Which of the following personal protective equipment may be reused by the same nurse during a single shift caring for a single client?
Description of PrecautionsStandard Precautions are a group of infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Proper selection and use of PPE, such as gowns and gloves, is one component of Standard Precautions, along with hand hygiene, safe injection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. Use of PPE is based on the staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). More detail about Standard Precautions is available as part of the Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all Settings. Show
Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident’s environment. Contact Precautions require the use of gown and gloves on every entry into a resident’s room. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed into a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be cohorted, or grouped together. Residents on Contact Precautions should be restricted to their rooms except for medically necessary care and restricted from participation in group activities. Because Contact Precautions require room restriction, they are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. More detail about Transmission-Based Precautions, including descriptions of Droplet Precautions and Airborne Precautions are available in the CDC Guideline for Isolation Precautions. In addition, other infections (e.g. norovirus, C. difficile, and scabies) and conditions for which Contact Precautions are indicated are summarized in Appendix A – Type and Duration of Precautions Recommended for Selected Infections and Conditions of the guideline. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:
In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident’s stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Who this is for: Healthcare workers, supervisors, and administrators at U.S. hospitals. What this is for: To protect healthcare workers and other patients at facilities that provide care to a patient with confirmed Ebola or PUI who is clinically unstable or has bleeding, vomiting, or diarrhea by describing protocols for using PPE. How to use: Incorporate into infection control and safety training for healthcare workers who provide care to patients with Ebola and use in planning for staffing and supply management. How it relates to other guidance documents: There are two PPE guidance documents for U.S. hospital workers who may evaluate or care for Ebola patients. Workers should wear this recommended PPE ensemble when evaluating and caring for:
Refer to For U.S. Healthcare Settings: Donning and Doffing Personal Protective Equipment (PPE) for Evaluating Persons Under Investigation (PUIs) for Ebola Who Are Clinically Stable and Do Not have Bleeding, Vomiting, or Diarrhea recommended when evaluating and caring for a PUI who is:
Key points
Updates to previous versions of this guidanceThis Ebola PPE guidance has been updated to add detail, clarify where needed, and improve the format. Specifically, the guidance was updated to:
Selecting Protective Clothing > Respiratory Protection for Ebolaexternal icon IntroductionThe following guidance on the types of PPE to be used and the processes for donning (putting on) and doffing (removing) PPE is for all personnel entering the room of a patient hospitalized with Ebola. This guidance reflects lessons learned from the recent experiences of U.S. hospitals caring for patients with Ebola and emphasizes the importance of training, practice, competence, and observation of healthcare workers, especially in correct donning and doffing of PPE. In healthcare settings, Ebola is spread through direct contact with blood or body fluids of a person who is sick with Ebola or with objects (e.g., bathroom surfaces, medical equipment) that have been contaminated with infectious blood or body fluids. The virus in blood and body fluids can enter a person’s body through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth. For all healthcare workers caring for patients with Ebola, PPE that fully covers skin and clothing and prevents any exposure of the eyes, nose, and mouth is recommended to reduce the risk of accidental self-contamination of mucous membranes or broken skin. All PPE must be used in the context of a comprehensive infection control program that follows CDC recommendations and applicable Occupational Safety and Health Act of 1970 (OSHA) requirements, including the Bloodborne Pathogens (29 CFR 1910.1030)external icon, PPE (29 CFR 1910.132)external icon, and Respiratory Protection (20 CFR 1910.134)external icon standards, and other requirements under OSHA (e.g., the General Duty Clause, section 5(a)(1); and prohibitions against discrimination or retaliation against workers, section 11(c)). To protect healthcare workers who are caring for patients with Ebola, healthcare facilities must provide onsite management and oversight of adherence to safely using PPE, and implement administrative and environmental controls with continuous safety checks through direct observation of healthcare workers, including during the PPE donning and doffing steps. Section 1. Recommended Administrative and Environmental Controls for Healthcare FacilitiesProtecting healthcare workers and preventing spread of Ebola to other patients requires that proper administrative procedures and safe work practices be carried out in appropriate physical settings. These include the following:
Section 2. Principles of PPEHealthcare workers must follow the basic principles below to ensure that no infectious material reaches unprotected skin or mucous membranes while providing patient care.
Double-gloving provides an easy way to remove gross contamination by changing an outer glove during patient care and when removing PPE. Beyond this, more layers of PPE may make it more difficult to perform patient care duties and put healthcare workers at greater risk for percutaneous injury (e.g., needlesticks), self-contamination during care or doffing, or other exposures to Ebola. If healthcare facilities decide to add additional PPE or modify this PPE guidance, they must consider the risk/benefit of any modification and train healthcare workers on how to correctly don and doff for the modified procedure. Donning and doffing steps may need to be adapted on the basis of the specific PPE that is purchased by the hospital. If adaptations are made, facilities must select PPE that offers a similar or higher level of protection than what is recommended here, train healthcare workers in its use, and ensure they demonstrate competence in its use before caring for a patient with Ebola. Section 3. Training on Correct Use of PPETraining ensures that healthcare workers are knowledgeable and proficient in donning and doffing PPE before caring for a patient with Ebola. Comfort and proficiency when donning and doffing are only achieved by repeatedly practicing correct use of PPE. Healthcare workers should be required to demonstrate competency in using PPE, including donning and doffing while being observed by a trained observer, before working with patients with Ebola. Training should be tailored to the intended audience and effectively transmit the required information. In addition, during practice, healthcare workers and their trainers should assess proficiency and comfort with performing required duties while wearing PPE. People unwilling or unable to fulfill these requirements should not care for a patient with Ebola.
Section 4. Use of a Trained ObserverBecause the sequence and actions involved in each donning and doffing step are critical to avoid exposure, a trained observer should read aloud to the healthcare worker each step in the procedure checklist and visually confirm and document that the step has been completed correctly. The trained observer has the sole responsibility of ensuring that donning and doffing processes are adhered to. The trained observer must be knowledgeable about all PPE recommended in the facility’s protocol and the correct donning and doffing procedures, including how to dispose of used PPE, and must be qualified to provide guidance and recommendations to the healthcare worker. The trained observer will coach, monitor, and document successful donning and doffing procedures, and provide immediate corrective instruction if the healthcare worker is not following the recommended steps. However, the trained observer should NOT provide physical assistance during doffing, which would require direct contact with potentially contaminated PPE. The trained observer is required to wear PPE, nonetheless, because the coaching role will necessitate being present in the PPE removal area during the doffing process. PPE for the trained observer is described in Section 8. The trained observer should know the exposure management plan in the event of an unintentional break in procedure. A designated doffing assistant or “buddy” might be helpful in some circumstances, e.g., during the doffing of the PAPR. Section 5. Designating Areas for PPE Donning and Doffing
Facilities should ensure that space and layout allow for clear separation between clean and contaminated areas. Separate the space into distinct areas and establish a directional, one-way flow of care, moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where potentially contaminated PPE is removed and discarded). The direction of flow should be marked (e.g., signs on the floor) with visible signage; temporary plastic enclosures can be added if necessary. Existing anterooms to patient rooms have been used for doffing but in many cases are not ideal because of their small dimensions. As an alternative, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window) and provided that the healthcare worker doffing PPE can hear the instructions of the trained observer. Whenever possible, close the end of the hallway of a ward or ICU to through traffic, thereby restricting access to the patient’s room to essential personnel who are properly trained in recommended infection prevention practices for caring for patients with Ebola. Designate two adjacent rooms, located on either side of the patient’s room, to be cleared of equipment and furniture and used as donning and doffing areas. Glass-enclosed rooms or other designs (e.g., wide glass doors, windows, video monitoring) to observe ongoing care in the patient room and activity in the doffing area are preferred. The path from the room of the patient with Ebola to an external doffing room should be as short as possible and clearly defined and/or enclosed as a contaminated area that is cleaned frequently along with the doffing area. If areas are reconfigured, the facility should make certain the space remains compliant with all applicable building and fire codes. Post signage to highlight key aspects of PPE donning and doffing, including
Designate the following areas with appropriate signage1. PPE Storage and Donning AreaThis is a clean area outside the patient room (e.g., a nearby vacant patient room, a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers don PPE before entering the contaminated area and the patient’s room. Do not store potentially contaminated equipment (e.g., PAPR components that have not been cleaned and disinfected), used PPE, or waste removed from the patient’s room in the clean area. If waste must pass through this area, it must be properly contained. 2. Patient RoomUse a single-patient room, preferably with a private bathroom; a covered bedside commode with bagging of human waste is an alternative approach. Plan ahead for the need to store many bags of regulated medical waste before their secondary containment. Additional guidance on waste management can be accessed at Ebola-Associated Waste Management and www.osha.gov/Publications/OSHA_FS-3766.pdf pdf icon[PDF – 6 pages]. The door to the patient room should be kept closed. Any item or healthcare worker exiting this room should be considered contaminated. 3. PPE Doffing AreaDesignate an area near the patient’s room (e.g., anteroom or adjacent vacant patient room that is separate from the clean area) where healthcare workers leaving the patient’s room can stand to doff and discard their PPE. Alternatively, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window and provided that the healthcare worker doffing PPE can hear the instructions of the trained observer). Do not use this designated area within the patient room for any other purpose. Stock gloves in a clean section of the PPE removal area accessible to the healthcare worker while doffing. In the PPE removal area, provide supplies to disinfect PPE and perform hand hygiene and space to remove PPE, including an easily cleaned and disinfected seat where healthcare workers can remove boot or shoe covers. If space allows, designate stations around the perimeter of the doffing room where each piece of PPE will be removed, moving from more contaminated to less contaminated areas of the room as PPE is doffed. Provide leak-proof disposable infectious waste containers for discarding used PPE. Provide a container to collect all reusable PAPR components. Frequently clean and disinfect the PPE removal area, including after each doffing procedure has been completed. One way such cleaning may be achieved is by having another healthcare worker who has just donned their full PPE clean the doffing area, moving from cleaner to dirtier areas within the doffing area, before entering the patient’s room. Facilities should consider making showers available for use for the comfort of healthcare workers after doffing PPE at the end of their shift; the heat from wearing PPE is likely to cause significant perspiration. Section 6. Selecting PPE for Healthcare Workers Who Care for Patients with EbolaThis section outlines several PPE combinations and how they should be worn. The key to safely wearing PPE is consistent and correct use reinforced by repeated training and practice. Variations in PPE used to care for patients with Ebola should be avoided within a facility. A facility should select and standardize the PPE to be used by all healthcare workers who are directly interacting with patients with Ebola. OSHA’s Bloodborne Pathogens standard requires employers to establish a written Exposure Control plan designed to eliminate or minimize employee exposures and should include procedures for donning and doffing the PPE ensemble that is chosen. The protocol must be reviewed by staff who participate in Ebola care and the trained observer should ensure the protocol is adhered to. Airborne transmission of Ebola has not been documented in hospitals or households during any of the human outbreaks investigated to date. However, certain procedures (e.g., bronchoscopy, endotracheal intubation) might create mechanically generated aerosols that could be infectious. Such aerosol-generating procedures require additional precautions. Experience in the care of patients hospitalized with Ebola in the United States indicates that the level of care may change unexpectedly and could require an aerosol-generating procedure. Because there might not be time for staff to leave the room to don proper PPE for an aerosol-generating procedure, CDC recommends that all healthcare workers entering the room of a patient with Ebola wear respiratory protection that would protect them during an aerosol-generating procedure. This would include a NIOSH-certified, fit-tested N-95 or higher respirator, or a PAPR. Safety and comfort are both critical for healthcare workers wearing PPE while caring for patients with Ebola. Standardized attire under PPE (e.g., surgical scrubs or disposable garments and dedicated washable footwear) helps the donning and doffing process and eliminates concerns of contaminating personal clothing. Footwear should be closed-toe, soft-soled, washable, and have a closed back. If facilities elect to use different PPE from what is outlined below (e.g., coveralls with either an integrated hood or a surgical hood with integrated full face shield), they must train healthcare workers on how to use each type of PPE type and ensure that donning and doffing procedures are adjusted and practiced accordingly. Extra layers of PPE are not advised because they can reduce comfort, field of vision, and mobility and increase the risk of error and injury while adding no meaningful protection for the wearer. In this guidance, impermeable gowns and coveralls indicates that the material and construction have demonstrated resistance to synthetic blood and simulated bloodborne pathogens. In contrast, fluid-resistant indicates a gown that has demonstrated resistance to water or a coverall that has demonstrated resistance to water or synthetic blood. These categories reflect the currently available U.S. product specifications; specific test methods that assess resistance for these products are listed in Table 1. When purchasing gowns and coveralls, facilities should follow specifications in Table 1 to ensure they select gowns and coveralls as described in Sections 5 and 6 below. Table 1. Specifications for impermeable and fluid-resistant gowns and coveralls
*Testing by an ISO 17025 certified third party laboratory is recommended. For more details, refer to technical document “Considerations for Selecting Protective Clothing used in Healthcare for Protection Against Microorganisms in Blood and Body Fluids”, which provides a more detailed explanation of the scientific evidence and national and international standards, test methods, and specifications for fluid-resistant and impermeable protective clothing used in healthcare. Section 7. Recommended PPE When Caring for a Patient with Confirmed Ebola or Unstable PUI
Section 8. Recommended PPE for Trained Observer and Doffing Assistant during Observations of PPE DoffingThe trained observer should not enter the room of a patient with Ebola but must be in the PPE donning and doffing area to observe donning and doffing procedures, as outlined in Section 7. The following PPE are recommended for trained observers and doffing assistants observing the doffing process:
Trained observers should don and doff selected PPE according to the same procedures outlined below. Facilities may elect to use impermeable gowns or coveralls for their trained observers to standardize the PPE in the unit, for ease of training personnel on a single item, and to prevent healthcare personnel entering the patient care area from inadvertently selecting a fluid-resistant gown or coverall instead of the recommended impermeable garment. If facilities elect to use fluid-resistant gowns or coveralls for their trained observers, they must take measures (e.g., staff training, good signage, clear labeling of the product, good inventory management practices) to ensure that the correct garment is selected by appropriate personnel. Section 9. Recommended Sequences for Donning PPESection 9A. Donning PPE, PAPR OptionDonning PPE, PAPR Option – This donning procedure assumes the facility has elected to use PAPRs. An established protocol facilitates training and compliance. A trained observer should verify compliance with the protocol.
Section 9B. Donning PPE, N95 Respirator OptionDonning PPE, N95 Respirator Option – This donning procedure assumes the facility has elected to use N95 respirators. An established protocol facilitates training and compliance. Use a trained observer to verify successful compliance with the protocol.
Preparing for DoffingThe purpose of this step is to prepare for the removal of PPE. The doffing area should be separated into areas where early and later steps of doffing are conducted (e.g., separate chairs or ends of a bench). Before entering the PPE removal area, look for, clean, and disinfect (using an *EPA-registered disinfectant wipeexternal icon) visible contamination on the PPE. As a final step before doffing, disinfect outer-gloved hands with either an *EPA-registered disinfectant wipeexternal icon or ABHR, and allow to dry. Verify that the trained observer is available in the PPE removal area before entering and beginning the removal process. Some facilities, especially those using PAPRs, might find it helpful to have a designated assistant to help with doffing. An assistant who is only assisting in doffing should wear the same PPE as the trained observer. If the doffing assistant is entering the patient’s room (e.g. as a clinician), the assistant should wear the same PPE as other personnel entering the patient’s room. The observer should not touch the person who is doffing and should not serve as the doffing assistant or “buddy.” A mirror in the room can be useful for the healthcare worker while doffing PPE. Section 9C. Doffing PPE, PAPR OptionDoffing PPE, PAPR Option – PPE should be doffed in the designated PPE removal area. Place all PPE waste in a leak-proof infectious waste container.
Section 9D. Doffing PPE, N95 Respirator OptionDoffing PPE, N95 Respirator Option – PPE should be doffed in the designated PPE removal area. Place all PPE waste in a leak-proof infectious waste container.
Footnotes *EPA-registered disinfectant wipe: Use a disposable wipe impregnated with a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus); see EPA list of Disinfectants for Use Against Ebola Virus at http://www.epa.gov/oppad001/list-l-ebola-virus.htmlexternal icon. When caring for a single client during on shift it is appropriate for the nurse to reuse only Which of the following personal protective equipment?When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1).
Which is the most effective nursing action for preventing and controlling the spread of infection?Hand hygiene. Hand hygiene is the single most effective measure to stop transmission of health care associated pathogens[18]. Use of personal protective equipment.
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