The Occupational Safety and Health Administration (OSHA) issued respiratory protection guidance for assisted living, nursing home, and other long-term care facilities. The guidance focuses on the use of respirators while emphasizing a primary reliance upon engineering and administrative controls for controlling exposures, consistent with good industrial hygiene practice and the agency’s traditional adherence to the “hierarchy of controls.”
The industrial hygiene “hierarchy of controls” is a series of workplace safety and health interventions that begins with elimination of hazards, followed by substitution, then engineering controls, administrative controls (including work practices), and personal protective equipment (PPE).
OSHA has instructed its compliance safety and health officers in its area offices to exercise discretion in the enforcement of the respiratory protection standard during the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is a respiratory disease caused by the SARS-CoV-2 virus.
The agency insists that workers wear respirators when necessary, such as when in close contact with a resident of a long-term care facility with suspected or confirmed coronavirus infection. Employees then must wear an N95 filtering facepiece respirator (FFR) or equivalent or a higher-level respirator approved by the National Institute for Occupational Safety and Health (NIOSH).
The guidance describes other source control measures, including the use of cloth face coverings, face masks, and U.S. Food and Drug Administration (FDA)-cleared or -authorized surgical masks. Healthcare workers should wear such source control products or devices at all times while inside a long-term care facility, according to the agency, including in break rooms or other spaces where they might encounter other people.
OSHA told employers that they should reassess their engineering and administrative controls, such as ventilation and practices for physical distancing, hand hygiene, and cleaning and disinfecting surfaces, to identify changes that could avoid over-reliance on respirators and other PPE. OSHA reminded employers that the agency has temporarily allowed for some enforcement flexibility regarding respirators, including requirements for annual fit testing that consumes disposable respirator supplies.
However, the agency also reminded employers that when respirators must be used, employers must implement a written, worksite-specific respiratory protection program that includes medical evaluation, fit testing, training, and other elements of the agency’s respiratory protection standard (29 CFR 1910.134).
OSHA offered employers the following advice for administering a respiratory protection program during the ongoing pandemic:
- Consider alternatives to N95 FFRs, including other FFRs (for example, P100s and N99s); reusable elastomeric respirators; and powered air-purifying respirators (PAPRs), given shortages of N95 FFRs during the pandemic.
- Choose eye and face protection to be worn with the type of respirator used, but exercise care to ensure the eye or face protection does not interfere with the seal of the respirator.
- Consult NIOSH’s list of approved N95 FFRs and warnings about counterfeit respirators or misrepresentation of NIOSH approval.
- Assign a suitably trained program administrator to oversee all elements of the program, such as an infection prevention and control practitioner or a nurse administrator, or consider hiring a local industrial hygiene consulting service if no suitably trained administrator is available on staff.
- Conduct a risk assessment to identify which workers are at risk of exposure to any airborne hazards such as SARS-CoV-2, tuberculosis (TB), Legionella, or certain hazardous chemicals, and classify exposure risk to SARS-CoV-2, according to OSHA’s four risk exposure levels.
- Implement procedures for performing medical evaluations of workers required to use respirators to determine their ability to safely wear a respirator before needing to wear one in the workplace; identify a physician or other licensed healthcare professional who can conduct medical evaluations and maintain confidentiality.
- Ensure that any worker using a tight-fitting respirator is fit tested following OSHA-approved fit-test protocols before initial use and whenever a different respirator size, style, model, or make is used.
- Establish procedures and schedules for the maintenance and storage of any respirators used beyond a single use, including procedures for cleaning, disinfecting, storing, repairing, and discarding respirators.
- Train workers who wear respirators on how to properly put them on (donning) and take them off (doffing), as well as how to conduct proper user seal checks and recognize respiratory hazards in their workplace and the capabilities and limitations of respirators.