The Brody School of Medicine
Office of Prospective Health
East Carolina University
188 Warren Life Sciences Building ● Greenville, NC 27834
252-744-2070 office ● 252-744-2417 fax
February 9, 2011
Occupational
Medicine
Employee Health
Radiation Safety
Infection Control
Biological Safety
MEMORANDUM
To:
Infection Control Committee
From: Office of Prospective Health
Re:
Respiratory Protection Annual Program Review 2010
The annual inspection and program evaluation is performed to determine the continued
effectiveness of the East Carolina University Respiratory Program for Infectious Agents program.
Periodic monitoring is necessary to ensure staff are adequately protected and ensure they are using
respirators properly for the appropriate hazard. Any discrepancy or shortfall in the program is
addressed immediately and appropriate corrective action measures are taken to prevent recurrence.
The last revision date of our written program was performed on 3/02/2010. The program is
reviewed annually and will be modified if any changes occur in regulations or best practices. The
Respiratory Protection Program Fit Test Procedure Policy was also reviewed and revised on
2/9/2011.
In calendar year 2010, 223 staff (includes departmental staff and new hires) were fit tested for the
N-95 respirator to be used for 1) TB or other airborne infection agent exposure. Exposure risk: as
indicated during their annual health history medical questionnaires they treat TB patients (OSHA
required Respiratory Protection Program), 2) do not treat TB patients but had not been fit tested for
the respirator in the past 5 years (Optional Program) and are fit tested annually.
Bi-weekly respiratory protection fit test are performed on new hire staff during orientation.
Prospective Health Staff follow our Infection Control Plan and Biological Safety PolicyRespiratory Program and the 29 CFR 1910.134 OSHA fit test protocol. The fit test aerosol
solutions used are Saccharin (primary) and Bitrix ™ (alternate). During each evaluation, all staff
interviewed are instructed on how to don/doff, wear, care, store and perform the user seal check.
Small and Regular N-95, 3M respirators are used giving 95% filtration efficiency. Staff are
instructed to remember their size, i.e., small or regular; this is also recorded in their chart and in
IRKS.
During Infection Control and Biological Safety site inspections with departments, Prospective
Health Staff observe staff respiratory protection storage areas, ask staff pertinent questions to test
their knowledge and observe donning if possible. Respiratory etiquette signage was observed in
patient waiting areas.
Facility items evaluated during inspections are risk level, respiratory storage and etiquette signage,
negative pressure isolation room monitor including monthly smoke test and powered air purifying
respirator operation. Deficiencies noted during inspections include not having an adequate supply
of respirators on hand and staff not knowing their proper respirator size. A recommendation is for
the nurse managers to post their staff respirator sizes where they keep the N-95 respirators. During
inspections, personnel interviewed explain how to properly don/doff the N95 respirator, perform a
user seal check, PAPR location and the location of their negative pressure room (if equipped). At
the conclusion of the inspections, any deficiencies found are communicated to the nurse managers
for corrective actions verbally and in writing.
Prospective Health currently has four staff members trained to successfully perform respiratory fit
testing. Departmental Supervisors and Nurse Managers are to continue to ensure their staff utilize
respiratory protection when needed as personal protective equipment, of course utilizing negative
pressure isolation rooms and biological safety cabinets as engineering controls.