6 for healthcare facilities.