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PERSONAL PROTECTIVE EQUIPMENT PROCEDURE A STANDARD PRECAUTION

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					NHS Central Lancashire

Infection Prevention and Control

PERSONAL PROTECTIVE EQUIPMENT PROCEDURE (A STANDARD PRECAUTION)

REFERENCE NUMBER APPROVING COMMITTEE(S) AND DATE

AUTHOR(S) / FURTHER INFORMATION LEAD DIRECTOR THIS DOCUMENT REPLACES REVIEW DATE RATIFICATION DATE/DRAFT No VALIDATION SIGNATURE

Infection Prevention Sub-Group, September 2008 11th December 2008 - Governance Sub Committee (formally Provider Management and Quality Outcomes Committee) Infection Prevention and Control Team Maggi Morris, Director of Public Health CLPCT Standard Infection Control Precautions Policy 2007 December 2009 December 2008 Governance Sub-Committee awaiting signature

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CONTENTS
1.0 1.1 2.0 2.1 2.2 2.3 2.4 3.0 3.1 3.2 3.3 3.4 3.5 3.6 4.0 4.1 4.2 4.3 5.0 5.1 5.2 5.3 5.4 6.0 6.1 7.0 Appendix 1 Appendix 2 Appendix 3 INTRODUCTION Background PROCEDURE All staff Good practice points for PPE Incident reporting Training GLOVES How to chose the correct gloves and when to wear gloves How to put gloves on When to change gloves How to remove and dispose of gloves Hand lotion and glove use How to store a supply of gloves (this includes storage in cars / bags) APRONS AND GOWNS When to wear and how to chose an apron / gown When to change an apron / gown and how to remove and dispose How to store supplies of aprons / gowns(this includes storage in cars / bags) FACE, MOUTH / EYE PROTECTION How to chose the correct protection and when and how to wear it When to change face protection How to remove and dispose of face protection (see appendix 3) How to store a supply of face protection items (this includes storage in cars / bags) PAGE 3 3 3 4 4 4 5 5 5 5 6 6 7 7 7 7 8 8 8 9 9 9 10

FOOTWEAR 10 The principles of footwear and infection 10 control REFERENCES Risk assessment, glove usage flow chart Summary guide to the use of PPE 10 12 14 15

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1.0 Introduction To meet the requirements of the national agenda for infection prevention and control, all NHS organisations are monitored by the Healthcare Commission with regard to Standards for Better Health (DH, 2004) and The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections (HCAI) (DH, 2006). The Health Act (2006) stipulates that NHS bodies must, in relation to preventing and controlling the risks of HCAI, have in place appropriate core policies, including personal protective equipment procedure. Implementation of this procedure will achieve compliance with the Health Act (2006). Effective personal protective equipment (PPE) that is used appropriately in situations that put healthcare workers and patients at risk will prevent cross infection and save lives. Employers have a basic duty concerning the provision and use of personal protective equipment at work. (Personal Protective Equipment at Work Regulations 1992 (as amended). Personal Protective Equipment at Work Regulations 1992 states that personal protective equipment is supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways. For the purpose of this procedure, the PPE described, which might be in use in general care settings, includes: • • • Gloves Aprons/gowns Face, mouth/eye protection, e.g. masks/goggles/visors.

Specialised situations where particular organisms/infections are present e.g. respiratory infections which require specific PPE i.e. specialised masks are not covered in this procedure. This must be addressed within a local service/area procedure. 1.1 Background The goal of preventing transmission of infection can be achieved by many means and it is always possible to modify recommendations providing the basic principles are always adhered to. These basic principles include maintenance of the principles of epidemiology and disease transmission and the precautions, which are used to interrupt the spread of infection by all routes likely to occur in health care settings. 2.0 Procedure

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2.1 All staff • • • Have the responsibility to wear PPE appropriately to avoid contamination as far as possible Have a responsibility to display available, relevant posters detailing information on the use of PPE All staff are required to undertake training on all aspects of PPE and its uses in order to avoid potential contamination with organisms/infection, and attend annual mandatory training. Good practice points for PPE Should be appropriate fit for purpose and suitable for the person using/wearing it, with supplies located close to the point of use and donning and removing of items carried out correctly. Hand washing must never be preformed while wearing gloves and never use alcohol hand products to clean gloves. Disposable gloves generally used for procedures where exposure to blood/other body fluids may occur are single use and must be removed and replaced as appropriate, with hand hygiene performed in between times (see NHS Central Lancashire hand hygiene procedure) PPE must be disposed of correctly and should not once removed, be a cause of further contamination by being left on environmental surfaces, or by being removed inappropriately by wearers and as such contaminating hands unnecessarily. The use of PPE such as gloves does not remove the need for hand hygiene. Stocks of PPE must be stored off the floor, e.g. on appropriate shelving in a designated, clean and dry storage area to ensure that they are not contaminated before use. (When any repair or refurbishment work takes place within the vicinity of clean equipment storage areas stores must be boxed and stored away to avoid dust contamination). Reliability of PPE must not be affected during procedures, as this could potentially lead to exposure to blood, other body fluids, excretions, secretions e.g. products used such as hand creams. Single use items should be used where appropriate and never reused. Manufacturers instructions should always be followed PPE must be removed immediately following a procedure, it should never be worn while moving to a different patient/ area Incident reporting Where there has been an actual/potential risk of exposure to infection, e.g. needlestick injury, has occurred, an IR1 form must be completed.

2.2 •

•

•

• •

•

• • 2.3 •

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•

•

An occupational exposure to infection must be managed following guidance from Occupational Health and the Trusts Prevention of Occupational Exposure to Blood and Body Fluids Including Safe Sharps Practice Procedure. Adverse reactions relating to the use of PPE e.g. latex glove allergies/sensitivities must be reported to Occupational Health, the GP and Health and safety manager. Training

2.4

All staff within the PCT should receive training in respect to PPE on a yearly basis. New staff at induction will receive training and then annual mandatory sessions also include PPE. This training is provided by the Infection Prevention and Control Team. 3.0 3.1 • Gloves How to choose the correct glove and when to wear gloves Gloves must be suitable for use, fit for purpose and well fitting to avoid interference with dexterity, friction, excessive sweating, finger and hand muscle fatigue, therefore the supply and choice of the correct size of glove, e.g. small, medium or large, is important Expiry dates/lifespan of gloves must be adhered to, according to the manufacturers’ instructions Disposable latex gloves containing powder must never be used due to the risks associated with aeroionisation and increased risk of developing latex allergies. See Appendix 1 Glove Usage Flowchart describing types of gloves. Gloves should be worn when contamination might occur. See Appendix 2 Summary Guide to the Use of Personal Protective Equipment. In addition It is important to remove PPE immediately following a procedure. PPE should never be worn for more than one patient/procedure/area. All gloves should comply with EU regulation EN 455. How to put on gloves • • • • • • • • Wash hand or alcohol gel on visibly clean hands before putting on gloves Remove all hand jewellery Pick up one glove with the right hand Line the thumb side of the glove up with the thumb side of the left hand Slip the open end of the glove over the left hand and thumb Stretch the palm side of the glove with the right hand, pulling the glove on to finger level Position the fingers of the glove in line with the fingers of the left hand Pull the remainder of the glove onto the left hand

• •

•

• • • 3.2

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• • • • • • • 3.3 • • • • •

Pick up the second glove with the gloved left hand. Line the thumb side of the glove up with the thumb side of the right hand. Slip the open end of the glove over the right hand and thumb. Stretch the palm side of the glove with the left hand pull the glove on to finger level. Position the fingers of the glove in line with fingers of the right hand. Pull the remainder of the glove onto the right hand Proceed with activity requiring gloves. When to change gloves Gloves should be changed between patients/ procedures It may be necessary to change gloves between tasks on the same patient to prevent unnecessary cross-contamination Do not wear PPE, such as gloves, which have been used for a procedure after the task is complete, remove them immediately. Gloves are not a substitute for employing good hand hygiene, this should be performed each time gloves are removed Torn, punctured or otherwise damaged gloves should not be used and should be removed immediately (safety permitting) if this occurs during a procedure Never perform hand washing while wearing gloves Never use products such as alcohol hand products to clean gloves or wash single use disposable gloves Gloves worn for protection when exposure to blood/ other body fluids may occur are single use and should be removed and replaced as appropriate, with hand hygiene performed in between times. How to remove and dispose of gloves Remove gloves promptly after use, before touching non-contaminated/ clean areas/ items, environmental surfaces, or other persons (including you). Gloves being worn for a procedure/ activity should not be worn to handle or write on charts, or to touch any other communal, clean surfaces.

• • •

3.4 •

•

Care should be taken when removing

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• • • • • • • 3.5

Grasp outside edge near wrist. Peel away from hand turning glove inside-out Hold in opposite gloved hand Slide ungloved finger under the wrist of the remaining glove, be careful not to touch the outside of the glove. Peel off from inside, creating a bag for both gloves. . Used gloves should never be placed on environmental surfaces Dispose of all PPE, including disposable gloves, safely and immediately following use into appropriate waste stream Perform hand hygiene immediately after removal/ disposal of gloves. Gloves are not a substitute for employing good hand hygiene Hand Lotion and Glove Use

Usually hand lotions that contain petroleum products are incompatible with latex gloves. The can accelerate the deterioration process which can increase penetration of chemicals and viruses. Only use water based emollients for hand care. 3.6 How to store a supply of gloves (This includes storage in cars/bags etc.) • Supplies of gloves used/ opened should be stored in a clean, dry place, e.g. do not store boxes of gloves in a dirty area such as a sluice • Gloves should not be decanted from the original box, to ensure the expiry date is known and the integrity maintained. 4.0 4.1 Aprons and Gowns When to wear and how to choose an apron/ gown

Aprons/ gowns should be worn when contamination might occur. • • Colour coding for in patient areas should follow the national guidelines for cleaning materials and equipment. (NPSA 2007) Aprons/ gowns should be appropriate for use, fit for purpose, and to avoid any interference during procedures, and any expiry dates, e.g. on sterile gowns, should be adhered to, according to manufacturers’ instructions Disposable, single-use plastic aprons should preferably be worn when exposure to blood and other body fluids might occur, particularly in care settings. Colour-coded aprons are often used for specific tasks/ in specific areas. Never reuse/ wash single use disposable aprons/gowns. An impermeable gown should be worn when there is a risk of significant splashing of body fluids rather than a plastic apron, e.g. in theatre type settings/ during invasive procedures. There are many types of gowns available and the most appropriate should be considered following risk assessment with involvement of the Infection Prevention and Control Team and Occupational Health.

•

•

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•

•

Reusable items, such as non-disposable aprons that have to be used for care delivery in the home setting, should have a clearly documented cleaning schedule, e.g. laundering and must be checked for cleanliness before being donned Do not wear PPE, such as plastic aprons/gowns, which have been used for a procedure after the task is complete, remove them immediately - they should never be worn while moving to a different patient/ area.

See Appendix 2 Summary Guide to the Use of Personal Protective Equipment. 4.2 • When to change an apron/ gown and how to remove and disposal Aprons/ gowns should be changed between patients/ procedures. It may be necessary to change aprons/ gowns between tasks on the same patient to prevent unnecessary cross-contamination. Do not wear PPE, e.g. gloves, which have been used for a procedure once the task is complete, they should be removed immediately - they should never be worn while moving to a different patient/ area. Torn or otherwise damaged aprons/ gowns should not be used and should be removed immediately (safety permitting) if this occurs during a procedure Remove aprons/ gowns promptly after use, avoiding contact with most likely contaminated areas, e.g. the front surface, and avoiding contamination of undergarments. The outer contaminated side of the apron/ gown should be turned inward, rolled into a ball and then the item should be discarded. Used aprons/ gowns should never be placed on environmental surfaces Remove aprons/ gowns before going on to work with/ touch noncontaminated/ clean areas, items, environmental surfaces, or other persons (including yourself) Change disposable aprons used for clinical/ care procedures before serving meals as per the colour coding system Dispose of all PPE, including disposable aprons/ gowns, safely and immediately following use into appropriate receptacles Perform hand hygiene immediately after removal/ disposal of aprons/ gowns How to store supplies of aprons/ gowns (This includes storage in cars/bags etc.) Supplies of aprons/ gowns waiting to be used should be stored in a clean, dry place, e.g. do not store unused supplies of aprons/ gowns in a dirty area such as a sluice, only aprons being used in this area should be stored here. Face, mouth/ eye protection includes:

•

•

•

• • • 4.3

•

5.0

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• • •

surgical masks goggles visors

5.1 it

How to choose the correct protection and when and how to wear

Face, mouth/ eye protection should be worn when contamination from blood/ other body fluids might occur, see Appendix 2 Summary Guide to the Use of Personal Protective Equipment. In addition: • Well fitting, fit for purpose, comfortable protection is important to ensure adequate protection. Manufacturers’ instructions including expiry dates should be adhered to Manufacturers’ instructions should be adhered to while donning face protection to ensure the most appropriate fit/ protection Surgical masks should always fit comfortably, covering the mouth and nose. When not in use for protection, they should be removed and not worn around the neck Goggles should provide adequate protection when the risk of splashing is present, e.g. those used must ‘wrap around’ the eye area to ensure side areas are protected Face shields/ visors may be considered, in place of a surgical mask and/ or goggles, where there is a higher risk of splattering/ aerosolisation of blood/ other body fluids Face protection should not be touched whilst being worn Risk assessment to dictate the need for other types of masks, e.g. Respirator-type masks should be carried out in conjunction with the Health and Safety Lead, in line with specific policies on specific infections when these needs arise. When to change face protection Face protection should be changed between patients/ procedures. It may be necessary to change between tasks on the same patient to prevent unnecessary cross-contamination. If surgical masks become wet or soiled they should be changed in order to ensure continued protection from splashes/ splattering to the mouth and nose. (The efficacy of surgical masks in providing protection against airborne/ droplet infections rather than from splashes of blood/other body fluids is the subject of continuing debate, as is the length of time they can be worn for) Torn or otherwise damaged face protection should not be used and should be removed immediately (safety permitting) if this occurs during a procedure

• •

•

•

• •

5.2 •

•

•

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5.3 •

How to remove and dispose of face protection (see appendix 3) Remove face protection promptly after use, avoiding contact with most likely contaminated areas, e.g. the front surface; this should be done by handling the straps/ ear loops/ goggle legs only (manufacturers’ instructions where given should be followed). The outer contaminated side of masks should be turned inward upon removal for disposal Dispose of all PPE, including disposable masks/ face protection, safely and immediately following use into appropriate receptacles Single use disposable items should never be reused. Used face protection should never be placed on environmental surfaces Reusable items, e.g. non-disposable goggles/ face shields/ visors should have a clear decontamination schedule with responsibilities assigned in accordance with manufacturers instructions) and items should be dealt with immediately following use Perform hand hygiene immediately after removal/ disposal of face protection

• • •

•

5.4 How to store a supply of face protection items (This includes storage in cars/bags etc.) • • Face protection supplies should be stored in a clean, dry place, e.g. do not store unused boxes in a dirty area such as a sluice Face protection with expiry dates should not be stored out with their original box to ensure their expiry date is known and their integrity maintained Footwear The principles of footwear and infection control

6.0 6.1

The correct use of footwear should be considered to encourage infection control • When providing care, closed-toed shoes should be worn to avoid contamination with blood or other body fluids or potential injury from sharps Footwear should be kept clean Care should be taken when donning/ removing shoes at any time during care delivery to avoid hand contamination Hand hygiene should be performed following handling of footwear Overshoes should not be worn as they can lead to unnecessary hand contamination while putting on / removing and can cause aerosolisation of microorganisms due to bellowing when walking. References

• • • •

7.0

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Department of Health (2003) Winning Ways. London. Department of Health (2004) Towards Cleaner Hospitals and lower rates of infection. A summary of action. London. Department of Health (2004) Standards for Better Health. London. Department of Health (2006) Code of Practice for the Prevention and Control of Health Care Associated Infections. London. Health Protection Scotland (2007) Personal Protective Equipment Policy and Procedure [online] [05.02.08] http://www.documents.hps.scot.nhs.uk/hai/infectioncontrol/sicp/ppe/mic-p-ppe-2007-02.pdf NPSA (2007) Safer Practice Notice 15 National colour coding hospital cleaning materials and equipment www.npsa.nhs.uk/health/alerts Personal Protective Equipment at Work Regulations 1992 Guidance on Regulations L25 HSE Books 2005

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Appendix 1 RISK ASSESSMENT – GLOVE USAGE FLOWCHART
Are gloves really necessary?
Gloves are NOT required for procedures where there is minimal risk of cross infection between patients and staff e.g. • Basic care procedures without contact with blood or body fluids • Transferring food from food trolleys to patient bedside • Making uncontaminated beds/changing or removing patients’ uncontaminated clothing • Taking recordings (BP, Temp, Pulse) • Closed Endotracheal Suction Gloves ARE required for procedures where there is a risk of cross infection between patients and staff and further risk assessment should be carried out

IS THERE A HIGH RISK OF EXPOSURE TO BLOOD AND BODY FLUIDS

NO NON-STERILE VINYL

YES IS A STERILE FIELD REQUIRED?

DON’T WEAR GLOVES

YES

NO

NON-THEATRE ENVIRONMENT • STERILE NITRILE

THEATRE ENVIRONMENT: • ELASTRYN • NEOPRENE • NITRILE • NON-POWDERED LOW PROTEIN LATEX • SYNTHETIC POLYISOPRENE • TACTYLON

NON-STERILE NITRILE OR SYNTHETIC GLOVE CONFORMS TO EUROPEAN COMMUNITY (EC) STANDARD & KITE MARK 2 EN455 WITH EQUIVALENT BARRIER PROPERTIES

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Appendix 1 (Continued) GLOVE SELECTION – GUIDANCE TYPE OF ACTIVITY

Cleaning

Food handling, preparation, serving

General cleaning

Polythene

Colour-coded marigolds

Isolation room

Vinyl

Blood borne virus exposure/spillage

Tasks where there is a low risk of contamination, non-invasive clinical care, or environmental Cleaning e.g. • Oral care • Emptying catheter drainage bags • Emptying urinals/ bedpans and suction jars • Handling low risk specimens • Clinical cleaning • Dressing wounds when contact with blood/ body fluids is unlikely e.g. gastrostomy dressings • Endotracheal suction • Applying creams • Touching patients with unknown skin rash/ scabies/ shingles • Making beds/ changing clothing of patients in isolation

Procedures involving high risk of exposure to BBVs and where high barrier protection is needed e.g. • Potential exposure to blood/ body fluids e.g. blood spillages, faecal incontinence, blood glucose monitoring, administering enemas/ suppositories and rectal examinations • Handling cytotoxic material • Handling disinfectants • Venepuncture/ cannulation • Vaginal examination • Basic care and specimen collection procedures on patients known or suspected to be high risk of BBV • Non Surgical dentistry/ podiatry • Handling dirty/ used instruments • Processing specimens in a laboratory

Procedures requiring a sterile field and high barrier protection, e.g. • Lumbar punctures • Liver biopsies • Clinical care to surgical wounds/ drain sites • Procedures for neutropenic patients • Insertion of urinary catheters • Vaginal examination in obstetrics

All Surgery and Invasive Radiological procedures

STERILE SURGICAL GLOVES • Elastryn • Neoprene • Nitrile • Non-powdered low protein latex • Synthetic polyisoprene • Tactylon

Sterile Nitrile Examination Gloves

Non-sterile nitrile

Non-sterile vinyl

Non-sterile nitrile

All staff using latex gloves of any type will be required to participate in the OHS skin surveillance scheme

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Appendix 2

Summary Guide to the Use of PPE

This guide is not exhaustive; it offers examples of common health and social care activities where blood/ other body fluid exposure may occur and protection must be worn. As standard, a risk assessment must be undertaken to consider the risks of blood/ other body fluid exposure prior to activities. For further details, refer to the introduction of this guideline or consult with the Infection Control Lead.
Activity Aprons/ Gowns (depending on significant splashing/ exposure) N/A Face, eye. Mouth protection (surgical masks, goggles) N/A Gloves (for type of glove to be used where indicated below see Risk Assessment Glove Usage Flowchart N/A

Contact with intact skin. No visible blood/ body fluids, rashes Sterile procedures Contact with wounds, skin lesions Cleaning up incontinence Potential exposure to blood/ other body fluids e.g. performing suctioning, cleaning up spillages, taking specimens Venepuncture/ cannulation Vaginal examination Applying topical creams, etc Touching patients with unknown skin rash Emptying/ changing urinary catheter bags, urinals, bedpans, etc Handling specimens Handling used instruments Using disinfectants, cleaning agents General cleaning of clinical areas Bed making, dressing patients Oral care Feeding patient General housework Handling waste Nail drilling

Risk assessment Risk assessment Risk assessment Risk assessment

N/A Risk assessment

N/A N/A N/A N/A Risk assessment

N/A N/A Risk assessment Risk assessment N/A N/A Risk assessment N/A N/A Risk assessment Risk assessment Risk assessment Risk assessment Risk assessment Risk assessment Risk assessment

Risk assessment Risk assessment Risk assessment Risk assessment

NB Hand hygiene must always be preformed on removal of PPE. This guideline does not detail information on the use of PPE to be used in specific situations where particular organisms/infections are present. This should be discussed with the Infection Control Lead however; the principles described should apply to all situations.

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Appendix 3

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Description: PERSONAL PROTECTIVE EQUIPMENT PROCEDURE (A STANDARD PRECAUTION)