#101 Voluntary versus Mandatory Respirator Use

 If your office does not require the use of respirators, what are the OSHA requirements if you decide to wear a N95 voluntarily? This podcast provides an overview of OSHA's requirements and important considerations for your respiratory protection. 

• Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic: https://bit.ly/3LNjkP5
• OSHA Respiratory Protection Standard: https://bit.ly/3nkZUaS
• Appendix D to OSHA Respiratory Protection Standard https://bit.ly/41Y3yqh

                                                 https://www.thecompliancedivas.com

Transcript

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SPEAKER_00 0:04

Welcome. I'm Leslie Cannon. I'm Mary Gavoni.

SPEAKER_02 0:09

I'm Linda Harvey. I'm Olivia Juan, and together we are the Compliance Divas. Hello, listeners. My name is Olivia Juan, and I'll be your moderator today with our podcast on a very timely subject about the difference between mandatory use of respirators versus voluntary use. As the compliance divas, we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedeevas.com. Any resources we mention during our podcast can be found at the ComplianceDivas.com website. You may also submit questions to support at thecompliancedivas.com. So lately I've noticed in visiting dental offices that very few are even wearing respirators. And those that are wearing respirators submit questions on whether they are supposed to do annual fit testing, as well as other questions related to the wearing respirators. Now, one of the things I wanted to mention to our listeners is that CDC's guidance continues to recommend respirators. For example, CDC cites that as community transmissions increase, there is that potential for encountering asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. And in these circumstances, we should consider implementing broader use of respirators and eye protection for healthcare personnel. Matter of fact, it mentions that if the community transmission is high, we should consider wearing NIOSH-approved respirators with N95 filters or higher for all aerosol generating procedures. So that guidance has not changed yet. So even though we see that it is dying down the discussion of COVID-19, there is still risk to encounter a patient as the guidance sets forth that may not have symptoms. So we thought this would be a good topic to share with our listeners and discuss the difference between mandatory use of respirators and voluntary use. So to kick us off, let's consult with Mary. Mary, talk with us about voluntary use and what the requirements are if the dentist does not make it mandatory to wear N95s.

SPEAKER_01 3:10

Great question, Olivia. What is the difference? If an employer requires the use of an N95 respirator, or if there is some atmospheric hazard, according to OSHA, that necessitates use of a respirator, then it is mandatory. But if an employer doesn't require the use of a respirator and permits you to wear it when it's not required, then it's considered to be voluntary use. But there are things that the employer must still ensure if they do allow voluntary use of respirators. So I would direct our listeners to the OSHA Respiratory Protection Standard, and we will have that listed in our resources. And in Appendix D, at the very end of the standard, the requirements for employers are first to make sure that employees read and heed all the instructions provided by the manufacturer. So the instructions for use for the respirator, the maintenance, cleaning, and care, and any warnings regarding the respirator's limitations. So an employer, even if they don't require a respirator to be worn, it's voluntary. They must, they do have the obligation to make sure that that respirator doesn't provide a health hazard to that employee. So in other words, that they don't have some kind of a health condition that would be exacerbated by wearing a respirator. So then employers must make sure that they choose or the employees choose the respirators that are certified by NIOSH to make sure that they meet the specific requirements. And that respirator should have a label or a statement of certification on the respirator or the packaging to make sure that it meets the standard that you're trying to protect employees from. So the other thing, and Olivia, you sort of alluded to this that the CDC mentions um recommendations for use of N95 respirators for aerosol generating procedures. So if you are in a state where your state dental board requires you to follow the CDC guidelines and guidance, then in your state, respirators would not be voluntary use, they would be mandatory. But if the respirators are voluntary use in your practice, then you do not have to do the annual fit testing. Although I think and I think the rest of us would agree that it's still a good idea because why go to the expense and the trouble of wearing a respirator if you don't know if it really fits you appropriately.

SPEAKER_02 6:14

Good points, Mary. So I think that's an excellent document that you referred to. And we will have that in the notes for our listeners. And just to reiterate that if the respiratory program is voluntary, then it does not require uh fit testing annually. And it also pointed out in that document about facial hairs. So if facial hair is not prohibited when it's voluntary use of the respirator. So good information, Mary. Thank you. Linda, if a dentist requires the use of respirators, what are the elements of a respiratory protection program?

SPEAKER_03 6:58

Olivia, that is the next step to look at, as you mentioned, when an employer requires the 95 respirator masks. So under OSHA's respiratory protection standard, there are five specific requirements that must be followed. First is the written respiratory protection program. And similar to the bloodborne pathogen and hazard communication standards, this must be a written program for what the protocols are in that office. So it must be customized to your office. And if someone is looking for that plan, Olivia, first I would send them to the source where they purchased their OSHA manual to find out if they have a respiratory protection plan update. There is one on OSHA's website. I believe it's more geared to hospitals, but it would give a office a starting point of where to begin. And sometimes the state OSHA plans have those similar tidbites as well. So that's an important piece. You have to have your respiratory protection program in writing. Next is medical evaluations. And I'd like to clarify for our listeners, Olivia, this is not a medical exam. This is a medical evaluation that includes using the mandatory health questions found in Appendix C of OSHA's respiratory protection standard, which is called the medical evaluation questionnaire. And if I remember correctly, there's probably about 200 different questions. And most of them center around someone's respiratory health and also the type of work you would be doing when wearing an N95 mask or higher N95 respirator or higher mask. So I want to mention that the completed medical evaluations are confidential and the employer is not privy to the contents of that medical evaluation. The contents of that medical evaluation must go to a licensed healthcare professional to evaluate the employee's status as to whether or not they're fit or their medical history allows them to wear this N95 mask. So only ultimately in the end, the medical clearance letter or some form from the healthcare professional is what's given to the employer. So that's what goes on file, and that would be kept in an employee's OSHA medical record. And that brings us to the third thing, Olivia, which is the fit testing. And with these N95 masks, similar to scrub jackets, one size does not fit all. We all have unique facial features. And so finding the right mask and the right fit is extremely important. And when you think about fit testing, this is not simply like trying on shoes and you find one that you're comfortable with and then you kind of go off and running. Fit testing is a formal process that has to be conducted by someone who's been trained in how to do fit testing. And at this point, then during the fit test, different N95 respirator masks are tested to see which one fits you properly. You see, unlike a level three mask, you're actually breathing through an N95 mask and there are no gaps around the side for the air to escape. So it's very important that you have the right fit. And then following along after that, Olivia, item number four that's required is the user seal checks. This is the point which once the mask, once the best mask is identified, then the user must perform what's called this user seal check each time the mask is donned and doffed. And what they are doing at this point is when they put the mask on, they're checking to be sure that the seal is properly. They're blowing, you know, through the mask and feeling if there's any air escaping around their nose or cheek or chin. And if so, then they don't have it seated properly on their face. So that's required to be done each time the mask is donned and doffed. Last, there are the training requirements. You know, this is last but not least because all OSHA standards, as with anything else in healthcare, where training is required. So this would be again training upon hire and annually thereafter. Those are the best approaches, I think, Olivia, for ultimate compliance with these requirements. And if someone is just now instituting their respiratory protection program, then begin training at that point. It may not be the point of hire, just be where you start, start your training and go forward. And then when new team members come on and they're wearing the respirator mask, do their fit testing, get their medical evaluation done, and train them on the seal checks as well. So those are the five key points, Olivia, that everybody must follow if wearing N95 respirator masks are mandatory in their practice.

SPEAKER_02 11:07

Thanks, Linda, for that explanation. So this is an important issue. If the dental office requires the use of respirators, we must have the program in place. So just to highlight what Linda mentioned, you would have a written respiratory protection program, medical evaluations, fit testing, training, and let's not forget those user seal checks. So great points, Linda. Leslie, we'd like to ask you to discuss some of California's requirements because, as Mary mentioned, we've got the CDC guidance, but we have to look to the individual states to see if there's requirements that it's not optional for them to choose whether they want to wear respirators or not. So can you share with us how California addresses respirators?

SPEAKER_00 11:59

Yeah, you're 100% right, Olivia. Uh, dental practices need to look at their state and local regulations. And as uh we have seen through other states and what's coming forward uh this May, the pandemic state of emergency is ending. California ended it on February 28th. Um, also, another interesting thing that ended uh or is going to end on April 3rd, 2023, is the mask mandate. So it'll be optional for patients and visitors and workers uh to wear a mask or not, and it gives more liberty to a dental practice to uh make their own site-specific facility decisions that way. However, CalOSHA has not dropped the requirement for N95 respirators. And with that being said, Cal OSHA expects dental practices that use aerosol generating devices such as ultrasonic or rotary air abrasion, air and water syringes, or other similar mechanical dental devices when treating patients to have that respiratory protection plan that Linda was talking about. And they also need to provide respirators and medical evaluation and fit testing, because again, in California, N95 respirators are still required by CalOSHA for aerosol generating procedures. So the written plans have to be in place just like many states, the COVID-19 emergency might be over, but the requirement for the written COVID prevention plans are still in place. And so with CalOSHA, employers are required to provide respirators to any worker, any worker, doesn't have to be a clinical, can be an administrative team member who works indoors and requests it, even though they are not occupationally exposed to dental aerosols. So uh the employer, when it's voluntary, we talked about the voluntary uh aspect of wearing an N95, then again, they don't have to comply with the fit testing, they don't have to comply with the medical evaluation, but they do have to make sure that the respirator is the proper size. And they also have to make sure that training is conducted on how to don and dock that respirator and how to inspect it so that they make sure that it isn't damaged and how to perform that user seal check. You know, the same uh the same information uh regarding all the aspects of donning a respirator, including uh whether facial hair is going to interfere with the fit of that respirator. So uh one other piece of information that I don't believe anyone else had mentioned is when there's a voluntary use of a respirator, uh, there is something called appendix D from OSHA that is provided to employees that gives them the information that they are using their respirator voluntarily and uh reminds them that the employer still has to conduct training and make sure that they understand uh how to use that respirator and when it needs to be used. And if it's something that's not a disposable respirator, how to maintain it and store it and that sort of thing.

SPEAKER_02 15:07

Awesome, Leslie. Thanks for sharing California's requirements. So it's very important that our listeners in California follow that information and those that are in other states to check with the state requirements. So fit testing, you know, sometimes that could present a challenge. Mary, what can you share with our listeners on how they can accomplish fit testing and save money?

SPEAKER_01 15:33

Thanks, Olivia. You are absolutely right. Fit testing is a key factor in as I mentioned earlier, there's not really a whole lot of logic into just wearing a respirator voluntarily if you're not fit testing it to at least make sure it's doing you some good. As Linda said, it really, we really need to know are you breathing in expressly in and out of that respirator so there isn't any air escaping? Um, and that's part of the fit testing protocol. There are some practices who will outsource fit testing to an occupational health center, or sometimes fire departments can do it and so forth. But what we have found is that it's much more economical to do fit testing right in the dental practice itself. And so it could be the OSHA safety coordinator, the infection control coordinator, or a team member who is trained to administer the fit tests. You can purchase fit test kits through your dental supply um companies, and some but not all of them do come with video training. Um, what we found is it's kind of a high-level training, it doesn't really get down as much into the nitty-gritty. And so what the divas have done is created a fit test video training program. So we have the documentation, we have video instructions, we relate it specifically to working in a dental practice, and that video is available if our listeners and subscribers are interested on the compliance divas website. So you can um go to the shop or the store on our website, and if you use the code TCD for the compliance divas TCD, we will give any listener a 10% courtesy on the fee for this training um video compliance package for fit testing. And we also then, of course, can be available through our support at the compliancedevas.com to answer any questions that anybody has about administering fit tests. But it's a relatively simple process. You need to make sure you buy the test kit that's most appropriate for um use in dentistry and the types of respirators that we're using. And it really is a great and efficient and affordable tool for making sure you can have a successful fit testing program.

SPEAKER_02 18:22

Thank you, Mary. I remember when we worked on that video, we put a lot of time into it, didn't we? And wanted to make the training program easy to follow and something that the dentist could save money by bringing that talent and skill in-house. So I hope that our listeners will take advantage of using the promotion code to save that 10% on the video. So at this time, we wanted to pick each other's brains on what we're seeing. And I'll start out, as I mentioned at the beginning of our episode, I do see a lot of offices wearing level threes with face shields. And some are very resistant to the respirators. They feel like they can't breathe, they don't like if it makes marks on their faces. And then on the other hand, those that are fans of the respirators love the peace of mind that they are protecting their respiratory system from not only COVID, but also influenza and other aerosol-transmittable infections that could be transmitted during an aerosol-generating procedure. So, what are your individual thoughts on what you're seeing, Mary? Would you like to start?

SPEAKER_01 19:46

I certainly would. I love what you said about making sure that we're protecting ourselves from other aerosol-generated infectious diseases. And if you've paid attention to any of the CDC Health Alert Network bulletins recently, we're having yet another outbreak of measles originating in Kentucky at a religious conference and people there from all over the country and around the world. So we could have widespread um issues with measles, so we need to protect ourselves. The thing that I see is that people who are wearing respirators are still, in some cases, under the mistaken notion that they can continue to reuse them, and they tend to resist the fact that they are disposable. They remember back to the days of the critical supply levels of N95s and assume that they can wear one for an entire day, and especially if they're wearing a face shield over it, or people are putting a level three or another um ASTM-rated mask over their respirator, which both NIOSH and the CDC say that you should not do because it can interfere with the fit of your respirator.

SPEAKER_02 21:07

Great info, Leslie.

SPEAKER_00 21:11

Olivia, I also want to remind everyone that a surgical N95 respirator, when it's used as a healthcare device, like not one that's a construction grade, but it's the one that is designed for healthcare workers, protects both the healthcare worker and the patient from the transfer of microorganisms, bodily fluid, and particular material. So if you think about it, so many times we hear about uh people who are vaccinated are still able to transmit COVID or other viruses for that matter. And you have a patient whose mouth is open right underneath you, you're working on them, and you're breathing, we're breathing and exhaling around a regular surgical face mask, there's likely to be some transfer of viruses and microorganisms to the patient. And so we protect both ourselves and the patients by using an N95. And now just one other point I wanted to make before we leave uh the um N95 respirator issue when it comes to aerosol generating procedures. In California, CalOSHA said that they're going to rely on what not only the public health department orders are, but they're also looking at the community levels and the community spread. When we have a higher community transmission of COVID than or even substantial community uh transmission, uh CalOSHA is going to be a little bit more um involved in enforcement of the N95 use. So we can't just give them up altogether and we need to think about uh more globally, besides ourselves and perhaps the discomfort it is uh that we in um the discomfort that we experience at first wearing an N95. Um eventually we get used to it, just like we got used to wearing exam gloves. And we are uh really looking out not only for ourselves, but we're looking out for the greater good of our patient population.

SPEAKER_02 23:08

I love that point that you made, Leslie. I remember when we had to start wearing gloves, when it became a requirement. And, you know, we were all complaining how we we just couldn't work with the gloves on because we were used to having bare hands. So that's a great analogy there. Uh Linda, do you have some thoughts for our listeners?

SPEAKER_03 23:26

I do, but I have to comment on the gloves, Olivia. I remember the same thing, and I'm sure now there's multiple generations of dental health care workers that wouldn't be able to relate to that of, you know, putting their hands in somebody's mouth without gloves on. So similar to that, you know, we're recognizing these aerosol transmissible diseases. There are many more that have been in existence far before long before SARS-CoV-2. So likewise, I'm seeing a lot of offices that are kind of going back to the level three mask. But unfortunately, every now and then I do come across an office where somebody, the doctor or staff, is choosing to wear the K in 95 mask. And most recently, I had a doctor tell me that um they were wearing the mask because they felt like it was a better fit than uh level three, and it was more comfortable than in 95 mask. And I just had to remind them that emergency use authorization had been resended almost two years now, this July. So, and they I'm I'm not sure where they're buying these, Olivia, but evidently they're still being sold, or they had plenty of a stockpile from the crisis and are still using them, which should not be done in dental practices.

SPEAKER_02 24:32

Thanks for adding that information. So I think this has been a great topic, uh, discussing the difference between mandatory use of respirators and voluntary use. As the compliance divas, we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions to support at the compliancedevas.com. And also we'll have the resources that we mentioned available in the notes. Thanks for tuning in, and we'll see you next time.