Any bodily fluid has the potential to be infectious and needs to be treated as such. It’s up to every health care worker to take universal precautions to prevent the spread of infectious diseases. As a health care worker, it is done by wearing personal, protective equipment (PPE). Wearing proper PPE will protect you from coming into contact with bodily fluids as you perform patient care tasks, it will also help stop the transmission of pathogens from person to person.
The Center for Disease Control (CDC) first published an infectious disease manual back in 1970 that depicted isolation techniques for community hospitals as well as teaching hospitals. By the mid-70s, most of the hospitals in the US were using the included guidelines for PPE. Then again in the 80s during the AIDS epidemic, the increased use of gloves, gowns, and masks really set the standards for patient care as we know it.
PPE Main Components
PPE most often includes the use of gloves, masks, gowns, and face shields. Most commonly, they are single-use items meant to be worn once and then disposed of, not to be worn more than once. Having single-use items reduces the risk of transmitting infectious diseases from patient to patient. Also, donning and doffing PPE in a methodical way will ensure that microorganisms will be left on the PPE and not transferred to the wearer. Removing your PPE must be done in a way that will not expose others to the infectious agents.
Knowing what PPE to use, and when to use it, may be confusing to some as facilities can have different guidelines. Double-check with your institution’s policies regarding PPE or ask your supervisor if you are unsure. In general, if you think there is a possibility of coming in contact with bodily fluids, it’s smart to don PPE.
The first step in wearing gloves correctly is proper handwashing. Wash with warm water and a disinfectant soap for 20 seconds. Dry with a single-use towel. Make sure you have the correct size of gloves for your hands, and that rings are either off or don’t have high sharp edges that can puncture through them. The ends should sit just above your wrist bone.
To remove gloves safely, pinch the outside of the glove without touching your bare skin and pull off the glove and hold the dirty glove in the gloved hand. With your bare finger, insert it at the wrist of the gloved hand and turn the gloves inside out. The CDC has an excellent easy chart for reference.
Make sure your nose and mouth are properly covered under your disposable mask. Most commonly used are the elastic earloop style face covering. Tie strings are also used in health care settings so you may see those as well.
To remove, simply place a clean finger behind your ear and remove the mask on each side by only holding the earloops. Place the mask in the receptacle and wash your hands. While wearing a mask to perform a procedure, make sure not to contaminate the outside of your mask by touching it with gloved hands. The same goes for eye protection if it is being used.
Gowns are not used as often in daily patient care, but they are used in situations where splashing of bodily fluids may occur. They are generally a one-size-fits-all type of gown, with ties in the back. Again remember to put them on with clean ungloved hands. When removing the gown, release the ties and pull from one shoulder to the other and roll the exposed part of the gown into a ball off of your body and discard.
Other Forms of PPE
Other PPE can involve the use of glasses or goggles to prevent droplets from going into your eyes. Just make sure they fit with a proper seal around and clean them in between uses.
Face shields are thin, clear plastic sheets that can be worn to cover a person’s entire face from splashes and droplets. Many physicians and nurses were using them while intubating patients during the recent COVID-19 pandemic.
PPE Use and Reuse Guidelines During PPE Shortages
The COVID-19 pandemic has seen a drastic shortage in PPE supplies across the country and the world. That’s led to many facilities and health care professionals trying to find ways to prolong the use of available PPE and find the best ways to reuse it when supplies are critically low.
In light of emergency events, the Centers for Disease Control and Prevention (CDC) released the following guidelines on optimizing PPE usage during supply shortages. Facilities and health care professionals should take into account normal PPE usage policies as well as extended use policies when protecting themselves and our patients.
Gloves are the most commonly used items of PPE in health care. In general, gloves should be changed between every patient, although the CDC has released guidelines on extended use for gloves if glove supplies are critically low. Disposable gloves should always be discarded if they fall into the following criteria listed by the CDC:
- If the gloves are visibly soiled with body fluids
- If there are any signs of damage or degradation
- If they have been used for a maximum of four hours
- If they have been used and removed.
Always wash your hands or use alcohol-based hand sanitizer whenever you take off your gloves, no matter the reason. This includes even if you’re going to put on a new pair of gloves immediately after.
Facemasks include surgical masks, which are regulated by the FDA, and other procedural masks that are sometimes not regulated. The CDC’s guidelines on how to use facemasks include the following:
- Discard the facemask if it’s visibly soiled, damaged, or difficult to breathe through
- If you touch or adjust your facemask, wash your hands with soap and water or an alcohol-based hand sanitizer
- If you are in a patient care area and need to remove your facemask, leave the area before removal.
Facemasks can be reused so long as they are intact and not visibly soiled or damaged, and if they are not difficult to breathe through. To store in between uses, follow the CDC’s recommended guidelines on facemask reusage:
- Carefully remove the mask when outside of patient care areas so that you do not touch the mask itself and only touch the ties or ear hooks.
- Fold the mask so the outer surface is facing inward towards itself so that it won’t touch anything else while being stored.
- Store the mask in a clean and sealable paper bag or in a breathable container.
How long facemasks can be reused varies by state or facility but is normally one full shift or several days, depending on supplies.
The CDC’s recommendations for reusing N95 respirators include the following:
- N95 respirators should be discarded based on discard policies listed in the section below.
- These PPE should be stored in a breathable paper bag or hung in a designated storage area between uses. Storage areas should be clearly labeled so respirators do not get mixed up.
- N95 respirators should be stored for 72 hours or more between uses to exceed the estimated survival time for SARS-CoV2.
Discard the N95 respirator in the following situations:
- The respirator is visibly contaminated with any bodily fluids
- If it was damaged
- It was used for any aerosol-generating procedure
- If it was used during any close contact with any patient who has an infectious disease that requires contact precautions
For any eye protection PPE such as face shields, the CDC recommends the following:
- Discard the eye protection if it is damaged
- If the eye protection is visibly soiled, remove and reprocess it and keep it dedicated to the same health care professional
- Before removing eye protection, leave patient care areas
- Do not touch your eye protection, and if you do, wash your hands with soap and water or use alcohol-based hand sanitizer
After use when storing eye protection or when it’s visibly soiled and needs to be reprocessed, follow the manufacturer’s instructions on how to clean and disinfect the eye protection. The CDC’s general instructions for cleaning and disinfecting are as follows:
- “While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.
- Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.
- Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.
- Fully dry (air dry or use clean absorbent towels).
- Remove gloves and perform hand hygiene.”
For extended use and reuse of isolation gowns, the CDC has the following recommendations:
- For extended use, the same HPC should be the only one to use the gown, and it should only be used between multiple patients if patients are known to have the same infectious disease and they’re in the same location.
- Discard gowns if they get visibly soiled or are damaged.
- Disposable gowns should not generally be taken off and stored to be reused, because they can easily be damaged at the ties.
- Cloth gowns should be laundered in between uses.
The ways in which a facility uses PPE won’t vary too far on the spectrum. However, the facility needs to have documented procedures in place so that everyone is aware of what is expected, and infection control is the anticipated outcome. The CDC and the Joint Commission are great resources and continue to set the standard for the expected uses of PPE professionally and now in our daily interactions since COVID-19.
When onboarded by a facility, the expectations for PPE usage should be reviewed with every health care worker so that that compliance is expected. As a nurse, you can expect disciplinary action for not following PPE requirements, and your facility could face fines if employees are caught by the Joint Commission. It’s important that every facility has a system of checks and balances to keep patients and their employees safe.