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Guidelines for fit testing N95 respirators during a pandemic

When the novel influenza A H1N1 virus, or swine flu, hit Mexico and subsequently the United States in April, infection control practitioners were gathering information as fast as possible. The first priority was to mitigate the spread of disease, and part of that prevention effort included ensuring that healthcare workers were protected.

For many, that meant working with employee health and safety in order to fit test employees quickly. Several surveys have found that a portion of the healthcare work force would not come in during a pandemic for fear of their health or the health of their family, so having a plan in place that is part of your pandemic planning will help ensure protection and provide reassurance for workers.

Although this may be a job that falls on the employee health and safety department, infection control nurses should have some input regarding the severity of the disease and what staff members could be at risk.

"We rely on [infection control] quite a bit in just communicating infections," says Bruce E. Cunha, RN, MS, COHN-S, manager of employee health and safety at the Marshfield (WI) Clinic. "We really are conjoined twins, if you want to call it that. We want to make sure we are taking care of our patients and taking care of our employees."

The "just-in-time" method

For a larger facility, it's not feasible to fit test all employees, especially if they are not at risk for exposure to diseases such as TB. Many hospitals and clinics can still comply with OSHA regulations and annually fit test employees only if they are going to wear an N95 respirator.

Cunha says his facility has incorporated the "just-in-time" method for fit testing into its pandemic plan.

"We fit test only specific areas like urgent care, pulmonary, and infectious disease," Cunha says. "But in preparing for a pandemic, we said, 'If we get a pandemic, we are going to have to do a lot of fit testing and get people up to speed.' "

Cunha says the facility has 40-50 staff members who are trained to fit test the 7,000 employees in the health system. If the pandemic plan goes into effect, as it did with the influenza A H1N1 virus, employees throughout the facility can get fit tested quickly. When the swine flu outbreaks occurred, Marshfield funneled patients through urgent care, where employees were already fit tested. Once the infection died down, the facility began fit testing more employees, such as family practice physicians and the internal medicine department.

"We keep it to specific departments that really are our main entry point departments, which keeps us down to a fairly small number of people that we really need to do on an annual basis, and with this train-the-trainer program, we can kick it in gear and literally have quite a few people [fitted] within a few days," Cunha says.

John A. Schaefer, MSF, CIH, HEM, CPEA, the associate director of health safety and environment at the Johns Hopkins University Hospital and Health System in Baltimore, took a similar approach and quickly fit tested roughly 7,000 employees once the outbreaks occurred.

Schaefer says Johns Hopkins incorporated the just-in-time method into its pandemic planning after the avian flu scare in 2004. This was the first time Johns Hopkins had to use it on such a large scale.

"It falls under the guidelines with everything else we do in the hospital with surge, and it really was a surge situation," Schaefer says. "We did off-shifts, and we had people here at 2 o'clock in the morning fit testing people. Yes, it's a burden on the people doing it, but we had people on the floors that were working night shift to train their staff, and it worked."

Training employees

The best part about the just-in-time method is that training employees to fit test coworkers is relatively simple and painless. Cunha says he initially trains his employees in about an hour, then annually for about 15 or 20 minutes to provide refresher information, ensure compliance, and provide any updates to the testing requirements. However, Marshfield isn't using machines, but simply manual fit testing, Cunha says.

Cunha says Marshfield realized it needed to implement this plan after looking at what happened in Toronto during the SARS outbreak in 2003.

"They had a lot of issues with not having employees fit tested and employees not understanding how to wear the respirators," Cunha says.

On the other hand, Schaefer says he spends about four hours initially training the employees on how to fit test people because he requires them to not only don and doff the respirators themselves, but also examine the person next to them to make sure there is a proper fit.

"So everyone in the class under supervision is fit testing someone else," Schaefer says.

Fit test or educate?

One of the recurring questions during a pandemic is whether you should make fit testing a priority over education.

In California, Cal/OSHA issued guidance during the swine flu outbreak that stated having no plan or an incomplete respiratory protection plan should not prevent employers from providing respirators as an interim measure and fit testing later.

"I would rather spend that time training them how to put it on correctly," says Cunha. "If I fit test you day one, and you wear that mask on day 364 of that year, do I have any assurance that it is fitting you correctly? Not really."

This issue could come into play if a facility received N95 masks from the national stockpile, which includes six or seven different brands, bringing into question whether everyone would have to be retested, Cunha says.

"I would say with the supply we would probably get the masks, train employees, and if we needed to refit, we would refit," he says.

Source: Adapted from Briefings on Infection Control, July 1, 2009