The Centers for Disease Control and Prevention (CDC) have recently developed a videotape and accompanying slide set concerning selection and use of personal protective equipment, or PPE. The design of these materials is to help “train the trainers.” The need for such training elements was identified during the worldwide outbreak of SARS (severe acute respiratory syndrome) when observations of PPE use among healthcare workers (HCW) indicated potentially unsafe practices when donning, using, and removing PPE.
The CDC program has a simple goal - improve personnel safety in healthcare environments through appropriate use of PPE. Meeting such a goal would also increase patient safety. Program objectives are two-fold - provision of information on the selection and use of PPE in healthcare settings, and describing how to safely don and remove PPE. The CDC uses the Occupational Safety and Health Administration’s (OSHA) definition for PPE, which is “specialized clothing or equipment worn by an employee for protection against infectious materials.”
There are regulations and recommendations for PPE issued by both OSHA and the CDC. OSHA promulgates workplace health and safety regulations. Regarding PPE, employers must provide appropriate PPE for employees and ensure that PPE are either disposable or, if reusable, are properly cleaned, laundered, repaired, and stored. OSHA also specifies circumstances for which PPE are indicated. The CDC recommends when, what, and how to use PPE.
Controls
There is a hierarchy of safety and health controls. Engineering controls are the most effective control for dental environments. Engineering controls are control methods (e.g., sharps disposal containers, self-sheathing needles, and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove an occupational hazard from the workplace.
The next most effective are work practice controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).
OSHA requires employers to use PPE as controls to reduce employee exposure to hazards. Use of PPE is very important when engineering and administrative controls are not feasible or effective.
Compliance concerning PPE is often dependent on personal preferences. However, increased comfort (better fit, ergonomics, allergies, and body temperature regulation) usually translates into higher levels of compliance.
Donning and removing
The CDC Web site (www.cdc.gov/ncidod/hip/ppe/default.htm) contains access to an especially valuable poster. It contains descriptions in both English and Spanish concerning the proper donning of PPE as well as methods for the correct removal of PPE after use. Also present are informative pictograms demonstrating the processes mentioned.
An example from the poster would be information concerning masks and respirators. Suggestions for placement include:
- Secure ties or elastic bands at the middle of the head and/or neck
- Fit flexible band across the bridge of the nose
- Fit snug to face and below chin
- Fit-check respiratory protectors
Suggestions for removal include:
- Front of a mask or respirator is contaminated - DO NOT TOUCH
- Grasp bottom of the mask, then the top ties and remove
- Discard in waste container
Sequence of events
The CDC offers some general points about PPE usage. Donning of PPE should occur before contact with the patient. The design of PPE is to protect both practitioners and patients by limiting direct contact and contamination of inert environmental surfaces. Remove and discard PPE carefully. Remove respirators outside of treatment rooms. After removal of PPE, immediately perform proper hand hygiene.
There is a sequence for donning PPE. Gowns go on first, then masks or respirators. Protective eyewear and/or face shields follow this and, finally, gloves. The combination of PPE used will affect the sequence of placement. Prudent use of PPE is always desirable.
There are two general physical areas of a PPE - contaminated and clean. Contaminated areas are usually on the outside front. These areas of PPE have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organisms may reside. Clean areas are usually inside, outside back, ties on the head or neck, and the backs of gowns.
The sequence for removing PPE is gloves first, then protective eyewear and/or face shields. Gowns are next, then, finally, masks or respirators.
Removal of most PPE should occur near the doorway of the treatment room, not outside the room. The exception is respirators, which occurs outside the treatment room, after closing the door. Hand hygiene facilities must be available at the point of need. This includes either a sink with appropriate hand hygiene products or alcohol-based hand rubs.
Hand hygiene and PPE
Immediately after removing PPE, perform hand hygiene. If during PPE removal hands become visibly contaminated, wash with either a nonantimicrobial soap and water or with an antimicrobial soap and water before continuing to removing the other PPE.
After removing gloves, you should first look at your hands. If not visibly soiled, then properly remove the remaining PPE. Then, wash your hands with either a nonantimicrobial soap and water, with an antimicrobial soap and water, or with an alcohol-based hand rub before removing the other PPE.
When to use PPE
Use of PPE is an important part of standard precautions, which are extensions of universal precautions. Standard precautions assume blood and body fluids of any patient could be infectious. The CDC recommends PPE and other infection-control practices to prevent transmission in healthcare settings. The type of clinical interaction that will occur with a patient determines final decisions about PPE use.
Standard precautions have specific recommendations concerning various forms of PPE. These are:
- Gloves are worn when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin.
- Gowns are for procedures and patient care activities where contact of clothing/exposed skin with blood/body fluids, secretions or excretions are possible.
- Masks, protective eyewear, or face shield are for patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Protective clothing
Potentially infectious materials may be present in aerosols, sprays, splashes, and droplets generated from patient oral fluids. These fluids could contaminate the arms and chest area. Larger droplets could settle on the lap of a person sitting next to the patient. Outer protective clothing can serve as a barrier against contamination.
Dental practice personnel should wear protective clothing whenever a chance exists for contamination of skin or other clothing. The same conditions that require gloves, masks, and protective eyewear also require protective clothing.
Protective clothing is the outer-most layer worn clinically. Examples include uniforms, smocks, clinic jackets, lab coats, aprons, and gowns. Clothing should be fluid-resistant; it does not have to be fluid-proof. Protection is important, but so is comfort. Fabrics that “breathe” are desirable. Generally, protective clothing should have long sleeves, high necks, and cover knees when sitting. The goal is to cover, as best as possible, regular work clothes. Dental care does not require the use of head and shoe covers. There are two basic types of protective clothing - disposable and reusable.
Disposable gowns have the advantage that there are only minimal free-end costs, making a change to a different style relatively easy. Disposable gowns are not a type of medical waste and thus can be disposed of in the regular trash. All protective gowns should be changed if they become obviously soiled, or at the end of the day. Wearing gowns outside the office is not acceptable.
Reusable gowns also can be appropriate. Reusable gowns, however, require start-up purchase costs. Dental practice personnel cannot take their protective clothing home to launder. This is the responsibility of the employer. Practices can install washers and dryers. It is acceptable, after adequate training, to ask staff members to launder reusable gowns. However, they must receive their regular wages.
Parting thoughts
PPE is available to adequately protect dental practitioners from exposure to infectious agents in the healthcare workplace.
All HCW need to know what types of PPE are necessary for the procedures they are performing and how to use them correctly. Staff members must work together to make the selection and use of PPE both efficient and effective.
The Organization for Safety and Asepsis Procedures (OSAP) is dentistry’s resource for infection control and safety. OSAP has recently published a book on the CDC Guidelines - “From Policy to Practice: OSAP’s Guide to the Guidelines.” The book’s design is to support the efforts of dental practices to understand better the recommendations and to identify effective and efficient methods for compliance, including proper use of PPE. Order information is available at www.osap.org.
Editor’s Note: References available upon request.
Dr. Charles John Palenik is an assistant director of Infection Control Research and Services at the Indiana University School of Dentistry. Dr. Palenik is the co-author of the popular “Infection Control and Management of Hazardous Materials for the Dental Team.” He serves on the executive board of OSAP, dentistry’s resource for infection control and safety. Questions about this article or any infection-control issue may be directed to [email protected].
PPE - types and selection factors
There are five basic types of PPE used in healthcare settings:
- Gloves - protect hands
- Gowns/aprons - protect skin and/or clothing
- Masks and respirators - protect mouth/nose (respirators also protect the respiratory tract from airborne infectious agents)
- Spectacles/goggles - protect eyes
- Face shields - protect face, mouth, nose, and eyes
A number of factors influence PPE selection:
- Type of exposure anticipated (splash/spray versus touch or category of isolation precautions)
- Allergies and sensitivities (to PPE construction materials)
- Design and features
- Durability (including shelf life)
- Appropriateness for the task
- Sizing or fit (comfort)
- Cost effectiveness
