Personal Protective Equipment for Health Care Providers

By Mark Graber, MSN, RN, ACNP-C, CCRN, and Julie Grishaw, MD, MSHCE, FACEP

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Information is from CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Information has been reformatted with some rewritten for clarity. 

COVID-19 is a coronavirus which is transmitted primarily by respiratory droplet and aerosol.  Given the possible severity of the illness, which includes death, special measures are recommended for health care facilities and healthcare providers.

Universal precautions should be maintained with patients.  Frequent hand washing for 20 seconds and/or the use of antibacterial hand gel is recommended.  However, this document reviews special precautions needed for those infected with or suspected of having COVID-19. 

The first step is proper patient handling/room placement.

Put a mask on all patients presenting with respiratory symptoms.

Ideally patients with known or suspected COVID-19 should be in a single patient room with the door closed. If the patient is going undergo a nebulizer or other aerosol generating procedure (e.g. humidified oxygen), he or she should be moved to an airborne infection isolation room (AIIR).

Potential Aerosol Generating Procedures

  • Nebulized medication administration (consider MDI with spacer instead)
  • Manual ventilation before intubation
  • Endotracheal intubation
  • Extubation
  • BiPAP/CPAP
  • High-frequency oscillating ventilation
  • Open suctioning
  • Sputum induction
  • Bronchoscopy
  • High Flow Nasal Cannula
  • CPR
  • Autopsy

According to the CDC, AIIRs consist of:

  • Single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 6 air changes per hour (12 air changes per hour are recommended for new construction or renovation).
  • Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter directly before recirculation.
  • Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.
  • Facilities should monitor and document the proper negative-pressure function of these rooms.

Personal Protective Equipment:

Instructions on using PPE can be found here (from Sunnybrook Hospital).

Providers should use personal protective equipment (PPE) to reduce exposure to the virus. Recommended PPE consists of: 

  • Eye shields
  • N95 or better masks/respirators/powered air-purifying respirators (PAPRs) with high-efficiency filters (A list of NIOSH-approved PAPRs is located on the NIOSH Certified Equipment List at (https://www.cdc.gov/niosh/npptl/topics/respirators/cel/).
    • What if we are short on N95 masks? “Facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand.  During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCPs” (see list above).
  • Gowns.
    • What if we are short of gowns? “If there are shortages of gowns, they should be prioritized or aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.”
  • Gloves

Optimizing PPE:

Summary List for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response. This checklist offers a series of strategies or options on how healthcare facilities can optimize supplies of disposable N95 filtering facepiece respirators when there is limited supply availability. This checklist is intended to help healthcare facilities prioritize the implementation of the strategies following the prioritization used in the concept of surge capacity.

The CDC provides strategies for optimizing various forms of PPE, with links provided below:

Optimizing Eye Protection

Optimizing Isolation Gowns

Optimizing Facemasks

  • The CDC issued a statement about homemade masks. The statement reads (italics added) that: “In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.” Also, per The Joint Commission, homemade masks are an extreme measure and should be used only when standard PPE of proven protective value is unavailable.
  • The CDC issued a statement about limited re-use of facemasks, noting that all facemasks cannot be re-used. The statement reads: “Facemasks that fasten to the provider via ties may not be able to be undone without tearing and should be considered only for extended use, rather than re-use. Facemasks with elastic ear hooks may be more suitable for re-use.”

Optimizing N95 Respirators

Strategies to Allocate Ventilators from Stockpiles to Facilities

Decontamination and Reuse of N95 Respirators:

The CDC states that Disposable filtering facepiece respirators (FFRs), such as N95 masks, are not approved for routine decontamination and reuse. However, the CDC recognizes that decontamination and reuse of these masks may need to be considered during this pandemic as a crisis capacity strategy to ensure continued availability. The CDC reports, based on limited research, ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat showed the most promise as potential methods to decontaminate FFRs. The CDC has provided extensive guidelines found HERE that provide specific details regarding each method of decontamination, outlining benefits and limitations associated with each.

The CDC also provides guidance for extended use and limited reuse of N95 FFRs.  The full statement can be accessed HERE.

Extended use: Defined as wearing the same N95 for multiple patient encounters, without taking it off.

Reuse: Defined as using the same N95 for multiple encounters but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next patient encounter with a patient.

The CDC indicates that extended use is preferred over reuse because reuse involves potential contamination of the mask as the provider touches the mask in order to don and doff the mask. The CDC gives extensive information about risks associated with both extended use and reuse of N95 respirators.  Please see the above link for more information about extended use and reuse of N95 respirators.

The CDC has also provided a PPE burn rate calculator that institutions can utilize to help determine how long the existing supply of PPE will last so that the can make the best individualized plan for their institution.  

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