Hand Hygiene andPersonal Protective Equipment (PPE)

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Purpose

To provide guidance for:•Proper hand hygiene•Donning, doffing (removal), and

disposal of Personal Protective Equipment (PPE)

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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

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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

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Hand Hygiene: “5 Moments”

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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

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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

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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

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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

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PPE = Gloves and….

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Standard Precautions

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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

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Contact Precautions

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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.

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Droplet Precautions

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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

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Droplet Precautions

• Hand Hygiene• Minimum PPE required:• Gloves • Gown• Eye Protection• Bonnet• Leggings/Boot Covers (or Shoe Covers)• Respiratory Protection….

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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 14-007 PPE

• Patient (especially if coughing or sneezing):• Standard surgical face mask or N95, if tolerated• Add Nasal Cannula O2, if supplemental oxygen

needed

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Airborne Precautions

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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

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Airborne Precautions

•Hand Hygiene•Minimum PPE required:• Gloves • Gown• Eye Protection• Bonnet• Leggings/Boot Covers (or Shoe Covers)• Respiratory Protection….

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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 14-007 PPE

• Patient (especially if coughing or sneezing):• N95 mask, if tolerated• Add Nasal Cannula O2, if supplemental oxygen needed

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Donning/Doffing Sequence

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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)• BonnetRemember: Do NOT touch your eyes, nose or mouth

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Doffing (Removal) = Critical Process

Most Provider exposures occur

during PPE Removal (doffing)!

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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

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“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

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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)28

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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

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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 30

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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

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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 Member32

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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

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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

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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• Report the exposure as soon as possible to your EMS Field

Supervisor for follow-up35

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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

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If you have any questions…

1. Contact your EMS Field Supervisor, or

2. Contact M. Allison Green, RN214-670-3220 Office469-323-5775 Cell

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