Infection Control: New York State Mandatory Training

Element IV: Selection and use of barriers and or personal protective equipment for preventing patient and healthcare worker contact with potentially infection material.

Introduction

Element I

Element II

Element III

Element IV

Element V

Element VI

Conclusion

Resources

References

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At a magnification of 1000X, this trichrome-stained photomicrograph revealed the morphologic characteristics of a blue-stained Giardia intestinalis protozoan trophozoite (center).
Photo courtesy of CDC/ DPDx - Melanie Moser.

Personal protective equipment (PPE) is defined by OSHA as specialized clothing or equipment worn by an employee for protection against infectious materials. They are selected based upon:

  • Anticipated exposure type - splash/spray versus touch.
  • Category of isolation precaution.
  • Durability and appropriateness for the task.
  • Fit.

As part of the Bloodborne Pathogen Standard, OSHA requires employers to provide appropriate PPE for employees. Employers must also ensure that PPE is disposed, or that reusable PPE is cleaned, laundered, repaired and stored after use. OSHA specifies the circumstances for which PPE is indicated; the CDC recommends when, what, and how to use PPE (CDC, 2007).

Types of PPE

  • 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 the eyes
  • Face shields - protect face, mouth, nose and eyes

There are four key points to remember about PPE use:

  1. First, don it before any contact with the patient is made, generally before entering the room.
  2. Once the PPE is on, use it carefully to prevent spreading contamination.
  3. When tasks have been completed, remove the PPE carefully and discard it in the receptacles provided.
  4. Then immediately perform hand hygiene before going on to the next patient.

Gloves

Gloves are used in patient care situations as well as for environmental services. They are made of vinyl, latex, nitrile and other materials. They are available in both sterile and non-sterile forms; some are made for single use, others are reusable. Healthcare workers sometimes wear a single pair of gloves; sometimes double gloving is utilized (CDC, 2007).

The procedure for donning gloves is:

  • Select correct type and size; use non-sterile for isolation; select according to hand size.
  • Insert hands into gloves.
  • Extend gloves over isolation gown cuffs.

Do's and Don'ts of Glove Use (CDC, 2007):

  • Work from "clean" to "dirty"
  • Limit opportunities for "touch contamination"
  • Protect yourself, others and the environment:
    • Don't touch your face or adjust PPE with contaminated gloves.
    • Don't touch environmental surfaces except as needed during patient care.
  • Change gloves
    • During use if torn or heavily soiled (even when caring for the same patient).
    • After use on each patient.
  • Discard in appropriate receptacle
    • Never wash or reuse disposable gloves.

The procedure for removing gloves is:

  • Remove PPE at doorway before leaving patient room or in anteroom;
  • Outside of gloves are contaminated;
  • Grab outside edge near wrist with opposite gloved hand;
  • Peel away from hand, turning glove inside out;
  • Hold removed glove in opposite gloved hand;
  • Slide ungloved finger under the wrist of the remaining glove;
  • Peel off from inside, creating a bag for both gloves;
  • Discard.

Gowns and Aprons

Gowns and aprons can be made of natural materials or synthetic materials; they can be disposable or reusable; they vary in level of fluid resistance; they can be sterile or clean. Three factors influence the selection of a gown or apron. Firstly, the purpose of its use must be considered. 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 to protect the patient and the healthcare provider.

The procedure for donning a gown is:
  • Select appropriate type and size; fully cover torso from neck to knees, arms to end of wrist and wrap around the back;
  • Opening is in the back;
  • Secure at neck and waist;
  • If gown is too small, wear 2 gowns:
    • Gown #1 ties in front.
    • Gown #2 ties in back.

The procedure for removing a gown is:

  • Gown front and sleeves are contaminated;
  • Unfasten ties at neck and then waist tie;
  • Peel gown down away from neck and each shoulder toward the same had;
  • Turn contaminated outside to the inside;
  • Hold removed gown away from body;
  • Fold or roll into a bundle;
  • Discard in appropriate receptacle.

Face Protection

Masks protect the nose and mouth; they should fully cover the nose and mouth and prevent fluid penetration. They should fit snuggly over the nose and mouth, making masks with flexible nose pieces that are secured to the head with string ties or with elastic are preferable.

The procedure for applying a mask is:
  • Pace over nose, mouth and chin;
  • Fit flexible nose piece over nose bridge;
  • Secure on head with ties or elastic;
  • Fit snug to face and below chin;
  • Adjust to fit.

 

For removal of a mask, use this procedure:

  • Front of mask/respirator is contaminated - Do Not Touch;
  • Grasp only bottom tie first, then top tie/elastic and remove;
  • Discard in appropriate waste container.

Goggles protect the eyes; personal prescription lenses do not provide optimal eye protection and are NOT a substitute for goggles. They should fit snuggly over and around the eyes; antifog feature improves clarity.

Face shields protect the face, nose, eyes, mouth and eyes; they should cover the forehead, extend below the chin and wrap around side of face. 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.

 

The procedure for donning eye and face protection is:
  • Position goggles over eyes and secure the head using the earpieces or headband.
  • Position face shield over face and secure on brow with headband.
  • Adjust to fit comfortably.

 

The procedure for removing goggles or face shields is:

  • Outside of goggles or face shield are contaminated;
  • Handle by "clean" head band or grasp ear pieces with ungloved hand (see sequence of removing PPE later in this section of the course);
  • Lift away from face;
  • Place in designated receptacle for disposal or reprossessing.

Respiratory Protection

The purpose of respiratory protection is to protect workers from inhalation of infectious aerosols (e.g. Mycobaterium tuberculosis).

Types of respiratory PPE include:

  • Particulate respirators,
  • Half- and full-face elastomeric respirators,
  • Powered air purifying respirators (PAPR).
The procedure for donning a particulate respirator is:
  • Select a fit tested respirator;
  • Place over nose, mouth and chin;
  • it flexible nose piece over bridge of nose;
  • Secure on head with elastic;
  • Adjust to fit;
  • Perform a fit check:
    • Inhale - respirator should collapse.
    • Exhale - check for leakage around face.

 

Removing a particulate respirator entails the following procedure:

  • Lift the bottom elastic over your head first;
  • Then lift the top elastic;
  • Discard.

Safe Work Practices

Key points about PPE:

  • Don before contact with the patient, generally before entering the room.
  • Use carefully - don't spread contamination.
  • Keep hands away from face;
  • Work from clean to dirty;
  • Limit surfaces touched;
  • Change when torn or heavily contaminated;
  • Remove and discard carefully, either at the doorway or immediately outside the patient room; remove respirator outside room.
  • Immediately perform hand hygiene.

Sequence for donning PPE: The order in which PPE is donned, is based on the combination of needed PPE, although the following recommendations are made, the specific situation will determine which sequence is practical.

  • Gown first,
  • Mask or respirator,
  • Goggles or face shield,
  • Gloves.

Knowing the difference between "clean" and "contaminated" areas of PPE is key to effective protection.

Contaminated areas include:

  • The outside front of the PPE; and any
  • Areas of the PPE that have had or are likely to have been in contact with body sites, materials or environmental surfaces where the infectious organism may reside.

Clean areas include:

  • The inside, outside back, ties on head and back; and any
  • Areas of PPE not likely to have been in contact with infectious organisms.

The order in which PPE is removed also is important in maintaining protection. The sequence is:

  • Gloves,
  • Face shield or goggles,
  • Gown,
  • Mask or respirator.

PPE is best removed at the doorway of the patient room. An anteroom is ideally used; hand hygiene facilities (sink or alcohol-based hand rub) are to be in this location, where they will be needed.

Continue to Element V