Personal Protective Equipment (PPE)

General Principles

PPE is used to prevent:

contact with non-intact skin, blood, body fluid, excretions and secretions

the transmission of particular organisms that may be transmitted via the air, or by contact with intact skin (see section on Additional Precautions)

PPE is only effective in infection control and prevention when applied, used, removed and disposed of properly

Avoid any contact between contaminated PPE and surfaces, clothing or people outside the patient care area

Discard used PPE in the appropriate disposal bags

Do not share PPE

Remove PPE completely and thoroughly perform hand hygiene each time you leave a patient to attend to another patient or move to a non-patient care area

The use of PPE does not replace the need for proper hand hygiene, which needs to be performed both before PPE is applied and after it is removed

It is essential to perform a risk assessment to determine the PPE needed

Individual components of routine practices are determined by a point-of-care risk assessment (PCRA) (i.e., one that includes an assessment of the task/care to be performed, the patient’s clinical presentation, physical state of the environment and the healthcare setting).



RESOURCE

Risk Algorithm to Guide PPE Use

Professional Accountabilities:

Increased knowledge, hand hygiene, appropriate PPE, immunization etc., are all part of a system that provides for the safety of our patient/clients, our Members and other members of the interprofessional team.

Did You Know?

All regulated health care professionals have the authority to initiate additional precautions without a physician’s order.

Gloves

Gloves must be worn when it is anticipated that the hands will be in contact with:

mucous membranes

non-intact skin

tissue

blood

body fluids

secretions

excretion

equipment and environmental surfaces contaminated with the above

REMEMBER

The use of gloves does not replace the need for proper hand hygiene.

Perform hand hygiene before and after each glove use/change.
Remove gloves and clean hands between patients and before leaving the patient care area.
Always use the appropriate technique for removing the gloves and disposing of them.
Gloves should be worn for specific tasks and discarded immediately following.
Change gloves if they become heavily soiled during the task.
Change or remove gloves when moving from a contaminated body site to a clean body site during the same task.

Do not use gloves for routine care activities e.g., taking a blood pressure in which contact is limited to intact skin, unless additional precautions are in place.
Do not use gloves if they are ripped or torn
Do not allow the outer surface of the glove to touch your skin.

Selection of Glove

GLOVE TYPE	SITUATION AND RATIONALE
Vinyl/ Clean	Provides protection for minimal exposure to blood/body fluids/infectious agents and short duration tasks.
Sterile	Used for activities that involve invasive procedures, or where contact with non-intact skin, blood, body fluids or body substances is sustained or continuous (e.g. arterial line insertion, central line insertion). Please note: there is increasing evidence of latex sensitivity and allergies amongst healthcare workers. To reduce this risk, latex gloves should only be used when needed and should be powder free and have low or reduced protein content.
Nitrile	Protection for heavy exposure to blood/body fluids/infectious agents and tasks of longer duration. Used when handling chemicals and chemotherapeutic agents and is the preferred replacement for vinyl gloves when a documented allergy or sensitivity is present.
Neoprene	Used as a replacement sterile latex glove when a documented allergy or sensitivity occurs. Recommended for contact with acids, bases, alcohols, etc.

REMEMBER

Gloves protect the healthcare professional, but once contaminated they can transmit pathogens to the skin, clothes or to other patients.

Gowns

Gowns are worn in order to protect the health care professional’s arms, exposed body areas, and clothing from contact with blood, body fluids, and other potentially infectious material.

Discard immediately after each patient encounter.
Gowns should fully cover the torso to mid-thigh, fit close to the body, tie in the back and have long sleeves that fit snugly at the wrists.

Do not reuse gowns.
Do not go from patient to patient wearing the same gown.

Selection of Gowns

GOWN TYPE	SITUATION AND RATIONALE
Cotton/linen, reusable or disposable, long-sleeved isolation gowns.	Use if contamination is anticipated and in contact/droplet precautions.
Fluid resistant isolation gown or plastic apron over isolation gown	Use if contamination of uniform or clothing from significant volumes of blood or body fluids is likely or anticipated.
Fluid impervious gowns (e.g., Gortex®)	Use if extended contact or large volume exposure (e.g. large volume blood loss during resuscitation of MVA victim or surgical assist).

Facial Protection

Facial protection may include a mask or respirator in conjunction with eye protection, or a face shield that covers eyes, nose and mouth. Facial protection is to be used if it is anticipated that a procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or within two metres of a coughing client/patient/resident (RPAP, 2012, p. 13).

Masks provide a barrier that protects the mucous membranes of the mouth and nose which are portals for infection. Droplets can carry microbes and other infectious agents and a surgical mask helps protect you from inhaling respiratory pathogens transmitted by the droplet route.

Eye protection used in addition to a mask to protect the mucous membranes of the eyes when:

it is anticipated that a procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions or excretions; and/or

providing care within two metres of a coughing client/patient/resident.

Eye protection includes:

safety glasses

safety goggles

face shields

visors attached to masks

Did You Know?

Personal eyeglasses and contact lenses are NOT adequate eye protection; they may not provide sufficient protection above, below, or around the eyes.

Mask

Mask should securely cover the nose and mouth.
Change mask if it becomes wet.
Remove mask correctly immediately after completion of task and discard into an appropriate waste receptacle.
Clean hands after removing the mask.

Do not touch mask while wearing it.
Do not allow mask to hang or dangle around the neck.
Do not re-use disposable masks.
Do not fold the mask or put it in a pocket for later use.

Selection of Masks

MASK TYPE	SITUATION AND RATIONALE
Procedure mask	Protection for minimal exposure to infectious droplets. Used for short duration tasks and those that do not involve exposure to blood/body fluids.
Fluid Resistant Mask	Protection for heavy exposure to infectious droplets or blood/body fluids.
Surgical Mask	Protection for exposure to infectious droplets or blood/body fluids and for longer duration tasks.

Did You Know?

Some studies have demonstrated that protection with a surgical mask against influenza appears to be similar to the N95 respirator. However, this should not be generalized to settings where there is a high risk for aerosolization (such as intubation or bronchoscopy), where use of an N95 respirator is required. (Loeb et al., 2009)

Respirators

N95 respirators prevent inhalation of small particles that may contain infectious agents transmitted via the airborne route and must:

filter particles one micron in size

have a 95% filter efficiency

provide a tight facial seal with less than 10% leak. A fit-tested N95 respirator covering the nose and mouth respirators should be worn when:

entering the client/patient/resident’s room or transporting patient/clients who are on Airborne Precautions (e.g., Active TB)

performing aerosol-generating procedures such as sputum induction and bronchoscopy.

Non-immune staff is required to enter the room of a client/patient/resident with measles or varicella.

N95

Undergo regular fit testing as part of an approved fit-testing program.
Performing a seal check each time an N95 respirator is used.
Remove the N95 respirator correctly and discard on removal into an appropriate receptacle.

NEVER put an N95 respirator on a patient/client (patient/clients should wear a surgical/procedure mask when outside their room)
Do not use N95 respirator if seal check fails.
Do not use N95 respirator if wet or soiled.

Did You Know?

In Ontario, the Ministry of Health and Long-Term Care recommends the use of a fit-tested, seal-checked N95 respirator and AIIR for MERS-CoV. This advice differs from guidance from the Public Health Agency of Canada. (PIDAC, 2016, p. 6)

Fit Testing for N95 Respirators

Fit Testing involves the evaluation of the fit of a specific respirator on an individual with respects to:

make

model; and

size

This procedure is to be done as required by health systems guidelines and directives, and whenever there is a change in respirator face piece or the user’s physical condition which could affect the respirator fit (e.g. significant weight change, facial structure change due to injury or major dental work).

Performing a Seal Check for an N95 Respirator

A Seal Check (also referred to as a ‘fit-check’) must be performed each time an N95 respirator is worn to ensure adequate respiratory protection.

Apply mask as per instructions
Cover exhalation valve or cup hands around the sides of the mask
Exhale gently into the mask – you should feel no leaks around the mask edge and the mask should rise/lift gently from your face

Apply mask as per instructions
Cover exhalation valve or cup hands around the sides of the mask
Gently inhale for 5 seconds – the mask should collapse slightly onto your face without any inward leakage of air around the edges of the mask

Professional Accountabilities

Members are required to know what size and manufacturer of N95 respirator is appropriate for them and adhere to their employer’s requirement for mask fit testing.

Scenario:

You are unable to pass a seal check with an N95 mask prior to entering an airborne isolation room.

What do you do?

You should notify your supervisor that you cannot provide care and ensure that you are mask fit tested as soon as possible.

Eye Protection

Eye protection must be removed immediately after the task for which it was used and discarded into waste or placed in an appropriate receptacle for cleaning.
Reusable eye protection must be sent to a central area for reprocessing after use.

Prescription eye glasses are not acceptable as eye protection.

Selection of Eye Protection

EYE PROTECTION TYPE	SITUATION AND RATIONALE
Goggles	Provides protection for exposure to infectious droplets or blood/body fluids. However, visibility is often poor.
Face Shield	Protection for exposure to infectious droplets or blood/body fluids. Provide good visibility.
Surgical Mask	Protection for minimal exposure to infectious droplets or blood/body fluids.

Organizational Expectations

Organizations have a responsibility to have systems in place with established procedures that enable compliance with Hand Hygiene, Routine Practices and Additional Precautions. Both the employer and the employee have duties under the Occupational Health and Safety Act15:

“An employer shall ensure that the equipment, materials and protective devices as prescribed are provided’ [S. 25(1)(a)] and ‘the equipment, materials and protective devices provided by the employer are maintained in good condition” [S. 25(1)(b)];

“A worker shall use or wear the equipment, protective devices or clothing that his employer requires to be used or worn’ [S. 28(1)(b)] and ‘a worker shall report to his or her employer or supervisor the absence of or defect in any equipment or protective device of which the worker is aware and which may endanger himself, herself or another worker” [S. 28(1)(c)].

Control of the Environment

These include:

appropriate placement and bed spacing, such as single room and private toileting facilities for clients/patients/residents who soil the environment

cleaning of equipment that is used for/on more than one client/patient/resident between uses

cleaning of the health care environment, including safe handling of soiled linen and waste (e.g., sharps) to prevent exposure and transmission to others,

engineering controls, such as: well-maintained heating, ventilation and air conditioning (HVAC) systems with sufficient air changes per hour, barriers, such as the use of Plexiglass® screens or curtains, point-of-care sharps containers and alcohol-based hand rub dispensers and adequate dedicated hand wash sinks

References

Association for the Advancement of Medical Instrumentation (AAMI). (2015). FDA proposes new criteria for surgical gowns. Retrieved from Association for the Advancement of Medical Instrumentation website: www.aami.org/newsviews/newsdetail.aspx?ItemNumber=2650

Canadian Patient Safety Institute. (n.d.). Ventilator-associated pneumonia (VAP). Retrieved from Canadian Patient Safety Institute website: www.patientsafetyinstitute.ca/en/topic/pages/ventilator-associatedpneumonia-(vap).aspx

Centers for Disease Control and Prevention. (2011). Central line-associated bloodstream infections: Resources for patients and healthcare providers. Retrieved from Centers for Disease Control and Prevention website: www.cdc.gov/HAI/bsi/CLABSI-resources.html

Critical Care Secretariat. (2012). Ventilator associated pneumonia and central line infection prevention toolkit. Retrieved from Critical Care Services Ontario website: www.criticalcareontario.ca/EN/Toolbox/Performance%20Improvement%20Collaborative/VAP%20and%2 0CLI%20Toolkit%20(2012).pdf

Immunize Canada. (2016). ImmunizeCA app. Retrieved from Immunize Canada website: http://immunize.ca/en/app.aspx

Loeb, M., Dafoe, N., Mahony J., John, M., Sarabia, A., Glavin, V., Walter, S.S. (2009). Surgical mask vs N95 respirator for preventing influenza among health care workers: A randomized trial. JAMA, 302(17), 1865- 1871. doi:10.1001/jama.2009.1466. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=184819

PIDAC. (2012a). Best practices for infection prevention and control programs in Ontario (3rd ed.). Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf

PIDAC. (2012b). Routine practices and additional precautions in all health care settings (3rd ed.). Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf

PIDAC. (2013). Annex B: Best practices for prevention of transmission of acute respiratory infection in all health care settings. Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_B_Prevention_Transmission_ARI_2013.pdf

PIDAC. (2014). Best practices for hand hygiene in all health care settings, (4th ed.). Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf

PIDAC. (2015a). Best practices for prevention, surveillance and infection control management of novel respiratory infections in all health care settings. Retrieved from Public Health Ontariowebsite: www.publichealthontario.ca/en/eRepository/Best_Practices_Novel_Respiratory_Infections.pdf

PIDAC. (2015b). Infection prevention and control for clinical office practice. Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdf

PIDAC. (2016). Tools for preparedness: Triage, screening and patient management for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infections in acute care settings. Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Preparedness_Tools_MERS_CoV_2013.pdf

Public Health Agency of Canada. (2013). Canadian immunization guide. Retrieved from Public Health Agency of Canada website: http://phac-aspc.gc.ca/publicat/cig-gci/p03-work-travail-eng.php#a1

Public Health Agency of Canada. (2014). Canadian Tuberculosis Standards (7th ed.). Retrieved from http://www.phac-aspc.gc.ca/tbpc-latb/pubs/tb-canada-7/assets/pdf/tb-standards-tb-normes-prefeng.pdf

Public Health Agency of Canada. (2016). Summary of assessment of public health risk to Canada associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Retrieved from Public Health Agency of Canada website: www.phac-aspc.gc.ca/eri-ire/coronavirus/risk_assessment-evaluation_risque-eng.php

Public Health Ontario. (n.d.a). Chain of transmission and risk assessment: Glossary of terms. Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/LearningAndDevelopment/OnlineLearning/InfectiousDiseases/IPACCore/Documents/CORE_Trainers_COT_and_RA_Module_Glossary_April _2014.pdf

Public Health Ontario. (n.d.b). Risk Algorithm to Guide PPE Use. Retrieved from Public Health Ontario website: www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_Risk_Algorithm_PPE_2013.pdf

World Health Organization. (2015). Middle East respiratory syndrome coronavirus (MERS-CoV). Retrieved from World Health Organization website: www.who.int/mediacentre/factsheets/mers-cov/en/