At the completion of this module, the nurse should be able to:
- Explain how to minimize a healthcare provider's risk of acquiring an infectious disease.
- Consider the latest CDC healthcare worker guidelines for protection from infectious disease.
- Identify the basic types of personal protective equipment (PPE) and safe use.
Healthcare workers are at risk of contracting infectious diseases each time they enter their workplace, and satisfactory infection control practices within the healthcare setting is a primary responsibility among all healthcare workers. In nursing, this responsibility affects all interactions with patients, coworkers, equipment, and the healthcare environment. For example, the state of New York specifies this responsibility in their official regulations for nurses in practice and includes the performance monitoring of all personnel for whom the licensee is responsible. It encompasses adherence to the following essential infection control practices:
- scientifically accepted standards for handwashing;
- aseptic technique, use of gloves and other barriers for preventing bi-directional contact with blood and body fluids;
- thorough cleaning followed by sterilization or disinfection of medical devices;
- disposal of non-reusable materials and equipment;
- cleaning of objects between patients that are visibly contaminated or subject to touch contamination with blood or body fluids;
- injury prevention techniques or engineering controls to reduce the opportunity for patient and employee exposures (Potter et al., 2017).
Compliance can be increased with regular and high-quality training to understand how infection control strategies work and why they are necessary, such as with the World Health Organization (WHO, 2009) multimodal approach, “My 5 Moments for Hand Hygiene” (WHO, 2009). There can be detrimental consequences with poor compliance to infection control practices, such as increased risk of illness or disease transmission for the healthcare worker, the patient, and the public, poor health outcomes, misconduct consequences for the healthcare worker, including disciplinary action, revocation of license, and professional liability. This module will focus on the use of PPE and its ability to protect the healthcare worker from the transmission of infection based on current guidelines as of April 2020 (The Centers for Disease Control and Prevention [CDC], 2020a).
Minimizing Risk for Exposure
Handwashing is the single most effective way to decrease disease transmission, nurses have much more risk of exposure than hands alone. Nurses are exposed through direct contact such as touching; indirect contact such as equipment, eating utensils, or other vectors or vehicles of transmission; droplet transmission such as coughing, sneezing, or spitting from the source to the eyes, nose, or mouth of others; or airborne transmission with the spread of microorganisms by dust particles or small droplets (less than 5 microns). The microorganisms become airborne and enter the host through a portal of entry (usually the respiratory system). A portal of entry is the route by which microorganisms enter the host. Portals of entry include skin, blood, and the respiratory, gastrointestinal, reproductive, and urinary tracts. Frequently, microorganisms enter the host's body by the same route they exited the source. Nurses use PPE to decrease the risk of exposure by limiting the ability of microorganisms to enter their bodies. PPE includes gloves, respirators, facemasks, eyewear, and/or gowns to prevent the transmission of infectious materials found in blood, body fluids, secretions, and excretions (CDC, 2019; WHO, 2009). See Figure 1 for the Chain of Infection.
Disposable gloves are made from a variety of polymers such as latex, nitrile rubber, polyvinyl chloride (PVC, or more commonly referred to as vinyl), and neoprene. They are available as unpowdered or powdered. Both nonsterile and sterile gloves are used by healthcare providers (HCPs) when delivering care to patients. Latex and nitrile mold to the hand and offer superior protection against pathogens. Nitrile gloves are preferred over vinyl for tasks that require a high degree of dexterity. Vinyl gloves are acceptable when the risk of exposure to pathogens is lower, and a high degree of dexterity is unnecessary (Potter et al., 2017).
The following are important points to consider when using gloves. Wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Apply gloves before touching mucous membranes and non-intact skin. Gloves should fit comfortably and not be reused. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves (Potter et al., 2017).
Change gloves between tasks and procedures on the same patient after contact with a material that may contain a high concentration of microorganisms (Potter et al., 2017).
Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Wash hands immediately to avoid transferring microorganisms to other patients or environments (Potter et al., 2017).
Wear sterile gloves when following the principles of surgical asepsis for keeping an area/object free of all microorganisms. Thorough handwashing must be performed before donning sterile gloves and after discarding the gloves (Potter et al., 2017).
The procedure for the proper application and use of nonsterile gloves is as follows:
- Perform hand hygiene until the product disappears and the hands are dry (see Figure 2).
- Select the appropriate size glove (see Figure 3).
Facemasks provide barriers to infectious materials and are often used with other PPE such as gowns and gloves. When worn correctly, facemasks and eye protection provide protection for the mouth, nose, and eyes during procedures where there is a potential for droplets or splashing of blood or body fluids. The use of facemasks during spinal/epidural access procedures is included within the definition of standard precautions. In addition to these standard precautions, transmission-based precautions are mandated by the CDC for highly transmissible diseases such as COVID-19, measles, varicella, tuberculosis, influenza, mumps, rubella, wound infections, scabies, and many other infectious diseases (Potter et al., 2017).
Procedure facemasks are flat/pleated and affix to the head with ear loops. They are used for any nonsterile procedure. Surgical masks come in two basic types: one that is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the bridge of the nose, and may be flat/pleated or duck-billed in shape. The second type of surgical mask has two elastic loops, one for each ear. Both have a flexible nose piece that is adjusted by pinching at the bridge of the nose. Both are loose fitting and provide one-way protection as they capture particles or droplets from the wearer and protect patients and operative sites (Potter et al., 2017).
All facemasks have some degree of fluid resistance, but those approved as surgical masks must meet specific standards for protection from penetration of blood and body fluids. Surgical masks protect not only the provider from sprays/splashes, but primarily prevent any pathogens within the nose/mouth of the wearer from potentially spreading to and infecting the patient. For applying a surgical mask follow the steps below (Potter et al., 2017).
- Place and hold the surgical mask over the nose, mouth, and chin while stretching the band over the ears or tying the ties behind the head and at the base of the neck (see Figures 11 and 12).
Current OSHA standards require that respirators are used for airborne transmission-based precautions; these minimally filter 95% of 0.3 µm-size particles. Respirators are also used for case-specific aerosolizing procedures where airborne particulates create a high risk of infection for the HCP. The N95 respirator and the HEPA respirator meet these requirements (see Figure 18); they are single use, disposable options. However, there are also reusable options available, including elastomeric respirators and powdered air purifying respirators (see Figure 19). All personnel who care for patients with these conditions (suspected and confirmed) must wear an N95/HEPA respirator when entering the patient's room. An N95 respirator mask is intended to be used for protection against solids. The N95 is exceptionally durable, has a soft and comfortable inner surface, an adjustable nosepiece, and secure head straps to provide a proper fit. A person using an N95/HEPA respirator must be fit-tested before use. Check with agency policy about respirator use for infection control. If the respirator has a full facemask (see Figure 20), this also protects the eyes and face in addition to the respiratory tract (CDC, 2019; Potter et al., 2017).
Understanding the Difference
Face and Eye Protection
Protective goggles, face shields, and safety glasses provide a barrier to infectious substances. They are typically used in conjunction with other personal protective equipment such as gloves, gowns, respirators, and facemasks. The type of face and eye protection chosen is dependent on the specific work conditions and potential for exposure. Personal knowledge of potential exposure is essential for making an informed decision about the right face and eye protection. Eyeglasses prescribed for vision correction and contact lenses are not considered eye protection. For complete and proper protection, it's also essential to evaluate the combination of protection recommended for the specific work situation. For example, some facemasks may not work with various goggles or shields. Likewise, a full-face respirator may provide adequate protection without additional components of PPE (CDC, 2019; Potter et al., 2017).
Goggles are available with direct or indirect venting. Direct-vented goggles have the potential for allowing the penetration of splashes and are not as reliable as indirect-vented goggles. Goggles must fit snugly to provide adequate protection from splashes, sprays, and respiratory droplets (CDC, 2019; Potter et al., 2017).
Face shields are sometimes used as an alternative to goggles. Because the face shield has a larger surface area, it protects other facial areas. Face shields do not fit snugly against the face, making them vulnerable to splash and spray going under the face shield. Face shields are typically used with other forms of protection and should not be considered the best protection (CDC, 2019; Potter et al., 2017).
Safety glasses are excellent for providing impact protection. However, they do not protect adequately from splash, spray, and respiratory droplets. Thus, they are not typically used for infection control purposes. For proper application see Figures 21-24 (Potter et al., 2017).
- To apply, grasp the ear or headpieces of the appropriate device, spread and slowly apply the device over the ears (see Figure 21).
- Adjust for comfort as needed (see Figure 22).
A clean, nonsterile gown is adequate for protecting skin and preventing soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Most patient interactions do not require the use of a gown, but they are always a needed item when caring for patients under contact isolation precautions for an infectious disease. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transferring microorganisms to other patients or environments. See Figures 25-30 for the steps on donning and removing gowns (Potter et al., 2017).
- Select the appropriate type and size of gown (see Figure 25).
- With the gown opening in the back, pull the arms through the sleeves one at a time and pull it over the shoulders. Secure at the neck and waist (see Figure 26).
- If using a washable gown, remove gloves first, then untie the gown at the waist and neck and pull it away from the shoulders. Roll it into a bundle while avoiding contact with the outside of the gown and place in the proper laundry container (see Figure 29).
- Regardless of the type of gown used, perform hand hygiene (see Figure 30) (Potter et al., 2017)
Proper Application and Removal
To reduce the spread of microorganisms, the CDC (2014) recommends applying (see Figure 31) and removing (see Figures 32 and 33) PPE in the proper order:
Latex and Latex-Free Equipment
Latex gloves are made from a natural rubber material, while nitrile and vinyl polymers are synthetic. See Figure 1 for comparison of latex, nitrile, and vinyl gloves. The use of latex gloves places both the health care provider and the patient at risk for a latex allergy. Powdered latex gloves create an additional risk because the latex allergen adheres to the powder. The powder is released into the air and then can be inhaled into the lungs (Potter et al., 2017).
Latex sensitivity and latex allergies are of concern to HCPs and patients. This is partly due to the potential for high exposure to latex gloves and medical supplies that contain latex. HCPs and patients who have a sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes should be screened carefully as they are at higher risk of having a sensitivity or allergy to latex (Potter et al., 2017).
Standard and Transmission-Based Precautions
There are currently two tiers of CDC precautions to prevent transmission of infectious agents: standard precautions and transmission-based precautions.
Standard precautions are applied to the care of all patients in healthcare settings, regardless of suspected or confirmed the presence of an infectious agent. Standard precautions are used with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. This infection prevention practice includes hand hygiene; use of gloves, gown, facemask, and face shield; respiratory hygiene/cough etiquette; and safe injection practices. The selection of PPE depends upon anticipated blood, body fluid, or pattern of splash (Siegel et al., 2019).
In 2013, the CDC recommended that respiratory hygiene/cough etiquette be incorporated into infection control as a component of standard precautions. These should be instituted in the healthcare setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a strong evidence base (Siegel et al., 2019).
Transmission-based precautions are additional protections recommended by the CDC in addition to the standard precautions discussed above. Also known as isolation precautions, they are based on the mode of transmission of specific diseases. There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. These are used for patients who have highly transmissible pathogens when the route of transmission is not entirely interrupted by standard precautions (Siegel et al., 2019).
Contact precautions are used when a disease is transmitted via direct contact, contaminated body fluids, or indirectly through contaminated instruments, equipment, or the hands of healthcare workers. This type of precaution requires the use of gloves and a gown for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. These patients should also be in a private room with a private bathroom if at all possible, to prevent cross-contamination. Examples of infections in which contact precautions are instituted include vancomycin-resistant Enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), respiratory syncytial virus (RSV), norovirus, rotavirus, and the herpes simplex virus. Contact precautions may also apply in the presence of excessive wound infection/drainage, fecal incontinence, or other discharges from the body that suggest an increased potential for extensive environmental contamination and risk of transmission (Siegel et al., 2019).
Droplet precautions are used when a disease is transmitted by large droplets expelled into the air. They are larger than 5 microns and can travel 3 to 6 feet away from the patient. This type of precaution requires the use of a surgical mask on the HCP when within 3 feet of the patient, proper hand hygiene, and some dedicated care equipment. The surgical mask should be applied before entering the patient's room. Examples of patients who require droplet precautions include those who have influenza, pertussis, meningococcal disease, COVID-19, or Mycoplasma pneumonia (CDC, 2020a; Siegel et al., 2019).
Airborne precautions are used when a disease is transmitted by smaller droplets (less than 5 microns). These droplets can remain airborne for more extended periods. If possible, the patient should be placed in a private room equipped with negative pressure airflow. This airflow filters air through a high-efficiency particulate air (HEPA) filter and then directs the air to the outside of the facility. This form of isolation requires an N95 respirator mask to be worn any time an HCP enters the patient's room. The respirator mask should be applied before entering the room. Respirators must be appropriately fitted before use. An example of a diagnosis that requires airborne precautions is pulmonary tuberculosis, measles, varicella, and severe acute respiratory syndrome (SARS) (Siegel et al., 2019).
With all of these types of transmission-based precautions, certain basic principles should be followed:
- Thoroughly perform hand hygiene before entering and leaving the room of a patient in isolation.
- Properly dispose of contaminated supplies and equipment according to agency policy.
- Apply knowledge of the mode of infection transmission when using PPE.
- Protect all persons from exposure during the transport of an infected patient outside of the isolation room (Siegel et al., 2019).
Disposable, single-use items are preferred. Self-awareness and self-protection are vital for HCPs. Following appropriate precautions and safe use of PPE is critical to avoid self-inoculation while working around patients with severe transmissible illnesses. Safe removal of PPE is crucial, as the WHO noted in 2003 that approximately 30% of infections of healthcare workers were due to poor practices while removing PPE (WHO, 2003).
Special notes in 2019 regarding COVID-19: With the current pandemic of COVID-19, the guidelines are changing rapidly, but adherence to the consistent and proper use of PPE is even more crucial. Those caring for individuals with COVID-19 should adhere to both standard and transmission-based precautions. The CDC (2020a) advises that gowns, gloves, eye protection, and a facemask or N-95 respirator should be used with COVID-19 patients. While disposable N-95 respirators or equivalent are recommended, in the event of limited resources, a facemask can be used instead for most patient care. Respirators should still be used during all aerosol-generating procedures. A facemask should also be placed on the patient if caregivers are to be within six feet of the patient. While one-time use of disposable facemasks, surgical masks, or respirator masks are preferred, this is not always possible. Guidelines for the extended (continuous) use of respirator masks include the following:
- The respirator must maintain its fit and function for extended use.
- The respirator can be used for eight hours of continuous use when cohorting a group of patients with the same diagnosis.
- The facility should consider additional training and reminders for staff regarding proper methods for reuse of respirators or facemasks.
- Respirators contaminated during aerosol-generating procedures should be discarded.
- Respirators contaminated with blood, respiratory secretions, or other bodily fluids should be discarded.
- Respirators used during the close contact of a patient requiring contact precautions should be discarded.
- Consider using a cleanable face shield in addition to masking the patient over N-95 respirators to reduce surface contamination (CDC, 2020b).
Further guidelines for the limited reuse (intermittent) of respirators should include:
- Follow the manufacturer’s directions for reuse of the device, including a seal check for the user.
- Follow the employer's maximum number of donning (or up to five if there are not further manufacturer guidance), ensuring recommended inspections with each application.
- Pack or store respirators between uses to avoid damage or contamination.
- Only a single HCP should use a respirator and labeling with name and date is needed to avoid cross-contamination (CDC, 2020b).
The risks of extending or reusing PPE are of concern to many nurses and currently voiced by media. Many of the devices are labeled for single use only and not cleared by the Food and Drug Administration (FDA) for reuse. Of most significant concern is the risk of contact transmission of infectious disease with reuse. Respiratory pathogens can be transferred from the respirator surface to the hands of the wearer and increase the risk of infection. The risk is increased with aerosolized procedures such as suctioning or sputum induction. Thus, discarding the N95 after use or the use of a face shield over the N-95 respirator is preferred. HCPs reusing respirators or facemasks may complain of discomfort from increased length of wear but should not pose a health risk and be tolerable to the wearer (CDC, 2020b).
Of vital importance is proper donning and removal of the PPE to avoid self-contamination (CDC, 2020a). While there may be diminished supplies or even shortages of PPE within a specific organization or state, maintaining a safe environment for the patient and the healthcare worker can still be accomplished. Once the supply chain is restored, a return to the best practices can be achieved. Meanwhile, it is essential to give priority to those working closest to the highest risk patients and procedures and are at the highest risk of coming into contact with aerosols.
***For further information on infection control outside the use of PPE, please refer to NursingCE’s module on Infection Control.
Assessment Technologies Institute®, LLC, wishes to thank North Idaho College, Coeur d’Alene, Idaho, for the generous use of their facilities in the making of these productions.
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