Selection & Use of PPE

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.”

OSHA issues regulations for workplace health and safety. These regulations require the 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 of, 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 training will cover those recommendations, beginning with the hierarchy of safety and health controls.

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 of 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.

All the PPE listed here prevents 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 the airborne transmission of infectious agents. 

Selecting Personal Protective Equipment

When you are selecting PPE, consider three key things:

1. 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, the combination of PPE, also is determined by the category of isolation precautions a patient is on.

• The durability and appropriateness of the PPE for the task. This will affect, for example, whether a gown or apron is selected for PPE, or, if a gown is selected, whether it needs to be fluid-resistant, fluid proof, or neither.

• Fit. 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 non-sterile
• One or two pair
• Single-use or reusable

Gloves are the most common type of PPE used in healthcare settings. As you can see here, there are several things to consider when selecting the right glove for a specified purpose.

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.

Who uses the other glove options? Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive patient procedures. During some surgical procedures, two pairs 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.

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 their glasses, rub their nose or touch their face with gloves that have been in contact with a patient? This is one example of “touch contamination” that can potentially expose oneself to infectious agents. Think about environmental surfaces too and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door, and cabinet knobs can become contaminated if touched by soiled 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

• Purpose of use
• Material
• Natural or man-made
• Reusable or disposable
• Resistance to fluid penetration
• Clean or sterile

Three factors 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 spun synthetic material that dictates whether they can be laundered and reused or must be disposed of. 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 a 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 the purposes of patient and healthcare worker protection.

Face Protection

• Masks – protect nose and mouth
• Should fully cover nose and mouth and prevent fluid penetration
• Goggles – protect eyes
• Should fit snugly over and around eyes
• Personal glasses not a substitute for goggles
• Anti-fog feature includes clarity
•  Face shields – protect face, nose, mouth, and eyes
• Should cover the forehead, extend below the chin, and wrap around the side of the face

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. This will be discussed later.

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.

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

• Purpose – protect from inhalation of infectious aerosols (e.g. Mycobacterium tuberculosis)
• PPE types for respiratory protection
• Particulate respirators
• Half- or full-face elastomeric respirators
• Powered air-purifying respirators (PAPR)

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. 

Before you use 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.

When to Use PPE

Decisions regarding when and which type of PPE should be worn are determined by CDC recommendations for Standard Precautions and Expanded Isolation Precautions.

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 the type of clinical interaction with a patient

Standard Precaution 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 the 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.

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 the 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.

Mask and goggles or a face shield should be used during patient care activities that are likely to generate splashes and sprays of blood, body fluids, secretions, or excretions.

Use of PPE for Expanded Precautions

• Contact Precautions – Gown and gloves for contact with the patient or environment of care (e.g. medical equipment, environmental surfaces). In some instances, these are required for entering a patient’s environment.
• Droplet Precautions – Surgical masks within 3 feet of the patient
• Airborne Infection Isolation – Particulate respirator (Negative pressure isolation room also required)

In some instances, healthcare personnel is required to wear PPE in addition to that recommended for Standard Precautions. The three Expanded Precaution categories (formerly called transmission-based precautions) where this applies are Contact and Droplet Precautions and Airborne Infection Isolation.

Contact Precautions requires gloves and gown for contact with the patient and/or the environment of care; in some instances, use of this PPE is recommended for even entering the patient’s environment.  Droplet Precautions requires the use of a surgical mask, and Airborne Infection Isolation requires that only a respirator be worn.

Hand Hygiene

• Required for Standard and Expanded Precautions
• Perform…
• Immediately after removing PPE
• Between patient contacts
• Wash hands thoroughly with soap and water or use alcohol-based hand rub

Hand hygiene is an essential infection control practice to protect patients, healthcare personnel, and visitors and is required for both Standard and Expanded Precautions. Hand hygiene should be performed immediately after removing PPE, even during PPE changes and removal if necessary, and between patient contacts. Wash your hands thoroughly with soap and warm water or, if hands are not visibly soiled, use an alcohol-based hand rub.

Conclusion: PPE Use in Healthcare Settings: Final Thought

PPE is available to protect you from exposure to infectious agents during healthcare. It is important that you know what type of PPE is necessary for the procedures you perform AND that you use it correctly.