COMPLIANCE


Next comes training. All staff mem- bers need respiratory protection train- ing that includes reviewing the OSHA standard and their ASC’s respiratory protection program. Staff also need to be trained on how to properly use the respirator, including donning and doff- ing. The program could be written by an ASC’s infection control coordina- tor and go through a multiple-disci- pline review. OSHA has a few sam- ples that might help ASCs write their own program. The training needs to be reviewed every year. The program also should include


any sort of cleaning of respirators, if needed. N95 masks are disposable but the PAPRs need a cleaning process in place. The process needs to be doc- umented in the program and include each step.


Record-keeping needs to be compre-


The Occupational Safety and Health Administration requires healthcare organizations to follow the OSHA Respiratory Protection Standard 29 CFR 1910.134 when using respirators.”


— Lisa Berus, RN Surgical Care Affiliates


The program manager is required to conduct annual evaluations to look at the work practices, whether they were being followed and if any changes are needed. Once the evalu- ation is done, the program manager should send it up to the governing body of the ASC for review.


hensive and accurate in case of an OSHA inspection. I have already seen a cita- tion issued to an ASC because a staffer wore a KN95 instead of an N95 mask. Every ASC needs to be careful and spe- cific when writing its respiratory protec- tion program. In this case, a program that stated “N95 or equivalent” could have helped the ASC avoid an OSHA citation. The National Institute for Occupational Safety and Health has a list of face cov- erings that are equivalent to N95 masks and acceptable alternatives. Visit OSHA for guidance on writ-


ing your ASC’s respiratory protec- tion program.


Lisa Berus, RN, is the director of clinical education and training at Surgical Care Affiliates headquartered in Deerfield, Illinois. Write her at Lisa.Berus@scasurgery.com.


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