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. Author manuscript; available in PMC: 2016 Sep 1.
Published in final edited form as: J Int Soc Respir Prot. 2016;33(1):1–11.

Table I.

Table of Guidelines and Regulations Affecting Hospital Airborne Safety Programs

OSHA Standards
Standard Intent Responsibilities of Hospital
1. OSHA Respiratory Protection Standard (29 CFR 1910.134) http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716 To protect the health of employees working in environments requiring the use of a respirator by requiring employers to provide appropriate equipment and training. To establish and maintain a written respiratory protection program that meets all requirements for respirator selection, storage, training, recordkeeping, and overall program evaluation outlined in this standard.
2. OSHA Personal Protective Equipment Standard (29 CFR 1910.132) http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9777 To ensure the safety of employees by requiring employers to evaluate workplace hazards and furnish all necessary personal protective equipment (PPE), including equipment for eyes, face, head, extremities such as protective clothing, respiratory devices, and protective shields and barriers. To complete a written certification verifying that the required workplace hazard assessment has been performed. To provide necessary PPE of all types to employees at no cost, and to train employees to use the PPE appropriately.
3. OSHA OSHA General Duty Clause for Employers http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=3359&p_table=OSHACT To maintain healthy and safe workplaces by establishing standards with which all employers must comply. To furnish a workplace free of hazards likely to cause death or serious harm. To comply with occupational safety and health standards.
Respirator Certification
4. NIOSH Approval of Respiratory Protective Devices: 42 CFR Part 84 http://www.ecfr.gov/cgi-bin/textidx?SID=34d5bb00513ff19a3c73bd2a348d1217&mc=true&node=pt42.1.84&rgn=div5 In the filing of applications for NIOSH approval of respirators, to establish procedures and requirements, fee schedules, and certificates of approval. Additionally, to specify minimum requirements to be adhered to by the applicant for conducting inspections, examinations, and tests to determine respirator effectiveness. To supply HCP with NIOSH approved respirators.
5. NIOSH The National Personal Protective Technology Laboratory Certified Equipment List http://www.cdc.gov/niosh/npptl/topics/respirators/CEL/default.html To test and certify respiratory protective devices, and verify their continued availability to the public. To provide employees with approved respirator(s) from this list.
Respirator Clearing
6. FDA FDA’s Role in Regulating PPE http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/ucm056084.htm To oversee the safety and effectiveness of medical devices, including certain PPEs that are subject to regulation under the device provisions of the Federal Food, Drug, and Cosmetic Act. For PPEs that are considered medical devices, and subject to regulation under the Federal Food, Drug, and Cosmetic Act, hospitals must purchase and provide FDA-cleared PPEs.
7. FDA Overview of Medical Device Regulation http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/Overview/default.htm To regulate firms who manufacture, repackage, relabel, and/or import medical devices sold in the United States. Under the Medical Device Reporting program hospitals must report incidents and or certain malfunctions of a device that may have caused or contributed to a death or serious injury.
Respirator Selection
8. NIOSH NIOSH Respirator Selection Logic 2004 http://www.cdc.gov/niosh/docs/2005-100/pdfs/2005-100.pdf To provide respirator program administrators with guidance on respirator selection for their employees. To answer the questions outlined in the Respirator Selection Logic Sequence to determine the class of respirators that will provide the minimum acceptable degree of protection for specific workplace conditions.
9. NIOSH NIOSH Respirator Trusted Source Page http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource.html To provide a trusted resource for respirator related questions, including listings of approved respirators, revoked approvals, relevant user notices, and frequently asked questions. To stay informed about respirator policies and to seek trusted information from NIOSH regarding appropriate types of respirators, implementation of the use of respirators in the workplace, and appropriate use.
General Guidelines Protecting Healthcare Personnel
10. HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html To provide guidelines to healthcare providers for administering infection control programs in the healthcare setting with the objective of reducing the rates of HAIs (Healthcare-Associated Infections) To commit to improving healthcare delivery and reducing the rates of HAIs by following the HICPAC recommendations and guidelines for infection control programs.
11. HICPAC Guideline for Infection Control in Healthcare Personnel http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf To recommend preventive strategies for occupational infections including immunizations, isolation precautions, management of HCP exposures. To follow recommended preventive strategies with the goal of reducing occupational infections in the hospital.
12. CDC Workplace Safety & Health Topics: Respirators http://www.cdc.gov/niosh/topics/respirators/ To compile respirator use resources from the CDC, NIOSH, and OSHA. To seek guidance from trusted resources when developing and implementing a respiratory protection program.
13. OSHA Respiratory Protection for Healthcare Workers Training Video http://www.dol.gov/dol/media/webcast/20110112-respirators/ To educate end users about the protection provided by respirator use as well as the responsibilities of employers related to respirator use. To adequately train healthcare personnel to use the respirators provided for them. This video may be part of the training; however, additional worksite specific training is required.
14. NIOSH Guidance on Emergency Responder Personal Protective Equipment (PPE) for Response to CBRN Terrorism Incidents http://www.cdc.gov/niosh/docs/2008-132 To provide emergency responders guidance for PPE use to protect against CBRN (Chemical, Biological, Radiological, and Nuclear) terrorism incidents. To select and provide the proper PPE for emergency responders based on the hazards anticipated to be present, and the probable impact of those hazards.
15. ACIP The Advisory Committee on Immunization Practices - Summary Report February 20-21, 2013 http://www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/minfeb13.pdf To reduce incidence of vaccine preventable diseases and to improve the safety of vaccine administration and immunization techniques. To consider general immunization guidelines when vaccinating HCP and the general public.
Guidelines for Protecting Healthcare Personnel Against Specific Diseases
16. CDC Prevention Strategies for Seasonal Influenza in Healthcare Settings http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm To recommend a multi-faceted approach to preventing the spread of influenza in healthcare settings among patients, HCP, and visitors. To implement the influenza prevention measures outlined in this guidance and to implement further supplemental measures during outbreaks.
17. CDC Interim Guidance for the Use of Masks to Control Influenza Transmission http://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm To provide interim guidance in response to questions regarding the use of masks to control the spread of influenza with suboptimal immunization of the public. Prior to ruling out all infectious agents requiring isolation precautions, to offer masks to symptomatic or infected patients and to require HCP to wear masks, who are in close contact with symptomatic patients.
18. CDC Recommendation s of the HICPAC and the ACIP – Immunization of Health-Care Personnel http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm To provide summary recommendations concerning influenza vaccination of HCP. To maximize HCP influenza vaccination rates, by following these recommendations and by adhering to the evidencebased approaches outlined in this guideline.
19. CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005: 54(No. RR- 17, 1-141) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf To avert a resurgence of TB and eliminate the threat to HCP of contracting TB from undiagnosed patients or other persons, by making updated TB control recommendations. To implement TB infection control measures while simultaneously safeguarding the confidentiality and civil rights of those who have been infected or who have developed the TB disease including HCP and patients.
20. NIOSH TB Respiratory Protection Program in Health Care Facilities – Administrator’s Guide http://www.cdc.gov/niosh/docs/99-143/ To provide guidance to administrators responsible for implementing the TB respiratory protection program in healthcare facilities. To establish one individual in charge of the respirator program, who must ensure that the program is written, reviewed, and implemented at the hospital. The program must include a TB risk assessment, process for selecting respirators, written standard operating procedures, manual screening for users, training, fit testing, and program evaluation.
Pandemic Response Guidelines
21. IOM Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel. Update 2010 http://www.iom.edu/Reports/2011/Preventing-Transmission-of-Pandemic-Influenza-and-Other-Viral-Respiratory-Diseases.aspx To assess the progress of PPE research to date, to identify future PPE directions for HCP, and to recommend a fourpronged strategy for effective PPE use in the healthcare setting. To adhere to the recommendations in this report for effective PPE use in the healthcare setting including deliberate planning and preparation, comprehensive training for all personnel, widespread and convenient availability of PPE, and accountability at all organizational levels.
22. OSHA Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers (OSHA Publication 3328) http://www.osha.gov/Publications/OSHA_pandemic_health.pdf To aid employers and HCP in the preparation and response to an influenza pandemic. To provide a safe and healthful workplace for employees during an influenza pandemic by considering the research and recommendations and by collaborating with state and federal partners.
23. OSHA Guidance on Preparing Workplaces for an Influenza Pandemic (OSHA 3327-05R 2009) http://www.osha.gov/Publications/OSHA3327pandemic.pdf To help employers properly plan for an influenza pandemic to lessen the impact of the pandemic on society and on the economy and to protect employees. To adhere to this planning guidance to identify risk levels in the hospital setting and to implement appropriate control measures including good hygiene, cough etiquette, social distancing, the use of PPE, and staying home from work when ill. Additionally, in the event of a pandemic, to seek up-todate information and guidance relative to the specific virus.
24. WHO Infection Control Recommendations for Avian Influenza in Healthcare Facilities. (Global Alert and Response Aide-Memoire, 2008) http://apps.who.int/csr/disease/avian_influenza/guidelines/EPR_AM1_E5.pdf?ua=1 To provide infection control recommendations, including PPE and hand hygiene advice, for preventing the transmission and spread of avian influenza in health-care facilities. In the midst of uncertainty surrounding the modes of human-to-human avian influenza transmission, to provide care for patients infected with avian influenza while protecting healthcare personnel, other patients, and visitors from transmission of the infection.
Healthcare Personnel Injury/Illness Response
25. OWCP Office of Workers’ Compensation Programs (OWCP), U.S. Department of Labor http://www.dol.gov/owcp/ To oversee disability compensation programs for workers or their dependents who have experienced a workrelated injury or occupational disease. To provide wage replacement benefits, medical treatment, vocational rehabilitation, and other benefits for workers compensation claims.
26. OWCP Workers’ Compensation System Overview http://emedicine.medscape.com/article/314020-overview To protect employee and employer in the wake of work-related injury or illness report. To provide medical treatment, rehabilitation, and a percentage of prior earnings to the injured worker.
27. OSHA PART 1904 –Recording and Reporting Occupational Injuries and Illnesses https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9638 To regulate recordkeeping and reporting by employers covered under the Occupational Safety and Health Act of 1970 for the purpose of developing information regarding the causes and prevention of occupation accidents and illnesses, and for maintaining a program of collection, compilation, and analysis of occupational safety and health statistics. To maintain a timely log and summary of occupational injuries and illnesses for the facility on a calendar year basis.
28. CDC 2013 National Notifiable Infection Conditions List http://wwwn.cdc.gov/nndss/script/conditionlist.aspx?type=0&yr=2013 *See your state’s Department of Health website for state reportable diseases To collect and publish data reported by the states concerning nationally notifiable diseases. To report cases of nationally notifiable diseases that occurred or were detected within the facility to the state which then informs the CDC.
29. States’ DOLs Frequently Asked Questions – Worker’s Compensation: Case Management http://www.tn.gov/laborwfd/wcfaq.shtml#WCcasemgmt *See your state’s Department of Labor website for state workers’ compensation policies To resolve any disputes and settle claims between employer and employee. Hospitals that provide case management services for injured/ill employees must develop and monitor treatment plans, assess whether services are cost effective, ensure that employees are following the medical care plan, and formulate a plan for a return to work with regard for workers’ recovery restrictions or limitations.
Joint Commission Standards in the Hospital Setting
30. TJC The Joint Commission Facts About Hospital Accreditation http://www.jointcommission.org/hai.aspx To provide a summary of the infection control standards and survey process for hospitals seeking Joint Commission accreditation. If all eligibility requirements are met, to apply for Joint Commission accreditation, to comply with unannounced on-site surveys.
31. TJC The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH) http://www.jointcommission.org/standards_information/hap_requirements.aspx To address the hospital’s performance in key areas, and specify requirements to ensure that patients receive care in a safe manner and in a secure environment. If the hospital provides services addressed by the Joint Commission’s standard, and has applied for Joint Commission accreditation, to undergo an on-site survey by a Joint Commission survey team in which the hospital’s compliance with the applicable standards is assessed.