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Urgent Message: Urgent care centers that offer occupational medicine services play an important role in protecting the safety of the nation’s workforce. One such service—offering respiratory fit testing—constitutes an important element of that mission while also creating a distinct revenue stream. To truly maximize the potential of offering this valuable eservice, however, it is important to understand the OSHA regulations, secure proper equipment, and assure staff is properly trained to conduct respirator fit tests.

Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine.

Introduction: The Purpose of a Respirator Fit Exam

Employees working in industries that require the use of a respirator—on a frequent, limited, or emergency basis—must be fit-tested for the respirator annually, whenever there is a change of respirator used, or whenever dental work, an injury to the jaw or face, or the growth of a beard change the facial structure. Industrial cleaning, auto body spray painting, and construction are all examples of such trades.

The respirator is necessary because contaminated air that lacks oxygen, inherent in such duties, is toxic and detrimental to an employee’s health. Extreme exposure to airborne hazards like chemical fumes and dust can damage lungs and lead to life-threatening diseases. Respiratory protection programs were established to increase the likelihood that workers have the best protection possible. The 1998 Occupational Safety and Health Administration (OSHA) guideline on respiratory protection requires that comprehensive programs exist in all relevant work environments. As such, it is essential for employers to follow an OSHA-approved fit test standard.

Who Needs to Get Fitted?
Whether employees are at high or low risk of exposure to respiratory hazards, they must have well-secured protective gear for the sake of their health and safety. In some cases, even a small amount of exposure can cause lasting, even permanent damage.

Some employees are required to wear respirators such as the N95 filtering facepiece, elastomerics, and compact powered air-purifying respirators (PAPRs). The Centers for Disease Control and Prevention requires these employees to have a fit exam.

Who Is Responsible for Implementing Respiratory Fit Exams?
The OSHA standard requires employers to maintain a respiratory protection program for employees as an exposure-control method. Following are examples of industries that are considered high-risk for respiratory hazards—and where urgent care centers may be wise to offer respiratory fit exams:

  • Chemical manufacturing
  • Construction
  • Agriculture
  • Automotive repair
  • Pharmaceuticals
  • Petro-chemicals
  • Military
  • Mining
  • Nuclear plants and electrical utilities

Anyone who is exposed to dust, vapors, fumes, and infectious diseases must use respirator masks to reduce the risk of respiratory damage or disease.

Action Plan to Implement Respiratory Fit Exams
Following are the fit testing procedures mandated by OSHA:

  1. Medical evaluation and follow-up examination. Before using a respirator, an employee must be confirmed medically fit through a medical evaluation. An urgent care center can evaluate employees using a medical questionnaire. That medical examination must reveal answers to the OSHA questionnaire in Appendix C of the standard, which may be found here. Any yes answers to the questions require follow-up examination for further evaluation.

In addition to the questionnaire, a pulmonary function test (PFT), using a spirometer, must be completed to assure normal respiratory function. Assuming no unaddressed medical risks exist, the urgent care provider can then proceed with fit testing of the respirator.

  1. Fit testing. Before the selection process, employees must be trained in how to put on the respirator; this includes positioning, setting the strap tension, and determining the acceptable fit. It may be helpful to use a mirror to assist employees throughout the fitting process. An employee must pick the most suitable respirator from different models and sizes to guarantee proper fitting and protection. In addition, the employee should wear the most comfortable mask for at least 5 minutes to assure a proper fit, removing the mask several times while adjusting the strap to set proper tension.

It is also essential to allow ample time for the employee to determine the respirator’s comfort level by assessing the following:

  • Position of the mask on the nose
  • Extent of eye protection
  • Room to talk
  • Position of mask on face and cheeks

Typically, the employee will arrive with his own mask, and already been trained on how to use it.

  1. Quantitative fit testing (QNFT). Quantitative fit testing is the method of using controlled negative pressure to calculate the exact amount of respirator leakage. Testing is conducted with a device such as a PortaCount Plus Respirator Fit Tester, which uses a nonhazardous test aerosol, produced in a test chamber to measure the respirator fit. This is applicable for any type of tight-fitting, full-faced or half-faced respirator. A probe is connected to the face piece and attached to the machine by a hose.

Fit factors are determined by comparing the particle concentration outside the respirator with the concentration inside the respirator face piece. An operator may fit test any tight-fitting respirator such as N95, P2, and P1 disposables.

The equipment required to perform quantitative fit testing can range from $9,000 to $12,000 or more for new, and from $2,500 to $7,500 for used, so a center must anticipate doing a sufficient volume of exams to make a business case for the capital investment. Usually, this type of investment is made initially when bidding for services of a single large employer, and then justified as other employers can be “sold” on the service.

OSHA accepts three quantitative fit tests:

  • Generated aerosol
  • Ambient aerosol
  • Controlled negative pressure

An acceptable fit is achieved after wearing the respirator and successfully completing six exercises:

  • Normal breathing
  • Deep breathing
  • Moving head up and down
  • Moving head side to side
  • Reading

Employees with large beards may experience difficulty in fitting a facepiece. No attempt should be made to fit a respirator if the employee’s facial hair comes between the sealing periphery of the facepiece and the face, or if facial hair interferes with the normal functioning of the exhalation valve of the respirator.

Workers who wear eyeglasses, goggles, helmets, and other face shields must likewise be cautious to not inhibit or interfere with the respirator seal.

  1. Qualitative fit testing (QLFT). Qualitative fit testing is a pass-or-fail method, relying on the employee’s reaction to a test agent. A person’s reaction to a chemical introduced outside the facepiece is monitored.

Several methods can be used, with the response being either voluntary or involuntary. Leakage is detected by testing the sense of taste or smell, or the reaction to chemical irritants. OSHA accepts four QLFT methods:

  • Isoamyl acetate. This test detects whether or not the subject can smell banana oil at low concentration. There are two bottles filled with water, one of which has a small amount of banana oil. Once the bottle containing the solution has been identified, the subject can proceed to selecting a respirator and fit testing. During this test, a saturated gauze pad is placed near the facepiece-to-face seal of the respirator. If the patient is unable to smell the chemical, then a satisfactory fit is assumed to be achieved. If the patient can smell the chemical, the fit is deemed unsatisfactory.
  • This is a taste tolerance screening to determine if the employee can detect the taste of saccharin. If the sweet taste of saccharin is identified, the respirator has failed its fit test.
  • Bitrex creates a bitter taste; if the subject detects its taste, then it is a failed test. If the subject does not taste the Bitrex, then the subject has passed the test.
  • Irritant Smoke Test. This test is used for high-efficiency particulate air (HEPA) filters. The administrator directs irritant smoke (stannic chloride or titanium tetrachloride) toward the respirator. The employee passes the test if there’s no involuntary coughing after the procedure.
  1. Training. The urgent care center can assist local employers in their training efforts through handouts, infection-prevention seminars, team meetings, safety reminders, and use of other screening tools.

Annual, ongoing education for employees is very important. A variety of strategies may be reinforced to help staff understand situations wherein they need to wear a respirator. Employees must demonstrate knowledge of why a respirator is necessary, when to use it in emergency situations, and how to inspect, put on, remove, and check the seals of a respirator.

The use of respirators is prevalent throughout higher education, health and life sciences, and industrial facilities. Urgent care centers can play a vital function, and increase their occupational medicine business, by facilitating and offering respirator fit testing to various industries nationwide. Respirators can be used only after a person receives proper training that complies with OSHA regulations. Done properly, respirator fit testing can generate a profitable stream of revenue while promoting the health and wellbeing of employees.

Respirator Fit Exams Breathe New Life into Occ Med Urgent Care Offerings

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine
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