Hepatitis B and human immunodeficiency virus (HIV) are potentially fatal infections. Most occupational exposures to these bloodborne illnesses occur among healthcare workers (HCWs). According to the National Institute for Occupational Health and Safety (NIOSH), more than 8 million healthcare workers in U.S. hospitals may be exposed to blood or other body fluids through the following types of contact:1
- Percutaneous injuries with contaminated sharp instruments such as needles and scalpels (82 percent)
- Contact with mucous membranes of the eyes, nose, or mouth (14 percent)
- Exposure of broken or abraded skin (3 percent)
For HCWs, a significant component of guarding against exposure to bloodborne pathogens involves the proper use of effective personal protective equipment (PPE). The Occupational Safety and Health Administration (OSHA)’s Bloodborne Pathogens Standard specifies that when the potential for occupational exposure is present, employers must provide appropriate PPE such as, but not limited to, gloves, gowns, lab coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. PPE is considered appropriate if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use, and for the duration of time which the protective equipment will be used.2
OSHA also specifies that employers must ensure that employees use PPE, unless the employer shows that the employee temporarily declined to use the equipment when, “under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker.”3 When an employee makes this judgment, the accompanying circumstances should be investigated and documented in order to determine whether changes need to be instituted to prevent similar occurrences in the future.
Selecting, Donning, and Removing PPE
The first step for HCWs is selecting PPE that is suitable for the task or procedure at hand. “You have to have several things in mind; you have to know what the prevailing standards requirements are, you have to know what the risk is, and once you evaluate that risk, then you can select your personal protective equipment,” says Cynthia Spry, RN, MS, an international clinical consultant for Advanced Sterilization Products.
“You have to know both things. For example, just to say, ‘I need a gown,’ is not enough; you need to know what type of gown, and that would be based on the potential for exposure.”
Once a HCW determines what type of equipment is needed, the correct sequence must be followed in terms of donning it. “You put the gown on first, choosing the proper type of gown and appropriate size, whether it’s strictly an isolation gown, or if you’re doing a procedure that may involve splashing and spraying, then you would choose a different type of gown,” says Christopher Florez, BS, CIC, director of infection control at San Antonio-based St. Luke’s Baptist Hospital. “Second would be a mask. You put it to your face and pinch the nosepiece so it’s secure on the bridge of the nose, and then fasten the ties after positioning them comfortably, so you won’t have to readjust the ties or elastic bands while you’re wearing the mask. The next step would be eye protection; once you have the facemask on, put on the eye protection, whether it’s goggles or protective glasses, or if you’re wearing the welder’s shield-type eye protection. Lastly you put the gloves on. If they’re sterile, you need to use aseptic technique. If they’re regular exam gloves, you just don them and pull them up over the elastic wristband of the gown and you’re set to go.”
Removing PPE similarly follows a specifi ed order, with gloves being doffed first. “You have to remember which part of the PPE is contaminated,” Florez points out. “For gloves, obviously the outside parts of the gloves are contaminated, so you make sure to remove those in a manner in which you minimize the risk of contact with the outer portion of the gloves.
Second is eye and face shields or goggles. You take off the goggles, grasping the arm of each side of the lens as you remove them, minimizing any potential contact with the skin of the face. After the goggles and face shield, you remove the gown, remembering that the outside is the contaminated portion, so you reach back and untie the top, untie the bottom, then you’ll slide the gown off over your body and pull it away from your neck and shoulders, preferably not touching the outside of the gown at all.
Then you try to fold it or roll it into a bundle so that the inside of the gown is now on the outside, and then it’s discarded. Last is the mask or respirator, again avoiding contact with the outside of the mask – grab it from the ties and pull the elastic over your head, or untie and pull it off and discard it.”
Although this process sounds simple, it is often not adhered to, Florez adds. “Healthcare workers often think that because they have gloves on, they should remove the mask and goggles, but the thing is that the outside of those gloves has been contaminated. After everything is removed, it should be discarded at the point of use. If you’re in a patient room, preferably right before you leave the room or just outside the door. Always remove a respirator or mask after you’ve left the room, and then obviously you want to perform hand hygiene.”
According to OSHA, gloves must be worn when it can be reasonably anticipated that an employee may experience hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing most vascular access procedures; and when handling or touching contaminated items or surfaces. Single-use gloves such as surgical or examination gloves should be replaced as soon as practical when contaminated, or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.4
The Centers for Disease Control and Prevention (CDC)’s Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings notes that HCWs should work from clean to dirty when wearing gloves. This refers to touching clean body sites or surfaces before touching dirty or heavily contaminated areas.5 HCWs should also limit opportunities for “touch contamination” of themselves, others, and environmental surfaces.
The CDC also notes that torn or heavily soiled gloves should be changed before additional patient care tasks are performed. Additionally, gloves should always be changed after use on each patient, and then discarded in the nearest appropriate receptacle. Patient care gloves should not be washed and used again.
“Not all gloves are created equal – make sure you choose a glove that’s going to be right for what you’re doing,” says Jacqueline Daley, HBSc, MLT, CIC, CSPDS, director of infection prevention and control at Sinai Hospital of Baltimore. “If there’s going to be a lot of movement or stretching or a lot of stress and strain put on the glove, you need to make sure you’re selecting the proper glove. Make that appropriate choice depending on your risk of exposure as you assess it at that time.
“If you’re wearing a pair of gloves all day long, that’s going to compromise everyone’s safety. You need to make sure that when you’re wearing gloves, you put them on at the time you need to use them and you take them off immediately after you’re finished, and then wash your hands,” Daley continues. “You don’t want to wear PPE because you eventually might be exposed to something; you need to make sure you choose the barrier that you need and put it on at the time that you assess the risk, and then remove it when you feel you have moved yourself out of that risk situation. Whenever you remove any PPE, it’s important to wash your hands afterward.”
Masks and Eye Protection
OSHA specifies that masks, in combination with eye protection devices such as goggles or glasses with side shields, or chin-length face shields, should be worn when splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination is anticipated.6
The CDC maintains that masks should cover the nose and mouth completely, and prevent fluid penetration. They should also fit snuggly over the nose and mouth. Masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable, according to CDC. In terms of goggles, 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.7
The CDC also notes that when additional skin protection is needed or desired, for example, when irrigating a wound or suctioning 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.
Florez emphasizes that masks must fit correctly in order to offer protection. Masks must be tied or strapped securely to the face, and the guard that falls on the bridge of the nose must be pinched and conform to the nose correctly.
“You often see masks that are not protecting the worker at all, where they’re falling off the bridge of the nose and almost exposing the mouth altogether,” he notes. “In those instances, you’re counting on another clinician in the area to assist that person by stepping in to help re-secure the mask.”
Several points must be considered for goggles as well. “If you’re providing goggles for individuals, do you issue them per person, or are they shared items?” Florez questions. “If they’re shared, you need to have steps in place to ensure they’re cleaned after each use. Certain individuals in certain environments may prefer to have prescription goggles, and that depends on who you work for as far as whether they will be paid for or if healthcare workers will have to pay for them out of their own pockets.”
The Association for Advancement of Medical Instrumentation (AAMI’s) standard entitled Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities defines four levels of protection that may be offered by gowns and drapes.8
The necessary level of barrier protection depends primarily on the potential for exposure to blood, body fluids, and other potentially infectious materials. The classifications of barrier performance explained in the standard relate to the risks associated with the potential for exposure involved in the type and duration of procedure or activity being performed. The classifications are:9
Level 1 – gowns and drapes: This classification describes surgical gowns, other protective apparel, surgical drapes, and drape accessories that demonstrate the ability to resist liquid penetration in a laboratory test.
Level 2 – gowns and drapes: This classification describes surgical gowns, other protective apparel, surgical drapes, and drape accessories that demonstrate the ability to resist liquid penetration in two water resistance tests, one for impact penetration and one for hydrostatic pressure.
Level 3 – gowns and drapes: This classification describes surgical gowns, other protective apparel, surgical drapes, and drape accessories that demonstrate the ability to resist liquid penetration in two water resistance tests, again for impact penetration and hydrostatic pressure. For Level 3, the test criterion is set to a higher value than for Level 2.
Level 4 – gowns: This classification describes surgical gowns and protective apparel that demonstrate the ability to resist liquid and viral penetration in a laboratory test for resistance of materials used in protective clothing to penetration by bloodborne pathogens.
Level 4 – drapes: This classification describes surgical drapes and drape accessories that demonstrate the ability to resist liquid penetration in a test for resistance of materials used in protective clothing to penetration by synthetic blood.
The classification system established by this standard seeks to set a common foundation for the different levels of barrier protection available, but does not take into account potential variations in specific procedures and techniques used in healthcare facilities. The end-user must ultimately determine of the appropriateness of the barrier level required, based on his or her experience and the potential or known exposure risks.
The proper gown can only protect HCWs if it is used correctly, however. “One of the things we see often from an infection control standpoint is when a healthcare worker puts a gown on but fails to secure it,” Florez observes. “Sometimes they don’t fasten the tape or tie that’s typically on the top, near the neck line, and near the lower portion of the back. They will just leave them on their shoulders, and the gown can then fall off during a procedure.”
Florez also suggests that specific gowns must be selected according to their usability. “You’re looking for comfort and how it allows your body to breathe and not become overheated over extended periods of time,” he says. “You need to look at the comfort of the sleeves too – some of them have a thumb hole on the arm, others have the elastic cuffs, and again it depends on the procedure when it comes down to looking at them and how they are secured; do you want ties on top and bottom, or will tape hold long enough? Usually tape is adequate, but how does it fasten and how is the gown being used. The big thing is comfort for the HCW.”
A comprehensive evaluation of any product involves seeking out all information and data available, Spry points out. “Users have a responsibility to look at the literature that the company can provide and determine for themselves whether or not they think the products are appropriate, and it’s up to the sales rep to provide that literature,” she explains. “I think in the end, the onus for selection falls on the infection control practitioner in conjunction with the person who’s going to use it. The worst thing is for a person with purchasing power to go ahead and get something that hasn’t been fully evaluated. You’ve got to include the users – they must do an evaluation. Furthermore, somebody needs to oversee the evaluation process to make sure the product is truly evaluated thoroughly before a decision is made.”
In the end, each individual HCW must take responsibility for his or her own protection, even in difficult circumstances. “I think people know a fair amount about PPE, and even have a good idea of when they should use it, but I think the pressure on people to get things done very quickly in a healthcare facility sometimes is a factor in people not being compliant with wearing the equipment,” Spry offers. “You can also have a situation where you don’t wear the protective equipment, but you don’t have a negative outcome, so there’s not always a direct cause and effect. Every time you don’t wear PPE it’s not going to equate to an infection or an exposure.
“However, if something happens like SARS (severe acute respiratory syndrome) and people begin to see the real, immediate impact of it, people will go overboard and wear protective equipment perhaps in ways that it’s not even intended to be worn, because they get scared,” Spry continues. “So sometimes it’s the perceived risk – the scare involved – that makes people compliant, and not necessarily a knowledge deficit. It’s kind of like hand washing; you need to educate people on hand washing, but education isn’t enough – how do you drive compliance? Everybody knows you’re supposed to wash your hands, so you don’t have to educate on that; it’s how you drive compliance, and that’s the key I think with personal protective equipment as well.”
1. NIOSH Publication No. 2004-146. Worker Health Chartbook 2004, chapter 2, Bloodborne Infections and Percutaneous Exposures.
2. Occupational exposure to bloodborne pathogens--OSHA. Final rule. Fed Regist. 1991 Dec 6;56(235):64004-182.
5. Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings--CDC. http://www.cdc.gov/ncidod/dhqp/pdf/ppe/PPEslides6-29-04.pdf
6. Occupational exposure to bloodborne pathogens--OSHA. Final rule. Fed Regist. 1991 Dec 6;56(235):64004-182.
7. Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings--CDC. http://www.cdc.gov/ncidod/dhqp/pdf/ppe/PPEslides6-29-04.pdf
8. ANSI/AAMI PB 70:2003. Liquid barrier performance and classification of protective apparel and drapes intended for use in healthcare facilities. 2003.