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Policies,Administrative,UWMF,UWMF-wide,Safety,Respiratory

Respiratory Protection Program (122.001)

Respiratory Protection Program (122.001) - Policies, Administrative, UWMF, UWMF-wide, Safety, Respiratory

122.001



Respiratory Protection Program
Effective Date: 07/2016 Page 1 of 40
Review date(s):6/2016


CONTENTS

I. Purpose and Scope ............................................................................................................................ 3
A. Purpose Statement ........................................................................................................................ 3
B. Scope ........................................................................................................................................... 3
II. Responsibilities ................................................................................................................................. 3
A. Respiratory Program Administrator ................................................................................................. 3
B. Employee Health Services ............................................................................................................... 3
C. Infection Control ............................................................................................................................ 3
D. Supervisors/Managers .................................................................................................................... 4
E. Respiratory Protection Program (RPP) Champions .............................................................................. 4
F. Employees .................................................................................................................................... 4
G. Contracted Non-Employees ............................................................................................................. 5
H. Environment of Care (EOC) Safety Committee ................................................................................... 5
I. Respiratory Protection Program (RPP) Subcommittee ......................................................................... 5
J. Infection Control Committee ........................................................................................................... 5
III. Respiratory Hazard Assessment and Respirator Selection ................................................................ 5
A. Administrative and Engineering Controls ........................................................................................... 5
B. Respiratory Hazard Assessment ....................................................................................................... 5
i. Identification and Evaluation of Air Contaminants ........................................................................ 5
ii. Identified Respiratory hazards and Appropriate Respiratory Protection ........................................... 6
C. NIOSH-Certified Equipment ............................................................................................................. 7
D. Assignment of Respirators by Task and Location ................................................................................ 7
E. Updating the Hazard Assessment ..................................................................................................... 7
F. Voluntary Use of Respirators ........................................................................................................... 7
IV. MEDICAL EVALUATION ...................................................................................................................... 7
A. Medical Evaluation Procedures ......................................................................................................... 8
B. Frequency of Medical Evaluation ...................................................................................................... 8
C. Additional Medical Evaluations ......................................................................................................... 8
D. Failure or Refusal of medical Evaluation ............................................................................................ 8
V. FIT TESTING ..................................................................................................................................... 8
A. Fit Testing Procedures .................................................................................................................... 8
B. Frequency of Fit Testing ................................................................................................................. 9
C. Additional Fit Tests ........................................................................................................................ 9
D. Failure to Complete Fit Testing ........................................................................................................ 9
VI. Training ............................................................................................................................................ 9
A. Frequency of Training ..................................................................................................................... 9
B. Additional Training ......................................................................................................................... 9
i. Respiratory Protection Program (RPP) Champion Training ............................................................. 9
ii. Training During Fit Testing ...................................................................................................... 10
iii. Decontamination Team Training .............................................................................................. 10
iv. Special/Emerging Pathogens Team Training .............................................................................. 10



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VII. Summary of Enrollment Process ..................................................................................................... 10
VIII. Respirator Use .......................................................................................................................... 10
A. N95 Filtering Facepiece Respirator Use ........................................................................................... 10
B. Powered Air-Purifying Respirator (PAPR) Use ................................................................................... 11
C. When to Leave the Respirator Use Area .......................................................................................... 11
IX. Storage, Reuse, Maintenance and Care of Respirators .................................................................... 11
A. Storage and Reuse ....................................................................................................................... 11
i. Disposable Respirators ........................................................................................................... 11
ii. Reusable Respirators ............................................................................................................. 11
B. Inspection, Maintenance and Repairs ............................................................................................. 12
i. Filter Change Schedules ......................................................................................................... 12
C. Cleaning and Disinfection .............................................................................................................. 12
X. Program Evaluation ........................................................................................................................ 12
XI. Record Keeping ............................................................................................................................... 12
A. Record Availability ....................................................................................................................... 13

RPP Appendix A: UW Health Scope of N95 Fit Testing .......................................................................... 14
RPP Appendix B: Ambulatory Plan ......................................................................................................... 15
RPP Appendix C: Respiratory Protection by Location............................................................................. 17
RPP Appendix D: OSHA Respirator Medical Evaluation .......................................................................... 29
RPP Appendix E: Unit/ Groups for Annual N-95 Respirator Fit Testing .................................................. 30
RPP Appendix F: Respirator Fit Test Instructions .................................................................................. 32
RPP Appendix G: Proper Use and Limitations of the N95 Class Respirator for Tuberculosis Protection 34
RPP Appendix H: Respirator Qualitative Fit Testing and Training Record .............................................. 36
RPP Appendix I: N95 Mask Fit Test Card ............................................................................................... 37
RPP Appendix J: RPP Champion Train-The-Trainer N95 Respirator Mask Fit Test Checklist ................... 38
RPP Appendix K: RPP PAPR Checklist Donning and Doffing Checklist .................................................... 39


























Respiratory Protection Program
Effective Date: 07/2016 Page 3 of 40
Review date(s):6/2016


I. Purpose and Scope

A. Purpose Statement

The purpose of the Respiratory Protection Program (RPP) for UW Health is to effectively protect staff
against atmospheric contamination during situations in which administrative and engineering controls
inadequately reduce the frequency and duration of hazardous exposure. The RPP establishes the program
plan necessary to meet the regulatory requirements described in OSHA’s Respiratory Protection standard
(29 CFR 1910.134).

B. Scope

This program applies to all employees, including medical staff, advanced practice providers, graduate
medical education trainees, as well as contracted non-employees (henceforth collectively referred to as
‘staff’) who are required to wear respirators during normal work operations, and during some non-routine
or emergency situations. Students, observers, volunteers, agency and travel staff are excluded from this
program as they are not allowed in areas that require respiratory protection. It applies to the use of air-
purifying and air-supplying respirators, including filtering facepiece respirators.

Refer to Appendix A for a detailed list of Respirator Assignments by task or location.

II. Responsibilities

A. Respiratory Program Administrator

The Director of Safety is the Respiratory Program Administrator (RPA), and is responsible for the overall
implementation and administration of the RPP. The RPA will:

ξ Identify and evaluate hazardous exposures.
ξ Develop and monitor respirator maintenance procedures.
ξ Supervise selection of respirators.
ξ Ensure staff identified in the RPP receive medical surveillance.
ξ Coordinate purchase, maintenance, repair, and replacement of respirators.
ξ Coordinate annual training in the use and limitations of respirators.
ξ Coordinate annual respirator fit testing.
ξ Evaluate the overall Respiratory Protection Program annually.
ξ Maintain a copy of the written respiratory protection program and program evaluations, and ensure
that they are readily accessible to anyone in the program.

The departments of Employee Health, Infection Control, and Safety will assist the RPA with the
implementation and administration of the RPP.

B. Employee Health Services

The Employee Health Services (EHS) Manager will:

ξ Provide or arrange for annual respirator fit testing for staff in the RPP.
ξ Provide or arrange for annual training in the use and limitations of respirators.
ξ Provide medical surveillance to staff identified in the RPP.
ξ Ensure staff training and qualitative respirator fit testing is appropriate.
ξ Create, update, and maintain records of fit respirator training, medical clearance, and fit testing.
ξ Maintain a list of all staff required to receive respirator fit testing, per the hazard risk assessment, and
coordinate with the Human Resources Department to ensure appropriate enrollment in the program.

C. Infection Control

The Infection Control Department will:

ξ Assist the RPA with developing and updating the hazard risk assessment.
ξ Assist the RPA with respirator selection.
ξ Develop infection control guidelines that incorporate respiratory protection requirements that stem
from the program risk assessment.



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ξ Ensure that respiratory protection decisions are implemented in the context of infection control
guidelines.

D. Supervisors/Managers

Supervisors and Managers of staff in the RPP will:

ξ Ensure that staff under their supervision that are enrolled in the program have received appropriate
training, fit testing, and medical evaluation as outlined by this program.
ξ Ensure that appropriate respirators and accessories are available.
ξ Be aware of tasks requiring the use of respiratory protection.
ξ Enforce the proper use of respiratory protection when necessary.
ξ Ensure that respirators are properly cleaned (as needed), maintained, and stored according to this
respiratory protection program.
ξ Be responsible for ensuring that staff under their supervision follow the procedures outlined in the
RPP.
ξ Participate in the hazard assessment by evaluating all potential exposures to respiratory hazards,
including chemical exposures and/or aerosol transmissible diseases (ATDs), and communicating this
information to the Infection Control Department.
ξ Routinely monitor patient status to ensure correct identification of hazards and appropriate selection
of respirators.
ξ Coordinate with the RPA on how to address respiratory hazards or other concerns regarding the
program.
ξ Communicate policy changes to staff.
ξ Report program problems to the RPA.
ξ Appoint a Respiratory Protection Program Champion for the unit/department, as applicable.
ξ Ensure all non-compliant staff are removed from work or reassigned to avoid tasks that require
respiratory protection.

E. Respiratory Protection Program (RPP) Champions

RPP Champions will:

ξ Receive training from EHS and Safety on how to appropriately conduct fit testing, don and doff
respirators, clean, store and inspect respirators as required and provide guidance as needed.
ξ Work directly with his/her supervisor to ensure all staff on their unit/department receive annual fit
testing.
ξ Be responsible for ensuring that complete and accurate documentation is submitted to EHS in a timely
manner.

F. Employees

Employees in the RPP will:

ξ Comply with the Respiratory Protection Program and proper procedures for wearing respiratory
protection.
ξ Participate in training, tests for competency validation, medical clearance procedures, and fit-tests for
the specific type of respirator to be used.
ξ Inform their supervisor if their respirator no longer fits well, and participate in new fit testing
procedures.
ξ Inform their RPP Champion, Supervisor, or the RPA of any respiratory hazards that they feel may not
be adequately addressed in the workplace and of any other concerns that they have regarding the
program.
ξ Verify that their respirator is cleaned, stored and maintained according to the parameters of their
training.
ξ Report any problems to their supervisors.
ξ Notify EHS of any changes in medical/physical condition or work practice that could impact their
medical clearance for respirator use.
ξ May be removed from work until such time as respiratory protection program requirements are met.

G. Contracted Non-Employees

Contracted non-Employees will:



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Review date(s):6/2016



ξ Receive training on air-purifying, non-fitted respirators from their company or just in time, as needed.
ξ Not be included in our fit testing staff list as contractors change routinely and may only be in our
facilities one time.


H. Environment of Care (EOC) Safety Committee

The EOC Safety Committee will evaluate reports on the RPP and approve actions to address identified
issues.

I. Respiratory Protection Program (RPP) Subcommittee

The RPP Subcommittee will assist in the periodic review of the program and meet when there are issues to
address or changes to be made to the program.

J. Infection Control Committee

The Infection Control Committee will make recommendations to the RPA when there is a need to update
the RPP based on new clinical information.

III. Respiratory Hazard Assessment and Respirator Selection

A. Administrative and Engineering Controls

In the control of those occupational diseases caused by breathing air contaminated with harmful dusts,
fumes, sprays, mists, fogs, smokes, vapors, gases or biological aerosols, the primary objective shall be to
prevent atmospheric contamination. This shall be accomplished to the greatest feasible extent by accepted
administrative and engineering control measures (e.g. substitution of less toxic materials, enclosure or
confinement of the operation, general and local ventilation, etc.). When effective administrative and
engineering controls are not feasible, or while they are being instituted or evaluated, appropriate
respirators shall be used.

B. Respiratory Hazard Assessment

The RPA will select the types of respirators to be used by staff based on the hazards to which staff may be
exposed and in accordance with all State and Federal (OSHA) regulations and Center for Disease Control
(CDC) and/or Wisconsin Department of Public Health (DPH) guidelines. With input from the respirator
user, the RPA and supervisor will conduct a hazard assessment for each task, procedure, or work area
with the potential for airborne contaminants. The hazard assessment will take into account the following
factors:

ξ The nature of the hazardous operation or process.
ξ The type of respiratory hazard.
ξ The location of the hazardous area in relation to the nearest area with uncontaminated air.
ξ The period of time for which respiratory protection must be provided.
ξ The activities of workers in the hazardous area.
ξ The physical characteristics, functional capabilities, and limitations of various respirator types.

i. Identification and Evaluation of Air Contaminants

Upon request from a manager or due to staff complaints, an initial assessment of the potential hazard
will be conducted by the Safety department. If deemed necessary by the Director of Safety and area
leadership, staff may be badged to evaluate exposure and/or a “sniffer” will be used to sample
contaminants in the air. If further evaluation is necessary, and industrial hygienist may be
contracted.

ii. Identified Respiratory Hazards and Appropriate Respiratory Protection

Hazard Potential Staff
Impacted
Required Respirator or
Engineering Controls
Fit Testing
required?
Biological (including but
not limited to): certain
Nursing, Nursing
support, Respiratory
Respirator - N95

Yes



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Effective Date: 07/2016 Page 6 of 40
Review date(s):6/2016


types of influenza,
measles, Tuberculosis,
fungi spores, biological
warfare agents,
emerging pathogens
Therapy, physician
staff, Facilities and
Engineering, EVS
Although many patients are placed in
airborne isolation rooms with negative
or positive pressure, engineering
controls are not sufficient to contain
or neutralize the potential hazard.

Chemicals (within
organization – including
but not limited to):
anesthetic gases,
chemical sterilants for
medical instruments
and equipment,
cleaning and
disinfection chemicals,
high-level disinfectants,
laboratory chemicals
EVS, pharmacy,
reprocessing, surgical
services, outpatient
services, laboratory
Respirator – NONE

Sufficient engineering controls are in
place, such as HVAC management,
filtered/vented hoods over
workspaces, and other means to
reduce the risk of exposure to staff.
No
Hazardous Drugs with
inhalation potential (see
policy 8.89 Preventing
Non-therapeutic
Exposure to Hazardous
Drugs
Oncology, Facilities and
Engineering, EVS
Respirator - N95 or PAPR If N95, yes
Chemicals released by
patients exposed to
hazardous materials

Unidentified or
uncharacterized
hazardous substances
with potential for
secondary
contamination
Emergency department
staff, decontamination
team members,
physician staff
Respirator – PAPR with canisters

The decontamination rooms directly
adjacent to the emergency
departments have engineering
controls to maintain the environment
but do not sufficiently reduce
exposure risk to staff.
No
Surgical smoke, cautery
smoke plumes
Surgical services staff,
physicians
Respirator – NONE

Sufficient engineering controls are in
place, such as HVAC management,
positive pressure rooms and a
vacuum device to capture smoke in
order to reduce the risk of exposure
to staff.
No
Radiation from
radiological incidents or
dispersal devices
Emergency department
staff, decontamination
team members,
physician staff,
radiology staff, MRI
staff, radiation safety
staff
Respirator –PAPR

The decontamination rooms directly
adjacent to the emergency
departments have engineering
controls to maintain the environment
but do not sufficiently reduce
exposure risk to staff.
For internal areas of the hospitals or
clinics, radiation safety staff will assist
with cleanup in appropriate PPE
according to the UW Radiation Safety
standard operating procedures.
No
Construction spaces
with potential for
hazardous substance
exposure (such as
drywall dust)
Facilities and
Engineering Services,
Planning/Development/
Construction
Respirator – PAPR with HEPA filtration
if no HEPA filtration unit is in use

In the absence of a HEPA filtration
unit forcing internal air to the outside
of the workspace, engineering
controls are not sufficient to contain
or neutralize the potential hazard.
No



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Effective Date: 07/2016 Page 7 of 40
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Note: Biological hazards are determined by Infection Control and generally have an accompanying disease
specific Infection Control Plan.

C. NIOSH-Certified Equipment

All respiratory protective equipment shall be approved by the National Institute for Occupational Safety
and Health (NIOSH) for the environment in which it is going to be used. The NIOSH Certified Equipment
list is found at the following Internet
address:https://www.cdc.gov/niosh/npptl/topics/respirators/cel/default.html. (Note that while there are
more NIOSH-certified respirators than those listed below, only those respirators listed below are to be
used by staff under this program.)

The following definitions apply to equipment that may be issued to staff under this program:

ξ Air-purifying respirator (APR) is a respirator that removes gases, vapors, or particles, or
combinations of gases, vapors, and/or particles from the air through the use of filters, cartridges, or
canisters that have been tested and approved by NIOSH for use in specific types of contaminated
atmospheres.

o Filtering facepiece respirator (FFR) is a disposable, negative-pressure, air-purifying respirator
in which an integral part of the facepiece or the entire facepiece is composed of the filtering
medium. These respirators are disposable and designed for a single use. However, a FFR may
be reused by the same user, under some circumstances, as long as the respirator has not been
obviously soiled or damaged.

 N95 filtering facepiece respirator is a half mask FFR with NIOSH-approved N95 filter
material. An N95 FFR has a filter efficiency of 95%.

o Powered air-purifying respirator (PAPR) is an air-purifying respirator that uses a blower to
force ambient air through air-purifying elements to the respirator facepiece, helmet, or hood.
Some PAPRs, those used for protection against air particulates, use high-efficiency particulate air
(HEPA) filtration, which remove at least 99.97% of particles from the air. Other PAPRs, those
used by the decontamination team, use cartridges or canisters that protect against hazardous
gases and vapors.

D. Assignment of Respirators by Task and Location

The RPA will use the hazard assessment to assign appropriate types of respirators for use by specific types
of personnel during specific procedures or in specific areas. These assignments are listed above in section
III. B.

E. Updating the Hazard Assessment

The RPA will revise and update the hazard assessment any time a staff member or supervisor identifies or
anticipates a new exposure or changes to existing exposures. Any staff member who believes that
respiratory protection is needed during any particular activity must contact their supervisor or the RPA
(the supervisor must subsequently contact the RPA whenever respiratory protection is requested). The
RPA will assess the potential hazard with the staff member and supervisor. If it is determined that
respiratory protection is needed, all elements of this program will be in effect for those tasks and the
program will be updated accordingly.

F. Voluntary Use of Respirators

Only those staff members who are included within the scope of this RPP, and who receive annual medical
evaluation and training, are permitted to use respirators. Staff members who are permitted to use
respirators may use the same type of respirator they normally would even when the use of a respirator is
not required by this RPP. All other respirator use is prohibited.

IV. Medical Evaluation

Staff whose work activities require the use of respiratory protective equipment shall receive medical clearance
prior to the use of a respirator and prior to being fit tested for a respirator.




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A. Medical Evaluation Procedures

ξ Medical evaluations will be performed by a physician or other licensed health care professional
(PLHCP) at Employee Health Services (EHS).
ξ All staff enrolled in this program will complete the OSHA-required Respirator Medical Evaluation
Questionnaire in Appendix D of this RPP.
ξ The medical evaluation at EHS will be conducted using the questionnaire, and may involve a physical
examination of the staff member.
ξ Staff will be granted the opportunity to speak with the PLHCP about their medical evaluation.
ξ The evaluation will be kept medically confidential.
ξ The evaluation will be provided at no cost to the staff member.
ξ EHS may need additional information to medically clear staff. This may include, but is not limited to:

o A copy of this Respiratory Protection Program
o A copy of OSHA’s Respiratory Protection Standard
o The type and weight of respirators to be used
o The duration and frequency of respirator use
o The expected physical work effort
o Any expected work conditions involving extremes of temperature or humidity
o Any additional protective clothing and equipment to be worn

B. Frequency of Medical Evaluation

ξ A medical evaluation must be completed prior to initial use of a respirator, and prior to initial fit
testing (if applicable).
ξ A more frequent schedule of re-evaluation for a staff member may be required, depending on PLHCP
recommendations.

C. Additional Medical Evaluations

An additional medical evaluation is required when:

ξ The staff member reports signs and/or symptoms related to their ability to use a respirator, such as
shortness of breath, dizziness, chest pains, or wheezing.
ξ A PLHCP, supervisor, or the RPA requests a reevaluation.
ξ Observations made during fit testing or program evaluation indicate a need for reevaluation.
ξ A change occurs in workplace conditions that may result in an increased physiological burden on the
staff member.

D. Failure or Refusal of Medical Evaluation

Staff are not permitted to wear respirators until a physician or PLHCP has determined that they are
medically able to do so. Any staff member who fails or refuses the medical evaluation will not be
permitted to work in an area requiring respirator use, and, if necessary, may be reassigned to a position
that does not require respirator use.

V. Fit Testing

THIS SECTION APPLIES ONLY TO STAFF IN UNITS/AREAS/GROUPS THAT HAVE BEEN ASSIGNED N95
RESPIRATORS FOR RESPIRATORY PROTECTION (See Appendix A).

After a staff member has received medical clearance by EHS, but before that individual is required to use any
respirator with a tight-fitting facepiece (i.e., an N95 filtering facepiece respirator), she/he will be fit tested to
determine the make, model, and size of respirator they will wear. Staff will be fit tested by EHS or their
department RPP Champion. Staff who cannot be fit tested (e.g., due to facial hair), or who do not pass the fit
test, will be directed to use a powered-air purifying respirator (PAPR) with HEPA filtration for tasks requiring a
respirator.

A. Fit Testing Procedures

For a detailed account of the fit-testing process, see Appendix F.

B. Frequency of Fit Testing



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Fit Testing will be conducted:

ξ Prior to a staff member being permitted to wear any respirator with a tight fitting facepiece
ξ Annually

Staff who receive one-off, just-in-time fit testing, who are not identified in Appendix A, will not be required
to be fit tested annually.

C. Additional Fit Tests

Additional fit testing is required when the staff member, PLHCP, supervisor, or RPA reports or observes
physical changes that could affect respirator fit. These changes include, but are not limited to, facial
scarring, dental changes, cosmetic surgery, or an obvious change in body weight.

D. Failure to Complete Fit Testing

If a staff member fails to complete required initial or annual fit testing for a N95 respirator, their
supervisor will be notified and they may be taken off of work. The staff member will only be allowed to
return to work when he/she completes required fit testing.

VI. Training

Respirator training will be provided for all staff covered by this program. The training will be conducted
through the Learning and Development System and will include the following:

ξ The contents of this Respiratory Protection Program
ξ The general requirements of the OSHA Respiratory Protection standard
ξ The circumstances under which respirators are to be used
ξ Respiratory hazards to which staff may be exposed
ξ The limitations and capabilities of the respirators that will be used
ξ Why proper fit, usage, and maintenance are crucial to respirator effectiveness
ξ How to inspect, don, seal-check (for tight fitting respirators), use, and doff the respirator
ξ The procedures for proper maintenance, storage, cleaning, and disposal of respirators
ξ How to recognize medical signs and symptoms that may limit or prevent the effective use of respirators
ξ How to identify and react to respirator malfunctions
ξ How and when to decontaminate (or safely dispose of) a respirator that has been contaminated with
chemicals or hazardous biological materials

Respirator training will be computer-based, and will include an electronic exam.

A. Frequency of Training

Training will be provided:

ξ Prior to a staff member being permitted to wear a respirator
ξ Annually

B. Additional Training

Additional training will be provided when there is a change in the type of respiratory protection used, or
when inadequacies in the staff member’s knowledge or use of the respirator indicate that she/he has not
retained the requisite understanding or skill.

i. Respiratory Protection Program (RPP) Champion Training
In addition, the Respiratory Protection Program Champion will attend a Train-the-Trainer class
provided by Employee Health Services or Safety. A N95 Respiratory Mask Fit Test or Positive Air
Purifying Respirator (PAPR) Use Checklist (See Appendix J and K) will be completed for each RPP
Champion before she/he will be authorized as a departmental champion. Annual training is required
for reevaluation. Any questions the RPP Champion may have during the year can be directed to the
RPA or EHS.



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ii. Training During Fit Testing

THIS SECTION APPLIES ONLY TO STAFF IN UNITS/AREAS/GROUPS THAT HAVE BEEN ASSIGNED N95
RESPIRATORS FOR RESPIRATORY PROTECTION (See Appendix A).

Staff will receive additional training during the fit testing procedure that will provide an opportunity to
handle the respirator, have it fitted properly, test its facepiece-to-face seal, wear it in normal air
familiarize themselves with the respirator, and finally to wear it in a test atmosphere. Every
respirator wearer will receive fitting instructions, including demonstrations and practice in how the
respirator should be worn, how to adjust it, and how to perform a user seal check. Staff should be
able to demonstrate how to correctly inspect, don, seal check, and doff the respirator they will wear.

iii. Decontamination Team Training

THIS SECTION APPLIES ONLY TO STAFF ON THE DECONTAMINATION TEAM.

Members of the Decontamination Team are required to complete a decontamination awareness
course, as well as a decontamination operations course. The hands-on operations course, called
Lanes Training, will be completed by decontamination team members annually.

iv. Special/Emerging Pathogens Team Training

THIS SECTION APPLIES ONLY TO STAFF ON THE SPECIAL/EMERGING PATHOGENS TEAM.

Members of the Special/Emerging Pathogens Team are required to attend periodic special/emerging
pathogens team training sessions.

VII. Summary of the Enrollment Process

All staff who are required to use a respirator will be medically evaluated upon hire and as needed
thereafter. Additional medical evaluations will be required of staff who experience changes in their
medical condition that affect their ability to wear a respirator.

All staff in units/areas/groups that have been assigned N95 respirators for respiratory protection (see
Appendix C) will complete fit testing. All staff who are successfully fit tested will complete fit testing
annually. It is not necessary for PAPR users to be fit tested. Additional fit tests will be required of staff
who experience changes in their physical condition that affect their ability to wear a respirator.

All staff who are required to use a respirator will be trained upon hire and annually thereafter. Members
of the decontamination team will also complete decontamination training, and will do so annually.
Members of the special/emerging pathogens team will also complete special/emerging pathogens training,
and will do so periodically. Additional training sessions will be required of staff who do not retain the
requisite understanding or skill necessary to use a respirator.

VIII. Respirator Use

Staff will follow procedures for proper use of their respirators under conditions specified by this program and in
accordance with the training they receive. In addition, a respirator shall not be used in a manner for which it
is not certified by NIOSH or by its manufacturer. The appropriate types of respirators to be used (see
Appendix C) and their corresponding exposure conditions are listed in the respirator selection Section III. B of
this RPP.


A. N95 Filtering Facepiece Respirator Use

Staff must use the respirator make, model, and size for which they were successfully fit-tested within the
prior year, and will receive a reminder card detailing this information at their fit testing. Staff should
contact EHS if they have any questions regarding this.

Staff and supervisors are expected to be diligent in observing practices pertaining to ensuring the safe use
of respirators. To ensure proper protection, the wearer will perform a user seal check, in accordance with



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manufacturer instructions and the training provided at the time of fit testing, each time she/he puts on a
tight-fitting respirator.

Respirators relying on a tight facepiece-to-face seal, such as N95 filtering facepiece respirators, must not
be worn when conditions prevent a good seal. Such conditions may be a beard, long moustache,
sideburns, or even razor stubble as well as scars, other facial deformities, piercings, and temple pieces on
glasses. In addition, the absence of one or both dentures can seriously affect the fit of a facepiece. Staff
who wear corrective glasses or other personal protective equipment must wear these during their fit
testing to ensure that it does not interfere with the facepiece seal.

B. Powered Air-Purifying Respirator (PAPR) Use

Staff who are unable to wear a N95 respirator or who are at locations relying on PAPRs only, can request a
PAPR on the downtime form or HealthLink isolation order. PAPR hoods are ordered separately through
Peoplesoft or Central Services Catalog. In most cases, staff will only need to order a few PAPRs to manage
care for the patient. Hoods can be provided for as many staff who need to enter the isolation room. Upon
patient discharge, the PAPRs must be returned to reprocessing for reuse by other requesting departments.

There are two different styles of PAPR hoods. The standard hood for non-sterile procedures is available in
two sizes (i.e. small/medium, medium/large). The default order size will be medium/ large, as most will fit
into this size. The other style of hood is an “Inner Collar” hood for sterile procedures (same available
sizes). Hoods are limited to one employee, per patient, per shift. At the end of the shift, the hoods can be
disposed of in regular trash.

C. When to Leave the Respirator Use Area

Regardless of the type of respirator in use, staff must leave the respirator use area:

• To adjust their respirator if the respirator is not fitting correctly or impeding their ability to work.
• To wash their face if the respirator is causing discomfort or rash.
• To change the respirator, filters, cartridges, or canister elements.
• To inspect the respirator if it stops functioning as intended, such as detection of vapor or gas
breakthrough, changes in breathing resistance or leakage of the facepiece (e.g., fogging of
eyeglasses).

IX. Storage, Reuse, Maintenance and Care of Respirators


A. Storage and Reuse

Respirators will be stored in a manner to protect them from damage, contamination, dust, sunlight,
extreme temperatures, excessive moisture, and damaging chemicals.

i. Disposable Filtering Facepiece Respirators

When caring for infectious patients, disposable filtering facepiece respirators (e.g., N95 respirators)
will be discarded after each use (i.e., patient encounter). Reuse by the same wearer in the care of
the same patient is acceptable as long as the respirator is not damaged or soiled. The respirator
must be discarded when it is no longer in its original working condition, whether that condition results
from contamination, structural defects, or wear. Respirators that will be reused in patient care areas
will be stored in a covered container (labeled with the user’s name) in an area that is free from
chemicals, high humidity and temperature extremes. Carrying a respirator in a pocket or wearing it
around the neck are not appropriate methods for storing a respirator when it is not being worn.

ii. Reusable Respirators

Reusable respirators (e.g., PAPRs) will be stored and charged at strategic locations throughout UW
Health hospitals and clinics. Staff must clean the PAPR with Caviwipes disinfectant towelette(s)
before returning for storage and recharging.


B. Inspection, Maintenance and Repairs



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All Respirators will be inspected by the user prior to each use. Inspection should include a check of:

ξ Condition of the various parts including, but not limited to, the facepiece, head straps, valves, and
cartridges, canisters, or filters
ξ All rubber or plastic parts, for pliability and signs of deterioration
ξ PAPR connecting tubes or hoses, air flow, and batteries

If during an inspection, a staff member discovers a defect in a respirator, he/she must bring the defect to
the attention of his/her supervisor. It is the supervisor’s responsibility to inform Central Supply/Materials
Management and to ensure that proper action is taken following the discovery of a defect. Any defective
respirators shall be removed from service immediately and marked appropriately to prevent accidental
use. Defective disposable respirators (e.g., N95 respirators) will be discarded and replaced. Should a
reusable respirator (e.g., a PAPR) need repair, to maintain NIOSH approval, only NIOSH approved parts
from the manufacturer of the respirator will be used. Only manufacturers or their trained representative
will be permitted to make repairs on respiratory equipment.

i. Filter Change Schedules (PAPRS only)

Staff wearing air-filtration respirators must, at a minimum, doff the respirator or change the filter
cartridge when they first begin to experience difficulty breathing (i.e., resistance) and/or when flow
alarm trips on the PAPR. In an event that a low flow alarm is activated, staff must leave the protected
area, doff the respirator and report the condition as specified in section VIII C and report any adverse
medical symptoms to Employee Health Services. Filter cartridges with an End of Service Life
Indicator (ESLI) sticker will be changed prior to the expiration date that appears on the sticker. If a
cartridge ESLI is not available, manufacturer recommendations or a cartridge life expectancy
calculator will be used to develop a change schedule.


C. Cleaning and Disinfection

Reusable respirators (e.g., PAPRs) will be cleaned and disinfected after each use using the below protocol
as a guide:
1. Disconnect disposable PAPR hood from hose and discard in regular trash.
2. Remove hose from PAPR blower unit and wipe clean with a Caviwipe towelette.
3. Wipe entire exterior surface of the PAPR blower unit (including belt) with a Caviwipe towelette.
Allow all PAPR components to air dry after cleaning.
4. Return PAPR unit to Central Supply or Materials Management for testing, recharging and storage.

X. Program Evaluation

The RPA will conduct an evaluation of the RPP to ensure that all aspects of the program meet the requirements
of the OSHA Respiratory Protection standard and that the RPP is being implemented effectively to protect staff
from respiratory hazards. This evaluation will be conducted periodically, and at least annually. The evaluation
will include:

ξ Review of the written program
ξ Inspection of records
ξ Observation of user proficiency
ξ Random inspection of respirators for cleanliness, deterioration, proper selection, and storage
ξ Examination of respirator fit, as well as proper and effective use of respirators in the workplace
ξ Regular consultation with staff to determine satisfaction with the implementation of the RPP
ξ Assessment of the appropriateness and availability of the respirators selected for use in the workplace
ξ Review of the degree of staff exposure to air contaminants
ξ Inspection for workplace conditions that may compromise respirator effectiveness
ξ Reevaluation of risk assessment to ensure all potentially-exposed staff are included in the program

Once the evaluation is finalized, the RPA is responsible for implementing the recommendations in the report as
part of the performance improvement process.

XI. Recordkeeping




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The RPA will ensure that the following records are established, maintained, and stored in accordance with
OSHA’s Respiratory Protection standard:

ξ A copy of this RPP
ξ Methodology and results of risk assessment
ξ Staff enrolled in the RPP
ξ Types of respirators selected for use
ξ Staff medical evaluation questionnaires
ξ Staff fit-testing and training records
ξ Program evaluation reports

Medical records will be maintained for the duration of employment and for 30 years after separation or
termination.


A. Record Availability

Medical clearance records will be made available in accord with the OSHA Access to Employee Exposure
and Medical Records standard (29 CFR 1910.1020). A copy of this RPP and records of program evaluation
and revisions will be made available to all affected staff, their representatives, representatives and OSHA,
and to the Assistant Secretary of Labor or his/her designee upon request as required by the OSHA
Respiratory Protection standard (1910.134).






























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RPP Appendix A: UW Health Scope of N95 Fit Testing

UW Health Scope of N-95 Respirator Use
April 2017
Infection Control Department

The current model of testing primarily based on the airborne risks which can be modified with N-95
respiratory protection and which are most commonly encountered in our patient population considering
geographic location, community and services provided. The most prominent risk is exposure to
pulmonary tuberculosis.

NOTE: Changes in local incidence or global emergence of infections requiring respiratory protection
(e.g., pandemic influenza, avian influenza, Ebola virus disease, SARS, MERS) may trigger the need for
rapid expansion of N-95 fit testing to ensure employee protection. Recommendations to expand the scope
of fit testing will be promulgated by the Hospital Epidemiologist and Infection Control Department, and
may entail activation of the Emergency Management Plan.

The annual N-95 fit testing requirement applies only to staff who enter patient rooms or who receive
patients into diagnostic or procedural areas to provide them care.

Because of the multiple factors affecting exposure risk, employees requiring annual N-95 fit testing are
identified by a combination of inpatient location, clinic setting, procedure area and employee group based
on job duties (see Appendix C). Recommendations for annual fit testing coverage are chosen based on the
following elements, or combinations thereof:
ξ Locations/staff to which patients with undiagnosed pulmonary tuberculosis are most likely to
present for initial assessment or diagnostic procedures.
ξ Inpatient units best suited to provide care for patients with active pulmonary tuberculosis.
ξ Locations/ staff who are less likely to receive patients with undiagnosed pulmonary tuberculosis
will be afforded PAPRs for respiratory protection as needed.

Staff must use the N-95 model and size for which they were successfully fit tested within the prior year.
Staff should consult EHS if there are any questions regarding the specific respirator to use or the time
interval since prior successful testing.

Staff who have not been successfully fit-tested for an N-95 respirator in the prior year will not rely on an
N-95 respirator to enter the risk environment (e.g., airborne isolation room housing the patient with
suspected or confirmed pulmonary tuberculosis).

In order to enter the risk environment, persons who have not been successfully fit tested for N-95
respirator use in the prior year will:
ξ Complete the Computer Based Training (CBT) on usage.
ξ Don a PAPR.

Until this option is achieved, the individual will decline entry into the risk environment.


See also: 2016 TB risk assessment.2016 TB Plan




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RPP Appendix B: Ambulatory Plan

Summary
UW Health will provide annual respirator fit-testing and all necessary education and training to
healthcare providers, with direct patient care, of the following clinic-based locations.
ξ 202 S Park Pulmonary
ξ University Hospital Pulmonary
ξ University Hospital Infectious Diseases
ξ Ophthalmology at University Station
ξ Urgent Care at Union Corners
ξ Urgent Care at West Towne Clinic
Patients suspected or confirmed of having pulmonary Mycobacterium tuberculosis (MTB) requiring
ambulatory level care will be referred to these locations.
Background
The incidence of diseases warranting respiratory protection in the ambulatory care setting is extremely
low for Mycobacterium tuberculosis (MTB), non-existent and unlikely to manifest for others (SARS,
smallpox) and not warranted and of variable incidence for other airborne isolation conditions (measles,
varicella). As such, respiratory protection, in the form of education, training and annual requirements
for healthcare providers should be limited to select settings where engineering controls (e.g. functioning
negative pressure isolation rooms) are present and patients can be most effectively served.
Locations Selected
Confirmed MTB patients undergoing treatment are likely to receive follow-up care in Pulmonary or
Infectious Disease clinics and may require ophthalmology follow-up to which they are referred to the
University Station location. High risk patients presenting with classic signs/symptoms of MTB whose
evaluation does not warrant inpatient or emergency room level care can be evaluated at Urgent Care
Centers at Union Corners (East) and West Towne Clinic (West). These locations: ID, Pulmonary (2),
University Station, Urgent Care (2) are the designated locations to receive and provide care for patients
suspected or confirmed as having MTB and all clinical staff will be obligated to meet all the same
requirements outlined in UW Health’s Respiratory Protection Management Plan.
Program Implementation
Staff at targeted locations will receive annual training and respiratory fit-testing. Personnel who fail the
fit-testing will have a powered air purifying respirator (PAPR) made available. One PAPR will be stocked
and charged at each targeted location. UW Health Facilities & Engineering Services will be responsible
for the preventative maintenance requirements of these units.



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Patient Triage/Scenarios
There are two categories through which suspected/confirmed MTB patients may present to ambulatory
care.
1. Confirmed/Known MTB Cases: These patients, if diagnosed at UW Health, are flagged in
HealthLink with “TB-Confirmed” in their Isolation Banner. The most pertinent services for the
confirmed MTB case are Infectious Diseases, Pulmonary and Ophthalmology-all of which are
included as targeted locations. Physicians referring their confirmed MTB patients for follow-up
care should restrict their locations for such care to the target locations. Persons scheduling MTB
patients for follow-up care shall schedule patients at the target locations.
2. Suspected: Traditional MTB algorithms
(http://www.who.int/tb/Decision_Tables_screening.pdf?ua=1) are complicated and require
clinical judgement. With a community and institutional prevalence rate as low as experienced by
UW Health and Wisconsin, the pretest probability from such algorithms is not conducive to our
use.
a. Scheduled appointments: Current clinic workflows include patients calling to schedule
appointments provide a chief complaint. Select chief complaints are referred to a triage
nurse (over the phone) for review prior to arrival. Patients who offer cough +
hemoptysis will be referred to a triage nurse. Patients with hemoptysis will be
scheduled at one of the target locations. For outlying clinics (>30 miles outside of
Madison), patients may be referred to non-UW Health locations (e.g. hospital
emergency room) in the interest of safe, patient-centered care. The triage nurse will
perform a hand-off direct call to the targeted location selected for the patient as well as
the physician of the day at the location.
b. Walk-Ins: Many clinics have walk-in hours or accept walk-ins. It is possible that a patient
with pulmonary MTB may present for initial evaluation via this route. Regardless of
where they present, patients with cough are masked upon arrival in accordance with
respiratory etiquette. Walk-ins presenting to any one of the target locations may then
be roomed in a negative pressure isolation room and evaluated by personnel donning
an approved respirator. Walk-ins who present to a non-targeted location will be
masked. If clinically appropriate, these patients will be referred to the nearest targeted
UW Health clinic location or outlying clinics (>30 miles outside of Madison), patients
may be referred to non-UW Health locations (e.g. hospital emergency room) in the
interest of safe, patient-centered care. Any referral will include a hand-off direct call to
the location selected for the patient as well as the physician of the day at the location.








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Appendix C: Respiratory Protection by Location








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RPP Appendix D: OSHA Respirator Medical Evaluation


This confidential medical evaluation is part of UW Health’s Respiratory Protection Program (RPP). The RPP ensures that you can wear a respirator safely and effectively
according to good practice and OSHA guidelines. The questionnaire must be signed and completed before the fit testing procedure.




I certify the above information is correct.

Employee Signature: __________________________________________________________________________________Date: ______________________________________

TO BE COMPLETED BY EMPLOYEE HEALTH SERVICES STAFF ONLY

Signature: __________________________________________________________________________________________ Date: ______________________________________
1. Any written recommendations regarding employee’s ability to wear the respirator? Yes (specify below): No


2. Any employee limitations related to respirator use? Yes (specify below): No


3. Can employee be tested to ensure the mask fits adequately? Yes No (specify below):

4. Are follow-up medical evaluations necessary (if so, how often)? Yes (specify below): No

l. Wheezing that interferes with your job
m. Chest pain when you breathe deeply
2. Have you ever had any of the following conditions? n. Any other symptoms that you think may be related to lung problems
a. Seizures (fits) 5. Have you ever had any of the following cardiovascular or heart problems
b. Diabetes (sugar disease) a. Heart attack
c. Allergic reactions that interfere with your breathing b. Stroke
d. Claustrophobia (fear of closed -in places) c. Angina
e. Trouble smelling odors d. Heart Failure
3. Have you ever had any of the following pulmonary or lung problems? e. Swelling in your legs or feet (not caused by walking)
a. Asbestosis f. Heart arrhythmia (heart beating irregularly)
b. Asthma g. High blood pressure
c. Chronic bronchitis h. Any other heart problem that you've been told about
d. Emphysema 6. Have you ever had any of the following cardiovascular or heart symptoms?
e. Pneumonia a. Frequent pain or tightness in your chest
f. Tuberculosis b. Pain or tightness in your chest during physical activity
g. Silicosis c. Pain or tightness in your chest that interferes with your job
h. Pneumothorax (collapsed lung)
i. Lung cancer
j. Broken ribs e. Heartburn or indigestion that is not related to eating
k. Any chest injuries or surgeries
l. Any other lung problem that you've been told about
7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems
a. Shortness of breath b. Heart trouble
c. Blood pressure
d. Seizures (fits)
d. Have to stop for breath when walking at your own pace on level ground
e. Shortness of breath when washing or dressing yourself a. Eye irritation
f. Shortness of breath that interferes with your job b. Skin allergies or rashes
g. Coughing that produces phlegm (thick sputum) c. Anxiety
h. Coughing that wakes you early in the morning d. General weakness or fatigue
i. Coughing that occurs mostly when you are lying down e. Any other problems that interferes with your use of a respirator
j. Coughing up blood in the last month
k. Wheezing
d. In the past two years, have you noticed your heart skipping or missing a
beat
f. Any other symptoms that you think may be related to heart or circulation
problems
8. If you've used a respirator, have you ever had any of the following
problems? (If you've never used a respirator, skip the following spaces and go
to question 9)
9. Would you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire?
1. Do you currently smoke tobacco, or have you smoked tobacco in the last
month?
4. Do you currently have any of the following symptoms of pulmonary or lung
illness?
c. Shortness of breath when walking with other people at an ordinary pace
on level ground
Yes / No Yes / No
b. Shortness of breath when walking fast on level ground or walking up a
slight hill or incline
Today’s date: ______________________ Name: ______________________________________________ Job Title: ___________________________________________
Height: ____ft. ____in. Weight: _______lbs. Birth Date: ____________________ Employee ID: ______________________ Age: ______ Sex: Male_____ Female_____
Phone number where you can be reached by the health care professional who reviews this questionnaire (include Area Code): ___________________________________
OSHA Respirator Medical Evaluation
Section 1910.134, Appendix C
EMPLOYEE HEALTH SERVICES
HC: 608-263-7535 – Fax 608-262-7284
MF: 608-826-6730 – Fax 608-287-2420






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RPP Appendix E: Unit/ Groups for Annual N-95 Respirator Fit Testing





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RPP Appendix F: Respirator Fit Test Instructions





Respirator Fit Test Instructions

There are two test solutions that can be used for testing: Bitrex (bitter)/Saccharin (sweet)
NOTE: OSHA requires that a medical evaluation be conducted prior to fit testing. Subjects should be informed of
the ingredients of the fit test solution and that they will be exposed to a fine mist.
Ingredients: Bitrex: Water, sodium chloride, denatonium benzoate, OR saccharin

















































Preparation of equipment:
1. Attach hood to collar by placing drawstring between flanges on collar. Tighten drawstring and tie with a square knot or
bow.
2. Pour a small amount (approximately one teaspoonful) of the Sensitivity Test Solution into the nebulizer labeled “#1
Sensitivity Test Solution”.
3. Pour the same amount of Fit Test Solution into the second nebulizer labeled “#2 Fit Test Solution.”
4. Immediately recap the bottles.
Sensitivity Test
This test is done to assure that the person being fit tested can detect the test solution (either bitter or sweet) at very low
levels, the Sensitivity Test Solution is a very dilute version of the Fit Test Solution.

Check boxes below upon completion:

□ Circle the test solution you will be using: Bitrex or Saccharin.

□ The test subject should not eat, drink (except water), or chew gum for 15 minutes before the test.

□ Have the test subject put on the hood and collar assembly without a respirator.

□ Position the hood assembly forward so that there is about six inches between the subject’s face and the hood window.

□ Instruct the test subject to breathe through his/her mouth.

□ Using Nebulizer #1 of the Sensitivity Test Solution, inject the aerosol into the hood through the hole in the hood
window. Inject 10 squeezes of the bulb, fully collapsing and allowing the bulb to expand fully on each squeeze. Both plugs
on the nebulizer must be removed from the openings during use. The nebulizer must be held in an upright position to
ensure aerosol generation.
ξ Ask the test subject if he/she can detect the fit test solution either bitter or sweet taste depending on solution
used. If tasted, note the number of squeezes as 10 and proceed to the Fit Test.
ξ If not tasted, inject an additional ten squeezes of the aerosol into the hood. Repeat with ten more squeezes if
necessary. Note whether 10, 20 or 30 squeezes produced a taste response.
ξ If 30 squeezes do not cause the subject to detect the fit test solution, then use the other test solution and repeat
above steps (If used saccharin switch to Bitrex, if used Bitrex switch to saccharin).
ξ Remove the test hood, and give the subject a few minutes to clear the taste from his/her mouth. It may be
helpful to have the subject rinse his/her mouth with water.


Check the number of squeezes of sensitivity solution it takes to taste the solution while breathing normally:
□10 □20 □30 □Failed (did not taste solution after 30 squeezes)

Once test subject is able to detect the solution perform the Fit Test. If the test subject is unable to detect either test
solution (Bitrex or saccharin) they cannot be fitted with the N95 respirator.





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Cleaning
At the end of each session, or at least every four hours, discard the unused solutions from the nebulizers. Do
not pour unused solutions back into bottles. Rinse the nebulizers with warm water to prevent clogging and
shake dry. Wipe out the inside of the hood with a damp cloth or paper towel to remove any deposited Test
Solution.

Fit Test
□ Have the test subject don the respirator and perform a user seal check
□ Subjects put on and position the test hood as before, and breathe through his/her mouth
□ Using Nebulizer #2 of the Fit Test Solution, inject the same number of squeezes as required in the Sensitivity
Test (10, 20 or 30). (A minimum of ten squeezes is required, fully collapsing and allowing the bulb to
expand fully on each squeeze. The nebulizer must be held in an upright position to ensure aerosol
generation).
ξ After the initial injection of aerosol, ask the test subject to perform the following test exercises for 60
seconds each in a standing position
ξ To maintain adequate concentration of aerosol during the test, inject half the number of squeezes (5,
10 or 15) every 30 seconds for the duration of the fit test procedure.
ξ The test is terminated any time the fit test solution is detected.
ξ Repeat the fit test after redonning and readjusting the respirator. If fails again, try a different size or
model of respirator.
1. Normal
breathing
Pass Fail
2. Deep breathing Standing position, the subject shall breathe slowly
and deeply through the mouth
Pass Fail
3. Turning head
side to side
Slowly turn head side to side holding and inhaling
at each side
Pass Fail
4. Move head up
and down
Slowly inhale in up position when looking at ceiling Pass Fail
5.Talking loud and
clearly
Can read from prepared text or count backward
from 100
Pass Fail
6. Bending at waist Jogging in place may be substituted for this
exercise
Pass Fail
7. Normal
breathing
Pass Fail

ξ If the entire test is completed without the subject detecting the bitter or sweet taste, the test is
successful and respirator fit has been demonstrated.



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RPP Appendix G: Proper Use and Limitations of the N95 Class Respirator for Tuberculosis Protection






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RPP Appendix H: Respirator Qualitative Fit Testing and Training Record

Employee Name Date Tested__________________
Through the respirator training I have received today, I understand the following:
• The contents of UW Health’s Respiratory Protection Program
• The general requirements of the OSHA Respiratory Protection standard
• The circumstances under which respirators are to be used
• Respiratory hazards to which I may be exposed
• The limitations and capabilities of the respirators that will be used
• Why proper fit, usage, and maintenance are crucial to respirator effectiveness
• How to inspect, don, seal-check (for tight fitting respirators), use, and doff the respirator
• The procedures for proper maintenance, storage, cleaning, and disposal of respirators
• How to recognize medical signs and symptoms that may limit or prevent the effective use of
respirators
• How to identify and react to respirator malfunctions
• How and when to decontaminate (or safely dispose of) a respirator that has been contaminated
with chemicals or hazardous biological materials

I acknowledge that I have been informed of and have received a copy of the training materials and
understand the above information.
Employee Signature ___________________________________________________




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RPP Appendix I: N95 Mask Fit Test Card

















































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RPP Appendix J: RPP Champion Train-The-Trainer N95 Respirator Mask Fit Test or PAPR Use Checklist








TRAINING REQUIRES KNOWLEDGE AND UNDERSTANDING OF THE FOLLOWING:
 Location of Protocols/Procedures, Forms and Videos (Organization Focused, Employee Health section.)
 Respirator Protection Protocol
 Respirator – Mask Fit Testing Procedure
 Respirator – Mask Medical Evaluation Questionnaire
 Respirator – Mask Fit Testing & Education Form
 Watch Fit Test Video on Hospital Bulletin Board

RESPIRATOR FIT TEST EQUIPMENT:
 Respirators (Masks)
 Equipment (Nebulizer/Hood) Assembly/Setup
 Bitrex Sensitivity Solution
 Bitrex Test Solution
 Equipment (Nebulizer/Hood) Cleanup
 Ordering Equipment/Supplies

RESPIRATOR MASK:
Preliminary Screening Checks/Fit Test:
 Facial hair (presence of facial hair defers to PAPR)
 Eating, drinking (except H2O), smoking, or gum chewing for 15 minutes prior to test
 Proper donning of mask
 Visual checks for gaps
 Instructs deep breathing to check for air leaks
 Instructs how to fit piece around nose if applicable
 Correctly performs sensitivity fit test

INSTRUCTS EDUCATION COMPONENTS OF FIT TESTING:
 When to wear respirator
 Maintenance/storage
 When to dispose of respirator
 Obtaining new respirator
 Perform seal check with each donning of respirator
 When re-testing/re-fitting indicated
 Facial hair prevents seal

is now certified
to perform fit testing of respirator masks having met the following criteria: observed a minimum of 1 fit test and
demonstrated a successful fit test.

Name of Trainer & Date:

TRAINEE:
TRAINER:
Name of Trainee:
TRAIN-THE-TRAINER
N95 RESPIRATOR MASK FIT TEST
CHECKLIST



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RPP Appendix K: RPP PAPR Checklist Donning and Doffing Checklist

Sequence for Donning (Putting On)
Powered Air Purifying Respirators (PAPRs)












Technical Skill Demonstration
Instructor will confirm attendee knowledge of the following by observing the
proper return demonstration of each task.

1. Attach the Hood Cover
a. Check hood cover for any defects or tears. Remove plastic film from hood
visor. NOTE: hoods are limited to one employee per patient per shift

b. Connect hose to hood by pressing the blue pinch clips by arrows and
connecting to air inlet of hood. The hose should make an audible click when
connected
c. Connect the breathing tube to the blower unit by connecting tube to blower
and turning clockwise to lock in place
2. Donning the PAPR
a. Clip on the PAPR belt and sling breathing hose over shoulder
b. Turn on the motor blower by pressing the blue button
c. Put on the hood, correctly placing brow pad on forehead
3. Sterile Procedure Hoods with Shrouds
a. Tuck in inner shroud into interior clothing. Consider using the buddy system.
Leave outer shroud draped over shoulders
4. Key Points
a. If unit alarms, immediately leave the isolation area and report any alarms or
defects to Central Supply or Materials Management
b. Do not use the PAPR until the defect has been resolved
c. Staff must immediately leave the isolation area if any adverse medical signs/
symptoms are experienced when wearing the PAPR.
d. Call Employee Health Services (263-7535) to report any adverse medical
signs/ symptoms related to wearing the PAPR.



Respiratory Protection Program
Effective Date: 07/2016 Page 40 of 40
Review date(s):6/2016




Sequence for Doffing (Taking Off) and Cleaning
Powered Air Purifying Respirators (PAPRs)


Technical Skill Demonstration
Instructor will confirm attendee knowledge of the following by observing the
proper return demonstration of each task.
5. Doffing the PAPR
a. Remove any additional isolation PPE (e.g. gowns or gloves) and perform
hand hygiene prior to leaving isolation area.
b. Once outside of isolation, you may need to solicit help with removing PAPR.

c. Turn off the motor blower by pressing the blue button for 3 seconds
d. Unfasten the battery pack. An assistant may support battery pack while
wearer unfastens pack.
e. Remove hood and head cover
ξ Discard head cover
ξ Continue holding hood
ξ Assistant may continue supporting battery pack

f. Detach hose from hood
ξ Detach hose by pressing the blue pinch clip by the arrows on the end
piece of hose.
ξ Store hood/ PAPR in plastic tote if reusing unit on same patient that shift
by same employee.
ξ At end of shift, discard hood in regular trash

6. Cleaning the PAPR
a. Clean the PAPR and hood each time when exiting “Contact” and/ or
“Enhanced Contact” Isolation rooms AND before returning PAPR to
Reprocessing (UH) or EVS (TAC)

b. Use CaviWipes to wipe the exterior parts of the blower unit, belt and
breathing hose clean

c. Do not clean the HEPA filters and Pre-filters Ensure electrical contacts on
battery and blower unit are kept dry. Do not immerse battery pack or blower
unit in water. Do not use solvents.
d. Perform hand hygiene