Personal Protective Equipment In Health Care
Use of Protective Barriers
Use of Protective Barriers
Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear. Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needles or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes.
Universal precautions are intended to supplement rather than replace recommendations for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands. Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised.
The risk of nosocomial transmission of HIV, HBV, and other bloodborne pathogens can be minimized if health-care workers use the following general guidelines:
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Do not recap used needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant containers for disposal. Locate the puncture-resistant containers as close to the use area as is practical.
Use protective barriers to prevent exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated.
Immediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply.
Glove Use for Phlebotomy
Gloves should reduce the incidence of blood contamination of hands during phlebotomy (drawing blood samples), but they cannot prevent penetrating injuries caused by needles or other sharp instruments. The likelihood of hand contamination with blood containing HIV, HBV, or other bloodborne pathogens during phlebotomy depends on several factors: 1) the skill and technique of the health-care worker, 2) the frequency with which the health-care worker performs the procedure (other factors being equal, the cumulative risk of blood exposure is higher for a health-care worker who performs more procedures), 3) whether the procedure occurs in a routine or emergency situation (where blood contact may be more likely), and 4) the prevalence of infection with bloodborne pathogens in the patient population. The likelihood of infection after skin exposure to blood containing HIV or HBV will depend on the concentration of virus (viral concentration is much higher for hepatitis B than for HIV), the duration of contact, the presence of skin lesions on the hands of the health-care worker, and -- for HBV -- the immune status of the health-care worker. Although not accurately quantified, the risk of HIV infection following intact skin contact with infective blood is certainly much less than the 0.5% risk following percutaneous needlestick exposures. In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low.
Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply:
Use gloves for performing phlebotomy when the health-care worker has cuts, scratches, or other breaks in his/her skin.
Use gloves in situations where the health-care worker judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative patient.
Use gloves for performing finger and/or heel sticks on infants and children.
Use gloves when persons are receiving training in phlebotomy.
The Center for Devices and Radiological Health, FDA, has responsibility for regulating the medical glove industry. Medical gloves include those marketed as sterile surgical or nonsterile examination gloves made of vinyl or latex. General purpose utility ("rubber") gloves are also used in the health-care setting, but they are not regulated by FDA since they are not promoted for medical use. There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. Thus, the type of gloves selected should be appropriate for the task being performed.
The following general guidelines are recommended:
Use sterile gloves for procedures involving contact with normally sterile areas of the body.
Use examination gloves for procedures involving contact with mucous membranes, unless otherwise indicated, and for other patient care or diagnostic procedures that do not require the use of sterile gloves.
Change gloves between patient contacts.
Do not wash or disinfect surgical or examination gloves for reuse. Washing with surfactants may cause "wicking," i.e., the enhanced penetration of liquids through undetected holes in the glove. Disinfecting agents may cause deterioration.
Use general-purpose utility gloves (e.g., rubber household gloves) for housekeeping chores involving potential blood contact and for instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused but should be discarded if they are peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration.
Waste Management
Universal precautions are not intended to change waste management programs previously recommended by CDC for health-care settings. Policies for defining, collecting, storing, decontaminating, and disposing of infective waste are generally determined by institutions in accordance with state and local regulations. Information regarding waste management regulations in health-care settings may be obtained from state or local health departments or agencies responsible for waste management.
Note: Implementation of universal precautions does not eliminate the need for other category- or disease-specific isolation precautions, such as enteric precautions for infectious diarrhea or isolation for pulmonary tuberculosis. In addition to universal precautions, detailed precautions have been developed for the following procedures and/or settings in which prolonged or intensive exposures to blood occur: invasive procedures, dentistry, autopsies or morticians' services, dialysis, and the clinical laboratory.
Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare
Personal Protective Equipment Definition
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.
Regulations and Recommendations for PPE
OSHA issues workplace health and safety regulations. Regarding PPE, employers must:
Provide appropriate PPE for employees
Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and stored after use
OSHA also specifies circumstances for which PPE is indicated
CDC recommends when, what and how to use PPE
OSHA issues regulations for workplace health and safety. These regulations require use of PPE in healthcare settings to protect healthcare personnel from exposure to bloodborne pathogens and Mycobacterium tuberculosis. However, under OSHAs 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 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 presentation will cover those recommendations, beginning with the hierarchy of safety and health controls.
Hierarchy of Safety and Health Controls
Training and administrative controls
Engineering controls
Work practice controls
Personal protective equipment
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 to healthcare worker safety programs. First are training, such as youre 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.
Types of PPE Used in Healthcare Settings
Gloves protect hands
Gowns/aprons protect skin and/or clothing
Masks and respirators protect mouth/nose
Respirators protect respiratory tract from airborne infectious agents
Goggles protect eyes
Face shields protect face, mouth, nose, and eyes
All of the PPE listed here prevent 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 airborne transmission of infectious agents.
Factors Influencing PPE Selection
Type of exposure anticipated
Splash/spray versus touch
Category of isolation precautions
Durability and appropriateness for the task
Fit
When you are selecting PPE, consider three key things:
First is 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, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on.
Second, and very much linked to the first, is 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.
Third is fit. (optional question) How many of you have seen someone trying to work in PPE that is too small or large? 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 nonsterile
One or two pair
Single use or reusable
Gloves are the most common type of PPE used in healthcare settings. There are several things to consider when selecting the right glove for a specified purpose.
Purpose patient care, environmental services, other
Glove material vinyl, latex, nitrile, other
Sterile or non-sterile
One or two pair
Single use or reusable
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 users 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.
Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive patient procedures. During some surgical procedures, two pair 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.
Dos and Donts of Glove Use
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 dos 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
During use if torn and when heavily soiled (even during use on the same patient)
After use on each patient
Discard in appropriate receptacle
Never wash or reuse disposable 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
There are three factors that 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 a spun synthetic material that dictate whether they can be laundered and reused or must be disposed. 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 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 purposes of patient and healthcare worker protection.
Face Protection
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. 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.
Face Protection
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
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 CDCs 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. However, if a bronchoscopy is performed on the patient
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