Ems tb 14 007 - Use of Medical Personal Protective Equipment (PPE)

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UTSW/BioTel EMS System October 2014

EMS TB 14-007:

Use of Medical Personal Protective Equipment (PPE) Purpose:

To provide UTSW/BioTel EMS agency EMS Providers with guidelines for the proper use and removal/disposal of Personal Protective Equipment (PPE).

Background:

Recent events surrounding the confirmed case of Ebola Virus Disease (EVD) in Dallas mandate refresher training and review of Department Policies in the proper use of PPE for all EMS Providers. PPE is the “what”, and Isolation Precautions are the “how” of personal protection in healthcare. The type of PPE components varies according to the mode of disease transmission. These PPE components are deployed within four different, partially overlapping levels of “Isolation Precautions” for treating the patient and interacting with the patient’s environment of care: Standard, Contact, Droplet and Airborne. The procedure for putting on (donning) and removing (doffing) PPE is likewise tailored to the specific type of PPE needed for each level of Isolation Precautions. A Buddy System with a second EMS Provider observing the first EMS Provider during donning and doffing can help to ensure proper PPE use, if staffing allows.

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Definitions (Adapted from CDC materials; Refer to the Pictorial Glossary on page 6):

The basic PPE components and representative examples, for each isolation category:

PPE Component Isolation Precautions Category Standard Contact Droplet Airborne

GLOVES: Disposable, Non-Latex + + + + GOWN/APRON: Fluid Resistant or Impermeable As needed + + + EYE PROTECTION:

• Face Shield with Eye Shield, OR As needed + + + • Wraparound Goggles As needed + + +

FACE PROTECTION: • Face Shield, or As needed + + + • Surgical Mask As needed + + +

RESPIRATORY PROTECTION: • Standard Surgical Mask As needed + + + • N95 or N100 Respirator (“TB mask”) -- -- + + • Air-Purifying Respirator (“APR”) -- -- -- +

Examples of Diseases – Known or Suspected – With Person-to-Person Transmission, For Which This Level of PPE & Isolation Is Required

ALL Patient Contacts

Ebola & most viruses,

Diarrhea, Generalized

rash, Influenza, Plague,

HIV, Hepatitis

Ebola & most

viruses, Influenza, Pertussis,

Plague

Measles, TB,

Chickenpox, Smallpox,

Disseminated Herpes Zoster

Standard, Contact & Droplet Precautions PPE Items Needed Prior to Patient Contact:

• Hand hygiene supplies • BioHazard bags & other infection control supplies • Disposable gloves (“GLOVES”) • Fluid resistant or impermeable gowns (“GOWN”) • Appropriate combination of the following (“EYE/FACE/RESPIRATORY PROTECTION”):

o Eye protection (face shield with eye shield or goggles that wrap around the eyes) o Face mask (e.g. standard surgical mask; NOTE: wrap-around goggles or a face

shield must be worn with face mask, in order to provide eye protection) (“MASK”) o N95 or N100 Respirators (for use during aerosol-generating procedures)

• Other PPE items that may be needed in certain circumstances: o Disposable shoe covers (“BOOTIES”) o Disposable leg covers (“LEGGINGS”)

PPE Selection:

1. Prior to and during contact with ALL patients, EMS providers shall ALWAYS wear at least disposable gloves (Standard Precautions).

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2. Prior to and during contact with any patient (or his/her environment of care) who may have any potentially communicable infection spread by contact, blood, body fluids/secretions/excretions, or droplets, appropriate PPE includes the following: • EMS Providers: GLOVES, GOWN, & EYE-FACE-RESPIRATORY PROTECTION

(Surgical MASK or higher) • Patient, especially if coughing or sneezing: Surgical MASK, if tolerated

3. Prior to and during contact with any patient who may have a potentially communicable

infection transmitted by airborne spread, appropriate PPE includes the following: • EMS Providers: GLOVES, GOWN, & EYE-FACE-RESPIRATORY PROTECTION

(N95 or N100 Respirator)

• Patient, especially if coughing or sneezing: Surgical MASK, if tolerated

Special Circumstances: • CPR and airway procedures (e.g. suctioning, intubation) may result in a large volume

of body fluids (e.g. vomit or saliva) and/or aerosolization. Performing these procedures in a less-controlled environment (e.g. a moving vehicle) increases the risk of exposure.

o If possible, perform these procedures under safer circumstances (e.g. in a stopped vehicle, or after hospital arrival, if appropriate).

o An N95 Respirator or higher should be worn for these high-risk procedures for agents transmitted by Contact & Droplets, such as Ebola.

o An Air-Purifying Respirator should be worn for these high-risk procedures for agents transmitted by Airborne spread, such as measles or tuberculosis. Proper use of Air-Purifying Respirators requires special training.

• Large amounts of blood and/or body fluids present in the environment: o DOUBLE GLOVES and/or BOOTIES and/or LEGGINGS may be required.

Procedures – Putting On (Donning) PPE:

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Procedures – Removing (Doffing) PPE: • PPE must be removed carefully and in the proper sequence, in order to minimize

possible contamination risk • Booties and leggings, if worn, should be removed prior to gown/gloves removal • Key concept: “Touch ONLY clean to clean & dirty to dirty” – In other words, do not touch

“dirty” surfaces with “clean” hands, or vice versa

• Wash hands thoroughly as soon as possible after removing all PPE • Local Resources – Parkland Hospital Special Pathogen Isolation Precautions (PPE Video)*:

https://www.youtube.com/watch?v=97wgknKHCWU

Steps To Take In the Event of Possible EMS Provider Contamination (Refer to the UTSW/BioTel TB 14-008 Decon):

• If blood, body fluids, secretions, or excretions from a patient with suspected Ebola or

other communicable disease come into direct contact with one’s skin or mucous membranes, stop working as soon as possible and wash the affected skin surfaces thoroughly with soap and water.

• Report the exposure to your EMS Supervisor for follow-up. • Follow all other EMS Agency-specific guidelines and policies regarding potential

infectious disease and bloodborne pathogen exposures.

*Accessed 6 October 2014

1.

2.

3.

2.

Grab the outside front of the gown with both hands & pull forward to release

outside

4.

Adapted from CDC.gov

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SUMMARY of Recommendations:

• Good hand hygiene is the single most important means to prevent infection spread. • EMS Providers shall wear appropriate PPE and apply appropriate isolation

precautions when entering the scene, and shall continue to wear PPE until no longer in contact with the patient or his/her environment.

• Gloves should be replaced when torn or visibly contaminated. • EMS Providers should limit the number of surfaces touched & should keep hands

away from their face, as much as possible. • EMS Providers shall not eat, drink, or use tobacco products during patient contact. • PPE should be carefully removed in the proper sequence, without contaminating

one’s eyes, mucous membranes, or clothing with potentially infectious substances. • PPE should be disposed of properly in a red “Biohazard” medical waste container, or

by double-bagging, labeling and maintenance in a secure location until appropriate disposal can be performed.

• Reusable PPE shall be cleaned and disinfected according to the manufacturer’s reprocessing instructions and EMS agency policies/procedures.

For ANY questions or concerns, contact your EMS Supervisor or BioTel immediately. CDC Resources*: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html http://www.cdc.gov/vhf/ebola/pdf/ems-checklist-ebola-preparedness.pdf http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html#e http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html http://www.cdc.gov/HAI/ppt/ppe/PPEslides6-29-04.ppt *Accessed 6 October 2014

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PICTORIAL GLOSSARY of PPE (Representative Examples, as of October 2014)

NOTE: All images downloaded from the public domain on 7 October 2014