What PPE is to be used when giving a bed bath to a resident who has a skin infection or open wound?

Personal protective equipment (PPE) is worn to prevent:

• Resident-to-resident, health care provider-to-resident and resident-to-health care provider exposure to and possible colonization or infection with community-and health care-associated infectious agents including MDRO, and
• Occupational exposure to bloodborne pathogens including, but not limited to hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

PPE should be readily available on all nursing units and in ancillary departments (e.g., physical therapy, activities, dining rooms, etc) at all times.

• Contamination of resident’s skin is greatest when they have diarrhea but haven’t started treatment yet.
• All health care providers who may have resident contact or work in resident care areas should be periodically observed for compliance with the PPE policy.
• For detailed instructions on how to put on and remove PPE, the facility should consult the CDC's Sequence for Putting On Personal Protective Equipment and How to Safely Remove Personal Protective Equipment (PDF).
  

Put ON in this order:

1. Wash or gel hands
2. Gown
3. Mask (if needed)
4. Eye cover (if needed)
5. Gloves

Take OFF and DISPOSE in this order:

1. Gloves
2. Eye cover (if used)
3. Gown
4. Mask (if used)
5. Wash or gel hands (even if gloves used)

Gloves

Gloves are a crucial element in preventing the spread of disease, including CDI. Most health care acquired infections are transmitted through contaminated hands of health care providers.
Gloves should be:

• Clean, durable, non-sterile, snug-fitting, disposable, examination gloves
• Put on after hand hygiene and immediately prior to contact with the resident’s:
  • Non-intact skin
  • Intact skin soiled with blood and body fluids
  • Clothing and linens soiled with blood and body fluids
  • Mucous membranes
• Worn when in contact with containers of blood and body fluids (e.g., suction canisters, urinals or commodes, emesis basins)
• Removed and hand hygiene performed after completing procedures that involve direct resident contact, contact with blood and body fluids, contact with environmental surfaces
• Changed and hands washed with soap and water when the integrity of the glove is compromised
• Changed and hand hygiene performed when moving from a contaminated body site (perineum or wound) to a clean body site (e.g., face or IV site)
• Removed, disposed of, and hand hygiene performed before moving from one resident to another in a multi-bed room or procedure area
• Removed and hand hygiene performed immediately upon exiting a resident occupied room (e.g., before exiting into a common area such as a corridor)
• Should not be worn for multiple-resident contacts

Gowns

Wear gowns to prevent soiling of clothing with blood and body fluids and the transfer of infectious agents from resident’s skin, clothing, bedding, and environmental surfaces. The physical characteristics of the material (e.g., moisture repelling vs. cloth) are based on the anticipated degree of physical contact with the resident and the potential for fluid penetration. Laboratory coats or jackets worn over personal clothing, uniforms and scrubs are not considered PPE.
Wear disposable moisture repelling gowns when:

• In contact with non-intact skin (e.g., large draining wounds, extensive dermatological conditions including skin rashes, burns, etc.)
• Handling fluid filled containers that are likely to leak, splash, spill or splatter when moved (e.g., bedside commodes, bedpans, urinals, and emesis basins)
• In contact with residents who soil their bed linens, clothing, and/or environmental surfaces with blood and body fluids
• Performing procedures likely to generate splashes, sprays, splatters or droplets of blood and other body fluids
• Entering a Contact Precautions designated room
  

Disposable aprons or cloth cover gowns can be worn for routine resident care activities that require prolonged contact (e.g.) bed bath, moving or turning the patient, etc.). They should be worn by only one health care provider and for only one resident.
Gowns should be:


• Worn correctly (tied at neck and waist, if applicable)
• Always worn in combination with disposable gloves that cover the cuff of the gown’s sleeve
• Removed after gloves and immediately before or upon exiting the resident’s room or when moving from one resident to another in a multi-bed room.

References

1. “Enhanced Standard Precautions (ESP) for Long-Term Care Facilities”. California Department of Health. 2010.

Jennifer’s needle stick protocol checklist included the incident report, exposed employee date of birth and contact info, her own risk status and information about her date, time and route of exposure. The required HIV testing included the following on the infection control nurse’s checklist:

Source: Needle stick protocol, occupy-medical.org. (n.d.).

When to Wear PPE

Personalized Protection Equipment (PPE) is specialized clothing or equipment worn by an employee for protection against hazards that remain after engineering controls and work practice controls are in place. PPE is not the first line of defense! Legally, the employer must provide PPE, ensure that the employee uses and must clean, repair, and replace this equipment as needed. You as the employee have the right to have PPE available to complete your job duties.

PPE includes gloves, gowns, laboratory coats, face shields or masks, eye protection, resuscitation masks, and other protective gear such as hats and booties. It may also include full protection suits, as were used for the Ebola patients. It must be readily accessible to employees and available in appropriate sizes. The hospital infection control process often determines the isolation requirements for patents including contact, droplet, and airborne and will require nurses and visitors to follow the protocol for each type of isolation.

The worker often must decide on their own when to wear PPE because exposure is likely. If exposure seems reasonably likely, you have the right to protect yourself with PPE.

An easy guideline to use is

If it is wet and not yours, stay out of it!

Gloves shall be worn when:

• It can reasonably be anticipated that the employee may have hand contact with blood, OPIM, mucous membranes and non-intact skin
• Performing all vascular access procedures or procedures involving uncontained blood, such as finger or heel sticks
• Gloves must be changed between patients (CDC, 2013)

Single use gloves cannot be washed or decontaminated for reuse. Utility gloves worn by engineering or housekeeping may be decontaminated if they are not compromised. They should be replaced when they show signs of cracking, peeling, tearing, puncturing, or deteriorating.

Traditionally, latex gloves are used to avoid contact with blood or OPIM. However, some workers are allergic to latex or vinyl. In most circumstances, nitrile or other glove alternatives may be used in place of latex gloves. Employers are required to provide non-latex alternatives to employees with sensitivities to latex and other materials. Sterile or nonsterile gloves are also available as PPE and dictated by the procedure.

Employees should wear eye and mouth protection such as goggles and masks, glasses with solid side shields, and masks or face shields when splashes, sprays, splatters, or droplets of blood or OPIM pose a hazard to eyes, nose, or mouth.

Gowns, aprons, surgical caps and hoods, shoe covers, or boots are needed when splash, spray, or gross contamination is expected. This may occur, for example, during labor and delivery, surgery and procedures with anticipated blood splash may occur.

Employers must provide the PPE and ensure that their workers wear it. This means that if a lab coat is considered PPE, it must be supplied by the employer rather than the employee. The employer also must clean or launder clothing and equipment and repair or replace it as necessary. This includes, but is not limited to dentistry, phlebotomy or processing of any body fluid specimen, and postmortem procedures.

Personal protective clothing and equipment must be appropriate for the level of protection needed for the expected exposure. For example, gloves would be sufficient for a laboratory technician who is drawing blood, whereas a pathologist conducting an autopsy would need considerably more protective clothing. Personal protective equipment may be required during the care of any patient, so it must be routinely available in patient-care areas, not just on isolation carts. You may need to wear a mask and eye protection during the care of a patient on Standard or Universal Precautions. Availability of PPE is required by the OSHA Standard. If you are not sure where to obtain it, ask your employer.

What PPE to Wear

Knowing what to wear for each different type of isolation is important for your protection. Factors influencing PPE selection include the fit, the type of exposure anticipated, durability, and appropriateness for the task.

Exception

The employer shall ensure that the employee uses appropriate PPE unless the employer shows that the employee temporarily and briefly declined to use PPE 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 healthcare or public safety services or would have posed an increased hazard to the safety of the worker or co-worker.

When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future. In other words, if using PPE would increase danger to the person receiving care or to the worker, then the worker may decline to use the PPE, but situations like this must be reported and investigated, and are rare.

Decontaminating and Disposing of PPE

Employees must remove personal protective clothing and equipment before leaving the work area or when the PPE becomes contaminated. If a garment is penetrated, workers must remove it immediately or as soon as feasible. Used protective clothing and equipment must be placed in designated containers for storage, decontamination, or disposal.

While use of PPE cannot prevent all exposures, wearing it properly and when needed can greatly reduce potential exposure to all bloodborne pathogens. The sequence for removing PPE is:

Gloves —> Goggles —> Gown —> Mask

Test Your Knowledge

Personal protective equipment:

1. Should be purchased by employees who are in frequent contact with blood or other body fluids.
2. Include only latex gloves, which have been shown to be the only type of glove that protects against bloodborne pathogens.
3. Are devices that isolate or remove the bloodborne pathogen hazard from the workplace.
4. Must be provided by the employer, who is required to clean, repair and replace it as needed.

Apply Your Knowledge

How diligent are you in using PPE’s in your facility? How meticulous are you in removing them correctly? Do you know the correct process to remove a gown, glove, and mask and do you follow it? What would you do if you saw a colleague using PPEs incorrectly with an isolation patient? How do you instruct and reinforce a visitor to wear PPEs in an isolation room when visiting?

Answer: D

What type of PPE would you wear when giving a bed bath?

What PPE do you use when giving a bed bath to a resident who has a skin infection or open wound?

What PPE do you wear for patients who have infections?

What PPE do you wear when irrigating a wound?