Okay, good morning. I'm Thomas Bender. I'm your speaker this morning, and I want to commend all of you for getting up bright and early to come here and talk about medical and legal esoterica at 7 a.m., so congratulations. My presentation, I hope, will be a useful tool for you if respirator medical approval is in your wheelhouse. Can I just get, before we get started, a quick show of hands as to how many of you might have at some point in the past read the OSHA respirator medical standard? Great, so I'm dealing with a group of experts here. Fantastic. So, I have no disclosures, and I'm going to start with a reference to the pandemic. As you might recall, in June of 2021, OSHA issued this emergency temporary standard for healthcare, and they basically said that there was a need to protect healthcare workers from occupational exposure to COVID-19. The net effect of this was that there was going to be an awful lot of new required respirator users. And then, in December, they said, we're not going to do that, but we still think it's a really good idea, and we're going to vigorously enforce the general duty clause and the protective personal equipment and respiratory protection standards, so keep that in mind. So, we have a challenge in this setting, and the challenge is that the OSHA requirements for respirator medical approval really didn't change in terms of what was required, even though you had a great increase in the number of required respirator users, and I don't know how things were in your circumstances, but probably not much increase, if at all, probably a decrease, in the resources available for occupational health services. So, increased demand, no increase in the supply of people to do that. The effective use of standing orders to delegate a physician's authority to supervised staff can ensure the efficient and effective respirator medical approval for required respirator users in a manner that is consistent with the OSHA respiratory protection standard. That's my objective to try to prove to you that that can be done. And so, in fact, using standing orders for this purpose is not only reasonable and preferable, but superior, I think, to the usual approach. So, our learning objectives today, I would like for you to understand the duties of a physician or other licensed healthcare professional, PLHCP, when granting respirator medical approval as specified by the OSHA standard. I'm going to be talking about the Michigan Public Health Code and how it empowers a physician to delegate authority via standing orders, but much of what I'm going to be talking about, though Michigan-specific, because that's where I practice and that's where I'm most familiar with the law, is likely to be applicable in the jurisdictions where you practice. And we'll talk more about how you might elucidate your legal circumstances. And then I would like to demonstrate how standing orders integrating an itemized conditional logic can empower your staff to grant respirator medical approval to some required respirator users or else to triage other required respirator users to the PLHCP for a more detailed evaluation. So we'll start with the first point first. And I think it's important to recognize that if you're going to go down this pathway of trying to change how you do things via the respiratory protection standard, you might be talking to people in a position of decision making or authority that aren't as familiar as we are with the respiratory protection standard. And this video that OSHA has on YouTube is actually a quite excellent introduction to the uninitiated about the respiratory protection standard and its requirements for medical evaluation. So it can be useful for the uninitiated. I always like to start from first principles. So if we have any residents attending, you can find the OSHA respiratory protection standard here. And in Michigan, we're a state plan state. And our standards are found at Michigan OSHA's website. And the state plans, as you might know, are monitored by OSHA. And they have to be at least as effective as OSHA. And in fact, in the Michigan standard, it says that OSHA's regulations on respiratory protection standards are adopted by reference in these rules. So it's all the same. This is what the Michigan standard looks like. I'm not going to ask you to read that. But I'm going to draw a few key points. So using a respirator may place a physiologic burden on employees. So what kind of burden is there? And does that require any sort of special evaluation or restriction? Most importantly, I think the medical evaluation must occur before fit testing or use. And there are lots of people who are going to either lean on you or try to convince you otherwise. But the standard is very clear on this point. The PLHCP must use the OSHA questionnaire or something equivalent. I'm not sure why someone would use something other than the standard questionnaire. But it's a very important point of departure regardless. And the questionnaire might not be enough to determine if a person can safely tolerate a respirator. So there can be follow-up medical exams required. The questionnaire must be administered confidentially. And this must occur during working hours. And the PLHCP must issue a written recommendation that notes any limitations, the need, if any, for follow-up medical evaluation, and a recommendation for a PAPR as required. Additional medical evaluations sometimes come into play. And these can be triggered when an employee reports signs or symptoms. It might be related to the ability to use a respirator. They can be triggered when a PLHCP or a supervisor or somebody else decides that the employee needs to be reevaluated because of something they've seen. Or maybe there's been a change in workplace conditions that substantially increased the physiological burden, perhaps a change in the role for an employee or an increase in the burden of that role. And notably, I've heard reference earlier in the conference about how respirator medical evaluations need to occur on an annual basis. In fact, the standard is silent on the periodicity. It has simply become a conventional practice to do this every year or every two years. And it's reasonable to want to do it more than once, for sure, so that you can stay abreast of changes in the condition of the employee. But the exact periodicity is not specified. So the Appendix C of the OSHA standard includes a questionnaire. The first section is basically just identifiers and demographics. And then there are nine required items and various sub-items. These cover topics such as cardiovascular disease, respiratory conditions, claustrophobia, allergies, etc. And any of these conditions could interfere with tolerating the use of a respirator. Now, I highly recommend this document. This is the Small Entity Compliance Guide for the Respiratory Protection Standard. So even if you're not a small entity, it's still a good document. And it basically translates the legalese of the standard into language that's far more readable and interpretable, especially for the uninitiated audience. So again, if you're trying to bring others up to speed, this is a good place to start. I'll draw your attention to the highlighted box on the right. And this asks the question, can a nurse perform a medical evaluation? And essentially, it depends. And so we'll talk about that in more detail. You might be familiar with the OSHA website's section that include standard interpretations. And this is a letter that was submitted back in 2014 asking the question, can a nurse in Wisconsin be classified as a PLHCP? Well, in their response, OSHA basically said, we're not going to answer your question. OSHA is not a licensing authority. So we recommend you talk to your state board of nursing. And we recommend that you practice according to the applicable licensing requirements where you practice. Always good advice. So if a nurse is not a PLHCP, there might still be a role for a nurse. This is a presentation from Michigan Licensing and Regulatory Affairs, or LARA. And this presentation talked about the importance of providing a medical evaluation before testing and use. And then it answers the question for Michigan, who is a PLHCP? And in Michigan, you have a physician. You have a nurse practitioner who's working under the supervision of a physician, or likewise, a PA working under the supervision of a physician. A nurse is not a PLHCP in Michigan. This document also from Michigan OSHA addresses this question. And it says that a nurse or an LPN cannot fulfill the role of PLHCP. Likewise, nurse practitioners and PAs cannot fulfill the role if they are acting independently. But nothing in this document detracts from a physician's ability to practice medicine in accordance with the laws and the jurisdiction where the physician is practicing. And so there are other laws that address how you can delegate authority and provide supervision. And so we'll look at that in some detail. And I was anticipating myself. So these are the Michigan laws that address delegation of authority and supervision. Under the delegation of authority, a licensee may delegate to either a licensed or an unlicensed individual who is otherwise qualified by education, training, or experience. The performance of selected acts, tasks, or functions that are performed under the licensee's supervision. So you don't just send someone forth to go do these things without any supervision. You need to keep an eye on them. And what does supervision mean? Well, that is also defined. Supervision means the overseeing of or participation in the work of another individual where at least all of the following conditions exist. And this is Michigan specific, but I think it's actually good practice for any jurisdiction. You should be continuously available for direct communication. And I do like that the standard even talks about being able to communicate via radio. So you can get your CV out if that's your preferred mode of communication. There is a need to be available on a regularly scheduled basis to review the practice, to provide consultation, and to further educate the supervised individual. I hope that we're always working in teams and environments where we're lifelong learners. And then there needs to be the provision of predetermined procedures. And this is where the standing orders come in. Now, look, I'm not an attorney, so nothing I'm providing to you today constitutes legal advice. I'm just a dumb doctor. But I did ask an attorney what she thought of my approach here and what she thought specifically of the laws in Michigan. And so I reached out to the Network for Public Health Law, which is based at the University of Michigan. And I got this letter of interpretation about delegation and supervision. And it's quite good. It addresses prohibited delegation. And that's important for you to understand in the circumstances where you might practice as well. I won't read this to you, but there's nothing under the prohibited delegation that bears resemblance or relevance to respirator medical approval or the ability to read a questionnaire response and apply conditional logic. And that's all that I'm going to ask my staff to do. There are several references here. And if you would find it worthwhile to reach out to the Network for Public Health Law, Denise Kreisler is the attorney who helped me with this, and she's really quite excellent. So what you see here is my distillation of those two Michigan laws addressing delegation and supervision. And I've distilled it in this way because I have made these part of the introduction of all the standing orders that I now create. And you might be familiar from the pandemic with immunization standing orders. These often come canned, and then you can just add your name at the bottom and date it. But there's not any restriction on your ability to create standing orders on whatever topic you choose, as long as you follow the requirements for delegation and supervision relevant to your jurisdiction. So I've included these in the preface of mine. You can take a look at those and see how that might be useful in your circumstance and in your legal environment. Now I'm going to point to this paper, which is from folks at the George Washington University published, I believe it was in 2013. And they looked at all the state laws, and specifically how standing orders could be used for immunizations. We're not talking about immunizations today, but I think this speaks to the fact that there are laws where either specifically or the law is silent on the delegation of authority from a physician to a nurse to administer an immunization. And I think it would work in very much an analogous way for what we're doing with respirator medical approval. So now I'm going to talk to you about how standing orders integrating this itemized conditional logic can empower your staff. I'm going to start with this email that was published to the Achmed Lisser back in 2020. This is from Daniel Brustein. And he had some really excellent comments. He said, here's a simple rule. If a person can do the job, the person can do the job wearing an N95 respirator or a PAPR. And that's a pretty good rule of thumb for respirator medical approval. He had a few contraindications that he pointed out, claustrophobia, poor fit, allergy or anaphylaxis to latex. But generally speaking, most people are going to be able to do this. This is a broad brush approach, but we're going to go a little bit more deeply into this topic. I just think that generally speaking, this is probably pretty good advice. So how do my standing orders for respirator medical approval start? Well, I referenced the OSHA standard, and I make sure to mention that this respirator medical approval needs to be granted before a person's fit tested or starts wearing a respirator, and identify who a PLHCP can be in Michigan. And so you're going to have a current or new hire employee who's going to complete the questionnaire, and then we're going to have a medical assistant or an RN review the responses. If all the responses are negative, then the PLHCP, that's me, clears the employee for fit test. And in that circumstance, the MA or the RN should record PLHCP written opinion as approved by PLHCP based on standing orders. Now not everybody's going to have uniformly negative responses, and so if any responses are positive, then the staff should follow an item-specific directions below to determine if additional information must be gathered, if additional testing must be performed, if the employee's personal health care provider must be contacted, and if the PLHCP is able to clear the employee for fit testing based on the standing orders, or if the questionnaire must be referred to the PLHCP for review. So essentially triage to me if all else fails. So I'm going to give you just a taste of how I've approached this in applying conditional logic to these items. The first question in the OSHA questionnaire is, do you currently smoke tobacco or have you smoked tobacco in the last month? And my conditional logic is clear the person for fit testing. We have to ask this question, but the answer doesn't matter. We're going to approve people who are smokers for fit testing regardless. The next question asks, have you ever had any of the following conditions? The first one they address is seizures or fits. I don't think we talk enough about fits in medicine. But I tried to bring some coherence to this, and I have several follow-up questions to ask. When were you diagnosed with seizure? When was your most recent seizure? If you have seizure triggers, what are the triggers? Which anti-seizure medications do you take? And when was your most recent visit with a neurologist or other provider for this condition? Obviously, you could choose or develop your own questions that your staff would ask and follow up, but these are the ones that I came up with. And so the action that I want my staff to take after gathering the answers to these questions is that if the most recent seizure was at least 12 months ago, then I'm going to clear the employee for fit testing with the following limitation. A safety plan should be confirmed such that if the employee experiences a seizure, then the employee will be promptly escorted out of an area requiring respirator use as soon as possible so that the respirator can be doffed during recovery from seizure activity. Otherwise, refer the employee for review, including all the related information that I asked for you to gather. So I'm okay if somebody had a seizure disorder and they haven't had anything in the last 12 months. That says to me, they're under pretty good seizure control, but I want to have some safety plan in place. Next item asks about diabetes. So if a person has diabetes, questions I'd like to know is, is your diabetes treated with oral medications, insulin, or an insulin pump? Can you specify your average peak or low blood glucose values? Can you specify your most recent hemoglobin A1c, preferably within the last six months? When was your most recent visit to your provider? Does your provider think your diabetes is well controlled? Now, depending on the medical IQ of your employee, your staff might be able to gather more or less information in response to these follow-up questions, but it's a place to start. And so if the PLHCP is able, the PLHCP is able to clear the employee for testing, as long as the average blood glucose is less than 200, or the hemoglobin A1c is less than 9%, or the above values are unknown, but the diabetes is managed without insulin. Otherwise, refer for review, including all the related information. So I have some benchmarks here that I think are medically justified to say this person is under good control. We don't need to trifle with them about their diabetes in order for them to get a fit test. But, you know, if they're outside of what looks like reasonable good control, then, you know, I can triage that questionnaire and see what else I can gather before I send them for fit testing. Generally speaking, diabetes is not going to be a big problem with going to get fit tested. So I have specified conditions to address a positive response, the follow-up questions should be medically justifiable and logically coherent, whatever you choose. But the staff is going to be directed to ask those questions, interpret the responses based on conditional logic, and they are exercised by delegated authority under my supervision. The next item asks about allergic reactions that might interfere with breathing. So was that reaction related to asthma, nasal congestion, or anaphylaxis? Do you have a latex allergy? Have you had an allergic reaction while wearing an N95 respirator? And so I'm able to clear this person for fit testing as long as the allergic reactions they report have been to foods, medications, or bee stings. Those aren't typically things you're going to encounter, certainly in a medical center occupational health, medical center workplace, not while you're wearing the respirator anyway. And if the employee has a latex allergy, then I'm going to have the staff impose the following limitation. The employee must be furnished with a latex-free respirator. Probably everybody is anyway. But otherwise, if there's something that's not covered by these few circumstances, then you know, I want to see what's the story with this person's allergy. Claustrophobia is an interesting one. So I ask, how severe is it? Does this happen with crowds, in an elevator, in an MRI machine? Has it ever happened while wearing an N95 respirator? Have you ever been evaluated by a physician or treated with medication? And generally speaking, I'm going to be able to clear the person for fit testing as long as the claustrophobia is untreated with any medication and unrelated to wearing an N95 respirator. Otherwise, refer to me for triage. I'm not going to beat you about the head too much more, but just to give you a flavor for some other things here. Have you ever had any of the following conditions? Trouble smelling odors. If the trouble smelling odors has resolved, does this remain an ongoing problem? Has trouble smelling odors interfered with N95 respirator in the past? I'm going to clear this person for fit testing. Now, item three has a whole bunch of sub-items about pulmonary or lung problems. And so, in the beginning here, before you get to the sub-item A, I've got all the sort of questions I'm going to ask in follow-up to positive response to any of these sub-items. So I'm going to ask, is the condition treated and well controlled? Which medications have you taken in the past, or do you currently take for the condition? Has the condition resolved without respiratory impairment or the need for further follow-up? Is the condition ongoing and a cause for continuing respiratory impairment? So, for the example with asbestosis or silicosis, I am willing to have the staff clear the person for fit testing if the asbestosis is resolved with no further follow-up indicated. Otherwise, send this person to me. That's asbestosis. I'm going to want to probably give that person a little scrutiny. Asthma is another condition that's addressed here. And, you know, I'm looking to see if the person has asthma that's treated and well controlled, or maybe resolved without any sort of respiratory impairment or need for follow-up. Otherwise, I'll take a look at them. Chronic bronchitis. This is an item on the questionnaire that many people, particularly those who might not have a very high medical IQ, will get confused about what does that mean. And so I have the staff ask, are you referring to a history of recurrent bouts of bronchitis occurring one or more times each year? Have you actually received a diagnosis of chronic bronchitis from a physician? And so if the person describes that the chronic bronchitis has resolved without respiratory impairment or need for follow-up, they can be cleared. If they give a history of recurrent bouts of bronchitis treated episodically with antibiotics or steroids, likewise they can be cleared. Otherwise, send this person to me and I'll figure out what this means. So for each of these items, and I'm not going to go into any of the rest of them on the questionnaire, I devise follow-up questions. I devise action plans that are based on information elicited by the staff. And I'm asking follow-up questions within the technical sophistication of either licensed staff or unlicensed staff who are qualified by training or experience. And obviously you're going to be supervising your staff. So there's really nothing that's terribly sophisticated about any one of these items. I wrap all this up with an authorization of my standing orders. And I say that an employee's completed OSHA medical questionnaire should be retained in the employee health record and made available to the employee upon request. And this authorization should remain in effect until we're sending it or until the end of the year. And so a good practice to always, when you issue standing orders, have an expiration date and have a schedule for when you're going to come back and revisit them, maybe make some adjustments, etc. Now, the respiratory protection standard has a number of items that I'm not going to read to you here that address written recommendations. And what should a written recommendation include and what should it address? And I offer to you here what I have produced as far as a template form for written recommendation. And I address each of those items that you didn't read here on this slide. So the person named above received a medical evaluation consistent with the standard and they completed the questionnaire. The PLHCP has issued the following written recommendation. Before the PLHCP can render a definitive recommendation, the person requires follow-up medical evaluations as specified. That could be one box that you might or might not check. Another box you might or might not check based on the person's medical condition or the workplace conditions in which the respirator will be used. The person is subject to limitations on respirator use as specified. Another option might be the PAPR route. And so OSHA wants you to issue a PAPR to somebody who might not be able to wear a non-powered respirator but could do their job with a PAPR if it's possible for them to do so. Another option would be to simply mark the box, there are no limitations on the person's respirator use that are related to the person's medical condition or to the workplace conditions in which the respirator will be used. So for most people, that's the box that's going to get checked. You're also going to check the box that says that you've provided the person with a copy of this recommendation because you have to, the standard says so. And then the last one here says the PLHTP finds the person needs to be re-evaluated in some time frame. And here I've put 12 months, 6 months, or one month depending on what I think about their condition and the whole picture I got from their questionnaire. So at the bottom, there's a signature section. And the signature is going to be you know, issuing this written recommendation either by some supervising PLHTP via delegated authority with standing orders executed by the staff person's going to sign their name. Or if it wound up being triaged to me, then I'm going to check the box that has been issued by the PLHTP after an individualized review and I'm going to sign my name on the lower box. So this is not rocket science, but it's I think a very comprehensive and nice form. And I haven't seen one that addresses all those written recommendation items. So this is my idea, but it's not, there's nothing new under the sun about it. Lots of other people have done this. I wanted to make sure that I wasn't, you know, rotting afoul of Michigan OSHA. And so I got in touch with someone from the consultation education and training division. And I talked to him about this. And he said, yeah, I think this is pretty good. In fact, I think what you're doing is probably going above and beyond what most everybody else is doing. So keep doing that. And if you want me to talk with you, and present this work to others, I would like to promote this use as well. So I thought that was a good endorsement. He ended up not being available for our fall conference last year, but the sentiment I was able to convey in the same way. So let's come back to our learning objectives and have we accomplished those. So the respiratory protection standard, whether you're talking about OSHA or my OSHA, basically the same thing. And it requires that you have your required respiratory user complete an OSHA questionnaire or something equivalent. There's obviously the role for PLHCP. We've talked about who that is or who it can be and who it can't be. And we've talked about the importance of having that respirator medical approval before fit testing occurs. We've talked about the Michigan legal requirements for delegation of authority and supervision. I encourage you to learn what are the requirements for delegation of authority and supervision wherever you work. And I got challenged about my approach, trying to be efficient, trying to deliver good results for the workplace where I was serving. And I got challenged by the in-house counsel that what I was doing was just flat out illegal. And so I bristled at that, and I didn't take very kindly to it. But I want to thank that attorney, and you should thank that attorney if you enjoy this talk. She was the impetus for me to put this together so that I could have a robust justification for what I was doing. And I think it's important that if you're going to do something similar where you work, that you put yourself on firm legal ground. My standing orders are essentially a distillation of my conditional logic that's item-specific, and it's how I grant respirator medical approval via delegated authority. And it's how I make sure that I get responses triaged to me for further evaluation. Now, I said before, there's nothing new under the sun. I know others have done this. I spoke with Karen Leniak, who's at 3M, and she explained to me that 3M does this internally as well. And in fact, their approach, which they probably have some different follow-up items and different conditional logic, but their approach has been effective for allowing them to essentially delegate approval for about 95% of the questionnaires that they evaluate. Now, I think that this approach is really important because of its ability to help you avoid inefficiency and pitfalls. So there's still room here for the PLACP to individually review questionnaires, but you don't wind up individually reviewing scores of them. There's nothing less satisfying than having to look at one completely negative questionnaire after the next just so you can apply your signature. And one of the critiques that I got from that attorney was, well, the OSHA standard says that all these questionnaires have to be signed by PLACP. But I challenge you, and as I challenge her, to go and find in the OSHA standard anywhere that the word signature appears. The OSHA standard does not require a signature. It requires a written recommendation. And written recommendations in the 21st century don't have to be in longhand. They can be printed. They can be a form that you fill out. They can be quite automated. And so this approach, I think, is very defensible because, importantly, it helps to ensure that fit testing occurs prior, sorry, fit testing does not occur prior to medical approval. Fit testing prior to medical approval is the solution that was proposed to me that we should do. Well, we'll just have everybody fill out the questionnaire, and we're not going to wait around for a physician because we don't really want to have that many physicians employed in this task. So as long as somebody gets around to looking at that questionnaire within the next couple weeks after the fit test occurs, we'll just call it good. That's problematic from a couple of different vantage points. Number one, of course, you're at odds with the standard, but you're documenting the fact that you're at odds with the standard. The fit test is going to occur on one date, and then the rest prior to medical approval is going to be signed or otherwise granted on some later date. And so for each employee that you might treat in this way, you're going to be documenting your lapse. That's not great. Now, another solution I've seen, and this is a real pitfall, is providing staff with a pre-signed blank written form for recommendation. That's just not consistent with the legal practice of medicine anywhere, as far as I know, to take a signature form and put your name on it and then just give it to them blank so that they can slip it in underneath the completed questionnaire for any employee they decide they want to apply it to. That, too, was held up as a solution, and not one that I could embrace. So at this point, I have gotten to the end of my prepared remarks, and I'm happy to take questions from you. We have plenty of time for questions. If you don't have questions, I've got some knowledge checks that we can go through as well, but I'll throw it open to you. Any questions? Yes? Thomas. Thomas. Thomas, hi. Thanks for a great presentation, obviously. This is golden, as it expands in time for the position, et cetera. Two questions, one in general. Beyond respirators, medical clearance, and vaccines, do you have other support that you provide to your employees? So currently, I spend most of my time doing local public health work, and so in my capacity as medical director for a local health department, I have quite a number of things that occur under my delegation of authority, and so they're not relevant to occupational medicine, but everything that occurs in the family planning clinic at my health department, all those procedures and protocols, those are also governed by standing orders. Other examples that I can think of are probably also not going to be real relevant to occupational health, but I don't think there's any barrier to extending this to other circumstances where you can envision the appropriate use of conditional logic addressing reasonably anticipated circumstances. So yeah, those are the big areas for me, immunizations and respirator medical approval. Great, thank you. Quick second question. You mentioned diabetes and some chronic lung conditions. If the individual is going to be performing a safety-sensitive funnel, you're asking them to self-report potentially their control. Do you require records in any of the conditions according to this agenda? Yeah, so I didn't go through all of the items in the questionnaire, but there are some where one of my follow-up to-do items for the staff is to send a letter to the person's PCP and to ask the PCP, do you think this person needs to have any restrictions on their use of a respirator? Do you think that they're, let's say the example of somebody who has high blood pressure that's been measured in our clinic as being high, wearing a respirator can exacerbate high blood pressure. And so, you know, I have a series of questions in my letter to the PCP asking about whether or not they've reviewed a log of this person's blood pressure that's been collected since we measured it as high, and have they made any changes to the person's medication? And do they think that the person's blood pressure is under good control? So I have some items that are specific to hypertension, because that's really common. I have some other things that are more general to other conditions. But I ask those questions of the PCP, not because I'm trying to delegate to them my job to decide whether the person is medically fit, medically approved to be fit, tested, and wear a respirator, but because I would like to benefit from their insights. And if the PCP says, you know what, I think this person does need to be restricted, then that takes some of the onus off me. And I can point to the employee's own PCP as saying, you know, your PCP doesn't think it's safe for you to do this, so I'm going to follow their advice and lean on their greater depth of knowledge and understanding of your medical condition, and I'm going to impose some restrictions that I've elicited from them. So I find that to be very useful, and it invites, as you might guess, less controversy than the company doctor telling somebody that they can't wear a respirator or their respirator use needs to be restricted. Thank you again. Yeah. Bill Martin. So thank you for the presentation. I just recently went through a built-in algorithm that does this for like the pre-pandemic 2.0, I guess you could say at this point. So I guess one of the things I made an assumption here that these evaluations are mainly for healthcare workers, because an important part of the medical evaluation for respirator use is the context in which the respirator is going to be used and the hazards. Are these standing orders being largely restricted for healthcare workers, or is this going towards your private clients or other people that may be doing, as we talked about, safety-sensitive work, or sensitizers, or other areas where the consequences of respirator failure can be pretty high? I can see a couple of these ones being ones where I'd really want them flushed out. Yeah, and so my circumstance in developing this was in the context of medical center occupational health and N95 fit testing. Now, there's not any reason why I think you couldn't adjust your follow-up questions, your conditional logic, your triggers for triage for the additional questions that are relevant to SCBA use, or for any of these other items in particular that would essentially trigger triage in a wider range of circumstances. So I think it's very useful to give careful consideration to how do you want to approach these circumstances. And the nice thing about the standing orders approach is that it's going to help bring uniformity and consistency to your practice, both you as an individual LHCP and any colleagues that you work with, so that it forces you to sit down and discuss, what are we going to do in this circumstance for people with conditions X, Y, and Z? And so I would say there's nothing, there's no holy grail here. You have to know the circumstances of the employees that are your required respirator users and decide what you're comfortable with and what's reasonable and appropriate. Do you treat periodical retests and recertifications for respirator use the same as you treat the conditional? And specifically on this view hypothetical, do you have required partners? Do you see people for initial reoccupation, medical evaluation? However, from my standpoint, it's easier for the employee and for my staff to do the test for the next medical evaluation. I'm perfectly fine with that. I wonder, you know, how do you handle that? Yeah, so you raise some excellent points. With somebody who, let's say, maybe they find themselves in a circumstance where the available respirator has changed, they need to have an interval fit test for that reason, or, you know, they're going to have, it's been a year or two or whatever you decide is the periodicity of choice, and they need to have a follow-up. It's not required by OSHA that you have somebody go through the entire questionnaire again. There's nothing that prevents you from doing that, but it's not required. I think what I have done in the past has been to use a sort of interval questionnaire that tries to elicit interval changes in their medical history since we saw them last. And then if those items come up, and essentially if there's any significant change, and significant, you know, this is a judgment, right, then, you know, I would probably want those to get triaged to me. I will admit that I have been less robust in developing my interval respirator medical approval process than I have in the baseline, but the interval process could benefit from this sort of conditional logic approach as well. I think the key thing is that if somebody has, you know, some new diagnosis, maybe a heart or lung disease, or maybe some, they've had a surgery that might impact their ability to move air, those would be things that, you know, you want to make sure your staff understand, this needs to be brought to my attention so that I can interview, examine, review records, otherwise decide is it safe for this person to continue wearing a respirator. And so part of the education process that I think that should go along with granting respirator medical approval and fit testing someone is to make sure that the employee knows that if they have a change in their health status that they should report that to employee health so that we can be sure to continue to keep them safe in their use of a respirator. Does that answer your question? Okay. Thank you. Make sure that that questionnaire is given before the field test is given and not on the arresting page of the respirator clearance. Because our plants do things differently, some of the field tests may not occur right at the same time, you know, right after the respirator clearance. It might occur six months or eight months after. But always make sure that you're doing that field test under the current respirator clearance. They have a pattern, they have a file in in terms of, you know, reporting your change in your health status. And that's where it's from. So, SCDA, if you're a veteran of non-rescue, will clear for two years. Your rescue folks do that field check every one year. But I do leave it up to my individual providers at those facilities. Thank you. I'm sorry, I didn't I didn't hear Oh, a positive air purifying respirator, you know, I have granted positive air purifying respirators in multiple circumstances and they have all been somewhat unique and I have tended to make the approval of that somewhat infrequent and dependent on whether or not somebody really has a medical need for it. So if somebody has, for example, asthma or chronic bronchitis, they answer, yes, I have one of these things and it's not medically controlled or they don't have great ability to move air, I'll send them for spirometry. And if the spirometry is less than 80% of predicted for their age and height, then that's someone to whom I would recommend a PAPR. And I think that's, you know, is 80% the right threshold? I don't know, but it's something. And I've had other people who've come looking for PAPRs because they don't want to shave or they don't like the way the respirator feels on their face and that's not a reason that I feel like an employer needs to furnish a PAPR because of the expense imposed from it and the lack of a legitimate medical need. So if somebody had, now, you know, you can have dermatologic conditions that can be exacerbated by a respirator, a tight-fitting respirator, and if somebody were to go and see their dermatologist and their dermatologist said, you know, this person just, if they continue to wear a respirator, they're going to have skin breakdown and they're going to have allergic reaction, et cetera, then, you know, that would be a reason, a medically justifiable reason to grant a PAPR. But I haven't done it enough to say that I would know what would be the most common or frequent conditions. I would say probably asthma and chronic bronchitis would rank highly in that list, though. And what would be a best situation considering epilepsy? Epilepsy. You know, epilepsy is a tough nut to crack from a lot of occupational health perspectives and no different with respirator use. I talked at the beginning of how if somebody's seizure disorder is reasonably well-controlled and as much as they haven't had any seizure within the last 12 months, then I can approve them for fit testing, but I want them to have a safety plan. If somebody hasn't been that far removed from their seizure, then I don't know how comfortable I am putting a tight-fitting respirator on them because if somebody is unpredictably having, as seizures tend to be, unpredictably having seizures, then, you know, it can interfere with their ability to recover and breathe freely when they need to be, especially if they're working in some sort of solo environment. So I think the key thing is to consider the circumstances of the employee and whether are they working by themselves? Are they working where they're going to be observed by others? And then it's a judgment call. But it's a tough one. I had, in my tenure at the Dow Chemical Company, I had a young engineer who was newly diagnosed with a seizure disorder shortly after starting with the company. And, you know, the place that she was supposed to work was on the second floor of the building. And there needed to be some sort of safety plan for her in case there were, you know, a fire or something like that where she was going to have to descend a stairwell. And so seizure disorder is a tough one, but that's going to wind up being triage to you and it's going to be your reward for being a physician to help problem-solve that. Dr. Washington, from his health, good talk, thank you. Mm-hmm. The other thing, uh... Because when it says clear for a respirator, what does that mean? Right. It means clear for any kind of respirator, or many times what we find is the person's not cleared for a negative pressure respirator because they have asthma or COPD, but they could easily be cleared for a PAPR or an SAR. Right. Supplied air. So I think. you should bring those to a hospital PAPR or under ADA. Make sure that you say, they can't wear a negative, so our form. You cannot wear a negative pressure respirator, but you probably can wear a positive pressure respirator if they have absence. And what we've branched to is just... No, I think your point is well taken and that's a great approach. I would actually love to follow up with you after and hear or maybe even see that approach because being specific about the type of respirator that somebody is or is not approved for I think is essential. And you're right about most people being able to tolerate wearing a PAPR. I had one circumstance in medical center occupational health where I couldn't issue a PAPR because the person's work environment was the MRI suite. So that wasn't going to work. But generally speaking, you know, even if you can't wear a negative, you could wear a positive. Yes? I really wonder about... I almost feel like it could be handled very well. Yeah, so I I appreciate your point and and that you know, that's one of the reasons why I included that that listserv email That talked about how if somebody can do a job they can probably do the job wearing an n95 The the number of times that somebody really needs to be restricted Hasn't been very often and and so that's one of the reasons why I was motivated to try to put the energy and effort into developing the the standing orders approach that works in my practice environment because it allows me to work at the top of my training and allows my staff to work at the top of theirs and it it has the beneficial effect of triaging people who need to come to my attention to my attention so that I can explore those circumstances with them a little bit more carefully and You know, I've had some unique circumstances. I had an employee who's a required respirator user who is status post Lung resection and so they only have one lung to move air with and I decided that was a good person to send for spirometry and to see You know how much air they're moving and and were they're going to be able to tolerate wearing an n95 and in that case I think that person wound up in a pamper Because you know, it's very hard to to get to 80% of predicted with one lung But no, you're right most people in n95 does not pose a great risk and You know is is OSHA gonna revise their respirator protection standard anytime soon? I don't think so They're not particularly timely about developing or revising other standards. So I think we're this is one that you know Clearly during the pandemic they thought it was was important enough to underscore And I think we can anticipate that it's it's going to continue to be part of the landscape. I Think lapses in in doing respirator medical evaluations Probably pose one of the the greater organizational risks Because if OSHA decides to come calling and they decide to do some review of your occupational health records This is a place where they could they could find fault even if you know, that's not why they were there to start with right and so I think If you if you have this architecture in place and you present This is how we do things This is why these forms haven't been individually reviewed by a physician or licensed health care provider But have been reviewed by our staff who are operating under these standing orders with this supervision At least you know the the folks at Michigan OSHA think that that's not going to get me in trouble with the with the Kosho So I'm I'm I feel relatively comfortable about Implementing this in in a medical center setting and and as several of you pointed out in other respirator Environments you you would want to have a modified approach Yes, sir. Outside of the hospital, there are quite a few views. Somehow, we in the fitting have to say you're technically disqualified under FIT, but it's not that simple. So thus far, we have just said you are administratively disqualified in the FIT testing. I was wondering if you had addressed something like that in your algorithm. And I've had circumstances just as you described that somebody doesn't want to shave and so they really can't be FIT tested properly. And in those cases, you know, I've simply said I've issued a restriction to their supervisor that says this person cannot wear a respirator for work. And then that's an HR issue, and they'll just have to either accommodate this person who's restricted from wearing a respirator or the person's going to have to figure out how they can otherwise wear a respirator. I would like to see people given the option to purchase their own use of a PAPR if that is what suits them. I think PAPRs are actually great respiratory protection. I just don't know that it is reasonable to expect an employer to pay for a PAPR for everyone who wants one. I know plenty of people that would be happy to pay two and a half grand not to shave. Right, right. And then I think there ought to be some pathway for them to do that. During the pandemic, one of the things that was granted to some health care workers who, you know, they're wearing a N95 in the clinical setting all the time was that they could choose to supply their own respirator as long as it was at least as good as what they would have been issued in the workplace. And I think that ought to apply for a PAPR as well. Well, if nothing else, then thank you so much. And let me ask, if you found this presentation useful, if you think you might like to implement this approach, please consider sending me an email or you can connect with me through the conference app. I'm happy to share or exchange materials and learn from you and you can benefit from these materials. And so happy to continue the dialogue. I have, if I muster the energy and initiative, I was thinking that I might try to put together a paper for JOEM on this. So if you have thoughts on my presentation that you'd like to offer me, I welcome those. So thank you.

respiratory protection

medical approvals

standing orders

fit testing

medical conditions

epilepsy

positive air purifying respirators

PAPRs

administrative disqualification

individualized evaluations