Hand Hygiene and Personal Protective Equipment (PPE)

1. 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

10. PPE = Gloves and…. Oct 2014

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 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 Oct 2014

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 14-007 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 • Report the exposure as soon as possible to your EMS Field Supervisor for follow-up 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 214-670-3220 Office 469-323-5775 Cell Oct 2014