INFECTION PREVENTION: Dress up for safety with PPE
TERRI REBMANN RN, CIC, PhD 

LPN2008
March/April 2008 
Volume 4 Number 2
Pages 6 - 13

YOUR WORK AS a nurse can be hazardous: It may put you at risk for catching a health care-acquired infection (HAI) or inadvertently spreading infection from one patient to another. Some microorganisms in hospitals can cause severe infection because they may be antibiotic resistant, or they could be a more serious strain of the bug than what you'd encounter in most public areas.



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Everyone staying, visiting, or working in a health care facility is at risk of acquiring an infection, but patients are at greatest risk for HAIs. According to the Centers for Disease Control and Prevention, 1.7 million Americans acquire an HAI each year, and the infection kills about 99,000.

Infection control precautions are key to protecting both you and your patient from HAIs. Examples of infection control precautions include using personal protective equipment (PPE), decontaminating the environment through disinfection and cleaning procedures, conducting surveillance to identify new cases of disease, and isolating patients with infectious diseases. Focusing on how the disease is transmitted will help you determine the correct measures to use.

Infectious diseases can be spread through respiratory droplets (large, heavy drops of moisture containing millions of bacteria and viruses and released from the respiratory tract via the nose or the mouth), airborne particles, environmental sources, or person-to-person contact. Your facility has a policy that you are obligated to follow for infectious patients.

In this article, I'll focus on the essentials of PPE, including how to properly put it on and remove it safely.

Your own personal bodyguard

Personal protective equipment is gear designed to protect the wearer from exposure to microorganisms. Examples of PPE include gloves, gowns, goggles, face shields, masks, and respirators. Choose PPE based on the procedure you're performing and the mode of transmission of potential pathogens. For example, if you're performing tasks in which you expect hand exposure to any body fluid—when changing dressings or inserting an intravenous (I.V.) catheter, for example—you should wear gloves. If you expect splashing or spraying, such as when you empty a urine collection bag, you should wear a gown, gloves, and protective eyewear.

Always assume that your patient's body fluids may be infectious, regardless of his known or suspected infection status. For a more in-depth look at standard precautions, see What's the standard?

Although there are times when PPE is mandatory, such as wearing a mask for patients on respiratory droplet precautions, you can use PPE any time you feel you're at risk for an exposure. For example, if a patient presents with coughing and fever, you should place a mask on the patient and yourself when you're in the same room until a diagnosis is made. Early use of a mask will protect you and others.

What to wear?

Different diseases or pathogens require different types of PPE based on how the pathogen is transmitted. This can range from using gloves only to wearing full PPE. For most patients, when the potential for splashing of blood or body fluids isn't present, routine use of gloves and hand hygiene, along with the occasional use of goggles or a face shield if necessary, will be sufficient to protect you from infection. For some patients and some procedures, though, you'll need to wear additional PPE; for example, when performing suctioning or when providing personal care for an incontinent patient.

Hospital isolation precaution categories—contact, droplet, and airborne precautions—are also based on transmission routes (see Know your categories). Some diseases require more than one category of isolation precautions and multiple kinds of PPE for each patient encounter. For example, severe acute respiratory syndrome (SARS) requires contact precautions with gown and gloves, airborne precautions with an N95 respirator, and the use of a face shield. For a list of the PPE required for each category of isolation precautions, see Which PPE is needed?

If you're not sure what PPE you need for a specific situation, refer to your facility's policy and procedure manual. The amount and type of PPE you need affects the order in which you put on the gear.

Puttin' on the PPE

Don PPE in the following order before you have any contact with the patient:

1. gown
2. mask or respirator
3. goggles or face shield
4. gloves.

Let's take a closer look at each type of protection.

A gown should cover you from neck to trunk as well as the full length of your arms. The opening of the gown should always be in the back. Securely tie the gown at your neck and waist to make sure it doesn't slip down during patient care. If that were to happen, you could accidentally contaminate your clothing or skin by pulling up the gown with contaminated hands or gloves. Also, use a new gown every time you enter the patient's room, and discard it as you leave the room. Never wear a contaminated gown into another patient's room or to the nurses' station; you could spread pathogens around the entire facility.

Use a mask for all patients with diseases that are spread via respiratory droplets. Because respiratory droplets are heavy, they can't remain airborne. They settle quickly to the ground, falling within about 3 feet of the patient. If you're within that 3-foot radius when the patient sneezes or coughs, you can inhale the particles. Wearing a mask prevents you from inhaling the particles and becoming infected.

To put on a mask, place it over your nose, mouth, and chin. Fit the flexible nose piece to the bridge of your nose before tying the mask in back. Then secure the ties at the middle of your head and neck. Use a new mask every time you enter the patient's room, and discard it as you leave the room.

Use a respirator for patients with diseases like tuberculosis (TB) that are spread via the airborne route. An N95 respirator, which is available in many brands and types, is a special type of protective equipment that can filter out more particles than a regular mask. Occupational Safety and Health Administration regulations state that, for your own protection, you shouldn't wear an N95 respirator without first being fit-tested. Without fit testing, you can't be sure you have an adequate seal to provide maximum protection from aerosolized particles.

To put on a respirator, place it over your nose, mouth, and chin. Then fit the flexible nose piece over the bridge of your nose and secure the ties. Next, perform a fit check: When you exhale, check for leaks around your face (see Seal of approval). Remember to use a new respirator for each patient encounter.

Place goggles or a face shield over your eyes or on your face and adjust to fit. Some face shields have cords or elastic bands that require fastening or tying behind the head and neck, much like masks. The goggles or face shield should completely cover your eyes to provide the best protection.

Gloves should cover the cuff of the gown at your wrist and should be free of obvious rips, tears, or holes to prevent areas of unprotected skin. To put on gloves, select the correct size and type, insert a hand into each glove, and extend the gloves over the cuffs of your gown. Remember to put on gloves last, and use a new pair when switching from dirty to clean procedures or between patients.

Gloves should never be reused, whether for the same patient or between patients. Although gloves keep most microorganisms from getting on your hands, they aren't completely protective. Always perform hand hygiene before and after removing gloves.

The dirt on PPE

If your PPE becomes dirty, you must change it to prevent cross-contamination. Cross-contamination occurs when a clean site becomes exposed to microorganisms from a dirty source, such as contaminated gloves or equipment.

To further prevent cross-contamination, you should always start with clean procedures and then progress to more dirty tasks. For example, if you plan to perform routine I.V. care and check the patient's intake and output, start by assessing the I.V. site (a clean task). If the I.V. site dressing doesn't need to be changed, you don't need to change gloves before progressing to the next task. If the dressing is soiled or loosened and needs to be changed (a dirty task), perform the dressing change using appropriate infection control procedures, perform hand hygiene (see Mom always said, wash your hands on page 12), and then put on a new pair of gloves before progressing to the next task.

If you were to start by assessing the patient's urinary output and emptying the urine drainage bag (a dirty task) and then changing the patient's I.V. site dressing, you'd cross-contaminate the I.V. site. If you must switch from a dirty task to a clean one, remove your gloves, perform hand hygiene, and put on a new pair of gloves before moving to the clean task to minimize the risk of cross-contamination. In addition, always perform hand hygiene and change your gloves whenever the gloves become grossly soiled, ripped, or torn. For a list of common clean and dirty nursing tasks, see Is it clean or dirty?

Take it off!

Until recently, removing PPE wasn't considered a high-risk procedure; however, an outbreak of SARS in Canadian health care workers was believed to be associated with improper removal of PPE. The theory was that the staff weren't routinely performing hand hygiene before removing their respirators and were taking off the respirators from the nose and mouth area rather than using the respirator's ties. When the staff were retrained on how to properly remove PPE without contaminating themselves, the rate of secondary infection greatly decreased.

The order in which you remove PPE is very important. You should remove all PPE except a mask or respirator at the doorway of the patient's room, before you leave the room. Remove a mask or respirator outside the patient's room after you've closed the door. If at any time your hands become visibly contaminated while removing PPE, wash them before you remove the remaining gear.

When you're removing PPE, remember that the front or outside of all equipment is considered dirty, and the back or inside is clean. You should always touch the cleanest part of the gear and remove it to avoid cross-contamination.

Remove PPE in the following order:

1. gloves
2. goggles or face shield
3. gown
4. mask or respirator.

To remove gloves, start by grasping the outside of one glove with the opposite gloved hand and peel it off inside out, making sure to avoid touching your exposed wrist or hand. Hold the glove in the hand that's still gloved. Next, slide two or three fingers of your exposed hand inside the cuff of the remaining glove and peel the glove off inside out. Avoid touching the outside of the glove with your exposed hand so you don't cross-contaminate it. Dispose of the gloves in the proper receptacle.

To remove goggles, grasp the arm of the goggles to pull them off. To remove a face shield, grasp the ties or elastic bands from behind your head and lift the shield away from your face. Don't grab the front of the goggles or face shield for removal because this will contaminate your exposed hands. Place the goggles or face shield in the designated receptacle for disposal.

To remove a gown, unfasten the ties in the back, then pull the gown away from your torso by grasping the inside of the material at the shoulder or neck area and pulling it away from your body. Don't touch the outside of the gown. Fold or roll the used gown into a bundle, making sure that the cleanest (inside) portion of the gown is on the outside of the bundle as you roll it. Next, dispose of the gown in the designated receptacle.

To remove a mask or respirator, wait until leaving the patient's room. Removing your respiratory protection inside the room would put you at risk for inhaling infectious particles. Also, it's recommended that you wash your hands before you take off a mask or respirator, even if you correctly follow procedure. (The door and doorknob of the patient's room are likely to be contaminated and your hands will become dirty when you touch them as you leave the room.) Grasp the ties or elastic bands from behind your head and pull the mask over your head. Don't grab the front of the mask or respirator for removal because the front of the mask is considered contaminated, and touching it would introduce microorganisms into your body.

Mom always said, wash your hands

A fter you've removed all your PPE, wash your hands or use an alcohol-based hand rub. Proper hand hygiene is the best way to protect yourself from the spread of disease.

When your hands are visibly dirty, you must wash them using soap and warm water. (Alcohol-based products don't remove dirt or debris, so you must use soap and water.) The mechanical action of scrubbing your hands together helps to remove the contamination. Avoid using hot water because it increases skin irritation and dryness. Numerous studies have shown that most health care workers wash their hands for less than 10 seconds, which isn't long enough. You must wash your hands for at least 15 seconds. It's difficult to time yourself when washing your hands, but an easy solution is to hum “Twinkle Twinkle Little Star,” which lasts about 15 seconds.

After washing your hands, thoroughly dry them with a paper towel. Next, turn off the faucet with the paper towel you used to dry your hands or a clean paper towel. Don't touch the faucet handles with your clean hands because faucets are covered in microorganisms; touching them to turn off the water will recontaminate your hands.

If your hands aren't visibly dirty, you may use an alcohol-based hand foam or gel to clean them. These waterless products are more effective than soap and water in decreasing the number of microorganisms on your hands. They're also faster to use and cause less skin irritation. Apply the manufacturer-recommended amount of product to the palm of one hand and rub your hands together, making sure to cover all surfaces of your hands, until they're dry.

Protect yourself

As nurses, we're all at risk for contracting and spreading infectious diseases. Following proper infection control procedures can stop the spread of disease, and the proper use of PPE can protect you from becoming sick and can help protect your patients and their visitors.

What's the standard?

Follow standard precautions for all patients to help prevent transmitting infection. Here's how.

Hand hygiene

Wash your hands for at least 15 seconds or use an alcohol-based hand rub:

* after you've touched blood, body fluids, secretions, or contaminated items (whether or not you wore gloves)
* after you remove your gloves
* between patients
* between performing procedures and patient care on the same patient.

Gloves

To protect your hands while performing procedures and patient care that require you to touch blood, body fluids, secretions, or excretions:

* wear clean gloves (especially when touching mucous membranes or nonintact skin)
* change gloves between performing tasks and procedures on the same patient
* remove gloves promptly and perform hand hygiene before moving to another patient.

Gown

To protect your skin and clothing while performing patient care that may result in splashes or sprays of blood, body fluids, secretions, or excretions:

* wear a clean gown
* select a gown that's appropriate for the procedure you're performing and the amount of fluid you may encounter
* remove a soiled gown as soon as possible, and then perform hand hygiene.

Mask and protective eyewear

To protect your eyes, nose, and mouth while performing procedures and patient care that may result in splashes or sprays of blood, body fluids, secretions, or excretions:

* wear a mask and protective eyewear, such as goggles or a face shield.

Other preventive measures

* When handling used patient-care equipment or linen that's soiled, avoid contact with your skin, mucous membranes, and clothing.
* To prevent accidental needle sticks, never recap a used needle; don't remove used needles from disposable syringes by hand; don't bend, break, or otherwise manipulate a used needle by hand; and place used syringes in designated puncture-resistant containers.
* When performing cardiopulmonary resuscitation, use a mouthpiece, resuscitation bag, or other ventilation device instead of mouth-to-mouth resuscitation, if possible.
* Place a patient who may contaminate the environment or who can't be expected to maintain appropriate hygiene in a private room.
Know your categories

Besides standard precautions, three categories of isolation precautions—contact, droplet, and airborne precautions—are determined by the mode of transmission of the infectious organisms. Here's a list of diseases for each category or precaution.

Standard precautions

Use standard precautions for the care of all patients (see What's the standard?)

Contact precautions

In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples include:

* gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program to be of special clinical and epidemiologic significance
* enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile; for diapered or incontinent patients; enterohemorrhagic Escherichia coli 0157:H7, Shigella species, hepatitis A, or rotavirus
* respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children
* skin infections that are highly contagious or that may occur on dry skin, including:
- diphtheria (cutaneous)
- herpes simplex virus (neonatal or mucocutaneous)
- impetigo
- major (noncontaminated) abscesses, cellulitis, or pressure ulcers
- pediculosis
- scabies
- staphylococcal furunculosis in infants and young children
- zoster
* viral and hemorrhagic conjunctivitis
* viral and hemorrhagic infections (Ebola, Lassa, or Marburg).

Droplet precautions

In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples include:

* invasive Haemophilus influenzae type B disease, including meningitis, pneumonia, epiglottitis, and sepsis
* invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
* other serious bacterial respiratory infections spread by droplet transmission, including
* diphtheria (pharyngeal)
* primary atypical pneumonia (Mycoplasma pneumoniae)
* pertussis
* pneumonic plague
* streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children
* serious viral infections spread by droplet transmission, including:
* adenovirus
* influenza
* mumps
* Parvovirus B19
* rubella.

Airborne precautions

In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplets. Examples include:

* measles
* varicella (including disseminated zoster)
* TB.

Note: Certain infections require more than one type of precaution.

Source: Centers for Disease Control and Prevention. For a complete list and the most up-to-date information on isolation precautions, see http://www.cdc.gov/ncidod/dhqp/gi_isolation_appendixA.html .

Which PPE is needed?

Besides observing standard precautions, you'll need the following PPE for each isolation precautions category.

Contact precautions

For diseases spread by a fomite (an inanimate object that serves to transmit an infectious agent from person to person) or hand-to-hand contact, you'll need to wear:

gloves

gown.

Droplet precautions

For diseases spread by respiratory droplets, you'll need to wear:

mask.

Airborne precautions

For disease spread by aerosolized particles, you'll need to wear:

particulate respirator.

Seal of approval

Before using a respirator, always check the seal. To do this, place both hands over the respirator and exhale. If air leaks around your nose, adjust the nosepiece. If air leaks at the respirator's edges, adjust the straps along the side of your head. Recheck the respirator's fit after making this adjustment.



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Is it clean or dirty?

You may need to change your personal protective equipment between tasks, depending on which tasks you're performing. Remember to always move from clean tasks to dirty ones. This list can help you determine whether a task is clean or dirty.

Clean tasks

* administering medication P.O., I.M., or I.V.
* obtaining vital signs
* assessing the patient
* obtaining a medical history
* checking input and output in a continent patient
* feeding the patient
* putting on clean bed linens

Dirty tasks

* administering medication vaginally or rectally
* caring for a wound
* changing a wound dressing or I.V. site dressing
* checking urine output in a catheterized or incontinent patient
* caring for a urinary catheter
* performing suctioning
* removing used or soiled bed linens
* bathing the patient
* performing oral care
* changing a diaper
* obtaining body fluid specimens (urine, blood, sputum)
Selected references

Association for Professionals in Infection Control and Epidemiology (APIC). APIC Text of Infection Control and Epidemiology. Washington, D.C., APIC, 2005.

Centers for Disease Control and Prevention. Personal protective equipment (PPE) in healthcare settings. http://www.cdc.gov/ncidod/dhqp/ppe.html. Accessed July 7, 2007.

Institute for Bio-Security. http://bioterrorism.slu.edu . Accessed September 8, 2006.

LPN Expert Guides: Advanced Skills. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006.

Rebmann T. Protect yourself, protect your patients: The essentials of PPE. Nursing Made Incredibly Easy! 5(1):30–39, January/February 2007. Ovid

Smeltzer SC, et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.



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