PPE : precautions, procedures and resources for safe use

PPE
PERSONAL PROTECTIVE EQUIPMENT
Precautions, procedures and resources for safe use.

SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)
The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE.
1. GOWN
Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back
Fasten in back of neck and waist
2. MASK OR RESPIRATOR
Secure ties or elastic bands at middle of head and neck
Fit flexible band to nose bridge Fit snug to face and below chin Fit-check respirator
3. GOGGLES OR FACE SHIELD
Place over face and eyes and adjust to fit

4. GLOVES
Extend to cover wrist of isolation gown

USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION
Keep hands away from face Limit surfaces touched Change gloves when torn or heavily contaminated Perform hand hygiene

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HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1

There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence:
1. GLOVES
Outside of gloves are contaminated! If your hands get contaminated during glove removal, immediately
wash your hands or use an alcohol-based hand sanitizer Using a gloved hand, grasp the palm area of the other gloved hand
and peel off first glove Hold removed glove in gloved hand Slide fingers of ungloved hand under remaining glove at wrist and
peel off second glove over first glove Discard gloves in a waste container

2. GOGGLES OR FACE SHIELD
Outside of goggles or face shield are contaminated!
If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer
Remove goggles or face shield from the back by lifting head band or ear pieces
If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container

3. GOWN
Gown front and sleeves are contaminated! If your hands get contaminated during gown removal, immediately
wash your hands or use an alcohol-based hand sanitizer Unfasten gown ties, taking care that sleeves don't contact your body
when reaching for ties Pull gown away from neck and shoulders, touching inside of gown only Turn gown inside out Fold or roll into a bundle and discard in a waste container

4. MASK OR RESPIRATOR
Front of mask/respirator is contaminated -- DO NOT TOUCH! If your hands get contaminated during mask/respirator removal,
immediately wash your hands or use an alcohol-based hand sanitizer Grasp bottom ties or elastics of the mask/respirator, then the ones at
the top, and remove without touching the front Discard in a waste container

5. WASH HANDS OR USE AN

ALCOHOL-BASED HAND SANITIZER

OR

IMMEDIATELY AFTER REMOVING

ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
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HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2

Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence:

1. GOWN AND GLOVES

A

Gown front and sleeves and the outside of gloves are contaminated!
If your hands get contaminated during gown or glove removal, immediately wash your hands or use an alcohol-based hand sanitizer
Grasp the gown in the front and pull away from your body so that the ties break, touching outside of gown only with gloved hands
While removing the gown, fold or roll the gown inside-out into a bundle
As you are removing the gown, peel off your gloves at the same time, only touching the inside of the gloves and gown with your bare hands. Place the gown and gloves into a waste container

B

C

D

E

2. GOGGLES OR FACE SHIELD
Outside of goggles or face shield are contaminated! If your hands get contaminated during goggle or face shield removal,
immediately wash your hands or use an alcohol-based hand sanitizer Remove goggles or face shield from the back by lifting head band and
without touching the front of the goggles or face shield If the item is reusable, place in designated receptacle for
reprocessing. Otherwise, discard in a waste container
3. MASK OR RESPIRATOR
Front of mask/respirator is contaminated -- DO NOT TOUCH! If your hands get contaminated during mask/respirator removal,
immediately wash your hands or use an alcohol-based hand sanitizer Grasp bottom ties or elastics of the mask/respirator, then the ones at
the top, and remove without touching the front Discard in a waste container
4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

OR

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
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Use of Cloth Face Coverings to Help Slow the Spread of COVID-19
How to Wear Cloth Face Coverings
Cloth face coverings should-- fit snugly but comfortably against the side of the face be secured with ties or ear loops include multiple layers of fabric allow for breathing without restriction be able to be laundered and machine dried without damage or
change to shape
CDC on Homemade Cloth Face Coverings
CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission.
CDC also advises the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others. Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.
Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the cloth face covering without assistance.
The cloth face coverings recommended are not surgical masks or N-95 respirators. Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance.
Should cloth face coverings be washed or otherwise cleaned regularly? How regularly?
Yes. They should be routinely washed depending on the frequency of use.
How does one safely sterilize/clean a cloth face covering?
A washing machine should suffice in properly washing a cloth face covering.
How does one safely remove a used cloth face covering?
Individuals should be careful not to touch their eyes, nose, and mouth when removing their cloth face covering and wash hands immediately after removing.

CS316353B 04/04/2020, 12:22 PM

cdc.gov/coronavirus

Sewn Cloth Face Covering
Materials
Two 10"x6" rectangles of cotton fabric Two 6" pieces of elastic
(or rubber bands, string, cloth strips, or hair ties)

Needle and thread (or bobby pin) Scissors Sewing machine

Tutorial
1. Cut out two 10-by-6-inch rectangles of cotton fabric. Use tightly woven cotton, such as quilting fabric or cotton sheets. T-shirt fabric will work in a pinch. Stack the two rectangles; you will sew the cloth face covering as if it was a single piece of fabric.

2. Fold over the long sides inch and hem. Then fold the

double layer of fabric over inch along the short sides

and stitch down.

fold

1/4 inch

stitch

6 inches

1/4 inch fold
1/2 inch

stitch 1/2 inch

10 inches

fold

fold

3. Run a 6-inch length of 1/8-inch wide elastic through the wider hem on each side of the cloth face covering. These will be the ear loops. Use a large needle or a bobby pin to thread it through. Tie the ends tight. Don't have elastic? Use hair ties or elastic head bands. If you only have string, you can make the ties longer and tie the cloth face covering behind your head.
thread through
knot

stitch

stitch

4. Gently pull on the elastic so that the knots are tucked inside the hem. Gather the sides of the cloth face covering on the elastic and adjust so the cloth face covering fits your face. Then securely stitch the elastic in place to keep it from slipping.

tuck in knot

stitch

stitch

Quick Cut T-shirt Cloth Face Covering (no sew method)
Materials
T-shirt Scissors

Tutorial
1.

2.

3.

67 inches

cut out

cut tie strings

Tie strings around neck, then over top of head.

78 inches

Bandana Cloth Face Covering (no sew method)

Materials

Bandana (or square cotton cloth approximately 20"x20") Coffee filter

Rubber bands (or hair ties) Scissors (if you are cutting your own cloth)

Tutorial

1.

2.

3.

Fold filter in center of folded bandana.
Fold top down. Fold bottom up.

cut coffee filter

4.

5.

6.

7.

Place rubber bands or hair ties about 6 inches apart.

Fold side to the middle and tuck.

This chart was configured to address crisis capacity (strategies that are not commensurate with standard U.S. standards of care. These measures, or a combination of these measures, may need to be considered during periods of known isolation, eye protection, gown, face mask/shield shortages, N95) usages as recommended by the CDC website.

Administrative Controls
Protective Personal Equipment

Administrative Activities to Reduce Spread and Infection

Use physical barriers such as glass or plastic windows at reception areas, curtains between patients, etc
Limit the number of patients going to hospitals or outpatient settings by screening patients for acute respiratory illness prior to non-urgent care or elective visits Consultation with clinical professional may be required to implement the aforementioned recommendation
Exclude all HCP not directly involved in patient care (e.g., dietary, housekeeping employees) Reduce face-to-face HCP encounters with patients (e.g., bundling activities, use of video
monitoring) Exclude visitors to patients with known or suspected COVID-19 Implement source control: Identify and assess patients who may be ill with or who may have
been exposed to a patient with known COVID-19 and recommend they use facemasks until they can be placed in an AIIR or private room. Cohort patients: Group together patients who are infected with the same organism to confine their care to one area Cohort HCP: Assign designated teams of HCP to provide care for all patients with suspected or confirmed COVID-19 Use telemedicine to screen and manage patients using technologies and referral networks to reduce the influx of patients to healthcare facilities

Quick Glance Medical PPE Chart

Indicated Use (given COVID related
Shortage)

Consideration when donning and/or doffing PPE

Optimizing Strategy

Eye



Protection



During care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures. During activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable.

HCP should take care not to touch their eye protection. If they touch or adjust their eye protection they must immediately perform hand hygiene. HCP should leave patient care area if they need to remove their eye protection. See protocol for removing and reprocessing eye protection below.





Definition of Optimization: Extended use of eye protection is the practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters. If there is no date available on the eye protection device label or packaging, facilities should contact the manufacturer. The user should visually inspect the product prior to use and, if there are concerns (such as degraded materials), discard the product. Extended use of eye protection can be applied to disposable and reusable devices. If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on. See protocol for removing and reprocessing eye protection below. Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through.

Gowns

Used for routine patient care in

Nonsterile, disposable patient isolation

healthcare settings, are appropriate gowns, which are used for routine

for use by HCP when caring for

patient care in healthcare settings, are

patients with suspected or

appropriate for use by HCP when caring

Use isolation gown alternatives that offer equivalent or higher

confirmed COVID-19.

for patients with suspected or confirmed protection

COVID-19.

Several fluid-resistant and

impermeable protective clothing

options are available in the

marketplace for HCP. These include

isolation gowns and surgical gowns.

Facemasks


FDA-cleared surgical masks are



designed to protect against splashes

and sprays and are prioritized for

use when such exposures are



anticipated, including surgical

procedures.

Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

The facemask should be removed and

discarded if soiled, damaged, or hard to

breathe through.

HCP must take care not to touch their

facemask. If they touch or adjust their

facemask they must immediately

perform hand hygiene.

HCP should leave the patient care area if

they need to remove the facemask.



Definition of Optimization: Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters.
Restrict facemasks to use by HCP, rather than patients for source control.
Have patients with symptoms of respiratory infection use tissues or other barriers to cover their mouth and nose.

N95



Respirators

Use surgical N95 respirators only for HCP who need protection from both airborne and fluid hazards (e.g., splashes, sprays). If needed but

Implement just-in-time fit testing: Plan for larger scale evaluation, training, and fit testing of employees when necessary during a pandemic

Use respirators as identified by CDC as performing adequately for healthcare delivery

unavailable, use face shield over standard N95 respirator.

Cloth Face CDC recommends wearing fit snugly but comfortably against the

Coverings

cloth face coverings in public

side of the face

settings where other social

be secured with ties or ear loops

distancing measures are difficult to include multiple layers of fabric

maintain (e.g., grocery stores and allow for breathing without restriction

pharmacies), especially in areas

of significant community-based

transmission

Use respirators approved under standards used in other countries that are similar to NIOSH-approved respirators beyond the manufacturer-designated shelf life
Implement limited re-use of N95 respirators by one HCP for multiple encounters with different patients, but remove it after each encounter
Prioritize the use of N95 respirators and facemasks by activity type with and without masking symptomatic patients
be able to be laundered and machine dried without damage or change to shape

STRATEGIES TO OPTIMIZE PPE
CONTACT PRECAUTIONS
When individuals are on Contact Precautions meaning a condition that can be contracted through touching or contact wear Gloves and Gown (if contact will be prolonged or exposure to large portion of the individual's body)
Handing something to an individual on contact precautions gloves
High contact activities such as Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing use glove and gown
DROPLET PRECAUTIONS
When individuals are on Droplet precaution such as the COVID 19 patient who is coughing wear mask, glove and gown. If available, a face shield over face mask will offer additional protection.
These PPE are protective when engaged in activities that place the care provider in close contact within 6 feet for up to 5 minutes such as helping with high contact activities - Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing
Ask the coughing person to cover their mouth by coughing into their sleeve. If available, person with coughing should wear a mask. If mask unavailable scarf or paper tissues or homemade mask any measure to control the source of droplets is helpful.
And always, always have person coughing engage in hand washing and care provider should also practice good hand hygiene.
AIRBORNE PRECAUTIONS
A COVID 19 positive patient who is getting a procedure such as nasopharyngeal swab will generate aerosol (a shower of droplets that can travel a greater distance). In these instances, N-95 mask under proper conditions of Fit testing, seal check and proper donning and removal is recommended.
Per CDC guidelines, routine care of a suspected or COVID -19 positive individual does not call for N 95 mask use.
Also, in times of limited supply of PPE alternates, reuse and extended use strategies for mask and gown may be used.

GLOVES
1. If no medical grade gloves are available, consider using non-medical gloves such as those used for food service. 4a
2. Extend the use of medical gloves for health care providers without changing the gloves between patients with the same infectious disease diagnosis or exposure and no other infections. Gloved hands can be cleaned between patients and at other times when hand hygiene would normally be performed during routine patient care. This is an extreme use situation. 4a
EYE PROTECTION
1. May use any goggles and face shields. 3
2. Clean inside first then outside with cleaner appropriate for medical devices with gloved hands.
3. Air dry
GOWNS4b
1. Cloth gown if no disposable gowns available can be laundered
2. If no gowns available, alternate options include: Reusable patient gowns, Reusable laboratory gowns, Disposable Aprons, Painter's Coveralls
FACE MASKS3
Individuals who are coughing do source control meaning decrease spread of droplets by using mask or face cover for the person coughing.
1. Face mask with elastic ear hooks may be reused.
2. Fold in half so that outside surface meet (it is the contaminated surface, so care should be taken not to touch this side) and store in breathable paper bag that can seal to decrease contamination. Label the bag with user name. Do not share with others. Keep for work alone.
3. If no face mask is available may use face shield if available by themselves or in combination with homemade masks.
4. If no face masks or face shield available Homemade masks offer some protection from droplets.
5. Extend use of masks during care for multiple patients for the shift. Do not touch outside of mask as it is the contaminated surface avoid adjusting mask after wearing, do hand hygiene often.

N-95 RESPIRATORS2
1. These are for health care workers who are likely to engage in close contact with COVID-19 positive individual.
2. Routine care does not require use of N-95 per CDC guidelines.
3. Reuse - Label a paper bag with staff name and date of first use. Drop the N-95 mask in after use for that shift. Do not touch the inside of respirator. This mask may be used after 5 days by the same individual. Hang the bag in a designated area to keep from contamination.
4. Extended use + Reuse - Staff may use same respirator between patients, through shift, put it in paper bag in designated area to ensure no contamination and use for the next shift max use 5 times before discard.
5. Do not share masks with others.
OTHER IDEAS TO CONSERVE PPE
1. Organize yourself before engaging in patient care activity to maximize tasks that may be completed and minimize trips between patient care area and sterile or non-contaminated areas.
2. Cluster activities as much as possible, so PPE donning (putting it on) and doffing (taking it off) is minimized.
3. Decrease med pass to no more than 2 a day, ideal if only one med pass; combine med pass activity with other needed patient care task.
4. Designated staff to complete tasks that require PPE, so that PPE use is restricted to that one or two individuals rotate so task distribution is fair.
5. Review workflow to see if reorganization allows for minimal PPE use.
6. Judicious suspension of rules. For example if Individuals are not allowed to keep medication with them, but may have medication boxes prepared for them, so they can self-administer meds under supervision this may eliminate staff from using a PPE other than to prepare med boxes for all individuals.
7. Avoid using PPE as an anxiety reducing tool meaning using a mask and Glove when it is not indicated in order to feel enhanced protection.
8. PPE is not a substitute for hand hygiene.

Personal Protective Equipment Quick Reference: CRC/ DAS/Admission Center
Checking temperature and assessing unscreened individuals: Facemask & Gloves
Fever ( 100.4F) and/or Cough: Facemask, Gloves, Eye Protection,
Gown*
* = If Available Persons-served with fever or cough should be given a facemask if supplies are adequate.
Personal Protective Equipment Definitions: Facemask: Any standard facemask or N95 respirator (N95 only if available AND wearer has undergone formal fit-testing) Gloves: Any medical exam gloves, perform hand hygiene after removal Eye Protection: Goggles or a disposable face shield that covers the front and sides of the face (NOT personal eyeglasses) Gown: disposable garment that completely covers the wearer's arms and personal clothing
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Personal Protective Equipment Quick Reference: Outpatient/Office

Fever ( 100.4F) and/or Cough?

No

No Personal Protective Equipment Needed,

Maintain 6-foot distance from client when

possible

Yes, Within 6 feet AT ANY TIME

Yes, NEVER within 6 feet

Facemask, Gloves, Eye Protection, Gown*

Facemask, Gloves & Eye Protection*

* = If Available, Injections may be performed without gown if necessary Persons-served with fever or cough should be given a facemask if supplies are adequate.

Personal Protective Equipment Definitions: Facemask: Any standard facemask or N95 respirator (N95 only if available AND wearer has undergone formal fit-testing) Gloves: Any medical exam gloves, perform hand hygiene after removal Eye Protection: Goggles or a disposable face shield that covers the front and sides of the face (NOT personal eyeglasses) Gown: disposable garment that completely covers the wearer's arms and personal clothing
PITTSBURGH MERCY
A MEMBER OF TRINITY HEALTH, SERVING IN THE TRADITION OF THE SISTERS OF MERCY

Personal Protective Equipment Quick Reference: Client's Home/Shelter

Fever ( 100.4F) and/or Cough?

No Personal Protective Equipment Needed,

No

Maintain 6-foot distance from client when

possible, may perform vitals and injections

without Protective Equipment

Yes, Within 6 feet AT ANY TIME

Yes, NEVER within 6 feet

Facemask, Gloves, Eye Protection, Gown* Maintain 6-foot distance when possible

Facemask, Gloves, Eye Protection*

* = If Available, Injections may be performed without gown if necessary Persons-served with fever or cough should be given a facemask if supplies are adequate.

Personal Protective Equipment Definitions: Facemask: Any standard facemask or N95 respirator (N95 only if available AND wearer has undergone formal fit-testing) Gloves: Any medical exam gloves, perform hand hygiene after removal Eye Protection: Goggles or a disposable face shield that covers the front and sides of the face (NOT personal eyeglasses) Gown: disposable garment that completely covers the wearer's arms and personal clothing
PITTSBURGH MERCY
A MEMBER OF TRINITY HEALTH, SERVING IN THE TRADITION OF THE SISTERS OF MERCY

Personal Protective Equipment Quick Reference: Residential

Fever ( 100.4F) and/or Cough?
Yes, Within 6 feet AT ANY TIME

No

No Personal Protective Equipment Needed,

Maintain 6-foot distance from client when

possible, may perform personal care and

injections without Protective Equipment

Yes, NEVER within 6 feet

Facemask, Gloves, Eye Protection, Gown*
Maintain 6-foot distance when possible
Gown is highly recommended if performing ANY personal care, ambulatory assistance,
or changing linens

Facemask, Gloves, Eye Protection*

* = If Available, Injections may be performed without gown if necessary Persons-served with fever or cough should be given a facemask if supplies are adequate.

Personal Protective Equipment Definitions: Facemask: Any standard facemask or N95 respirator (N95 only if available AND wearer has undergone formal fit-testing) Gloves: Any medical exam gloves, perform hand hygiene after removal Eye Protection: Goggles or a disposable face shield that covers the front and sides of the face (NOT personal eyeglasses) Gown: disposable garment that completely covers the wearer's arms and personal clothing
PITTSBURGH MERCY
A MEMBER OF TRINITY HEALTH, SERVING IN THE TRADITION OF THE SISTERS OF MERCY

Sources: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
PITTSBURGH MERCY
A MEMBER OF TRINITY HEALTH, SERVING IN THE TRADITION OF THE SISTERS OF MERCY

RESOURCES
1. The discussion under `Fit Under Fire' section https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/
2. NETEC webinar March 27th Extended use, Reuse and decontamination strategies https://youtu.be/Md2Qb3cdyeM
3. CDC guidance Crisis capacity strategy https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html
4. Letter from FDA a. https://www.fda.gov/medical-devices/letters-health-care-providers/medical-glove-
conservation-strategies-letter-health-care-providers b. https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-
gown-conservation-strategies-letter-healthcare-providers
5. World Health Organization (WHO) https://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf

RETURN TO WORK PROCEDURES
Return to work for staff after confirmed COVID -19 or suspected COVID -19
No fever for 3 days without fever reducing medication AND Improvement in respiratory symptoms AND At least 7 days from initial symptom
After return to work,
Staff should wear a mask until 14 days from onset of symptoms, continue self-monitoring and follow infection control guidance.
Return of patients from quarantine
Can return to patient community after 14 days
Return of patients from Isolation (ill from COVID-19)
Same as staff return to work after confirmed or suspected COVID-19