Universal Precautions for Prevention of Transmission of Bloodborne Pathogens in Health-Care Settings
Introduction
Universal precautions are intended to prevent parenteral, mucous membrane, and nonintact skin exposures of health-care workers to bloodborne pathogens. In addition, immunization with HBV vaccine is recommended as an important adjunct to universal precautions for health-care workers who have exposures to blood.
Body Fluids to Which Universal Precautions Apply
Universal precautions apply to blood and to other body fluids containing visible blood. Occupational transmission of HIV and HBV to health-care workers by blood is documented. Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting. Infection control efforts for HIV, HBV, and other bloodborne pathogens must focus on preventing exposures to blood as well as on delivery of HBV immunization.
Universal precautions also apply to semen and vaginal secretions. Although both of these fluids have been implicated in the sexual transmission of HIV and HBV, they have not been implicated in occupational transmission from patient to health-care worker. This observation is not unexpected, since exposure to semen in the usual health-care setting is limited, and the routine practice of wearing gloves for performing vaginal examinations protects health-care workers from exposure to potentially infectious vaginal secretions.
Universal precautions also apply to tissues and to the following fluids: cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk of transmission of HIV and HBV from these fluids is unknown; epidemiologic studies in the health-care and community setting are currently inadequate to assess the potential risk to health-care workers from occupational exposures to them. However, HIV has been isolated from CSF, synovial, and amniotic fluid, and HBsAg has been detected in synovial fluid, amniotic fluid, and peritoneal fluid. One case of HIV transmission was reported after a percutaneous exposure to bloody pleural fluid obtained by needle aspiration. Whereas aseptic procedures used to obtain these fluids for diagnostic or therapeutic purposes protect health-care workers from skin exposures, they cannot prevent penetrating injuries due to contaminated needles or other sharp instruments.
Body Fluids to Which Universal Precautions Do Not Apply
Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent. HIV has been isolated and HBsAg has been demonstrated in some of these fluids; however, epidemiologic studies in the health-care and community setting have not implicated these fluids or materials in the transmission of HIV and HBV infections. Some of the above fluids and excretions represent a potential source for nosocomial and community-acquired infections with other pathogens, and recommendations for preventing the transmission of nonbloodborne pathogens have been published.
Precautions for Other Body Fluids in Special Settings
Human breast milk has been implicated in perinatal transmission of HIV, and HBsAg has been found in the milk of mothers infected with HBV. However, occupational exposure to human breast milk has not been implicated in the transmission of HIV nor HBV infection to health-care workers. Moreover, the health-care worker will not have the same type of intensive exposure to breast milk as the nursing neonate. Whereas universal precautions do not apply to human breast milk, gloves may be worn by health-care workers in situations where exposures to breast milk might be frequent, for example, in breast milk banking.
Saliva of some persons infected with HBV has been shown to contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum. HBsAg-positive saliva has been shown to be infectious when injected into experimental animals and in human bite exposures. However, HBsAg-positive saliva has not been shown to be infectious when applied to oral mucous membranes in experimental primate studies or through contamination of musical instruments or cardiopulmonary resuscitation dummies used by HBV carriers. Epidemiologic studies of nonsexual household contacts of HIV-infected patients, including several small series in which HIV transmission failed to occur after bites or after percutaneous inoculation or contamination of cuts and open wounds with saliva from HIV-infected patients, suggest that the potential for salivary transmission of HIV is remote. One case report from Germany has suggested the possibility of transmission of HIV in a household setting from an infected child to a sibling through a human bite. The bite did not break the skin or result in bleeding. Since the date of seroconversion to HIV was not known for either child in this case, evidence for the role of saliva in the transmission of virus is unclear. Another case report suggested the possibility of transmission of HIV from husband to wife by contact with saliva during kissing. However, follow-up studies did not confirm HIV infection in the wife.
Universal precautions do not apply to saliva. General infection control practices already in existence -- including the use of gloves for digital examination of mucous membranes and endotracheal suctioning, and handwashing after exposure to saliva -- should further minimize the minute risk, if any, for salivary transmission of HIV and HBV. Gloves need not be worn when feeding patients and when wiping saliva from skin.
Special precautions, however, are recommended for dentistry. Occupationally acquired infection with HBV in dental workers has been documented, and two possible cases of occupationally acquired HIV infection involving dentists have been reported. During dental procedures, contamination of saliva with blood is predictable, trauma to health-care workers' hands is common, and blood spattering may occur. Infection control precautions for dentistry minimize the potential for nonintact skin and mucous membrane contact of dental health-care workers to blood-contaminated saliva of patients. In addition, the use of gloves for oral examinations and treatment in the dental setting may also protect the patient's oral mucous membranes from exposures to blood, which may occur from breaks in the skin of dental workers' hands.
NOTE: Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
Use of Protective Barriers
Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear. Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needles or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes.
Universal precautions are intended to supplement rather than replace recommendations for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands. Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised.
The risk of nosocomial transmission of HIV, HBV, and other bloodborne pathogens can be minimized if health-care workers use the following general guidelines:
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Do not recap used needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant containers for disposal. Locate the puncture-resistant containers as close to the use area as is practical.
Use protective barriers to prevent exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated.
Immediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply.
Glove Use for Phlebotomy
Gloves should reduce the incidence of blood contamination of hands during phlebotomy (drawing blood samples), but they cannot prevent penetrating injuries caused by needles or other sharp instruments. The likelihood of hand contamination with blood containing HIV, HBV, or other bloodborne pathogens during phlebotomy depends on several factors: 1) the skill and technique of the health-care worker, 2) the frequency with which the health-care worker performs the procedure (other factors being equal, the cumulative risk of blood exposure is higher for a health-care worker who performs more procedures), 3) whether the procedure occurs in a routine or emergency situation (where blood contact may be more likely), and 4) the prevalence of infection with bloodborne pathogens in the patient population. The likelihood of infection after skin exposure to blood containing HIV or HBV will depend on the concentration of virus (viral concentration is much higher for hepatitis B than for HIV), the duration of contact, the presence of skin lesions on the hands of the health-care worker, and -- for HBV -- the immune status of the health-care worker. Although not accurately quantified, the risk of HIV infection following intact skin contact with infective blood is certainly much less than the 0.5% risk following percutaneous needlestick exposures. In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low.
Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply:
The Center for Devices and Radiological Health, FDA, has responsibility for regulating the medical glove industry. Medical gloves include those marketed as sterile surgical or nonsterile examination gloves made of vinyl or latex. General purpose utility ("rubber") gloves are also used in the health-care setting, but they are not regulated by FDA since they are not promoted for medical use. There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. Thus, the type of gloves selected should be appropriate for the task being performed.
The following general guidelines are recommended:
Waste Management
Universal precautions are not intended to change waste management programs previously recommended by CDC for health-care settings. Policies for defining, collecting, storing, decontaminating, and disposing of infective waste are generally determined by institutions in accordance with state and local regulations. Information regarding waste management regulations in health-care settings may be obtained from state or local health departments or agencies responsible for waste management.
Note: Implementation of universal precautions does not eliminate the need for other category- or disease-specific isolation precautions, such as enteric precautions for infectious diarrhea or isolation for pulmonary tuberculosis. In addition to universal precautions, detailed precautions have been developed for the following procedures and/or settings in which prolonged or intensive exposures to blood occur: invasive procedures, dentistry, autopsies or morticians' services, dialysis, and the clinical laboratory.
Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare
Personal Protective Equipment Definition
Personal protective equipment, or PPE, as defined by the Occupational Safety and Health Administration, or OSHA, is "specialized clothing or equipment, worn by an employee for protection against infectious materials."
Regulations and Recommendations for PPE
• OSHA issues workplace health and safety regulations. Regarding PPE, employers must:
– Provide appropriate PPE for employees
– Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and stored after use
• OSHA also specifies circumstances for which PPE is indicated
• CDC recommends when, what and how to use PPE
OSHA issues regulations for workplace health and safety. These regulations require use of PPE in healthcare settings to protect healthcare personnel from exposure to bloodborne pathogens and Mycobacterium tuberculosis. However, under OSHA's General Duty Clause PPE is required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure that PPE is disposed or, if reusable, that it is properly cleaned or laundered, repaired and stored after use.
The Centers for Disease Control and Prevention (CDC) issues recommendations for when and what PPE should be used to prevent exposure to infectious diseases. This presentation will cover those recommendations, beginning with the hierarchy of safety and health controls.
Hierarchy of Safety and Health Controls
• Training and administrative controls
• Engineering controls
• Work practice controls
• Personal protective equipment
The protection of healthcare personnel from infectious disease exposures in the workplace requires a combination of controls, one of which is the use of PPE. It is important to recognize that your protection as a healthcare worker also involves other prevention strategies. There are four major components to healthcare worker safety programs. First are training, such as you're receiving today, and administrative controls, like isolation policies and procedures, and procedures for recognizing patients with a communicable disease before they expose workers. Second are engineering controls like negative pressure rooms for patients with airborne diseases such as TB; third are work practice controls such as not recapping needles, and finally personal protective equipment . While PPE is last in the hierarchy of prevention, it is very important for protecting healthcare workers from disease transmission.
Types of PPE Used in Healthcare Settings
• Gloves – protect hands
• Gowns/aprons – protect skin and/or clothing
• Masks and respirators– protect mouth/nose
– Respirators – protect respiratory tract from airborne infectious agents
• Goggles – protect eyes
• Face shields – protect face, mouth, nose, and eyes
All of the PPE listed here prevent contact with the infectious agent, or body fluid that may contain the infectious agent, by creating a barrier between the worker and the infectious material. Gloves, protect the hands, gowns or aprons protect the skin and/or clothing, masks and respirators protect the mouth and nose, goggles protect the eyes, and face shields protect the entire face. The respirator, has been designed to also protect the respiratory tract from airborne transmission of infectious agents.
Factors Influencing PPE Selection
• Type of exposure anticipated
– Splash/spray versus touch
– Category of isolation precautions
• Durability and appropriateness for the task
• Fit
When you are selecting PPE, consider three key things:
First is the type of anticipated exposure. This is determined by the type of anticipated exposure, such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing. PPE selection, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on.
Second, and very much linked to the first, is the durability and appropriateness of the PPE for the task. This will affect, for example, whether a gown or apron isselected for PPE, or, if a gown is selected, whether it needs to be fluid resistant,fluid proof, or neither.
Third is fit. (optional question) How many of you have seen someone trying to work in PPE that is too small or large? PPE must fit the individual user, and it is up to the employer to ensure that all PPE are available in sizes appropriate for the workforce that must be protected.
Gloves
• Purpose – patient care, environmental services, other
• Glove material – vinyl, latex, nitrile, other
• Sterile or nonsterile
• One or two pair
• Single use or reusable
Gloves are the most common type of PPE used in healthcare settings. There are several things to consider when selecting the right glove for a specified purpose.
• Purpose – patient care, environmental services, other
• Glove material – vinyl, latex, nitrile, other
• Sterile or non-sterile
• One or two pair
• Single use or reusable
Most patient care activities require the use of a single pair of nonsterile gloves made of either latex, nitrile, or vinyl. However, because of allergy concerns, some facilities have eliminated or limited latex products, including gloves, and now use gloves made of nitrile or other material. Vinyl gloves are also frequently available and work well if there is limited patient contact. However, some gloves do not provide a snug fit on the hand, especially around the wrist, and therefore should not be used if extensive contact is likely. Gloves should fit the user's hands comfortably – they should not be too loose or too tight. They also should not tear or damage easily. Gloves are sometimes worn for several hours and need to stand up to the task.
Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive patient procedures. During some surgical procedures, two pair of gloves may be worn. Environmental services personnel often wear reusable heavy duty gloves made of latex or nitrile to work with caustic disinfectants when cleaning environmental surfaces. However, they sometimes use patient care gloves too.
Do's and Don'ts of Glove Use
Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces. Therefore, the way YOU use gloves can influence the risk of disease transmission in your healthcare setting.
These are the most important do's and don'ts of glove use:
Work from clean to dirty. This is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas.
Limit opportunities for "touch contamination" - protect yourself, others and environmental surfaces. How many times have you seen someone adjust theirglasses, rub their nose or touch their face with gloves that have been in contact witha patient? This is one example of "touch contamination" that can potentially exposeoneself to infectious agents. Think about environmental surfaces too and avoidunnecessarily touching them with contaminated gloves. Surfaces such as lightswitches, door and cabinet knobs can become contaminated if touched by soiledgloves.
• Change gloves
– During use if torn and when heavily soiled (even during use on the same patient)
– After use on each patient
• Discard in appropriate receptacle
– Never wash or reuse disposable gloves
Change gloves as needed. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.
Gowns or Aprons
There are three factors that influence the selection of a gown or apron as PPE.
First is the purpose of use. Isolation gowns are generally the preferred PPE for clothing but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist.
Second are the material properties of the gown. Isolation gowns are made either of cotton or a spun synthetic material that dictate whether they can be laundered and reused or must be disposed. Cotton and spun synthetic isolation gowns vary in their degree of fluid resistance, another factor that must be considered in the selection of this garb. If fluid penetration is likely, a fluid resistant gown should be used.
The last factor concerns patient risks and whether a clean, rather than sterile gown, can be used. Clean gowns are generally used for isolation. Sterile gowns are only necessary for performing invasive procedures, such as inserting a central line. In this case, a sterile gown would serve purposes of patient and healthcare worker protection.
Face Protection
A combination of PPE types is available to protect all or parts of the face from contact with potentially infectious material. The selection of facial PPE is determined by the isolation precautions required for the patient and/or the nature of the patient contact. Masks should fully cover the nose and mouth and prevent fluid penetration. Masks should fit snuggly over the nose and mouth. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable.
Goggles provide barrier protection for the eyes; personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. Goggles with antifog features will help maintain clarity of vision.
Face Protection
When skin protection, in addition to mouth, nose, and eye protection, is needed or desired, for example, when irrigating a wound or suctioning copious secretions, a face shield can be used as a substitute to wearing a mask or goggles. The face shield should cover the forehead, extend below the chin, and wrap around the side of the face.
Respiratory Protection
PPE also is used to protect healthcare workers' from hazardous or infectious aerosols, such as Mycobacterium tuberculosis. Respirators that filter the air before it is inhaled should be used for respiratory protection. The most commonly used respirators in healthcare settings are the N95, N99, or N100 particulate respirators. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Respirators are approved by the CDC's National Institute for Occupational Safety and Health.
Like other PPE, the selection of a respirator type must consider the nature of the exposure and risk involved. For example, N95 particulate respirators might be worn by personnel entering the room of a patient with infectious tuberculosis. However, if a bronchoscopy is performed on the patient, the healthcare provider might wear a higher level of respiratory protection, such as a powered air-purifying respirator or PAPR.
Elements of a Respiratory Protection Program
• Medical evaluation
• Fit testing
• Training
• Fit checking before use
Prior to your using a respirator, your employer is required to have you medically evaluated to determine that it is safe for you to wear a respirator, to fit test you for the appropriate respirator size and type, and to train you on how and when to use a respirator. YOU are responsible for fit checking your respirator before use to make sure it has a proper seal.
How to Safely Don, Use, and Remove PPE
Key Points About PPE
• Don before contact with the patient, generally before entering the room
• Use carefully – don't spread contamination
• Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room
• Immediately perform hand hygiene
There are four key points to remember about PPE use. First, don it before you have any contact with the patient, generally before entering the room. Once you have PPE on, use it carefully to prevent spreading contamination. When you have completed your tasks, remove the PPE carefully and discard it in the receptacles provided. Then immediately perform hand hygiene before going on to the next patient.
Sequence* for Donning PPE
• Gown first
• Mask or respirator
• Goggles or face shield
• Gloves
*Combination of PPE will affect sequence – be practical
The gown should be donned first. The mask or respirator should be put on next and properly adjusted to fit; remember to fit check the respirator. The goggles or face shield should be donned next and the gloves are donned last. Keep in mind, the combination of PPE used, and therefore the sequence for donning, will be determined by the precautions that need to be taken.
How to Don a Gown
• Select appropriate type and size
• Opening is in the back
• Secure at neck and waist
• If gown is too small, use two gowns
– Gown #1 ties in front
– Gown #2 ties in back
To don a gown, first select the appropriate type for the task and the right size for you. The opening of the gown should be in the back; secure the gown at the neck and waist. If the gown is too small to fully cover your torso, use two gowns. Put on the first gown with the opening in front and the second gown over the first with the opening in the back.
How to Don a Mask
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with ties or elastic
• Adjust to fit
Some masks are fastened with ties, others with elastic. If the mask has ties, place the mask over your mouth, nose and chin. Fit the flexible nose piece to the form of your nose bridge; tie the upper set at the back of your head and the lower set at the base of your neck.
If a mask has elastic head bands, separate the two bands, hold the mask in one hand and the bands in the other. Place and hold the mask over your nose, mouth, and chin, then stretch the bands over your head and secure them comfortably; one band on the upper back of your head, the other below the ears at the base of the neck.
Adjust the mask to fit. Remember, you don't want to be touching it during use so take the few seconds needed to make sure it is secure on your head and fits snuggly around your face so there are no gaps.
How to Don a Particulate Respirator
• Select a fit tested respirator
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit
• Perform a fit check –
– Inhale – respirator should collapse
– Exhale – check for leakage around face
The technique for donning a particulate respirator, such as an N95, N99 or N100, is similar to putting on a pre-formed mask with elastic head bands. Key differences, however, are 1) the need to first select a respirator for which you have been fit tested and 2) fit checking the device, as you have been instructed, before entering an area where there may be airborne infectious disease. Be sure to follow the manufacturer's instructions for donning the device. In some instances, the manufacturer's instructions may differ slightly from this presentation. You may also be asked to wear an elastomeric or powered air purifying respirator, or PAPR.
How to Don Eye and Face Protection
• Position goggles over eyes and secure to the head using the ear pieces or headband
• Position face shield over face and secure on brow with headband
• Adjust to fit comfortably
If eye protection is needed, either goggles or a face shield should be worn. Position either device over the face and/or eyes and secure to head using the attached ear pieces or head band. Adjust to fit comfortably. Goggles should feel snug but not tight.
How to Don Gloves
• Don gloves last
• Select correct type and size
• Insert hands into gloves
• Extend gloves over isolation gown cuffs
The last item of PPE to be donned is a pair of gloves. Be sure to select the type of glove needed for the task in the size that best fits you. Insert each hand into the appropriate glove and adjust as needed for comfort and dexterity. If you are wearing an isolation gown, tuck the gown cuffs securely under each glove. This provides a continuous barrier protection for your skin.
How to Safely Use PPE
• Keep gloved hands away from face
• Avoid touching or adjusting other PPE
• Remove gloves if they become torn; perform hand hygiene before donning new gloves
• Limit surfaces and items touched
In addition to wearing PPE, you should also use safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting PPE. Also, remove your gloves if they become torn and perform hand hygiene before putting on a new pair of gloves. You should also avoid spreading contamination by limiting surfaces and items touched with contaminated gloves.
How to Safely Remove PPE
"Contaminated" and "Clean" Areas of PPE
• Contaminated – outside front
• Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside
• Clean – inside, outside back, ties on head and back
• Areas of PPE that are not likely to have been in contact with the infectious organism
To remove PPE safely, you must first be able to identify what sites are considered "clean" and what are "contaminated." In general, the outside front and sleeves of the isolation gown and outside front of the goggles, mask, respirator and face shield are considered "contaminated," regardless of whether there is visible soil. Also, the outside of the gloves are contaminated.
The areas that are considered "clean" are the parts that will be touched when removing PPE. These include inside the gloves; inside and back of the gown, including the ties; and the ties, elastic, or ear pieces of the mask, goggles and face shield.
Sequence for Removing PPE
• Gloves
• Face shield or goggles
• Gown
• Mask or respirator
The sequence for removing PPE is intended to limit opportunities for self contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they are more cumbersome and would interfere with removal of other PPE. The gown is third in the sequence, followed by the mask or respirator.
Where to Remove PPE
• At doorway, before leaving patient room or in anteroom*
• Remove respirator outside room, after door has been closed*
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
The location for removing PPE will depend on the amount and type of PPE worn and the category of isolation a patient is on, if applicable. If only gloves are worn as PPE, it is safe to remove and discard them in the patient room. When a gown or full PPE is worn, PPE should be removed at the doorway or in an anteroom. Respirators should always be removed outside the patient room, after the door is closed. Hand hygiene should be performed after all PPE is removed.
How to Remove Gloves (1)
• Grasp outside edge near wrist
• Peel away from hand, turning glove inside-out
• Hold in opposite gloved hand
Using one gloved hand, grasp the outside of the opposite glove near the wrist. Poland peel the glove away from the hand. The glove should now be turned inside-out, with the contaminated side now on the inside. Hold the removed glove in the opposite gloved hand.
How to Remove Gloves (2)
• Slide ungloved finger under the wrist of the remaining glove
• Peel off from inside, creating a bag for both gloves
• Discard
Slide one or two fingers of the ungloved hand under the wrist of the remaining glove. Peel glove off from the inside, creating a bag for both gloves. Discard in waste container.
Remove Goggles or Face Shield
• Grasp ear or head pieces with ungloved hands
• Lift away from face
• Place in designated receptacle for reprocessing or disposal
Using ungloved hands, grasp the "clean" ear or head pieces and lift away from face. If goggle or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the waste receptacle.
Removing Isolation Gown
• Unfasten ties
• Peel gown away from neck and shoulder
• Turn contaminated outside toward the inside
• Fold or roll into a bundle
• Discard
Unfasten the gown ties with the ungloved hands. Slip hands underneath the gown at the neck and shoulder, peel away from the shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull the hand into the sleeve, grasping the gown from inside. Reach across and push the sleeve off the opposite arm. Fold the gown towards the inside and fold or roll into a bundle. (Only the "clean" part of the gown should be visible.) Discard into waste or linen container, as appropriate.
Removing a Mask
• Untie the bottom, then top, tie
• Remove from face
• Discard
The front of the mask is considered contaminated and should not be touched. Remove by handling only the ties or elastic bands starting with the bottom then top tie or band. Lift the mask or respirator away from the face and discard it into the designated waste receptacle.
Removing a Particulate Respirator
• Lift the bottom elastic over your head first
• Then lift off the top elastic
• Discard
The bottom elastic should be lifted over the head first. Then remove the top elastic. This should be done slowly to prevent the respirator from "snapping" off the face.
Hand Hygiene
• Perform hand hygiene immediately after removing PPE.
– If hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE
• Wash hands with soap and water or use an alcohol-based hand rub
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
Hand hygiene is the cornerstone of preventing infection transmission. You should perform hand hygiene immediately after removing PPE. If your hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE. Wash your hands thoroughly with soap and warm water or, if hands are not visibly contaminated, use an alcohol-based hand rub.
When to Use PPE
Standard Precautions
• Previously called Universal Precautions
• Assumes blood and body fluid of ANY patient could be infectious
• Recommends PPE and other infection control practices to prevent transmission in any healthcare setting
• Decisions about PPE use determined by type of clinical interaction with patient
Standard Precautions is an outgrowth of Universal Precautions. Universal Precautions was first recommended in 1987 to prevent the transmission of bloodborne pathogens to healthcare personnel. In 1996, the application of the concept was expanded and renamed "Standard Precautions." Standard Precautions is intended to prevent the transmission of common infectious agents to healthcare personnel, patients and visitors in any healthcare setting. During care for any patient, one should assume that an infectious agent could be present in the patient's blood or body fluids, including all secretions and excretions except tears and sweat.
Therefore appropriate precautions, including use of PPE, must be taken. Whether PPE is needed, and if so, which type, is determined by the type of clinical interaction with the patient and the degree of blood and body fluid contact that can be reasonably anticipated and by whether the patient has been placed on isolation precautions such as Contact or Droplet Precautions or Airborne Infection Isolation.
PPE for Standard Precautions (1)
• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated
items; for touching mucus membranes and nonintact skin
• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated
Under Standard Precautions, gloves should be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and nonintact skin. A gown should be used during procedures and patient care activities when contact of clothing and/or exposed skin with blood, body fluids, secretions, or excretions is anticipated. Aprons are sometimes used as PPE over scrubs, such as in hemodialysis centers when inserting a needle into a fistula.
PPE for Standard Precautions (2)
• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions
Final Thoughts
• PPE is available to protect you from exposure to infectious agents in the healthcare workplace
• Know what type of PPE is necessary for the duties you perform and use it correctly
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Universal precautions are intended to prevent parenteral, mucous membrane, and nonintact skin exposures of health-care workers to bloodborne pathogens. In addition, immunization with HBV vaccine is recommended as an important adjunct to universal precautions for health-care workers who have exposures to blood.
Body Fluids to Which Universal Precautions Apply
Universal precautions apply to blood and to other body fluids containing visible blood. Occupational transmission of HIV and HBV to health-care workers by blood is documented. Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting. Infection control efforts for HIV, HBV, and other bloodborne pathogens must focus on preventing exposures to blood as well as on delivery of HBV immunization.
Universal precautions also apply to semen and vaginal secretions. Although both of these fluids have been implicated in the sexual transmission of HIV and HBV, they have not been implicated in occupational transmission from patient to health-care worker. This observation is not unexpected, since exposure to semen in the usual health-care setting is limited, and the routine practice of wearing gloves for performing vaginal examinations protects health-care workers from exposure to potentially infectious vaginal secretions.
Universal precautions also apply to tissues and to the following fluids: cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk of transmission of HIV and HBV from these fluids is unknown; epidemiologic studies in the health-care and community setting are currently inadequate to assess the potential risk to health-care workers from occupational exposures to them. However, HIV has been isolated from CSF, synovial, and amniotic fluid, and HBsAg has been detected in synovial fluid, amniotic fluid, and peritoneal fluid. One case of HIV transmission was reported after a percutaneous exposure to bloody pleural fluid obtained by needle aspiration. Whereas aseptic procedures used to obtain these fluids for diagnostic or therapeutic purposes protect health-care workers from skin exposures, they cannot prevent penetrating injuries due to contaminated needles or other sharp instruments.
Body Fluids to Which Universal Precautions Do Not Apply
Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent. HIV has been isolated and HBsAg has been demonstrated in some of these fluids; however, epidemiologic studies in the health-care and community setting have not implicated these fluids or materials in the transmission of HIV and HBV infections. Some of the above fluids and excretions represent a potential source for nosocomial and community-acquired infections with other pathogens, and recommendations for preventing the transmission of nonbloodborne pathogens have been published.
Precautions for Other Body Fluids in Special Settings
Human breast milk has been implicated in perinatal transmission of HIV, and HBsAg has been found in the milk of mothers infected with HBV. However, occupational exposure to human breast milk has not been implicated in the transmission of HIV nor HBV infection to health-care workers. Moreover, the health-care worker will not have the same type of intensive exposure to breast milk as the nursing neonate. Whereas universal precautions do not apply to human breast milk, gloves may be worn by health-care workers in situations where exposures to breast milk might be frequent, for example, in breast milk banking.
Saliva of some persons infected with HBV has been shown to contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum. HBsAg-positive saliva has been shown to be infectious when injected into experimental animals and in human bite exposures. However, HBsAg-positive saliva has not been shown to be infectious when applied to oral mucous membranes in experimental primate studies or through contamination of musical instruments or cardiopulmonary resuscitation dummies used by HBV carriers. Epidemiologic studies of nonsexual household contacts of HIV-infected patients, including several small series in which HIV transmission failed to occur after bites or after percutaneous inoculation or contamination of cuts and open wounds with saliva from HIV-infected patients, suggest that the potential for salivary transmission of HIV is remote. One case report from Germany has suggested the possibility of transmission of HIV in a household setting from an infected child to a sibling through a human bite. The bite did not break the skin or result in bleeding. Since the date of seroconversion to HIV was not known for either child in this case, evidence for the role of saliva in the transmission of virus is unclear. Another case report suggested the possibility of transmission of HIV from husband to wife by contact with saliva during kissing. However, follow-up studies did not confirm HIV infection in the wife.
Universal precautions do not apply to saliva. General infection control practices already in existence -- including the use of gloves for digital examination of mucous membranes and endotracheal suctioning, and handwashing after exposure to saliva -- should further minimize the minute risk, if any, for salivary transmission of HIV and HBV. Gloves need not be worn when feeding patients and when wiping saliva from skin.
Special precautions, however, are recommended for dentistry. Occupationally acquired infection with HBV in dental workers has been documented, and two possible cases of occupationally acquired HIV infection involving dentists have been reported. During dental procedures, contamination of saliva with blood is predictable, trauma to health-care workers' hands is common, and blood spattering may occur. Infection control precautions for dentistry minimize the potential for nonintact skin and mucous membrane contact of dental health-care workers to blood-contaminated saliva of patients. In addition, the use of gloves for oral examinations and treatment in the dental setting may also protect the patient's oral mucous membranes from exposures to blood, which may occur from breaks in the skin of dental workers' hands.
NOTE: Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
Use of Protective Barriers
Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear. Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needles or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes.
Universal precautions are intended to supplement rather than replace recommendations for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands. Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised.
The risk of nosocomial transmission of HIV, HBV, and other bloodborne pathogens can be minimized if health-care workers use the following general guidelines:
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Do not recap used needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant containers for disposal. Locate the puncture-resistant containers as close to the use area as is practical.
Use protective barriers to prevent exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated.
Immediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply.
Glove Use for Phlebotomy
Gloves should reduce the incidence of blood contamination of hands during phlebotomy (drawing blood samples), but they cannot prevent penetrating injuries caused by needles or other sharp instruments. The likelihood of hand contamination with blood containing HIV, HBV, or other bloodborne pathogens during phlebotomy depends on several factors: 1) the skill and technique of the health-care worker, 2) the frequency with which the health-care worker performs the procedure (other factors being equal, the cumulative risk of blood exposure is higher for a health-care worker who performs more procedures), 3) whether the procedure occurs in a routine or emergency situation (where blood contact may be more likely), and 4) the prevalence of infection with bloodborne pathogens in the patient population. The likelihood of infection after skin exposure to blood containing HIV or HBV will depend on the concentration of virus (viral concentration is much higher for hepatitis B than for HIV), the duration of contact, the presence of skin lesions on the hands of the health-care worker, and -- for HBV -- the immune status of the health-care worker. Although not accurately quantified, the risk of HIV infection following intact skin contact with infective blood is certainly much less than the 0.5% risk following percutaneous needlestick exposures. In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low.
Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply:
- Use gloves for performing phlebotomy when the health-care worker has cuts, scratches, or other breaks in his/her skin.
- Use gloves in situations where the health-care worker judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative patient.
- Use gloves for performing finger and/or heel sticks on infants and children.
- Use gloves when persons are receiving training in phlebotomy.
The Center for Devices and Radiological Health, FDA, has responsibility for regulating the medical glove industry. Medical gloves include those marketed as sterile surgical or nonsterile examination gloves made of vinyl or latex. General purpose utility ("rubber") gloves are also used in the health-care setting, but they are not regulated by FDA since they are not promoted for medical use. There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. Thus, the type of gloves selected should be appropriate for the task being performed.
The following general guidelines are recommended:
- Use sterile gloves for procedures involving contact with normally sterile areas of the body.
- Use examination gloves for procedures involving contact with mucous membranes, unless otherwise indicated, and for other patient care or diagnostic procedures that do not require the use of sterile gloves.
- Change gloves between patient contacts.
- Do not wash or disinfect surgical or examination gloves for reuse. Washing with surfactants may cause "wicking," i.e., the enhanced penetration of liquids through undetected holes in the glove. Disinfecting agents may cause deterioration.
- Use general-purpose utility gloves (e.g., rubber household gloves) for housekeeping chores involving potential blood contact and for instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused but should be discarded if they are peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration.
Waste Management
Universal precautions are not intended to change waste management programs previously recommended by CDC for health-care settings. Policies for defining, collecting, storing, decontaminating, and disposing of infective waste are generally determined by institutions in accordance with state and local regulations. Information regarding waste management regulations in health-care settings may be obtained from state or local health departments or agencies responsible for waste management.
Note: Implementation of universal precautions does not eliminate the need for other category- or disease-specific isolation precautions, such as enteric precautions for infectious diarrhea or isolation for pulmonary tuberculosis. In addition to universal precautions, detailed precautions have been developed for the following procedures and/or settings in which prolonged or intensive exposures to blood occur: invasive procedures, dentistry, autopsies or morticians' services, dialysis, and the clinical laboratory.
Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare
Personal Protective Equipment Definition
Personal protective equipment, or PPE, as defined by the Occupational Safety and Health Administration, or OSHA, is "specialized clothing or equipment, worn by an employee for protection against infectious materials."
Regulations and Recommendations for PPE
• OSHA issues workplace health and safety regulations. Regarding PPE, employers must:
– Provide appropriate PPE for employees
– Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and stored after use
• OSHA also specifies circumstances for which PPE is indicated
• CDC recommends when, what and how to use PPE
OSHA issues regulations for workplace health and safety. These regulations require use of PPE in healthcare settings to protect healthcare personnel from exposure to bloodborne pathogens and Mycobacterium tuberculosis. However, under OSHA's General Duty Clause PPE is required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure that PPE is disposed or, if reusable, that it is properly cleaned or laundered, repaired and stored after use.
The Centers for Disease Control and Prevention (CDC) issues recommendations for when and what PPE should be used to prevent exposure to infectious diseases. This presentation will cover those recommendations, beginning with the hierarchy of safety and health controls.
Hierarchy of Safety and Health Controls
• Training and administrative controls
• Engineering controls
• Work practice controls
• Personal protective equipment
The protection of healthcare personnel from infectious disease exposures in the workplace requires a combination of controls, one of which is the use of PPE. It is important to recognize that your protection as a healthcare worker also involves other prevention strategies. There are four major components to healthcare worker safety programs. First are training, such as you're receiving today, and administrative controls, like isolation policies and procedures, and procedures for recognizing patients with a communicable disease before they expose workers. Second are engineering controls like negative pressure rooms for patients with airborne diseases such as TB; third are work practice controls such as not recapping needles, and finally personal protective equipment . While PPE is last in the hierarchy of prevention, it is very important for protecting healthcare workers from disease transmission.
Types of PPE Used in Healthcare Settings
• Gloves – protect hands
• Gowns/aprons – protect skin and/or clothing
• Masks and respirators– protect mouth/nose
– Respirators – protect respiratory tract from airborne infectious agents
• Goggles – protect eyes
• Face shields – protect face, mouth, nose, and eyes
All of the PPE listed here prevent contact with the infectious agent, or body fluid that may contain the infectious agent, by creating a barrier between the worker and the infectious material. Gloves, protect the hands, gowns or aprons protect the skin and/or clothing, masks and respirators protect the mouth and nose, goggles protect the eyes, and face shields protect the entire face. The respirator, has been designed to also protect the respiratory tract from airborne transmission of infectious agents.
Factors Influencing PPE Selection
• Type of exposure anticipated
– Splash/spray versus touch
– Category of isolation precautions
• Durability and appropriateness for the task
• Fit
When you are selecting PPE, consider three key things:
First is the type of anticipated exposure. This is determined by the type of anticipated exposure, such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing. PPE selection, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on.
Second, and very much linked to the first, is the durability and appropriateness of the PPE for the task. This will affect, for example, whether a gown or apron isselected for PPE, or, if a gown is selected, whether it needs to be fluid resistant,fluid proof, or neither.
Third is fit. (optional question) How many of you have seen someone trying to work in PPE that is too small or large? PPE must fit the individual user, and it is up to the employer to ensure that all PPE are available in sizes appropriate for the workforce that must be protected.
Gloves
• Purpose – patient care, environmental services, other
• Glove material – vinyl, latex, nitrile, other
• Sterile or nonsterile
• One or two pair
• Single use or reusable
Gloves are the most common type of PPE used in healthcare settings. There are several things to consider when selecting the right glove for a specified purpose.
• Purpose – patient care, environmental services, other
• Glove material – vinyl, latex, nitrile, other
• Sterile or non-sterile
• One or two pair
• Single use or reusable
Most patient care activities require the use of a single pair of nonsterile gloves made of either latex, nitrile, or vinyl. However, because of allergy concerns, some facilities have eliminated or limited latex products, including gloves, and now use gloves made of nitrile or other material. Vinyl gloves are also frequently available and work well if there is limited patient contact. However, some gloves do not provide a snug fit on the hand, especially around the wrist, and therefore should not be used if extensive contact is likely. Gloves should fit the user's hands comfortably – they should not be too loose or too tight. They also should not tear or damage easily. Gloves are sometimes worn for several hours and need to stand up to the task.
Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive patient procedures. During some surgical procedures, two pair of gloves may be worn. Environmental services personnel often wear reusable heavy duty gloves made of latex or nitrile to work with caustic disinfectants when cleaning environmental surfaces. However, they sometimes use patient care gloves too.
Do's and Don'ts of Glove Use
Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces. Therefore, the way YOU use gloves can influence the risk of disease transmission in your healthcare setting.
These are the most important do's and don'ts of glove use:
Work from clean to dirty. This is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas.
Limit opportunities for "touch contamination" - protect yourself, others and environmental surfaces. How many times have you seen someone adjust theirglasses, rub their nose or touch their face with gloves that have been in contact witha patient? This is one example of "touch contamination" that can potentially exposeoneself to infectious agents. Think about environmental surfaces too and avoidunnecessarily touching them with contaminated gloves. Surfaces such as lightswitches, door and cabinet knobs can become contaminated if touched by soiledgloves.
• Change gloves
– During use if torn and when heavily soiled (even during use on the same patient)
– After use on each patient
• Discard in appropriate receptacle
– Never wash or reuse disposable gloves
Change gloves as needed. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.
Gowns or Aprons
There are three factors that influence the selection of a gown or apron as PPE.
First is the purpose of use. Isolation gowns are generally the preferred PPE for clothing but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist.
Second are the material properties of the gown. Isolation gowns are made either of cotton or a spun synthetic material that dictate whether they can be laundered and reused or must be disposed. Cotton and spun synthetic isolation gowns vary in their degree of fluid resistance, another factor that must be considered in the selection of this garb. If fluid penetration is likely, a fluid resistant gown should be used.
The last factor concerns patient risks and whether a clean, rather than sterile gown, can be used. Clean gowns are generally used for isolation. Sterile gowns are only necessary for performing invasive procedures, such as inserting a central line. In this case, a sterile gown would serve purposes of patient and healthcare worker protection.
Face Protection
A combination of PPE types is available to protect all or parts of the face from contact with potentially infectious material. The selection of facial PPE is determined by the isolation precautions required for the patient and/or the nature of the patient contact. Masks should fully cover the nose and mouth and prevent fluid penetration. Masks should fit snuggly over the nose and mouth. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable.
Goggles provide barrier protection for the eyes; personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. Goggles with antifog features will help maintain clarity of vision.
Face Protection
When skin protection, in addition to mouth, nose, and eye protection, is needed or desired, for example, when irrigating a wound or suctioning copious secretions, a face shield can be used as a substitute to wearing a mask or goggles. The face shield should cover the forehead, extend below the chin, and wrap around the side of the face.
Respiratory Protection
PPE also is used to protect healthcare workers' from hazardous or infectious aerosols, such as Mycobacterium tuberculosis. Respirators that filter the air before it is inhaled should be used for respiratory protection. The most commonly used respirators in healthcare settings are the N95, N99, or N100 particulate respirators. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Respirators are approved by the CDC's National Institute for Occupational Safety and Health.
Like other PPE, the selection of a respirator type must consider the nature of the exposure and risk involved. For example, N95 particulate respirators might be worn by personnel entering the room of a patient with infectious tuberculosis. However, if a bronchoscopy is performed on the patient, the healthcare provider might wear a higher level of respiratory protection, such as a powered air-purifying respirator or PAPR.
Elements of a Respiratory Protection Program
• Medical evaluation
• Fit testing
• Training
• Fit checking before use
Prior to your using a respirator, your employer is required to have you medically evaluated to determine that it is safe for you to wear a respirator, to fit test you for the appropriate respirator size and type, and to train you on how and when to use a respirator. YOU are responsible for fit checking your respirator before use to make sure it has a proper seal.
How to Safely Don, Use, and Remove PPE
Key Points About PPE
• Don before contact with the patient, generally before entering the room
• Use carefully – don't spread contamination
• Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room
• Immediately perform hand hygiene
There are four key points to remember about PPE use. First, don it before you have any contact with the patient, generally before entering the room. Once you have PPE on, use it carefully to prevent spreading contamination. When you have completed your tasks, remove the PPE carefully and discard it in the receptacles provided. Then immediately perform hand hygiene before going on to the next patient.
Sequence* for Donning PPE
• Gown first
• Mask or respirator
• Goggles or face shield
• Gloves
*Combination of PPE will affect sequence – be practical
The gown should be donned first. The mask or respirator should be put on next and properly adjusted to fit; remember to fit check the respirator. The goggles or face shield should be donned next and the gloves are donned last. Keep in mind, the combination of PPE used, and therefore the sequence for donning, will be determined by the precautions that need to be taken.
How to Don a Gown
• Select appropriate type and size
• Opening is in the back
• Secure at neck and waist
• If gown is too small, use two gowns
– Gown #1 ties in front
– Gown #2 ties in back
To don a gown, first select the appropriate type for the task and the right size for you. The opening of the gown should be in the back; secure the gown at the neck and waist. If the gown is too small to fully cover your torso, use two gowns. Put on the first gown with the opening in front and the second gown over the first with the opening in the back.
How to Don a Mask
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with ties or elastic
• Adjust to fit
Some masks are fastened with ties, others with elastic. If the mask has ties, place the mask over your mouth, nose and chin. Fit the flexible nose piece to the form of your nose bridge; tie the upper set at the back of your head and the lower set at the base of your neck.
If a mask has elastic head bands, separate the two bands, hold the mask in one hand and the bands in the other. Place and hold the mask over your nose, mouth, and chin, then stretch the bands over your head and secure them comfortably; one band on the upper back of your head, the other below the ears at the base of the neck.
Adjust the mask to fit. Remember, you don't want to be touching it during use so take the few seconds needed to make sure it is secure on your head and fits snuggly around your face so there are no gaps.
How to Don a Particulate Respirator
• Select a fit tested respirator
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit
• Perform a fit check –
– Inhale – respirator should collapse
– Exhale – check for leakage around face
The technique for donning a particulate respirator, such as an N95, N99 or N100, is similar to putting on a pre-formed mask with elastic head bands. Key differences, however, are 1) the need to first select a respirator for which you have been fit tested and 2) fit checking the device, as you have been instructed, before entering an area where there may be airborne infectious disease. Be sure to follow the manufacturer's instructions for donning the device. In some instances, the manufacturer's instructions may differ slightly from this presentation. You may also be asked to wear an elastomeric or powered air purifying respirator, or PAPR.
How to Don Eye and Face Protection
• Position goggles over eyes and secure to the head using the ear pieces or headband
• Position face shield over face and secure on brow with headband
• Adjust to fit comfortably
If eye protection is needed, either goggles or a face shield should be worn. Position either device over the face and/or eyes and secure to head using the attached ear pieces or head band. Adjust to fit comfortably. Goggles should feel snug but not tight.
How to Don Gloves
• Don gloves last
• Select correct type and size
• Insert hands into gloves
• Extend gloves over isolation gown cuffs
The last item of PPE to be donned is a pair of gloves. Be sure to select the type of glove needed for the task in the size that best fits you. Insert each hand into the appropriate glove and adjust as needed for comfort and dexterity. If you are wearing an isolation gown, tuck the gown cuffs securely under each glove. This provides a continuous barrier protection for your skin.
How to Safely Use PPE
• Keep gloved hands away from face
• Avoid touching or adjusting other PPE
• Remove gloves if they become torn; perform hand hygiene before donning new gloves
• Limit surfaces and items touched
In addition to wearing PPE, you should also use safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting PPE. Also, remove your gloves if they become torn and perform hand hygiene before putting on a new pair of gloves. You should also avoid spreading contamination by limiting surfaces and items touched with contaminated gloves.
How to Safely Remove PPE
"Contaminated" and "Clean" Areas of PPE
• Contaminated – outside front
• Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside
• Clean – inside, outside back, ties on head and back
• Areas of PPE that are not likely to have been in contact with the infectious organism
To remove PPE safely, you must first be able to identify what sites are considered "clean" and what are "contaminated." In general, the outside front and sleeves of the isolation gown and outside front of the goggles, mask, respirator and face shield are considered "contaminated," regardless of whether there is visible soil. Also, the outside of the gloves are contaminated.
The areas that are considered "clean" are the parts that will be touched when removing PPE. These include inside the gloves; inside and back of the gown, including the ties; and the ties, elastic, or ear pieces of the mask, goggles and face shield.
Sequence for Removing PPE
• Gloves
• Face shield or goggles
• Gown
• Mask or respirator
The sequence for removing PPE is intended to limit opportunities for self contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they are more cumbersome and would interfere with removal of other PPE. The gown is third in the sequence, followed by the mask or respirator.
Where to Remove PPE
• At doorway, before leaving patient room or in anteroom*
• Remove respirator outside room, after door has been closed*
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
The location for removing PPE will depend on the amount and type of PPE worn and the category of isolation a patient is on, if applicable. If only gloves are worn as PPE, it is safe to remove and discard them in the patient room. When a gown or full PPE is worn, PPE should be removed at the doorway or in an anteroom. Respirators should always be removed outside the patient room, after the door is closed. Hand hygiene should be performed after all PPE is removed.
How to Remove Gloves (1)
• Grasp outside edge near wrist
• Peel away from hand, turning glove inside-out
• Hold in opposite gloved hand
Using one gloved hand, grasp the outside of the opposite glove near the wrist. Poland peel the glove away from the hand. The glove should now be turned inside-out, with the contaminated side now on the inside. Hold the removed glove in the opposite gloved hand.
How to Remove Gloves (2)
• Slide ungloved finger under the wrist of the remaining glove
• Peel off from inside, creating a bag for both gloves
• Discard
Slide one or two fingers of the ungloved hand under the wrist of the remaining glove. Peel glove off from the inside, creating a bag for both gloves. Discard in waste container.
Remove Goggles or Face Shield
• Grasp ear or head pieces with ungloved hands
• Lift away from face
• Place in designated receptacle for reprocessing or disposal
Using ungloved hands, grasp the "clean" ear or head pieces and lift away from face. If goggle or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the waste receptacle.
Removing Isolation Gown
• Unfasten ties
• Peel gown away from neck and shoulder
• Turn contaminated outside toward the inside
• Fold or roll into a bundle
• Discard
Unfasten the gown ties with the ungloved hands. Slip hands underneath the gown at the neck and shoulder, peel away from the shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull the hand into the sleeve, grasping the gown from inside. Reach across and push the sleeve off the opposite arm. Fold the gown towards the inside and fold or roll into a bundle. (Only the "clean" part of the gown should be visible.) Discard into waste or linen container, as appropriate.
Removing a Mask
• Untie the bottom, then top, tie
• Remove from face
• Discard
The front of the mask is considered contaminated and should not be touched. Remove by handling only the ties or elastic bands starting with the bottom then top tie or band. Lift the mask or respirator away from the face and discard it into the designated waste receptacle.
Removing a Particulate Respirator
• Lift the bottom elastic over your head first
• Then lift off the top elastic
• Discard
The bottom elastic should be lifted over the head first. Then remove the top elastic. This should be done slowly to prevent the respirator from "snapping" off the face.
Hand Hygiene
• Perform hand hygiene immediately after removing PPE.
– If hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE
• Wash hands with soap and water or use an alcohol-based hand rub
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
Hand hygiene is the cornerstone of preventing infection transmission. You should perform hand hygiene immediately after removing PPE. If your hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE. Wash your hands thoroughly with soap and warm water or, if hands are not visibly contaminated, use an alcohol-based hand rub.
When to Use PPE
Standard Precautions
• Previously called Universal Precautions
• Assumes blood and body fluid of ANY patient could be infectious
• Recommends PPE and other infection control practices to prevent transmission in any healthcare setting
• Decisions about PPE use determined by type of clinical interaction with patient
Standard Precautions is an outgrowth of Universal Precautions. Universal Precautions was first recommended in 1987 to prevent the transmission of bloodborne pathogens to healthcare personnel. In 1996, the application of the concept was expanded and renamed "Standard Precautions." Standard Precautions is intended to prevent the transmission of common infectious agents to healthcare personnel, patients and visitors in any healthcare setting. During care for any patient, one should assume that an infectious agent could be present in the patient's blood or body fluids, including all secretions and excretions except tears and sweat.
Therefore appropriate precautions, including use of PPE, must be taken. Whether PPE is needed, and if so, which type, is determined by the type of clinical interaction with the patient and the degree of blood and body fluid contact that can be reasonably anticipated and by whether the patient has been placed on isolation precautions such as Contact or Droplet Precautions or Airborne Infection Isolation.
PPE for Standard Precautions (1)
• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated
items; for touching mucus membranes and nonintact skin
• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated
Under Standard Precautions, gloves should be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and nonintact skin. A gown should be used during procedures and patient care activities when contact of clothing and/or exposed skin with blood, body fluids, secretions, or excretions is anticipated. Aprons are sometimes used as PPE over scrubs, such as in hemodialysis centers when inserting a needle into a fistula.
PPE for Standard Precautions (2)
• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions
Final Thoughts
• PPE is available to protect you from exposure to infectious agents in the healthcare workplace
• Know what type of PPE is necessary for the duties you perform and use it correctly
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