1. Hand Hygiene and Personal Protective Equipment (PPE)
Oct 2014
Hand Hygiene and
Personal Protective Equipment (PPE)

2. Purpose To provide guidance for: Proper hand hygiene
Donning, doffing (removal), and disposal of Personal Protective Equipment (PPE)
Oct 2014

3. Background
DFR provides prehospital medical care to the residents of and the visitors to the City of Dallas
Provision of this care potentially exposes DFR personnel to infectious diseases
Good hand hygiene, and the proper selection, use and disposal of PPE are critical to prevent the spread of disease
Oct 2014

4. Background
The human body produces many body fluids, secretions and excretions that may contain pathogens
Potentially infectious body fluids include: blood, vomit, feces, urine, sputum, saliva, and sweat, as well as amniotic, spinal, vaginal, pleural, pericardial, peritoneal, synovial fluids and semen
To prevent exposure, ANY body fluid from any patient must be treated as potentially infectious
Oct 2014

5. Hand Hygiene: “5 Moments”
Oct 2014

6. Hand Hygiene: Soap & Water
Use soap and warm, running water
Keep fingers pointing down
Rub hands vigorously for 20 seconds
Wash all surfaces, including:
Backs of hands
Wrists
Between fingers
Tips of fingers
Thumbs
Under fingernails
Dry vigorously with paper or clean cloth towel
Turn off faucet with towel and open door with towel
Oct 2014

7. Hand Hygiene: Sanitizer
If hands are visibly contaminated, soap and water must be used first
If hands are not visibly contaminated, or if soap and water are not available, use alcohol-based hand rub (gel, foam or wipes)
Apply a generous amount of hand rub gel/foam to the palm of one hand, or use an alcohol- based hand rub wipe
Rub hands together, covering all surfaces of hands and fingers until hand rub is absorbed
Oct 2014

8. Isolation Precautions
4 Categories:
Standard Precautions (ALL patients)
Contact Precautions (“blood/body fluid”)
Droplet Precautions (think “flu”)
Airborne Precautions (think “TB”)
These categories may be combined in certain cases
Oct 2014

9. PPE Components Disposable Gloves
Disposable Gown (Impermeable or Fluid Resistant)
Eye Protection
Wraparound Goggles, Safety Glasses or Face Shield
Respiratory Protection (must be worn with eye protection)
Lowest: Standard surgical face mask
Higher: N95 filter mask (respirator)
Highest: Air-Purifying Respirator (“APR”) – powered or not; half-face, full-face or hood
Components for high volume fluid or high-risk conditions:
Disposable Boot Covers (or Shoe Covers)
Disposable Bonnets
Oct 2014
*SCBA or other supplied-air respirator is the highest level of respiratory protection, but is not commonly used in healthcare.

10. PPE = Gloves and…. Oct 2014 *Add png 3M Tourguard Safety Glasses
*Add png Leg covers = FluidGuard® Boot Covers
Remove “Booties”, change to “Shoe Covers”

11. Standard Precautions
Oct 2014

12. Standard Precautions All patients, all the time, any setting
Minimum PPE required:
Disposable Gloves
Hand Hygiene
Additional PPE, as needed, to protect against blood, body fluids, secretions and excretions:
Eye protection (goggles or face shield)
Respiratory protection (surgical face mask)
Impermeable or fluid-resistant gown
Oct 2014

13. Contact Precautions
Oct 2014

14. Contact Precautions
Protection against viruses (such as Ebola), Influenza, HIV, Hepatitis; plague, MRSA, VRE, Strep; patients with diarrhea, vomiting, or generalized rash
Minimum PPE Required
Disposable Gloves (change if visibly soiled)
Gown
Hand Hygiene
Disinfection of all equipment and surfaces
Examples: monitor, glucometer, BP cuff, etc.
Oct 2014

15. Droplet Precautions
Oct 2014

16. Droplet Precautions
Large particles created by coughing, sneezing, suctioning or intubation
Disease examples: Influenza, meningitis, pertussis, plague, Ebola, mumps, rubella, and most viruses (including Enterovirus D68)
Any patient with fever, respiratory symptoms, rash, and/or flu-like signs/symptoms, such as weakness, vomiting, diarrhea, severe headache, abdominal pain, or muscle and body aches
Oct 2014

17. Droplet Precautions Hand Hygiene Minimum PPE required: Gloves Gown
Eye Protection
Bonnet
Leggings/Boot Covers (or Shoe Covers)
Respiratory Protection….
Oct 2014

18. Droplet Precautions What level of respiratory protection?
Healthcare Providers (with eye protection):
At least standard surgical face mask
N95 mask for “Aerosol-Generating Procedures” or other high-risk procedures (e.g. CPR)
See UTSW/BioTel TB PPE
Patient (especially if coughing or sneezing):
Standard surgical face mask or N95, if tolerated
Add Nasal Cannula O2, if supplemental oxygen needed
Oct 2014
*AGP: BiPAP, intubation, open airway suctioning, sputum collection, etc.
CPR is NOT strictly considered an AGP; however, endotracheal intubation is often performed during CPR, so it is included.
Nebulized medication delivery is also not strictly included in CDC definition, but it seems reasonable to include it.

19. Airborne Precautions
Oct 2014

20. Airborne Precautions
Small particles created by coughing, sneezing, suctioning, intubation or even talking
Disease examples: TB, measles, chickenpox, disseminated Herpes zoster, smallpox
Any patient known or suspected to be infected with an organism spread through the air, or for a patient “found down” with unknown history
Oct 2014

21. Airborne Precautions Hand Hygiene Minimum PPE required: Gloves Gown
Eye Protection
Bonnet
Leggings/Boot Covers (or Shoe Covers)
Respiratory Protection….
Oct 2014

22. Airborne Precautions What level of respiratory protection?
Healthcare Providers (with eye protection):
At least N95 filter mask
Air-Purifying Respirator for “Aerosol-Generating Procedures” or other high-risk procedures (e.g. CPR)
See UTSW/BioTel TB PPE
Patient (especially if coughing or sneezing):
N95 mask, if tolerated
Add Nasal Cannula O2, if supplemental oxygen needed
Oct 2014

23. Donning/Doffing Sequence
Oct 2014

24. Donning Sequence Hand Hygiene
Leggings/Boot Covers (or Shoe Covers), if used
Gown (tie at waist and neck)
Gloves
Double glove if gross contamination or large volume of body fluid
Single or Inner Pair MUST completely cover gown cuff, so that there is no exposed skin
Mask or Respirator (ensure proper fit)
Eye and Face Protection (ensure proper fit)
Bonnet
Remember: Do NOT touch your eyes, nose or mouth
Oct 2014

25. Doffing (Removal) = Critical Process
Most Provider exposures occur during PPE Removal (doffing)!
Oct 2014

26. Doffing (Removal) = Critical Process
PPE must be removed in the proper sequence & with extreme care/caution, to prevent inadvertent exposure
Basic Principle:
Touch ONLY “clean to clean” and “dirty to dirty”
Perform hand hygiene and replace gloves if hands become contaminated during removal, AND immediately after PPE removal
PPE must be removed immediately after patient care is transferred to hospital staff
Oct 2014

27. “Buddy System” A trained observer shall monitor the doffing procedure
Can be used during donning, as well
“Buddy” (in PPE) watches to prevent compromises or other procedural breaches
Any compromise/breach must be reported to your EMS Field Supervisor immediately
Oct 2014

28. Doffing – Equipment Needed
Clean disposable gloves
Biohazard receptacle and bags (triple bag for high-risk)
Hand hygiene supplies
Lysol spray (bring can from Rescue, discard in E.D. after use)
1 set or package of hospital “Standard Precautions” PPE
Disposable gloves (at least two pairs per team)
Disposable gown
Standard surgical mask (preferably with attached face shield or other eye protection, or equivalent)
Oct 2014

29. Doffing: Overall Sequence
2 Members in Full PPE (including double gloves)
1st member serves as “Buddy” for 2nd member during doffing
2nd member then dons fresh Standard Precautions and serves as “Buddy” for 1st member during doffing
1st member then dons clean gloves and serves as “Buddy” for 2nd member during doffing
Both members shall use meticulous hand hygiene after all PPE is removed
NOTE: Proceed slowly and carefully to avoid breaches!
NOTE: Gloves shall be removed, hand hygiene performed and fresh gloves donned at any point in the procedure, if needed, because of inadvertent contamination
Oct 2014

30. Doffing Sequence Details
Buddy sprays member with Lysol (especially legs and feet)
Boot Covers: Touch ONLY outside, remove  Biohazard disposal, one at a time, as each is removed
Do NOT contaminate by crossing legs
Lean against wall or sit in chair, if needed
Outer Gloves: Do not contaminate inner gloves, remove  Biohazard disposal
Gown and Inner Gloves: Buddy unfastens from rear, then wearer rolls away from body, down to wrists, rolls into small bundle and removes without contaminating skin  Biohazard disposal
HAND HYGIENE: Allow hand gel to be fully absorbed
Oct 2014

31. Doffing Sequence (cont’d.)
Don TWO pairs of clean gloves
Bonnet: With ONE hand, grasp as far to the rear as possible and pull away from head and face  Biohazard disposal
Goggles: With OTHER hand, grasp as far to the rear as possible and pull away from face  Biohazard disposal
Outer Gloves: Remove without contaminating inner gloves or skin  Biohazard disposal
Respirator/Mask: Grasp from as far to the rear as possible and pull away from face while actively exhaling  Biohazard disposal
Oct 2014

32. Doffing Sequence (cont’d.)
Inner Gloves: Without contaminating skin, remove  Biohazard disposal
HAND HYGIENE: Allow hand gel to be fully absorbed
Don Hospital Standard Precautions PPE
Gown, Mask and TWO PAIRS of Disposable Gloves
Wipe or Spray Lysol Can
Outer Gloves: Without contaminating inner gloves, remove  Biohazard disposal
Serve as the “Buddy” for the Repeat Doffing Procedure for the other DFR Member
Oct 2014

33. Doffing Sequence (cont’d.)
After 2nd Member has removed all PPE and performed Hand Hygiene, (s)he dons a final pair of clean gloves and serves as a “Buddy” one final time, to assist the 1st Member with doffing of the Hospital Standard Precautions PPE
Both Members wash hands and all at-risk skin surfaces with soap and water, then perform thorough Hand Hygiene
Oct 2014

34. Disposal of Contaminated PPE
Once the contaminated PPE is placed in the Biohazard bag and the bag is triple-sealed:
At a hospital, follow directions of facility staff
If the Biohazard bag must be returned to a DFR station, deposit the bag in the contaminated material box for processing through Waste Management
Oct 2014

35. Procedure Breach or Contamination
In the event of contact with patient blood, body fluids, secretions or excretions during patient care:
Stop work as soon as possible
Wash the affected area thoroughly with soap and water
Report the exposure as soon as possible to your EMS Field Supervisor for follow-up
In the event of inadvertent contamination during doffing:
Stop the doffing sequence immediately
Wash the affected area thoroughly with soap and water, or with alcohol-based gel or foam
Oct 2014

36. Summary
Hand hygiene is the single most important way to prevent infection spread
Proper selection of appropriate PPE is vital
Standard: ALL Patients
Contact + Droplet: Sick Patients at risk for infectious diseases
Airborne: Patients at risk for airborne-spread infection
Doffing (removal) = greatest risk to Providers
A “Buddy System” – especially during doffing – will reduce the risk of compromise/breach
PPE must be disposed of properly after removal
Oct 2014

37. If you have any questions…
Contact your EMS Field Supervisor, or
Contact M. Allison Green, RN
Office
Cell
Oct 2014