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Expert Perspectives on Personal Protection Guidelines and Standardization Practices

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personal protective equipment page offers written and video content on the proper use and—during the time of COVID-19 surges—reuse of PPE, including masks, respirators, gloves, gowns, face shields, goggles, and more. What are the proper donning and doffing methods? How long can PPE be extended? How are these items decontaminated? What comprises proper fit testing? Our experts will tell you.

As COVID-19 restrictions eased up, other respiratory viruses began circulating alongside SARS-CoV-2. It's crucial to identify cases and understand the symptoms of these infections to track the evolution of the virus and what health care workers should look out for.

Evolving Symptomatology: Respiratory Viruses in the Era of COVID-19 Variants

Randomized controlled trials show masks are effective. With COVID-19, even one mistake in protective gear usage could lead to infection and obscure results.

Organized Disinformation Fanning the COVID-19 Flames of Vaccine Hesitancy    

Plague doctors' historical attire was an early form of PPE. While modern PPE has improved, the quest for better, more comfortable protection continues as we aim for a future where health care workers can provide care confidently.

Protecting HCWs: Plague Doctor's Masks to the Personal Protective Equipment of Tomorrow

Health Watch USA’s annual conference will examine many aspects of long COVID with speakers from across the globe on November 1, 2023, from 8:30 AM to 2:00 PM EST.


Health Watch USA's 17th Annual Conference: Exploring Long COVID's Impact on Patients, Workers, and Society

In this Hot Topics in IPC, Saskia v. Popescu, PhD, MPH, MA, CIC, FAPIC, discusses whether masks need to return for COVID-19, Virginia’s outbreak, and interesting articles to read. 

IC Today Hot Topics: COVID-19 Readiness, Meningococcal Outbreak, and Norovirus 

The Association for the Health Care Environment (AHE) Exchange Conference & Solution Center brings together individuals who are passionate about environmental hygiene in the health care industry. Doe Kley, MPH, RN, T-CHEST, LTC-CIP, CIC, Infection Prevention Fellow for Clorox Healthcare, and adjunct lecturer for the department of education and human ecology at The Ohio State University at the conference and shared valuable insights with 

) about her presentation and 2 sessions she found valuable. The AHE was held in Dallas, Texas, from July 31 to August 2, 2023.

: Please summarize your AHE presentation?

Doe Kley, MPH, RN, T-CHEST, LTC-CIP, CIC:

 The presentation that I gave at AHE was titled “Deepening Your Understanding of Environmentally Spread Emerging Pathogens.” As the title implies, this talk was specific to those emerging pathogens that have the potential to be spread by contaminated surfaces—albeit some more than others. This talk was inspired by the events of the past few years. The 21st century has been impacted by emerging infectious diseases on an unprecedented scale.

I started this talk with a little background into the problem, primarily why we are seeing an increase in novel pathogens (eg, climate change and urbanization). I then reviewed some of the challenges associated with these pathogens, particularly as they relate to environmental services [EVS], including things like our general lack of preparedness, limited treatment options, a tendency to cause outbreaks, and cleaning and disinfecting against pathogens. Because it can be quite complex, I reviewed the EPA’s viral emerging pathogen policy, including a comprehensive overview of EPA’s List Q.

I also reviewed several selected emerging pathogens. These included 

], carbapenem-resistant organisms, hemorrhagic viral fevers, and seasonal respiratory pathogens. Since we went several years with a nearly nonexistent influenza season, these seasonal pathogens are reemerging. Last year’s influenza season started and peaked a few months earlier than usual. However, the experts at BlueDot Global Surveillance believe that the timing of these seasonal pathogens is progressing back to prepandemic patterns.

Finally, I provided the participants with several resources, including pathogen education sheets on the pathogens I addressed, a cleaning frequency risk assessment, and an emerging pathogen checklist for EVS leaders.

: What are you most excited about at this year’s AHE meeting?

 I was excited to see several IPs [infection preventionists] attending the conference along with their EVS teams. Every IP should attend the AHE conference at least once in their career and, better yet, attend with your EVS manager. Another thing that was great is that I am seeing more EVS leaders bringing their supervisors, leads, and even frontline workers to the conference with them.

As for sessions, 2 stood out to me. The first was a session presented by the CDC titled “The Role of Environmental Services in Controlling Outbreaks of High-Impact Pathogens.” This presentation piggybacked nicely on the one I gave. The CDC presenters reminded us that cleaning and disinfection are part of standard precautions.

I also appreciated how the presenters helped participants understand the importance of communication between EVS and IPs, particularly during outbreaks or other emergency situations, such as the presence of an emerging pathogen. They also made this session interactive with “what would you do” scenarios leveraging a real-life outbreak of carbapenem-resistant 

The second session was titled “From Survival Mode to Flourishing.” In this highly motivating talk, Benjamin Kenyon, an EVS supervisor in upstate New York, shared ideas for EVS leaders to move outside of their status quo comfort zone to establish a highly engaged team

 Mr Kenyon was very much about having the frontline workers be part of the solution to whatever problem is being faced. He also discussed standardization quite a bit, ranging from EVS cart setup to cleaning processes. Another area that is ripe for standardization is product. For example, why have EVS use one bleach manufacturer’s product for 

rooms and terminal cleans while clinical staff use a different manufacturer’s bleach wipes? Wouldn’t it be easier and make more sense to educate everyone [on] the same product, same instructions for use, and same contact time?

ICT: Anything else you would like to add?

 Every IP should consider attending the AHE conference. They do such a great job with the program, ranging from the quality of speakers to the exhibit hall to the fun activities. By attending this conference, IPs will gain an appreciation for the EVS profession that they otherwise may never have.

This interview has been edited for length and clarity. You can watch the video to see the entire interview.

Doe Kley, MPH, RN, T-CHEST, LTC-CIP, CIC, speaks to Infection Control Today about her presentation and other exceptional presentations at the Association for the Health Care Environment (AHE) Exchange Conference & Solution Center 

Environmental Spread of Emerging Pathogens: AHE Conference Discussion

As students return to school, a crucial question arises: Should they be required to wear masks? The answer to this question, like many aspects of the COVID-19 pandemic, is complex and depends on various factors.

) spoke with Ambassador Deborah Birx, MD, a highly respected American physician and public health expert who has played a pivotal role in the field of global health and infectious diseases. Throughout her distinguished career, Birx has made significant contributions to the fight against HIV/AIDS and has been at the forefront of the response to the COVID-19 pandemic. In 2020, during the outbreak of the COVID-19 pandemic, Birx was appointed as the White House Coronavirus Response Coordinator on the US Coronavirus Task Force. In this role, she played a key part in guiding the nation's response to the pandemic, providing valuable insights and data-driven recommendations to mitigate the virus spread

The effectiveness of vaccines in providing long-term protection against infection is limited. Additionally, natural immunity acquired through previous infection also wanes relatively quickly. This raises concerns about the vulnerability of children under 18 in the school system, where close contact and the exchange of saliva are common occurrences. However, now “we have tools to treat people who are at risk,” Birx told 

. “ And we have tools in the vaccines to ensure that the teachers who are vulnerable are actively immunized so that we don't have to worry about if they get infected [that] they're at risk.”

The key question is whether masks should be mandatory for students. The consensus is that vulnerable children should wear masks during waves or surges of COVID-19 cases. The decision should be informed by local data and community circumstances. Well-fitted masks, including N95s, offer a level of protection that is especially crucial for vulnerable children.

Furthermore, it's important to foster understanding among students and their families. Rather than assuming that mask-wearing is a political statement, it should be seen as a matter of personal safety and consideration for others. “I have a great respect for people who proactively mitigate during a surge…to protect their family members. And we should see that as a point of personal empowerment and respect for others, particularly that they may have people at home at risk,” Birx said.

Timely communication from public health agencies, like the CDC, is crucial. They must provide specific, localized guidelines based on the status of the virus in each community. This information empowers individuals to make informed decisions about their safety.

It's important not to underestimate BA.2.86 potential impact. This variant, while a distant relative of Omicron, carries mutations that make it just as concerning in terms of its ability to infect individuals and potentially evade immunity. 

Global surveillance efforts are designed to identify and study variants that pose a risk to public health. If a variant is identified as potentially problematic, action should be taken promptly. This includes developing and producing updated vaccines if necessary. The mRNA vaccine technology allows for rapid adjustments to vaccines, ensuring that we can stay ahead of evolving variants.

Ambassador Deborah Birx, MD, discusses whether students should be required to wear masks to protect themselves and others and what the public should know about the newest COVID-19 variant, B.A.2.86.

Fall 2023: Mask Mandates for Students Amidst COVID-19 and Latest Variant Concerns

CDC’s antimicrobial-resistant funding to global and domestic partners—from academic centers to local public health departments. CDC collaborates with partners to develop innovative strategies to slow the spread of AR, improve infection prevention and control, and safeguard individuals. Through CDC's investment, significant progress has occurred in enhancing the US and global capabilities to quickly detect, respond to, and contain existing and emerging AR threats.

Mary Alice Lavin, MJ, BSN, RN, CIC, FAPIC, is an infection control consultant at Hektoen Institute, LLC, Illinois Department of Public Health grantee, and spoke with Infection Control Today about the updated 

Antimicrobial Resistance (AR) Investment Map

She discusses antibacterial resistance and overviews the map and its origins.

“Antimicrobial resistance is not new; however, it is a growing concern. Even since the 1950s, or early 60s, when we first had treatments for 

, resistance developed quickly after those treatments became available. And over time, as we've seen different organisms of concern. We use antibiotics, and those germs become resistant. Now, one of the issues is that the germs can share those mechanisms of resistance with each other. And so one mechanism of resistance can then move on to another germ. Now that germ also has that mechanism of resistance, and as that occurs, more germs become resistant, potentially. And once they're resistant, there are fewer options for treatment. It makes it more difficult to treat those individuals. In some cases, unfortunately, there is nothing that can cure those individuals, and the cases are fatal.”

Lavin explains that the “goal of the map is to share the investment being made, certainly in the United States. It's also important to note that the CDC also funds initiatives overseas, and people may question why we are doing that. We know that germs are only a plane away. It's easy for people to travel and bring germs back. We also know that some medical tourism occurs and so people may go to other countries to receive medical care. In other countries, antimicrobials are not as well controlled as they are in the United States. In some countries, you can go into a store and ask for an antibiotic. And you don't need to have a prescription. And so when antibiotics are used more broadly, there's more pressure, and the germs and resistance develop more easily and more frequently. So if you've gone to one of these countries where antibiotics are not controlled, you receive medical care, and, unfortunately, are exposed to one of these germs, you return to the United States. Now that it gets introduced potentially into the health care environment. If people don't practice appropriately, cleaning their hands, using personal protective equipment, such as gowns and gloves, and ensuring instruments are adequately cleaned and disinfected, we shouldn't forget about the investments done overseas.”

These quotes have been edited for clarity.

What is the CDC's Antimicrobial Resistance Funding map? A key opinion leader explains. 

CDC’s Map Shows Antimicrobial Resistance Funding to Global/Local Partners  

The COVID-19 Public Health Emergency has been declared over. But that doesn’t mean that COVID-19 and the need for assistance for the effects of COVID-19 are over. Where do we go from here? 

) contacted Deborah Birx, MD, for her input, based on her work with global HIV initiatives. 

Birx is a renowned medical expert and leader with extensive experience in clinical and basic immunology, infectious disease, pandemic preparedness, vaccine research, and global health. She has served the United States as an Army Colonel and has overseen influential programs at the CDC and US Department of State. Birx is a formal Ambassador-at-Large and is currently a Senior Fellow at George W. Bush Institute in Dallas, Texas.

In the discussion, Birx discusses what she thinks the government did right, did wrong, and what still needs to be done going forward. One theme runs through the conversation: “If you give people the information and empower them, they'll make the right decisions, but we're not giving people the information and empowering them to make the right decisions.”

About the Public Health Initiative, Birx remarked, “It doesn't matter if the public health emergency goes away or not. Because we haven't really taken advantage of the public health emergency over the last 2 years to understand and address the gaps that are quite apparent to every American out there.”

About masks, Birx says, “I think the masking issue has demonstrated how important it is in aerosolized respiratory disease and how it may be less important and more droplet transmission that may still be more surface and direct contact with individuals.”

, “I'm going to be very clear: these vaccines were a miracle. They saved literally hundreds of thousands of American lives. But they're not perfect. They're far from perfect. And we have not been clear to the American public about their imperfection. I think because of that, people aren't clear on what these vaccines can do and can't do.”

Birx is optimistic about the world’s ability to handle future pandemics. “All of these things are addressable. We are incredibly smart in the United States and around the globe; we know how to make highly technical things fast. [So,] we need to figure out how we work effectively with communities to give them the information they need to do their own risk-benefit analysis, and [so] they don't feel like the federal government is misleading them with partial truths. There is never a reason to withhold information for fear that the American people will not understand it. That's how you lose the public. And that's been very well demonstrated in COVID-19.”

(Birx’s quotes are edited for clarity. Listen to the full interview for more of Birx’s views.)

“It doesn't matter if the public health emergency goes away or not. Because we haven't taken advantage of the public health emergency over the last 2 years to understand and address the gaps quite apparent to every American out there.”


ICT Exclusive: Deborah Birx, MD, Discusses the End of the COVID-19 Public Health Emergency

) requires the efforts of not just infection preventionists (IPs) and environmental hygiene services (EVS), but also the entire facility or community. What specific measures should IPs and EVS take to address this issue?

), along with our colleague Chris Spivey, editorial director for 

, reached out for answers from Megan Lyman, MD, medical officer, Mycotic Diseases Branch, CDC, and Danielle A. Rankin, PhD, MPH, health scientist, Division of Healthcare Quality and Promotion, Prevention and Response Branch, Antimicrobial-Resistance Team, CDC. 

This installment is the second in a series. The first is 

 in the news, but how do you recognize it? What are the symptoms? What do you see?

 There aren't any specific signs or symptoms for 

, which depends on the body site of where the infections are occurring. However, it's often similar to infections caused by bacteria and viruses. If you have a bloodstream infection, you might have a fever or sepsis. And if you have a wound infection from 

, you might see redness, swelling, and drainage. It's difficult because no symptoms specifically point to 

 [because] it's similar to infections caused by other pathogens.

: What can infection preventionists and environmental hygiene specialists do to help prevent this pathogen?

 There are many different infection control measures that can work and beyond the basics, I want to focus on 2 primary key points that we often recommend to our health care facilities for seeing 

 and 1 of them is admission screening. Admission screening is important because we are able to identify patients or residents coming from long-term care facilities who are, as Megan indicated, asymptomatically colonized with 

If we do asymptomatic colonization, we're able to detect when a patient with 

 is not showing those signs or symptoms. We know that asymptomatic colonization can also lead to a silent spread within a health care facility, often undetected, and so we see these larger outbreaks of 

. When we do admission screening, we're able to have the facility place the patient or resident (depending on what facility type it is), if they screen positive for 

, we recommend that those patients are placed on the appropriate transmission-based precautions. In acute care hospital settings, we recommend that contact precautions, which include gloves and gown, that health care providers ensure they're performing the appropriate hand hygiene, and that they have dedicated patient care equipment.

In nursing homes, that changes a little bit. We have what's called 

, again, includes that glove and gown, but only apply those during high-risk patient care activities such as bathing, changing, or toileting a resident, and hand hygiene. In addition to an admission screen, we recommend infection preventionists and facilities with a case of 

 focus on conducting direct observations of those [basic] control practices. So that includes hand hygiene, personal protective equipment usage, and environmental cleaning. But specifically with hand hygiene, [IPs] want to make sure that they have those direct observations are being done during patient care, so you can then help coach staff, and where there are some opportunities for improvement of when hand hygiene could have occurred to limit the spread from environment to patient. Then for personal protection equipment use, ensuring that donning (or putting on the gown and gloves) is in the proper order and taking off [doffing] is reducing any contamination to the person themselves.

Then specifically with environmental cleaning [for] 

] health care facilities should be using the disinfectants listed on Environmental Protection Agency’s 

 is shown to contaminate the environment and can be difficult to remove without meticulous cleaning efforts.

Because of this, we also recommend that IPs pair up with their environmental services (EVS) management team to conduct direct observations of environmental cleaning, to ensure that from start to finish are hitting all high-touch surfaces. All environmental services staff are moving in a systematic method when they're cleaning the room. Either starting clockwise or counterclockwise in a room and from the outer perimeter and going into the patient zone, typically where the patient or resident bed is. In addition to that, while they're watching those items, make sure that staff are moving from cleaner to dirty surfaces so that they're not cross-contaminating within the room itself. It gets complex, but the direct observations help formulate those opportunities for improvement and one-on-one coaching with those staff members.

To prevent the spread of C auris, the CDC recommends that IPs and environmental hygienists play a critical role. In this interview, the medical scientists clarify what specific actions they should take.


Video Series

CDC Discusses Candida auris: The Role of Infection Preventionists and EVS Staff

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.

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.

Personal Protective Equipment

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