What personal protective equipment (PPE) should be used in different medical settings?

Personal Protective Equipment (PPE) in Different Medical Settings

Healthcare workers should select appropriate personal protective equipment based on risk assessment of specific clinical scenarios, with selection varying according to the type of pathogen, transmission route, and procedure being performed. 1

General Principles of PPE Selection

• PPE should be implemented as part of a comprehensive infection prevention system, not as a standalone measure 1
• All components of PPE must work together as an integrated system to provide consistent protection 1
• Selection should be based on the type of pathogen and its transmission route (contact, droplet, or airborne) 1
• Proper training in donning and doffing procedures is essential before patient management to prevent self-contamination 1

PPE Requirements by Clinical Setting

Standard Precautions (All Patient Care)

• Hand hygiene before and after patient contact 1
• Gloves for anticipated contact with blood or body fluids 1
• Gowns, masks, and eye protection when splashes or sprays are anticipated 1

Emergency Department/Triage Area

• For suspected/confirmed infectious patients: Fitted N95 respirator or surgical mask (depending on pathogen), regular AAMI level-II gown, eye protection (goggles or face shield), and gloves 2
• Double gloves should be considered in trauma level I cases 2
• Hand hygiene before and after examining each patient 2

Procedure Rooms (Non-invasive Care)

• For suspected/confirmed infectious patients: Fitted N95 respirator (if available) or surgical mask, regular AAMI level-II gown, eye protection, and gloves 2
• Hand hygiene before and after examining each patient and donning/doffing PPE 2

Operating Room

• For suspected/confirmed COVID-19 or highly infectious patients: PAPR (preferred for long operations) or fitted N95 respirator, eye protection (goggles or full-face shield), disposable AAMI level-III surgical gown or coveralls, double high-cuffed surgical gloves, and fluid-resistant shoes 2
• Vertical strips of tape can keep gloves secured to the gown 2
• Regular surgical helmets cannot replace respirators when operating on infectious patients 2
• Avoid disposable shoe covers as they may increase contamination risk during removal 2

Induction Room (Aerosol-Generating Procedures)

• PAPR (if available) or fitted N95 respirator with eye protection, disposable AAMI level-III gown or coveralls, double high-cuffed surgical gloves 2
• A shower after respiratory aerosol-generating procedures is prudent 2
• Only senior anesthesiologists should perform these high-risk procedures 2

Recovery Room

• Special attention to avoid self-contamination during PPE doffing 2
• Implement a buddy system with observers to ensure proper technique 1

PPE Components and Selection Criteria

Respiratory Protection

1. Fitted N95/NIOSH-certified respirators:

   • Require fit testing each time 2
   • Consider placing a surgical mask over it to prevent gross contamination 2

2. Powered Air-Purifying Respirators (PAPR):

   • Preferred for long operations 2
   • Recommended when maintaining a close facial fit of N95 cannot be guaranteed 2

3. Surgical masks:

   • Consider double/multiple mask techniques with correct tight-fitting 2
   • Not recommended for aerosol-generating procedures with infectious patients 2

Eye Protection

• Full-face shields (preferred) or goggles that cover sides of eyes 2
• Disposable prescription eyewear shields for those who wear glasses 2
• Special spectacle kits designed for use with full face respirators should be used instead of conventional glasses 3

Gowns

• AAMI Level I for routine patient care 2
• AAMI Level III disposable gowns for aerosol-generating procedures 2
• Should be fluid-resistant 2

Head/Neck Protection

• Surgical hood with ties (head and neck covering) 2
• Should be fluid-resistant and easily decontaminated 2

Gloves

• Double high-cuffed surgical gloves for procedures 2
• Consider vertical strips of tape to keep gloves secured to gown 2

Footwear

• Shoes should be fluid-resistant and easily decontaminated 2
• Avoid disposable shoe covers due to increased contamination risk during removal 2

Common Pitfalls and How to Avoid Them

• Improper doffing technique is a major source of self-contamination - ensure proper training and use the buddy system 1
• Inadequate fit testing significantly reduces protection - perform proper fit testing initially and annually 1
• Confusing surgical masks with respirators leads to inadequate protection - ensure proper selection based on risk 1
• Allowing regular eyeglasses to be worn with full face respirators can break the seal - use special spectacle inserts 3
• Fogging of goggles/eyewear when using PPE - use anti-fog measures 1

Environmental Controls and PPE

• Implement specific circuits with color visual zone systems to distinguish contaminated (red), transition (yellow), and clean areas (green) 1
• Ideally, manage infectious patients in single, negative pressure rooms with good air exchange rates (>12 exchanges per hour) 1
• Allow enough time to ensure contaminated air is removed from the room before performing another procedure (at least 30 minutes) 1
• Establish clearly defined exposure zones with warning signs to minimize contamination risk 1

PPE Conservation Strategies

• Develop a strategy to conserve supplies of PPE in case of shortages 1
• Consider designating specific equipment for confirmed infectious patients 1
• Reduce and prioritize allocation of human resources according to outbreak evolution and hospital needs 1
• Separate healthcare workers into groups to reduce exposure and limit operators who may require quarantine simultaneously 1