BARRIERS AND PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE) includes a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the patient interaction and/or the likely mode or modes of transmission.

Types of Personal Protective Equipment

PPE must be readily accessible to employees and available in appropriate sizes. It is important to know which type of PPE is available at work and where it is stored. To protect themselves, healthcare providers must have a barrier between them and any potentially infectious material.

Types of PPE used in healthcare settings include:

• Gloves
• Gowns/aprons/coveralls
• Face and eye protection
• Head coverings
• Boots/shoe covers
• Respirators

Factors that influence the selection of appropriate PPE include:

• Type of exposure anticipated:
  • Blood or body fluid splash/spray vs. touch
  • Contact with minimal bleeding/drainage/body substances
  • Contact with large volume bleeding/drainage/body substances that are likely to soak through the contact area
  • Category of isolation precautions (Contact, Droplet, Airborne)
• Durability and appropriateness for the task. This affects whether a gown or fluid-proof apron is selected, or if a gown is selected, whether it must be fluid-resistant, fluid-proof, or neither.
• Fit of the equipment. The employer must ensure that all PPE are available in sizes appropriate for the workforce to be protected.

(See also “Standard Precautions” earlier in this course for additional information related to PPE.)

GLOVES

Gloves are the most common type of PPE. They are used for patient care as well as environmental service. Gloves can be sterile or nonsterile and single use or reusable. Because of allergy concerns, latex products have been eliminated in many facilities, and materials used for gloves are mostly synthetics such as vinyl or nitrile.

Gloves can protect both patients and healthcare personnel from exposure to infectious material that may be carried on the hands. Nonsterile disposable medical gloves are available for routine patient care. The selection of glove type for nonsurgical use is based on the task that is to be performed and anticipated contact with chemicals and chemotherapeutic agents.

For contact with blood and body fluids during nonsurgical patient care, a single pair of gloves provides adequate barrier protection. However, there is considerable variability among gloves, and studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves. For this reason, either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity and/or will involve more than brief patient contact.

Most patient-care activities require the use of a single pair of nonsterile gloves. Vinyl gloves are frequently available and work well if patient contact is limited. However, some gloves do not provide a snug fit on the hand, especially around the wrist, and should be not used if extensive contact is likely. Gloves should not tear or damage easily and must stand up to the task.

Sterile surgical gloves are worn when performing invasive patient procedures. At times, two pairs of gloves may be worn during surgical procedures for additional protection.

Heavier, reusable utility gloves are indicated for non-patient-care activities such as handling or cleaning contaminated equipment or surfaces. Environmental service personnel often wear reusable heavy-duty gloves to work with caustic disinfectants.

Proper glove use includes:

• Performing hand hygiene before putting on gloves
• Putting gloves on last when being worn in combination with other PPE
• Working from clean to dirty
• Limiting touch contamination (e.g., adjusting eyeglasses, touching light switches, etc.) when wearing gloves that have been in contact with a patient
• Changing gloves during the care of a single patient to prevent cross-contamination of body sites or if patient interaction also involves touching portable keyboards or other mobile equipment that is transported from room to room
• Changing gloves during use if torn or when heavily soiled and after use on each patient
• Discarding gloves between patients and disposing of gloves in proper receptacle
• Performing hand hygiene following glove removal
• Never washing or reusing disposable gloves
  (CDC, 2019c)

GOWNS/APRONS

Clinical and laboratory coats or jackets worn over personal clothing are not considered PPE.

Isolation gowns are preferred, but aprons occasionally are used where limited contamination is expected. Gowns must fully cover the torso, fit comfortably over the body, and have long sleeves that fit snugly at the wrist.

The type of protection is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. Clean gowns are generally used for isolation precautions. Sterile gowns are needed only when performing invasive procedures.

For prevention of transmission of an infectious agent, donning of both gown and gloves upon room entry is indicated. Gowns are always worn in combination with gloves and with other PPE when indicated, and are usually the first piece of PPE to be donned. Full coverage of arms and body front from neck to the mid-thigh or below ensures that clothing and exposed body areas are protected.

FACE AND EYE PROTECTION

Face and eye protection are used during patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Two mask types are available for use: surgical masks and procedure or isolation masks.

Masks are used for three primary purposes:

• Worn by healthcare personnel to protect from contact with infectious material from patients
• Worn by healthcare personnel who are engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in the healthcare worker’s mouth or nose
• Placed on patients to limit potential dissemination of infectious respiratory secretions from the patient to others

Eye protection depends on the circumstances of exposure, other PPE used, and personal vision needs. Goggles protect the eyes and should fit over and around them snuggly. Personal prescription glasses are not a substitute for goggles. Some goggles have antifog features that improve clarity, and many styles of goggles fit adequately over prescription lenses with minimal gaps.

Face shields protect the face, nose, mouth, and eyes. A face shield should cover the forehead, extend below the chin, and wrap around the sides of the face. Face shields can be worn along with face masks.

Removal of a face shield, goggles, and mask can be performed safely after removing gloves and performing hand hygiene (CDC, 2019c).

HEAD COVERINGS

Head coverings such as surgical caps are worn when gross contamination is expected, such as during orthopedic surgery or autopsies (OSHA, 2012).

BOOTS/SHOE COVERS

Theater boots are waterproof boots worn by surgical personnel as a protective measure from contamination with blood and other body fluids. Shoe covers protect the wearer from accidental spills and body fluids (OSHA, 2012).

RESPIRATORY PROTECTION

Respiratory protection includes both surgical and standard N95 or higher-level respirators. Respirators require medical evaluation to determine if it is safe for the healthcare worker to wear one and to fit the worker with the appropriate respirator size and type. Healthcare workers are responsible for performing a user-seal check (formerly called a “fit check”) each time a respirator is donned to minimize air leakage around the face piece.

A surgical N95 respirator is recommended only for use by healthcare personnel who need protection from both airborne and fluid hazards such as splashes and sprays.

The CDC currently recommends standard N95 or higher-level respirators for healthcare personnel who are exposed to patients with suspected or confirmed tuberculosis and COVID-19 (Siegel et al., 2019; CDC, 2020j).

Putting On and Removing PPE