The Proper Fit for PPE
By John Roark
Gowns, gloves and masks cannot protect you if they do not properly fit. Protect yourself and your patient by suiting up smart. The bottom line with all personal protective equipment (PPE) is that it must be user-friendly, says Geri Braddock, RN, BSN, PHN, CIC, infection control practitioner at Santa Monica-UCLA Medical Center in Santa Monica, Calif. PPE has to be comfortable, easy to put on, and not excessively hot. If people arent comfortable in it, theyre just not going to wear it, she says. If its tricky to put on and use, theyre either going to bypass it completely hospital workers are very clever with finding ways around things or figure out a way to get around using it correctly.
There are two components to gowns, says Keith Kaye, MD, MPH, assistant professor in medicine, an infectious disease attending physician, and associate hospital epidemiologist for Duke University Medical Center in Durham, N.C. First is protecting yourself. In universal precautions, if you anticipate a splash of bloody fluid or even fecal or urinary incontinence, you wear a gown to protect your gear and your person from things like HIV and hepatitis C. The other side of things is protection of patients, and trying not to contaminate yourself with something like Clostridium difficile spores or Vancomycin-resistant Enterococci (VRE).
One of the most important factors in surgical gowns is adequate coverage. Clinicians need to select gowns large enough to provide ample coverage and tie in the back, minimizing the risk of contamination. A gown that fits properly is not so tight that it binds or restricts movement, and not so large that it causes a hazard during a procedure. Gowns should be securely fastened at the neck and waist, and extend to the knees. Sleeves should cover the arms completely, preventing skin exposure between the end of the sleeve and the cuff of the clinicians gloves. If the sleeve is too short, flexing the elbow pulls the cuff of the sleeve beyond the cuff of the glove.
We like to look at the surgical gown as the suit and tie of the clinician, says Frank Czajka, senior product manager for the Proxima division of Medline. We give more room so that that suit fits better. Our focus is on room through the chest and sleeve areas, not skimping on cuts to make sure that the proper fit is assured and the clinician is not worrying about whether their gown fits well, but whether their patient is doing well.
Start by choosing the right size, says Donna Armellino, RN, MPA, CIC, infection control coordinator for North Shore University Hospital in Manhasset, NY. Most institutions make available various sizes of gloves. Most people who work in an area and utilize gloves frequently do know and do select the appropriate size glove. If your hands are small and you take a medium, you dont get the dexterity that you need. If you take a small and youre really a large, its going to easily tear. Its common sense.
There should be no excess material at the fingertips and the gloves should not be too tight across the palm, offers Donna Gaidamak, media relations manager for Cardinal Health. This can lead to hand fatigue, skin irritation and damage. The most common mistakes as it relates to glove selection are different for surgical and exam gloves. With surgical gloves, some people will select a glove that is too small, especially when changing suppliers. Glove sizes vary from manufacturer to manufacturer. With exam gloves, individuals may grab any available glove and end up with one that is too tight or too loose. A loose glove is more likely to get caught in pinch points with scissors and the barrier protection will be compromised.
Gloves that are too small will easily tear; gloves that are too large minimize tactile sensitivity and can be hazardous. People have to have a glove that fits fairly close to their hands, or they just cant do their work, says Braddock. If you do not have a good fit, the gloves especially the non-latex, which are not as flexible will literally come off your hands as youre making a patient bed or doing some procedures. People will get frustrated and just take them off, because theyre in the way of doing their care.
Gloves should be changed not only between patients, but between procedures on the same patient, continues Braddock. A very common mistake that people make is not changing gloves between a dirty and a less-dirty procedure on the same patient, she says. Lets say you just took the patient off of the bedpan or did some such contaminated procedure, and then proceeded to give the patient a drink of water with the same gloves on. There are nurses will do wound care on a dirty wound, and then proceed to do another procedure on that patient with the same gloves. Thats something that a lot of healthcare providers dont think about washing your hands, putting another pair of gloves for that same patient. They actually smear contamination from one end of the patient to the other.
Wava Truscott, PhD, director of scientific affairs and clinical education at Kimberly-Clark Health Care, agrees that compliance on this issue is lacking. Gloves do carry those organisms with them, and they attach to things. The organisms love to fi nd a place to hide and cuddle. Theyre on that glove until they find another place to transfer.
Sometimes clinicians dont think of it as a dirty area, because the word, dirty implies something you can see, continues Truscott. Although you may know it may be an infective area, you may not see organisms, and youre not even thinking as you reach up and grab something else. It also takes more time. Technically, clinicians should even be washing their hands between same-patient procedures. Theres also expense. Suddenly thinking about having to go through three pair of gloves to work with one patient seems wasteful to them when they dont see physical dirtiness on the glove.
Use the right mask for the right job, says Truscott. Unfortunately many clinicians dont understand which mask is the correct choice because the information is not communicated well, she says. Masks that tie at the crown of the head and the nape of the neck are surgical masks; masks with loops to go behind the ears are procedural masks. Molded cone-shaped masks present another option. Whichever mask is used, proper fit is paramount to minimize pathogenic exposure to both clinician and patient.
A properly fitting surgical or procedure mask will fit snugly about the face, without noticeable gaps at the sides of the nose, on the cheeks, ears or chin.
Often clinicians will tend to wear a larger mask, thinking its more comfortable, Truscott says. Theyve got more of a breathing area. But the problem is it doesnt fit around the edges. Most manufacturers construct the masks so that the top ties go toward the tip of the crown of the head, and the bottom ties go lower. By cris-crossing the ties you can get quite a crease at the cheeks, thus letting organisms in and out. Generally, your procedural mask will not fit quite as tightly at the sides of the cheeks.
Clinicians hypersensitive to infectious disease may don two masks, says Truscott, which is not the best course of protective action. Its much worse. What happens is you really decrease the amount of airflow that can possibly get through that much material. So it goes out the sides and over the top, on the sides of the nose. So they bypass it its actually worse protection.
Most surgical masks have a wire or molding that conforms to the face, originally developed to fit under glasses to prevent fogging. Its probably not that egregious if theres a gap between the bridge of the nose and the cheeks, says Braddock. This mask is not meant to filter the air, its really meant to be a barrier. If theres a splatter, youre not going to hit the mucous membranes of your nose or mouth. It would have to be a heck of a splatter or stream to get under that gap and hit your lips. It should be a reasonable fit, but it doesnt have to be an absolute fit.
Eye protection goes hand in hand with proper mask fit. Eye shields and protective goggles shield the mucous membranes of the eyes, but this PPE is often overlooked, says Braddock. Goggles are generally heavy and big, and people dont like them, she says. They will fall off most people, because they dont fit to your face properly. Either they pinch you and they hurt, or they will fall off as you are leaning over the patient. And theyre useless. Its hard to get people to buy in to wearing goggles before they do high-risk, splashy procedures this is just not something that we are good at. We wear gloves pretty good these days, but well put a mask on and still let our eyes be in harms way. During procedures such as intubating, suctioning or dealing with patients who are on ventilators, in my opinion you should always have eye protection. Those tubing connections can pop off and splatter your face.
People who are doing wound irrigation should be careful of a backsplash of that fluid into their faces. We arent as a society doing a good job of protecting our eyes, and I think thats partly due to infection control people needing to spend time teaching about it, and getting goggles that people will accept.
Kaye agrees. The mucous membranes in the eyes are very vascular, and you can absorb all sorts of things even aerosolized through the air, he says. With the SARS epidemic, healthcare workers were infected through their eyes they wore everything but goggles. Eyewear is underestimated particularly for things like GI insertions where people just dont anticipate having a spurt of blood. Eye care is very important for healthcare worker protection, particularly in the age of emerging infection and SARS.
The N95 respirator, worn as a preventive means against tuberculosis, SARS and other respiratory pathogens, should fit snugly over the face, without gaps. Elastic loops should be separated for the most effective fit.
Truscott brings up a concern about the N95s construction. During the SARS epidemic, clinicians were using masks with staples in the body of the filter media, about a half-inch in from the edge. That means that wherever the edges of that staple punctured that filter, organisms could come through. You could hold a flashlight up to it and see it. The reason they can do that is that the National Institute for Occupational Safety and Health (NIOSH) tests right at the very apex of the cone. All of their testing is of the material, not the structure. They are either unaware of it, or it is set up so it just doesnt test it.
Always hotly debated is the requirement for annual fit testing of N95 respirators. The Occupational Safety and Health Administration (OSHA) regulations mandate annual fit-testing of N95 respirators for employees. In August 2004, the American Association of Occupational Health Nurses, Inc. (AAOHN), conducted a Respirator Fit-Testing Compliance Survey of 2,196 occupational and environmental nurses and infection control professionals in hospital settings. The object of the survey was to better understand the issues, challenges and trends related to respirator fit-testing.
Among the survey findings: 69 percent of respondents reported a high level of difficulty complying with the new OSHA requirement. Of these, a majority (75 percent) work in non-government not-for-profit hospitals, are responsible for fit-testing between 500 and 5,000 individuals (61 percent), and have an employee health staff of three or smaller (69 percent).
Additional anecdotal findings of the survey revealed several recurring themes among participants asked to describe why compliance with OSHA created challenges. Among those reasons listed:
- High volume of employees to fit-test
- The large amount of time it takes to fit-test
- Lack of understanding about the need for fit-testing among those employees to be . t-tested/employee compliance
- Costly to administer fit-tests1
The Association for Professionals in Infection Control and Epidemiology (APIC) and other healthcare associations believe that the OSHA fit-test mandate, which went into effect July 1, 2004, is scientifically unjustified, and that workers are already adequately protected by guidelines issued by the Centers for Disease Control and Prevention (CDC), according to an APIC statement issued July 1, 2004.
Furthermore, the release stated, The scientific or epidemiologic rationale for this new mandate has not been met. This extremely burdensome task will take nurses and other staff away from their patient care duties to undergo a series of needless exercises.
ICPs are polarized on the issue. Based on what has occurred with the number of TB cases over time, we see the constant decline in new cases. That should be enough to keep things as is, says Armellino, who adds that the N95 is far from conducive to wear. If youve ever worn one, theyre restrictive. Theyre very uncomfortable. No matter which model you wear, its hard to breathe in these things, she says. OHSA should wear them and come take care of patients. You cant stay in the room for any extended period of time its a shame.
Braddock sees annual fit-testing as a nuisance. I think the whole nine yards of fit-testing is an enormous burden on our resources, and Im sure Im not alone, she says. I personally think its the silliest thing Ive ever heard of for this particular mask.
Ive said for years that we would be better served if we would do an annual competency on putting them on, taking them off, and fit-checking the masks. If I can see that people are putting them on properly and fit-checking them properly, in my mind that is the most important thing, that I know that theyve got a good seal. You can see it. I think that would only take a few minutes. That is reasonable to do, and that really is where we should be going if were really concerned about keeping people safe.