Tracy Field, RN, WCC, LALD, LTC-CIP

When it comes to personal protective equipment (PPE) practices, there are a couple of different governing bodies that facilities should pay attention to. Obviously, we look to CDC (Centers for Disease Control and Prevention) to determine what are infection prevention recommendations, when should we be using personal protective equipment and how should we be using personal protective equipment. How long should we be using personal protective equipment? We're going to look to CDC to answer those questions for us. And then we're going to look to OSHA (Occupational Safety and Health Administration) for the employer's understanding of what they're supposed to be providing to their employees and how they're supposed to be training employees on the use of personal protective equipment. So that's really our regulatory body surrounding the provision of personal protective equipment to our healthcare workers. And then we have NIOSH (National Institute for Occupational Safety and Health), which is also a branch of CDC, but they're really involved in the quality of our personal protective equipment. Vetting our PPE and ensuring that we are providing quality PPE to our healthcare workers. So, when choosing a mask, we're going to look to NIOSH to ensure that that mask is vetted, that it is quality mask. For example, that our respirators are NIOSH approved respirators. We're going to look to them to ensure that we are choosing the right personal protective equipment. So those three governing bodies should help facilities to ensure that they are training their healthcare workers on the correct PPE practices and using the right personal protective equipment for the situation. And then our facilities may want to go above and beyond. They may want to create additional policies and protocols for standardizing their use of PPE in their own facilities.

So, when healthcare workers are choosing the different types of personal protective equipment they're using, I would say that there are three things that they really need to pay in mind when making that decision. Number one, they need to choose the personal protective equipment that is best for their situation. And what I mean by that is that the personal protective equipment needs to be in line with what is recommended for caring for a patient on droplet, airborne, or contact precautions. In the use of personal protective equipment for standard precautions, they need to think about, will I be at risk of a splash or spray in the situation, what type of personal protective equipment should I use? So best for the situation. Second, they need to ensure that the personal protective equipment is best for the wearer. So, the person wearing the PPE needs to consider, is this the best equipment for me? For example, the mask that I'm wearing is it going to offer me the best fit. The third thing that they really need to pay in mind is ensuring that the use of their personal protective equipment is least contaminated.

Well ladies, thank you so much for taking the time to talk with us today and have this conversation. I think it is so incredibly important. Hopefully, this is helpful to our community as they continue to wrestle through the use of personal protective equipment, making sure that we are using personal protective equipment in a way that is keeping ourselves safe and keeping everyone else safe. Thank you so much.

Thank you, everyone, and all the health care workers for all that you do for our staff and for our patients.

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Experts in infection prevention review PPE standardization practices and Heather Saunders, MPH, RN provides her key takeaways for other healthcare practitioners on best practices related to PPE.

PPE Standardization Practices and Key Takeaways

Now Isis, I know that at Moffitt [Cancer Center, Tampa, Florida], you mentioned, you do surgeries. Surgical smoke has been something that has become a little bit more of a concern, the smoke that’s given off by surgical tools. I know ARRN just recently released another guideline recommending the use of respiratory protection to protect against surgical smoke inhalation. Could you just discuss a little bit about the permeability of N95 respiratory or respirators versus surgical masks in relation to protecting against surgical smoke?

Surgical smoke is a gaseous byproduct when tissue is dissected or cauterized by those heat-generating devices, such as lasers and respirators. They can filter those small particles that are released in the air caused by surgical smoke. Surgical masks are used to help prevent contamination of the work environment or sterile field from those larger particles generated by the wearer such as from spit or mucus. Surgical masks instead should be used to help reduce the risk of splashes or sprays of blood and body fluids and also protect the wearer’s mouth and nose. They wouldn’t be appropriate in order to protect from surgical smoke.

Thank you so much for clarifying that. I know influenza and RSV have been more rampant in different parts of the country over the past several months. What are we doing inside of our healthcare facilities to prevent and control the spread of influenza and RSV, and particularly how are we using personal protective equipment to prevent and control the spread of these?

I would say that we're more prepared now than we ever were. The education is really out there. We've educated not only the healthcare setting, but a lot of education out to the community. I think people are more self-aware when they have symptoms, and what they need to do about it. Can they go to work? Should they wear a mask at the grocery store? People are really paying more attention to that in healthcare. I think the identification of symptoms and putting somebody on isolation to prevent the spread is key. But I think we're more prepared now than we ever were.

Yes, I agree with Tracy. We understand how the flu transmits and we understand those key prevention efforts such as the flu vaccine, and also recommending that patients wear a mask if they have those flu-like symptoms. And we know that hand hygiene is critical for flu prevention. So, I think we are well-equipped to handle all of our flu season.

That's great. What about for the general public? I know the general public is a little nervous about some of the increases that they've seen not just in COVID, but flu and RSV over the past several months. There's been questions about how they should use personal protective equipment to prevent and control the spread of infection. Do you have any thoughts on that?

Yes. I would say that just in the aspect of the availability, the availability of masks that the general public can actually purchase, was kind of not a thing before COVID, or it would be very rare that somebody could purchase personal protective equipment. So having COVID tests at home and the awareness of hand hygiene, all of that put together has really changed the world, I think.

For the general public, I would also recommend to stay at home if you're not feeling well. If you are immunocompromised, discuss with your doctor any additional steps that you might take in order to protect yourself from flu season. For example, you might be requested to wear a mask or stay home during those peak flu points in the season. So, it's very critical to understand how flu is transmitting and those numbers in the community, as well as performing hand hygiene when you're out in the community.

What about the quality of personal protective equipment? In your experience, what should clinicians be concerned about when looking at the quality of the equipment that they're using?

Well, just making sure that there's no wear and tear, of course. And making sure that it's a product that is well known and not something that's being sold off the streets or something like that. We want the quality grade and something that's OSHA approved.

Yes, clinicians should ensure that the PPE that they're wearing has undergone quality requirements and testing, as well, in order to protect them from any hospital-acquired infections, and to prevent spreading infections, as well.

Great, thank you. I know that this was a big problem during the COVID pandemic when we were really short on PPE and had to pay attention to whether the equipment that we were getting was, in fact, quality personal protective equipment that was protecting our healthcare workers, as well as other individuals. So, speaking of the COVID pandemic, that brought about the use of PPE and masks, not just in healthcare, but in the public, and really put a spotlight on that, like we were just discussing about the shortages of personal protective equipment. So, can you talk about how practice has changed or shifted, since the COVID pandemic, in light of all that we've seen?

Since the COVID pandemic, PPE is more commonly accepted in hospitals and healthcare facilities, and we actually even saw some healthcare workers wanting to use PPE more than necessary, more than they needed to, in order to ensure that they were protected. So, we definitely saw a shift and more of a reliance on PPE. Healthcare workers wanted to wear that PPE in order to protect them, and it was important to educate them and let them know when PPE was necessary and when it wasn't necessary.

I agree with you, Isis, and then also just the lack of knowledge that there used to be on how to wear it, how to doff, when to wear it, why we wear it. All of those things have really come a long way as far as teaching providers in healthcare settings.

That's a good point, Tracy, because we did have to reeducate some of our healthcare workers and teaching them how to properly don and doff because we know that we can also spread contamination that way. And also, removing our PPE at the right time, right after we see a patient, before stepping back into the hallway, where there's other patients or other workers present.

Sounds like there was a lot of confusion amidst the healthcare workers about what is the best practice in wearing the personal protective equipment, how much personal protective equipment to wear. I know I saw a lot of that myself.

Isis Lamphier, MPH, CIC, reviews PPE considerations relating to surgical smoke and Tracy Field, RN, WCC, LALD, LTC- CIP shares her thoughts on the universality of masks and other protective equipment for transmissible viruses. 

PPE Considerations Surrounding Surgical Smoke and Transmissible Viruses

So, when it comes to PPE (personal protective equipment) contamination, this is a little tricky because we always want to assume that our PPE is contaminated. We know that there are certain areas of our personal protective equipment that are likely to be more contaminated than others. For example, with masks, we would assume that the front of the mask is going to be more contaminated than the ear loops or the ties on the back. When we go to touch or adjust our mask, we don't want to adjust by touching the front of that mask because we can assume that it is contaminated. Same with our gowns. With our gowns, we assume that the front of the gown and the sleeves on the front of the gown is most contaminated. Now those ties in the back of the gown, those are going to be the least contaminated portion of the gown. And because of that, we know that we want to avoid touching the front of the gown while we're providing patient or resident care. But what we want to also look for is any breaches in our personal protective equipment. Any areas such as tears or compromised equipment that we might observe or any visual contamination. If we have visual contamination of our PPE, like blood splatter for example, then that's something that we want to change immediately and remove without contaminating our garments, like our scrubs.

Now during the pandemic, unfortunately we ran into the scenario of needing to reuse a lot of different types of personal protective equipment because we were running low on personal protective equipment in all of our supply chains. We developed what we call contingency strategies for the reuse of personal protective equipment. Now that we're back to the supply chain, being able to keep up with supply and demand, we really don't want to be reusing personal protective equipment like we did whenever we were experiencing those supply shortages. However, we do want to be prepared for the possibility of needing to reuse PPE in the future and think through how contaminated our personal protective equipment is, and when it would be appropriate to change that personal protective equipment. So again, anytime we have visible soil, obviously we want to change that personal protective equipment. But CDC recommends for masks at least limiting the number of reuses to no more than five. So, we definitely want to look back at those contingency strategies and compare the amount of personal protective equipment we have available and see where we fall within those different strategies, using the least amount of reuse for our personal protective equipment as possible. Because we really want to get back to the single use that we have been maintaining all along. We must pay in mind that we need to make sure that we have enough personal protective equipment available for our healthcare workers. So, we may need to get into situations again where we're going to have to reuse personal protective equipment. Following CDC guidance is incredibly important. Looking at your institution's availability of personal protective equipment would be really important to determine where you fall in those contingency capacity strategies.

It's important that you're careful when you're wearing this PPE that you're not touching other components of your PPE. For example, your gloves. The inner part of your gloves is the most contaminated. You want to be careful what you're touching with that inner glove that you don't further contaminate your mask or your gown that you're wearing. So once you have that PPE on, you want to reduce the amount of times that you're adjusting it and ensure that it's secure prior to stepping into that patient's room.

Infection preventionists, Heather Saunders, MPH, RN, CIC; Tracy Field, RN, WCC, LALD, LTC- CIP; and Isis Lamphier, MPH, CIC provide their thoughts on the best approaches regarding the removal of contaminated PPE.

Best Approaches in the Removal of Contaminated PPE 

 Tracy, you mentioned enhanced respiratory precautions. Can you comment a little bit on what that is, and maybe also about whether we think universal masking, always wearing a mask in a healthcare facility, is going to be something that we continue for all patient interactions.

 Sure. So as far as the enhanced respiratory precautions, that really came in light just when COVID came about us. And it's a mixture of the droplet precautions and contact precautions, and that is proven to help us eliminate the spread of COVID. And as far as universal masking goes, it doesn't seem like it's going away anytime soon. It does seem to be helping, during the pandemic, and it is protecting us and protecting our patients that we take care of.

: I think we also saw maybe the impact that universal masking had on seasonal flu outbreaks in decreasing the transmission of flu, as well. Could you comment a little bit on how the use of personal protection equipment has impacted and decreased the transmission of influenza?

 Yes, we've seen a couple of trends with influenza. When universal masking was in effect, we saw a decrease in influenza because patients were using mask and they were protecting others from their respiratory droplets. But once we saw mask policies change a little bit, and masks no longer were a requirement, then we did see an increase in influenza, as well. I think it's important that if we see a patient come in that has respiratory-like illnesses, or influenza-like illness, that we request that they don a clean mask. Typically, they should also be segregated while they're waiting for their appointment or coming into the hospital. So, they should be in a different waiting area. And we should also emphasize just standard precautions that hand hygiene is important, and preventing infections through our hands is critical because most infections are spread through our hands.

 I was looking at and seeing that the American Society of Testing and Materials Guidelines (ASTM) has changed a little bit, maybe in light of some of what we've experienced. But can you comment on what is required as far as ASTM ratings for face barriers and what that looks like?

 ASTM has set forth clear expected standards for the development of facial barrier protection, and that's in order to ensure quality and protection for the wearer. Manufacturers are required to perform a design analysis, and in that design analysis they have to assess for leakage of exhaled air from the barrier covering. And they also look at filtration efficacy and airflow resistance as well. There's different standards that have to be met, and they need to ensure that all of those performance properties are being met in their testing.

 Thank you. Thank you for that. Sounds like quality is so important. Knowing what type of personal protective equipment to use is so important. Think it's also so important for clinicians to understand PPE contamination and breaches. Can either one of you comment a little bit on where we see the most contamination on articles of personal protective equipment that clinicians need to be aware of?

 I think doffing is where we see the biggest risk of contamination. Just it's so important to remove the equipment in a certain fashion. And then the biggest is hand hygiene.

 I think we also see contamination with prolonged use of PPE. A lot of individuals might not know that with prolonged PPE usage, they can be contaminating themself if they're continuing to use an unclean mask. And it's important to know the type of mask you're wearing or also your gown. Is it single-use disposable, or can you re-wear it? And if you can re-wear it, what are the proper conditions that have to be met? Do you have to disinfect it after use? We definitely see contamination when PPE is used outside of the instructions for use or the IFU, and it's important for wearers to understand what those specific requirements are for the PPE that they're wearing and if they can reuse it or use it for an extended period of time.

 Is there a specific area of personal protective equipment that seems to be the most contaminated? With doffing, I can assume that there is more of a risk in touching certain parts of personal protective equipment. Is that true?

 I think there are a couple. For example, mask. If a mask is reusable, for example if they're using a respirator, they need to properly store it after they remove it and also properly clean and disinfect it. Gloves can commonly cause contamination as well, especially if there's any tears in the gloves or microtears that you're unaware of. It's important to remove those gloves once they tear, perform hand hygiene, and then don a new set of gloves. It's also important to look at the CDC recommendations for removing PPE, so which items should be removed first and last, because that's sometimes a missed step when donning and doffing. It's important to note that when you're removing PPE, you want to go from your most contaminated item to your least contaminated. So, gloves should be removed first, and sometimes individuals might not want to remove those gloves first because then they're going to be touching their gown or their face shield or eye protection. So, it's important to perform that education so that they know which steps to take.

 It is a very important skill that does need a lot of reeducation because you're busy. You need to move on to the next patient. You might not be as careful as you should be in following that exact process. But it is very important.

Experts in infection prevention discuss PPE quality and highlight considerations relating to assessing appropriate levels of PPE contamination.

Insights into Appropriate Levels of PPE Contamination 

Let’s move on to talk a little bit about where PPE [personal protective equipment] falls into all the different measures that we take in infection prevention. Obviously, the use of personal protective equipment is just one measure of infection prevention. There are so many. I know the CDC [Centers for Disease Control and Prevention] had the hierarchy of controls, where they’ve spoken about PPE falling in order, amidst a multitude of different measures that we can use to prevent and control infection. So, can you just talk about that? Please comment on that a little bit, and where personal protective equipment falls in that hierarchy of controls?

According to the CDC hierarchy, there are 4 levels. There are Levels A, B, C, and D. Level A will be selected when there’s the greatest risk of skin, respiratory, and eye protection required. B is when lesser skin protection is required, but you still need some respiratory protection. There’s also C and D. C is when the concentration and the type of airborne substance is known, and the criteria used for air-purifying respirators are met. D is very minimal protection, just for any natural contamination that might occur day-to-day in the type of work that you might be doing.

In general, not just speaking about the COVID-19 pandemic, but how do clinicians or providers, other health care workers, decide what PPE needs to be worn? What requirements there are for providing care to various individuals?

Well, there are different levels of the contact precautions for an isolation patient. Also, there’s just general guidelines from the CDC as far as which pathogen we’re talking about, how it’s spread, and actually how to protect ourselves and our patients.

There’s different governing bodies, too, like OSHA [Occupational Safety and Health Administration] that provides recommendations in their bloodborne pathogen and how to prevent exposure. Also, some facilities might have different teams that help pick out that PPE and what will be used as a standard of care in their specific facility, whether it’s their store, and they might have some input from their infection prevention department, or their occupational health department. And we have a lot of input from all different types of departments, ensuring that we’re all wearing PPE that will protect us, and is quality, as well.

Heather Saunders, MPH, RN, CIC; Tracy Field, RN, WCC, LALD, LTC- CIP; and Isis Lamphier, MPH, CIC, review CDC, OSHEA, NIOSH, and American Society of Testing and Materials guidelines to selecting PPE and best practices for donning and doffing PPE.

Guidelines for Selecting and Wearing PPE

I told you we were going to get back to masks and I want to pause and talk a little bit about the difference between source control and a personal protection mask. What is the difference when we use those terms, source control or personal protection?

Source control is to protect a person’s mouth and nose and reduce the spread of those respiratory droplets. Personal protective equipment will protect the wearer. Source control will help reduce those droplets that are naturally transmitted when a person talks, sneezes, or coughs.

I know that with surgical masks, some of them we have ties, some of them we have ear loops. Does it matter? Does it impact the protection of the wearer or the individual that is being protected from the wearer?

The main thing is that it’s a well-fitting mask on your face and that you don’t have any gaps. So whether you use the straps or the ear loops or the ties, it’s just a matter of making sure that your face is completely protected.

Also, that it’s secured. Especially if you’re going into a room that requires isolation, you want to ensure that that mask will definitely stay on the whole duration that you’re in there. Choose a mask that’s properly secure and you know will stay on.

So, going back to the different types of masks, we also have tie masks versus ear loop masks, and we get a lot of questions about what is better. Having a mask that ties in the back behind the head or having a mask that has the elastics that go over the ear loops. And so, there's a couple of different considerations that healthcare workers and institutions can have and take here. And again, we want to always go back to what is the level of protection that we need to be providing our healthcare workers, providing ourselves when choosing what type of mask we're going to wear. Do we need a respirator, or do we need just a general surgical mask? But once we take care of that, we can look at what type of mask, ear loop, or tie we would prefer. Because it really goes back to preference. There's a couple of different considerations that you might want to pay in mind when you're making this decision. One of which is thinking about the length of time that you're going to be wearing this mask. Sometimes the ear loops over time can irritate the ears. Some people will then prefer the ties behind the back of the head, so they don't have that ear loop irritating the ears all day. For example, when wearing source control. However, that can also be avoided. There are different materials, 3D printed materials that can be worn as a headband around the back of the head, that the ear loops can secure on. Another consideration for tie masks would be that sometimes tie masks can really give us a better fit because the wearer can adjust the mask to the shape of their face and tighten the mask based on the shape of their face. Sometimes having those tie masks is advantageous for being able to tighten that mask around the face and get a really good seal. It's also important to think about the design of those masks and ensuring that the wearer's understanding of how those masks should be worn. One example of this is a lot of times masks will be flipped around where the blue side of the mask is facing inward, and the white side of the mask is facing outward. There is a correct way in which these masks should be worn. The blue should be facing outward and the white facing inward, because that blue is really the water-resistant side and the white is the absorbent side. So that's something to pay in mind too when choosing those masks, is whether or not the healthcare worker is going to be able to intuitively know which side of the mask should be facing outward, which side of the mask should be facing inward. As well as getting education on that matter.

Let's pause for just a moment and talk about what does best fit actually mean. Because I want to make sure that we understand what we mean by best fit. So, when we say best fit, best fit is really just referring to ensuring that the mask is conforming to the shape of the face of the wearer. Sometimes we have masks that will have a little bit of a gap on the outside of the face or maybe on the bottom of the face. And so best fit would just be ensuring that there are no gaps around the seal of the mask. And that's really what we refer to as best fit. But there are all kinds of different shapes of masks. And there's different materials of masks. Let's just, for example, talk about the duck shaped masks. We've heard about these duck shaped masks. They look kind of like a duck bill. What's the purpose of the duck shaped mask, is there any benefit to it, advantage over other types of masks? So, I would say with the duck shaped masks, the goal here and the purpose, the reason behind having these is really to have more breathing room. It's the breathability aspect of the mask that we're trying to achieve with the duck shaped mask. But that really is not lending itself to the level of protection that those masks are offering to us. We want to make sure and go back and look at the mask, whatever duck shaped mask we have and see is that a respirator mask that requires us to do some fit testing. Or is it just a regular surgical mask that is duck shaped or duck bill shaped? That would be something that we would want to look at. But that shape may offer wearers some more breathability, which really lends itself to comfort.

Another consideration that facilities might have is that tie masks are going to take a little bit longer to put on, because of course we have to tie the mask behind the back of our head. It also is going to take a little bit longer to take off since we'll have to untie those masks and it could be a little bit more challenging for the healthcare worker to reach behind their head and untie those without any contamination. So, the facility is going to want to take that into consideration. Also take into consideration if these masks are going to need to be put on quickly, then tie masks may not be the most advantageous option for that facility.

So, we need to look back at the level of protection that that mask is offering, because the shape of the mask does not always equivalate to the level of protection. We want to understand is that mask a respirator mask or is it a surgical mask? Because a surgical mask is going to offer protection against diseases that are transmitted by droplets. And those N95 or respirator masks are going to offer protection against those diseases that are transmitted by aerosol. So, we want to understand the level of protection the mask is providing and then we can look at what mask is more comfortable for a healthcare worker. It’s really difficult with all the different types of masks to know which masks people should be wearing. So just knowing that a well-fitting mask is what we really want to see.

Experts in infection prevention discuss how PPE protects both the wearer and others, and how a well-fitting mask ensures high protection from germs and other infectious substances.