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For very high risk procedures on patients with suspected or confirmed avian or pandemic flu appropriate PPE becomes crucial, including eye protection. High risk proceedures when caring for patients include suctioning or intubation, and Airborne isolation rooms should also be used if possible for these patients. High risk laboratory practices include centrifugation or pipetting.
All of the PPE listed here prevent contact with the infectious agent, or body fluid that may contain the infectious agent, by creating a barrier between you and the infectious material. Gloves, protect the hands, Gowns or aprons protect the skin and/or clothing, Masks and respirators protect the mouth and nose, Goggles protect the eyes, Face shields protect the entire face.
Now we’ll discuss gloves. Gloves protect the user against contamination with infectious material, but it’s important to realize that gloves may become sources of contamination if they are not used carefully. Here are some “do’s and don’t” of glove use: Work from clean to dirty. This is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for “touch contamination” - protect yourself, others and environmental surfaces. An example of “touch contamination” is when someone wearing gloves touches their face or adjusts their glasses with gloves that have been in contact with a patient. Touch contamination can potentially expose oneself to infectious agents. Think about environmental surfaces, too, and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door and cabinet knobs can become contaminated if touched by soiled gloves. Change gloves as needed, if this is possible. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking. Prioritization of tasks for glove use should include a erosol-generating procedures or extensive body-to-body contact. If it is necessary to wear the same gloves in care of more than 1 patient, do so only if they remain unsoiled and there is no direct contact with the patient and glove. However, remember that reuse of PPE is a potential source for cross-infection.
Gowns are generally the preferred PPE for clothing, but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist. Some gowns open in the back while others, such as Tyveks, open in the front; secure the gown at the neck and waist. If the gown is too small to fully cover your torso, use two gowns. Put on the first gown with the opening in front and the second gown over the first with the opening in the back. Prioritization of tasks for gown use should include a erosol-generating procedures or extensive body-to-body contact. If it is necessary to wear the same gown in the care of more than 1 patient, do so only if they remain unsoiled and there is no direct contact with the patient and gown.
Masks should fully cover the nose and mouth and prevent fluid penetration and should fit snuggly. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable. Respirators that filter the air before it is inhaled have been designed to protect the respiratory tract from airborne transmission of infectious agents. A commonly used respirator in healthcare settings is the N95 particulate respirators. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. It is used to prevent influenza infections from aerosol generating procedures. Prior to use, respirators should be fit tested for the appropriate size. And you should always check your respirator before use to make sure it has a proper seal.
You can protect your eyes with a face shield, which can be used as a substitute to wearing a mask or goggles and should cover the forehead, extend below the chin, and wrap around the side of the face. Goggles also provide barrier protection for the eyes. Personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. Prioritization: Remember that reuse of eye protection has a potential for cross-infection. If it is necessary to reuse eye protection, clean and disinfect with using agents recommended by manufacturer. Cleaning should always proceed disinfection and hand hygiene should be performed after disposal or cleaning.
We have to avoid inappropriate or random use of infection control practices, including the use of PPE. The picture here is an example of inappropriate use of PPE in Vietnam during SARS. Notice that people in the same vicinity are using different levels of PPE and inappropriate use of head covering. Below list examples of inappropriate infection control practices to avoid: Wearing protective equipment in public areas Failure to discard protective equipment after use Wearing too many protective garments Failure to remove gloves after each task
Since N-95s will likely be in short supply during a pandemic, prioritization of use is also recommended. As stated before, N-95 or higher level respirator (e.g. PAPR) should be used for high-risk procedures, in addition to contact precautions and eye protection. High risk procedures include Intubation, nebulizer treatment, bronchoscopy, Resuscitation and Direct care for patients with influenza-associated pneumonia.
While not formally a type of PPE, we will first discuss hand hygiene, because it is the cornerstone of infection control! This slide describes effective hand hygiene techniques: When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet. Of course, this assumes that clean water is available. If there is any doubt about this, boiled or bottles water, or water treated with chlorine tablets should be used. If hands are not visibly soiled, alcohol-based hand cleaners are also effective. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. If hands are not visibly soiled, alcohol-based hand cleaners are also effective. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. The volume to use depends on the manufacturer directions, but usually a coin-sized amount in your hand is sufficient. *Instructions from: Guideline for Hand Hygiene in Health-care Settings. MMWR 2002 ; vol. 51, no. RR-16.
Although it seems intuitive, there is objective evidence for the benefit of hand hygiene in reducing respiratory infections in healthcare and community settings. The following data uses the examples of a hand washing program implemented at a training center with navy recruits and a randomized study among students in residence halls. Among Navy Recruits: Hand washing program implemented at a Navy training center 45% reduction in outpatient visits for respiratory illness Frequent hand washers had fewer respiratory illnesses Source: American Journal of Preventive Medicine 2001;21:79-83 Among Students in Residence Halls: College dorms were randomized to having alcohol hand rubs in various locations vs. not Hand rub groups had:15%-40% reduction in respiratory illnesses 43% fewer sick days Source: American Journal of Infection Control 2003;31:364-70