# PPE & Transmission-Based Precautions

## Overview

Infection Prevention and Control (IPC) during procedures includes the safe management of ‘sharps’, encompasses high-level measures such as health facility design and management, protocol-based measures such as adherence to national and facility level guidelines, and individual actions by each health care provider and ancillary staff member. The health care provider is encouraged to familiarise themselves with their facility’s specific IPC protocols and reporting systems, which is outside the scope of this module.

All clinical procedures pursue the IPC goal of asepsis. The traditional hierarchy of sterile, aseptic, and clean is outdated, poorly-defined and misleading, and is no longer recommended. This module describes how to use Personal Protective Equipment (PPE) and other measures to protect yourself and patients against the transmission of diseases by contact, droplets, and the airborne route.

## Indications

1. Standard precautions: at all times, even when following transmission-based precautions

2. Contact precautions: prevent the spread of infections by contact (touch) with the patient or their surroundings, such as MRSA, C. difficile , or scabies

3. Droplet precautions: prevent the spread of infections by larger droplets caused by coughing and sneezing, such as pneumonia, bacterial meningitis, or influenza

4. Airborne precautions: prevent the spread of infections over long distances by microscopic droplets suspended in the air, such as TB, measles, and chicken pox

## Preparation & Choice of PPE

### Standard precautions

1. Perform hand hygiene.

2. Wear gloves for likely exposure to body fluids or infectious substances.

3. Wear a medical mask and eye protection for splash/spray exposure.

4. Wear an apron or gown for clothing exposure to body fluids or infectious substances.

5. Wear a medical mask and eye protection for aerosol-producing activities.

### Contact precautions

1. Place patients in single rooms, or space at least a metre space between ward beds.

2. Perform hand hygiene as usual.

3. Don gloves and an apron/gown before entering the

   patient’s surroundings
   patient’s surroundings

   includes the bed, linen, bedside cabinet, and the curtains

   .

4. Doff and discard PPE, and clean your stethoscope and other equipment on leaving.

5. Eye protection, medical masks, and respirators are not part of routine contact precautions.

### Droplet precautions

1. Place patients in single rooms, or space at least a metre space between ward beds. Draw the side curtains to shield other patients from droplets.

2. Perform hand hygiene as usual.

3. Don a medical mask on entering the patient’s surroundings, and doff and discard on leaving.

4. Routine eye protection such as a shield or goggles is

   optional
   optional

   There is no consensus on whether eye protection is helpful.

   .

5. Explain and instruct on cough hygiene and wearing a mask during transport.

6. Gloves, gowns/aprons, and respirators are not a part of routine droplet precautions.

### Airborne precautions

1. Place the patient in a single room, with special air extractors, with the door closed at all times. Leave the room vacant for at least an hour before use by another patient.

2. The patient should wear a medical mask when not in their room.

3. Perform hand hygiene before entering and after leaving the patient’s surroundings.

4. Wear an N95 respirator when in the patient’s room or surroundings.

5. Routine eye protection such as a shield or goggles is

   optional
   optional

   There is no consensus on whether eye protection is helpful.

   .

6. Gloves and gowns/aprons are not a part of routine airborne precautions.

## Procedure

### Donning

After performing hand hygiene, don PPE in the correct

order:

order:

This order changes when scrubbing and gowning for theatre.

1. Gowns and/or aprons: Unfold, slip your arms into the armholes (gowns) or around the neck (aprons), and tie at the back. You may need help with this.

2. Respirators: Separate the elastics if necessary and pull the respirator over your nose and mouth. Bend the flexible nose strip to fit your nose. Blow air out and suck air in to check for

   leaks
   leaks

   If there is a leak, a different size or model may be required. If unavailable, contact the IPC sister, your supervisor or the stores manager about procuring your size.

   . The mask should inflate and collapse accordingly.

3. Face shields: Place over your face and eyes. Adjust the back strap to fit comfortably.

4. Gloves: For how to don gloves, see gloving.

### Doffing

Remove PPE in the following order:

1. Gloves: Always doff gloves first and perform hand hygiene.

2. Gowns/aprons: Untie or break the apron/gown ties at the back. Touching only the insides of the apron/gown, pull it forward off your shoulders and bundle it inside-out. Dispose into waste or laundry.

3. Face shields: Touch only the headband and pull forward, off the face. Set aside for disinfection.

4. Respirators: Pull forward off the face, touching the elastics only. Dispose, or place in a paper bag for reuse. Perform hand hygiene.

## Troubleshooting

I am unsure of precautions needed for COVID-19 patients.

COVID-19 spreads by contact, droplets and the airborne route. Follow the protocol at your facility, which may differ for suspected and confirmed cases, and for routine and aerosolising procedures.

Due to shortages, I have to reuse my PPE.

- Gloves:

Gloves may only be worn for one patient. In a crisis, gloves may be sanitised or washed and used for multiple patients, but only when necessary. Gloves should not be taken off and re-used, as this increases the risk of tearing.

- Medical masks:

Medical masks should ideally only be worn for one patient encounter. In emergencies, a medical mask may be worn for 6-8 hours as long as it remains clean, dry, and untouched. Fabric masks should not be used to replace medical masks.

- Respirators:

Respirators should ideally only be worn for one day. They may be worn for up to a week, as long as they remain clean and dry.

- Gowns/aprons:

Gowns and aprons should ideally only be worn for one patient encounter. In a crisis, they may be worn for a cohort of patients such as a COVID-19 ward, as long as one remains in the ward.

- Face shields/goggles:

These may be worn until damaged or no longer wearable. They should be sanitised between each use.

## References

1. World Health Organisation. Rational use of personal protective equipment for COVID-19 and considerations during severe shortages. 2020.

2. Centres for Disease Control. Using Personal Protective Equipment (PPE). 2020.

3. World Health Organization. Transmission of SARS-CoV-2: implications for infection prevention precautions. 2020.

4. Centers for Disease Control. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007.