Personal Protective Equipment

Objective
•  Choose appropriate Personal Protective
Equipment (PPE) equipment and use without
contamination
•  Handouts/Materials:
–  One set of WHO recommended PPE for each person
–  Water based paint (red)
–  Step-by-step guide (photocopy)
–  Competency Checklist (photocopy)
 PPE

INTRODUCTION

December 19, 2014

Prior to entering the patient isolation rooms/
areas, ensure that all visitors and health-
care workers rigorously use personal
protective equipment (PPE) and perform
hand hygiene.

-WHO 2014
 PPE Guidance

•  PPE recommendations similar between

organizations (MSF, CDC, WHO)
•  Adaptations and discussions are ongoing

•  3 Important Principles:
•  Principle #1: Rigorous and repeated
training
•  Principle #2: No skin exposure when PPE
is worn
•  Principle #3: Trained monitor
CDC 2014 http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

 Principle #1:
Rigorous and repeated training
•  Focusing only on PPE gives a false sense of
security of safe care and worker safety.
•  Training is critical to ensure infection control.
–  Ensure all HCWs practice numerous times
–  Make sure HCWs understand how to appropriately
use the equipment
–  Especially the step by step donning and doffing of
PPE

CDC 2014 http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

 Principle #2:
No skin exposure when PPE is worn
•  Two specific, recommended PPE options with equivalent
protection if worn, donned and doffed correctly:
–  coverall/body suit
–  N-95/PAPR
•  Designated areas for putting on and taking off PPE
–  Ensure that space and lay-out allows for clear separation between
low-risk and high-risk areas
•  Step-by-step PPE removal instructions including:
–  Disinfecting visibly contaminated PPE using an 1:10 bleach
disinfectant wipe prior to taking off equipment
–  Disinfection of gloved hands using either an 1:10 bleach
disinfectant wipe or alcohol-based hand sanitizer between steps of
taking off PPE

CDC 2014 http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

 Principle #2:
No skin exposure when PPE is worn
PPE recommended for healthcare workers caring for
patients with Ebola includes:
–  Double gloves
–  Boot covers or fluid resistant boots
–  Coverall:
•  Single use fluid resistant or impermeable.
–  Respirators, including either N95 respirators or powered
air purifying respirator(PAPR)
–  Full-face shield or goggles
–  Hoods to ensure complete coverage of the head and neck
–  Apron that is waterproof and covers the torso to the level
of the mid-calf
CDC 2014; Images Johns
Hopkins Health System

 Principle #3: Trained monitor

•  CDC is recommending a trained monitor

–  Actively observe and supervise each worker taking
PPE on and off
–  To ensure each worker follows the step by step
processes, especially to disinfect visibly contaminated
PPE
–  Can spot any missteps in real-time and immediately
address

CDC 2014 http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

PPE
•  Nurse.com, 10/31/14
–  “The idea of a trained observer highlights some
practices we should be doing every day,” “There are
many more things that could be on the horizon when
it comes to infection, and the CDC’s new guidelines
are a reminder that we have the ability to watch out
for each other. Small decisions like pointing out
an error or reminding someone about something
can mean the difference in infection and
prevention.”
Linda Greene, MPS, RN, CIC, an infection prevention manager at Highland Hospital
in Rochester, N.Y., and a member of the regulatory review panel for the Association
for Professionals in Infection Control and Epidemiology.
Use of a Trained Observer

•  The sequence and actions involved in each donning and doffing

step are critical to avoiding exposure, a trained observer:
–  will read aloud to the healthcare worker each step in the procedure
checklist and visually confirm and document that the step has been
completed correctly.
•  The trained observer is a dedicated individual with the sole
responsibility of ensuring adherence to the entire donning and
doffing process.
•  The trained observer will be knowledgeable about all PPE
recommended in the facility’s protocol and the correct donning and
doffing procedures, including disposal of used PPE, and will be
qualified to provide guidance and technique recommendations to the
healthcare worker.
•  The trained observer will monitor and document successful donning
and doffing procedures, providing immediate corrective instruction if
the healthcare worker is not following the recommended steps.
•  The trained observer should know the exposure management plan
in the event of an unintentional break in procedure.
Recommended PPE for Trained Observer
during Observations of PPE Doffing
•  The trained observer should not enter the room of a patient with Ebola, but
will be in the PPE removal area to observe and assist with removal of
specific components of PPE.
•  The observer should not participate in any Ebola patient care activities while
conducting observations.
•  The following PPE are recommended for trained observers:
–  Single-use (disposable) fluid-resistant or impermeable gown that extends to at
least mid-calf or coverall without integrated hood.
–  Single-use (disposable) full face shield.
–  Single-use (disposable) nitrile examination gloves with extended cuffs. Two
pairs of gloves should be worn. At a minimum, outer gloves should have
extended cuffs.
–  Single-use (disposable) fluid-resistant or impermeable shoe covers or fluid-
resistant boots
•  Trained observers should don and doff selected PPE according to standard
procedures.
•  If the trained observer assists with PPE doffing, then the trained observer
should disinfect outer-gloved hands with an Bleach disinfectant wipe or
ABHR immediately after contact with healthcare worker’s PPE.
 More than PPE is needed
•  PPE is Only One Aspect of Infection Control
•  It is critical to focus on other prevention activities
to halt the spread of Ebola in healthcare
settings, including:
–  Prompt screening and triage of potential patients
–  Designated site managers to ensure proper
implementation of precautions
–  Limiting personnel in the isolation room
–  Effective environmental cleaning

CDC 2014 http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

 PPE COMPONENTS

December 19, 2014

Under the PPE
For wearing in low-risk area
•  Scrub suit (washable or
disposable)
•  Covered toes, fluid and
puncture resistant boots

Launder scrubs and clean

boots at health facility
Gloves
•  Intended to prevent skin contact with hazardous
substances, e.g. body fluids

•  Do not reuse disposable gloves

•  Double gloves are recommended

•  Gloves with long cuffs offer more protection

•  Use correct size

•  Apply hand hygiene to soiled gloves as soon as possible

to avoid transfer of microorganisms to other patients or
environments.
Slide adapted from World Health Organization

Boot Covers
•  Protects the boot from gross contamination
•  Fluid resistant or impermeable

•  Remove carefully by stepping on the back of the boot cover

and only touch the inside of the covers once removed

Slide adapted from World Health Organization

Coverall or Body Suit

•  Protects skin
•  Prevents soiling of clothing
•  Fluid resistant or impermeable

•  Remove a soiled garment as promptly as possible and apply

hand hygiene to avoid transfer of microorganisms to other
environments.

Slide adapted from World Health Organization

Apron
Apron protects front of coverall from gross contamination with
infectious body fluids resulting in safer removal
Essential if:
•  Strenuous activity with risk of disrupting the coverall
•  Large amount of blood and body fluids expected

Slide adapted from World Health Organization

Mask

•  Protects the mucosa of nose and mouth from

droplets, spills and splashes
–  Wear masks tightly to the face
–  Discard immediately after use
–  If wet or dirty with secretions, it must be changed
promptly (ie must leave high risk area and remove PPE)
Aerosol Generating Procedures

•  Wear a respirator for any procedures that stimulate

coughing or promote generation of aerosols
•  Different models available
•  Aerosols
–  Tiny particles < 5 µm
–  Float on air currents for long distances

Source: World Health Organization 2014

 Aerosol Generating Procedures

•  Aerosol generating procedures include:

–  Aerosolized or nebulized medication administration
–  Diagnostic sputum induction
–  Bronchoscopy
–  Airway suctioning
–  Intubation
–  Positive pressure ventilation via facemask
•  For Ebola patient, avoid as much as possible due to
potential for virus to become aerosolized

Source: World Health Organization 2014

Fit test ≠ seal check

•  Fit test evaluates the existence of leaks at the moment it is

performed for the model being tested
–  The conditions during the test may not be the same as "real life"
–  In the real life the type of respirator may differ from the one fit tested
•  Seal check
–  helps check if the respirator is well adjusted to the face
–  should be done before EACH USE
•  Users should be trained on how to use the respirator

Slide used with permission from World Health Organization

 Particulate Respirator Seal Check
•  Cup the respirator in your hand
with the nosepiece at your
fingertips allowing the headbands
to hang freely below your hand

•  Position the respirator under your

chin with the nosepiece up

Slide used with permission from World Health Organization

Particulate Respirator Seal Check

Pull the top strap over your head resting it

high at the back of your head. Pull the
bottom strap over your head and position
it around the neck below the ears

Place fingertips of both hands at the top of

the metal nosepiece. Mold the nosepiece
(USING TWO FINGERS OF EACH HAND)
to the shape of your nose. Pinching the
nosepiece using one hand may result in
less effective respirator performance

Slide used with permission from World Health Organization

 Particulate Respirator Seal Check
DO THIS
EACH TIME
YOU PUT
Cover the front ON
of the respirator with
both MASK
hands, being

careful not to disturb
the position of respirator

Positive seal check Negative seal check

§  Exhale sharply. A positive
pressure inside the respirator =
no leakage. If leakage, adjust
position and/or tension straps.
§  Retest the seal and repeat the
steps until respirator is sealed
properly
Slide used with permission from World Health Organization
§  Inhale deeply. If no leakage, negative
pressure will make respirator cling to
your face
§  Leakage will result in loss of negative
pressure in the respirator due to air
entering through gaps in the seal
Eye protection

Visor Goggles

Face shield
 PPE USE

December 19, 2014

 Designating Areas for PPE Donning and Doffing

•  Facilities should ensure that space and layout allow for clear
separation between high risk and low risk areas.
•  It is critical that physical barriers (e.g., plastic enclosures) be used
where necessary, along with visible signage, to separate distinct
areas and ensure a one-way flow of care moving from low risk areas
(e.g., area where PPE is donned and unused equipment is stored)
to the patient room and to the PPE removal area (area where PPE is
removed and discarded).
•  Post signage to highlight key aspects of PPE donning and doffing,
including:
–  Designating low risk vs high risk areas
–  Reminding healthcare workers to wait for a trained observer before
removing PPE
–  Reinforcing need for slow and deliberate removal of PPE to prevent self-
contamination
–  Reminding healthcare workers to perform disinfection of gloved hands in
between steps of the doffing procedure.

December 19,
Designate the following areas with
appropriate signage:

•  PPE Storage and Donning Area

–  This is an area outside the Ebola patient room (e.g., a
nearby vacant patient room, a marked area in the
hallway outside the patient room) where clean PPE is
stored and where healthcare workers can don PPE
before entering the patient’s room.
–  Do not store potentially contaminated equipment,
used PPE, or waste removed from the patient’s room
in this area.
–  Waste must not pass through this area, if it does it
must be properly contained.
 Preparation and Planning

•  Prepare designated area to put on PPE(in

low-risk)
•  Guarantee hand hygiene facility
•  Guarantee recommended PPE
–  Adequate supplies
–  Adequate space to put on
 PPE Removal Area

•  This is an area in proximity to the patient’s room (e.g., anteroom or

adjacent vacant patient room that is separate from the clean area)
where healthcare workers leaving the patient’s room can doff and
discard their PPE.
•  Some steps of the PPE removal process may be performed in a
clearly designated area of the patient’s room near the door, provided
these steps can be seen and supervised by a trained observer (e.g.,
through a window such that the healthcare worker doffing PPE can
still hear the instructions of the trained observer).
•  Do not use this clearly designated area for any other purpose.
•  Stock gloves in a clean section of the PPE removal area accessible
to the healthcare worker while doffing.
PPE Removal Area

•  In the PPE removal area, provide supplies for disinfection of PPE

and for performing hand hygiene and space to remove PPE.
•  Provide leak-proof infectious waste containers for discarding used
PPE.
•  Perform frequent environmental cleaning and disinfection of the
PPE removal area, including upon completion of doffing procedure
by healthcare workers.
PPE Removal Area

•  If a facility must use the hallway outside the patient room as

the PPE removal area:
–  construct physical barriers to close the hallway to through traffic and
thereby create an anteroom
–  should make sure that this hallway space complies with fire-codes.
–  Restrict access to this hallway to essential personnel who are properly
trained on recommended infection prevention practices for the care of
Ebola patients.
•  Facilities should consider making showers available for use
by healthcare workers after doffing of PPE/end of shift.
PPE Use

•  Avoid reuse of disposable PPE items

–  Reprocessed disposable PPE may not provide the same
protective efficacy and safety as new PPE
–  Reuse may increase the risk of infection in HCWs

Slide used with permission from WHO

PPE Use if Supplies are Limited

•  If resources are limited and disposable PPE items

are not available
•  properly disinfect reusable items after each use
•  Avoid wastage:
–  Critically evaluate situations in which PPE is indicated
–  Batch clinical care during each entry to the patient's room
–  Work from suspect to confirmed cases
–  Work from clean to dirty procedures
–  Prioritize for scenarios that have been consistently associated with
increased risk of pathogen transmission
•  Use of unnecessary PPE should be avoided
–  Training is not unnecessary use

Slide used with permission from World Health Organization

December 19, 2014

 Occasions for additional PPE

•  Environmental cleaning
•  Handling Infectious Waste
•  Activities that might damage exam gloves

Source: World Health Organization 2014

Important Points about wearing PPE
for Ebola

Before entering the isolation room/area:

–  Collect all equipment needed (time out)
–  Go to bathroom
–  Perform hand hygiene
–  Put on PPE
•  in the order that ensures adequate placement of
PPE items
•  prevents self-contamination and self-inoculation
while using and taking off PPE
Slide used with permission from World Health Organization

 Important Points about wearing PPE
for Ebola
•  Instructions should
be displayed on the
wall.
•  Supervised by
another trained
member of the team
(buddy).
•  A mirror can also
help to check PPE

Slide used with permission from World Health Organization

Images: http://www.ibtimes.co.uk/ebola-liberia-photos-west-point-slum-sealed-prevent-spread-disease-1462247

 RE-PROCESSING PPE

December 19, 2014

 Cleaning PPE

•  If necessary clean visors, goggles, boots:

–  Wear PPE
–  Clean with soap and water to remove any organic
matter
–  Prepare 0.5% chlorine solution daily
–  Immerse PPE fully overnight (minimum 30 minutes)
–  Rinse thoroughly with water and dry
–  Initial cleaning materials = infectious waste
–  Disinfection solution = pour down drain

December 19, Reference: WHO, 2014

Image: who.int

How much PPE do I need?
Things to consider:
•  Duration of each entry (in PPE)
•  Estimated number of entries per shift
•  Number of people caring for patient per shift
•  Number of days for each patient

Additional considerations:
•  Lab and medical procedures per person
•  Time for re-processing of reusable PPE

ADD EXTRA 10% AS BUFFER UNEXPTECTED

 HEAT - RELATED ILLNESS

December 19, 2014

 Heat Related Illness

•  Heat illness is a serious risk while wearing PPE

in tropical conditions
•  It is preventable
•  Heat storage is the major cause
•  Hydration is important but will not affect heat
storage
•  Team protocols are required for:
•  Prevention
•  Heat illness monitoring
•  Heat illness treatment

Slide used with permission from World Health Organization

Heat storage

•  YOU MUST PACE YOURSELF AND NOT

OVER-EXERT
–  If you do not your core temp will rise rapidly and reach
critical levels in under one hour.
–  Plan your day
–  Limit time in PPE (45-1hr minutes)
–  Make sure you are hydrated

•  Symptoms are a continuum of mild to

moderate to severe and even life threatening
 Heat Related Illness Spectrum

System   Heat  Cramps   Heat  exhaus0on   Heat  stroke  

Temperature       >380C   >40.50C  
or  104.90  F  
Skin  Temperature   Normal   Normal  or  cool  and   Hot  and  dry  (50%  
clammy   cases)  

Sweat  Rate   Increased   Increased  or   Decreased  

decreased  
Urine  Output   Normal   Oliguria   Anuria  
GI   Thirst   Nausea  +/-­‐  vomiRng   Nausea  and  vomiRng  
CVS   Tachycardia   Hypotension   +/-­‐  Circulatory  
Collapse  
CNS   Nil   Uncoordinated,   Delirium/seizure/
Irritable  or  confused   coma  
Other   Thirst       Renal  Failure  
Liver  Failure  
DIC  
Resources
WHO 2014 Interim Infection Prevention and Control Guidance for Care
of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever
in Health-Care Settings, with Focus on Ebola
http://apps.who.int/iris/bitstream/10665/130596/1/
WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1

CDC 2014Guidance on Personal Protective Equipment To Be Used by

Healthcare Workers During Management of Patients with Ebola Virus
Disease in U.S. Hospitals, Including Procedures for Putting On
(Donning) and Removing (Doffing)
http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html