Personal Protective Personal Protective Equipm ent Equipm ent ( - - PowerPoint PPT Presentation
Personal Protective Personal Protective Equipm ent Equipm ent ( PPE) ( PPE) Jurai W ongsaw at, MD Bam rasnaradura I nfectious Diseases I nstitute, THAI LAND Avian Influenza Training Module Workshop for FETP , ASEAN +3 and ACMECS , Training
Jurai W ongsaw at, MD Bam rasnaradura I nfectious Diseases I nstitute, THAI LAND
Avian Influenza Training Module Workshop for FETP, ASEAN+3 and ACMECS, Training for Trainer, 7-11 August 2006 , Bangkok, Thailand
Describe the essential PPE used for different em ergency situations. Dem onstrate how to put on and rem ove PPE Dem onstrate proper disposal of PPE Describe the different levels of PPE recom m ended for Avian I nfluenza investigations
Principle of infection control precautions I C recom m endation for Avian Flu Different situations
How to dispose PPE Occupation health
Direct ( skin, m ucosa, penetration, etc) I ndirect ( touch to clothes, bed, rails, etc) Fom ites transm ission Organism s rem ain on sites unless cleaned, disinfected, decontam inated Mode of eradication = cleaning, drying, + disinfection/ antiseptic
Large size, > 5 m icron diam eter droplets, visible if clustered Fall onto surfaces by gravity Short distance of spreading, < 3 feet from pt close personal or environm ental contact Exposure of m ucosa to droplets directly or indirectly ( probably via hand) Eradication ~ contacts
Sm all size, nuclei 1 -5 m icron, invisible Spreading ~ poor airflow Suspended on air several days Prolonged deep inhalation of nuclei Eradication = m aintenance of adequate, non-recirculated ventilation
Category of single room masks gown Gloves precautions
air pressure ventilation
(for persons close to patient)
* prefered but not required, cohorting patients with the same disease are acceptable
Transm ission - based Precautions for Hospitalized Patients
Universal precautions ( blood and body fluid) + body substance isolation ( m oist body substance) Apply to all patients regardless of their diagnosis or presum ed infection status Apply to blood, all body fluids except sw eat, nonintact skin, m ucous m em brane Designed to reduce the risk of transm ission
unrecognized sources of infection
Standard Precaution: Sum m ary Hand hygiene Personal Protective Equipm ent Patient placem ent Care of environm ent Patient care equipm ent Laundry & w aste m anagem ent Occupational Health
Hand w ashing w ith plain soap Hand antisepsis : antiseptic handw ash, antiseptic handrub
Hand Hygiene
Decontam inate hands in the follow ing circum stances, w hether or not gloves are w orn 1 . Before having direct contact w ith patients. 2 . After contact w ith blood, body fluids or excretions, m ucous m em branes ,non intact skin or w ound dressings.
A.Hand Hygiene
3 . After contact w ith a patient’s intact skin ( e.g.
w hen taking a pulse or blood pressure or lifting a patient) 4 . I f hand w ill be m oving from a contam inated- body site to a clean-body site 5 . After contact w ith inanim ate objects ( including m edical equipm ents) in the im m ediate vicinity of the patient 6 . After rem oving gloves
PPE refers to a variety of barriers and PPE refers to a variety of barriers and respirators used alone or in combination respirators used alone or in combination to protect mucous membranes, skin and to protect mucous membranes, skin and clothing form contact with infectious clothing form contact with infectious agents. agents.
Single room is indicated as follow ings: Active pulm onary or laryngeal tuberculosis Varicella or dissem inated Herpes Zoster Measles Multi-drug resistant organism s
4 . Care of the environm ent
Cleaning and m aintaining environm ental surfaces as appropriate for the level of patient contact and degree of soiling Clean and disinfect surfaces that are in close proxim ity to the patient :, bedrails, doorknobs, bed side equipm ent, toilet Use approved disinfectants
Handling, containing, transporting Appropriately cleaned and reprocessed. Single-use item s are properly discarded
5 . Patient-Care Equipm ent
Critical I tem s : Instruments that enter sterile tissue or the vascular system of any patient should be cleaned and sterilized before reuse Sem i-critical item s: Devices that contact intact mucous membranes should be cleaned and sterilized or receive high-level disinfectant before reuse. Non-critical item s: Devices that contact intact skin should be cleaned and receive medium to low level disinfectant before reuse
6 . Textile and laundry
Low risk of disease transm ission Linen soiled w ith blood or body fluids should be placed and transported in bag that prevent leakage. W ashed w ith detergent in w ater at least 7 1°C ( 1 6 0 F) for 2 5 m in. I f low -tem p. ( ≤7 0 °C) laundry cycles are used, w ash w ith detergent and Sodium hypochlorite
1 . Safe handling and disposal of sharps 2 . Safety engineered devices
Needles should never be recapped, purposely bent or broken or rem oved from disposable syringes. Sharp container should be placed as close as practical to the area w here sharps are being used.
Wet hands with water, apply soap, rub hands together for at least 20 seconds Rinse with clean water Dry with disposable towel or air dry Use towel to turn off faucet
Must use clean water
Resident Transient
Corynbacterium
Bacillus spp Enteric GNR Superficial < deep Superficial > deep Antiseptic w ashing plain soap w ashing Low virulence High virulence Rarely Pathogenic Com m only Pathogenic
Relative Relative efficacy efficacy of
solutions for for hand hand hygiene hygiene to to reduce reduce skin skin flora flora. .
Lancet Infectious Diseases 2001; April: 9–20
Microbial flora colonizing hands
~ 4.89 – 5.61 mean log10 CFU Alcohol 60- 95% (vol/vol) kill ~ 3.4 - 5.8 log10 CFU in 30 S
Time Time-
course of
efficacy of
unmedicated soap soap/ /water water and and alcohol alcohol-
based handrub handrub from from artificially artificially contaminated contaminated hands hands
EID Vol. 7, No. 2, March–April 2001, Lancet Infectious Diseases 2001; April: 9–20
1.8 – 2.8 0.6 – 1.1 ~ 4-5 ~ 3.5
Palm over palm
Fingers interlocked
Rotation holding thumb
Rotation rubbing
Digital rubbing
Wrist rubbing
Dry with paper towel
Activity no of droplet talk 5 min 3,000 cough 3,000 sneeze 40,000
2 4 – 4 8 hr. or hard, non porous surfaces 8 – 1 2 hr. on cloth, paper, tissue 5 m in. or hand in w ater 2 2 º c → 4 days, 0 º c → 3 0 days at 6 0 º c for 3 0 m ins inactivated by 7 0 % alcohol and by Chlorine
W HO. I nterim I nfection Control Guidelines for Healthcare Facilities for HPAI : http:/ / w w w .W PRO.W HO.int/ avian/ docs/ I C_ Guidelines_ for _ HPAI .pdf
Survival of influenza in the inanim ate environm ent and on skin
1 % Na Hypochlorite 7 0 % Alcohol for sm ooth m etal surface, tables top
I nfection Control precautions for HPAI
( CDC, W HO, Thai MOPH)
Standard Precautions Transm ission Based Precautions
I C for Avian I nfluenza ( W HO Aprl 2 0 0 6 ) Standard and droplets should be m inim al
level of precautions to be used in all health-care facilities when providing care with acute febrile respiratory illness. Full barrier precautions, include standard, contact, and airborne precautionsshould be used in contact w ith suspected/ confirm ed AI cases, particularly during aerosol-generating procedure. For limited resource setting, AI care need minimal of standard, contact, and droplets
Universal Respiratory Etiquette Strategy for Healthcare Facility
Encourage patients to alert staff it they have respiratory illness Provide surgical mask or tissue to all patients with respiratory illness Separate patients with respiratory illness to other patients in waiting area. Use droplet precautions Provide hand hygiene materials in OPD
WHO
Personal Protective Equipm ent Definition: specialized clothing or equipm ent w orn by an em ployee for protection against infectious m aterials.
Gloves – protect hands Gow ns/ aprons – protect skin and/ or clothing Mouth covering m aterials– Masks – prevent fluid penetration Respirators – protect respiratory tract from airborne infectious agents Eye protection Goggles – protect eyes Face shields – protect face, mouth, nose, and eyes Boots – prevent spreading by tracking
1 . Gloves
as soon as they are torn or punctured after contact with one individual is complete and before care is provided to another ; and when performing separate procedures on the same patients and there is a risk of transmitting infection from one part of the body to another
Remove gloves that are torn, cut or punctured Do not wash, disinfect
Increase in Methicillin – Resistant Staphylococcus aureus Acquisition Rate and Change in Pathogen Pattern Associated With an Outbreak of Severe Acute Respiratory Syndrome
Yap F, et al. CID 2004; 39: 511-6 2 2 – bed I CU Upgrading of IC precaution
w earing of gloves and gow ns all the tim e!!!
Change in ATB prescribing practices Extensive use of steroids
Hand hygiene com pliance 100% - in isolation wards 78 – 95% - in general wards QMH
2 . Gow ns
exposed skin w ith:
Should be im pervious m aterial Gow ns should be w orn by patients during essential transport to other areas of the hospital Outside surface of the gow n should be considered as being potentially contam inated at all tim es during use Should not be reused from one patient to another patient. I f gow ns are in short supply and gow ns are to be reused clear protocols and procedures should be developed to m inim ize the risk of contam ination during reuse.
Apron
W ear the apron over the gow n Plastic reusable aprons protect the w earer skin and clothing/ uniform / scrub suite from contam ination from splashing w hen w orking in an isolation room / area Select w ater repellent, plastic aprons, preferably disposable or single use. I f disposable aprons are not available reusable plastic aprons w ill need to be cleaned and disinfected betw een use on the sam e patient and betw een uses on different patients
3 . Mouth covering m aterials
N95 Medical mask
Following the manufactures instructions for positioning the mask and undertaking a user "fit test" or "user seal check” N95 and standard surgical masks should only be used once and discarded If supply is short and N95 masks are to be reused clear protocols and procedures should be developed to minimize the risk of contamination during reuse and storage of the mask between reuse.
Eye protection
Mask and goggles or a face shield Use w hen patient care activities likely to generate splash or spray of: Blood Body fluids Secretions Excretions
Photo: CDC Greg Knobloch
Protective Eyew ear/ Goggles/ visors/ faceshields Protect the m ucous m em branes of the w earer against droplet transm ission and exposure in the event of a splash. Ordinary spectacles do not provide adequate protection and protective eyew ear/ goggles/ visor
spectacles Protective eyew ear/ goggles/ visor or a faceshield should be w orn at all tim es w hen in the isolation room / area.
contam ination by tracking
Sequence for Donning PPE w ith Avian I nfluenza Patients
1 . Hand hygiene 2 . Gow n 3 . Particulate respirator
4 . Hair cover ( for aerosol-generating procedures) 5 . Goggles or face shield 6 . Gloves
Select appropriate type and size Opening m ay be in back or front Secure at neck and w aist I f gow n is too sm all, use tw o gow ns Gown # 1 ties in front Gown # 2 ties in back
Place over nose, m outh and chin Fit flexible nose piece over nose bridge Secure on head w ith ties or elastic Adjust to fit
Select a fit tested respirator Place over nose, m outh and chin Fit flexible nose piece over nose bridge Secure on head w ith elastic Adjust to fit Perform a fit check – Inhale – respirator should collapse Exhale – check for leakage around face
Proper selection of size - m ask Fit test
size of mask
Fit check
Fit Checking
Position goggles over eyes and secure to the head using the ear pieces or headband Position face shield over face and secure on brow w ith headband Adjust to fit com fortably
1 2 Source: Manual on Avian Flu clinical management for HCWs, Committee on prevention and control for Avian Flu, Thai MOPH, Nov 2005.
4 3 Source: Manual on Avian Flu clinical management for HCWs, Committee on prevention and control for Avian Flu, Thai MOPH, Nov 2005.
5 6 Source: Manual on Avian Flu clinical management for HCWs, Committee on prevention and control for Avian Flu, Thai MOPH, Nov 2005.
Don gloves last Select correct type and size I nsert hands into gloves Extend gloves over isolation gow n cuffs
Keep gloved hands aw ay from face Avoid touching or adjusting other PPE Rem ove gloves if they becom e torn; perform hand hygiene before donning new gloves Lim it surfaces and item s touched
Sequence for Rem oving PPE w ith Avian I nfluenza Patients
contaminating environment 1 . Gloves 2 . Face shield or goggles 3 . Hair cover 4 . Gow n
5 . Mask or respirator 6 . Perform hand hygiene
Grasp ear or head pieces w ith ungloved hands Lift aw ay from face Place in designated receptacle for disinfecting or disposal
Unfasten ties Peel gow n aw ay from neck and shoulder Turn contam inated outside tow ard the inside Fold or roll into a bundle Discard
Grasp outside edge near w rist Peel aw ay from hand, turning glove inside-out Hold in opposite gloved hand
Slide ungloved finger under the w rist of the rem aining glove Peel off from inside, creating a bag for both gloves Discard
Untie the bottom , then top, tie Rem ove from face Discard
Lift the bottom elastic over your head first Then lift off the top elastic Discard
Determ ine Expected Exposures Contact w ith Infected individuals Individuals suspected to be infected Potentially contaminated substances Potentially contaminated surfaces/ items High-risk procedures Corpses Animals
Have supplies ready Use locally produced PPE, or order from elsew here Creative alternatives Mask: tissue, scarf Boots: plastic bags Gown: laboratory coat, scrubs
Adapted from: WHO. Avian Influenza, including Influenza A(H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities. 24 Apr 2006.
PPE and Avian I nfluenza < 1 m eter contact Acute febrile respiratory disease No risk factors for avian influenza Hand hygiene Gloves during cleaning procedures Gow n during cleaning procedures Surgical m ask w orn by health care w orker Eye protection m ay be w orn ( assess risk) Surgical m ask on patient w hen outside isolation room
PPE and Avian I nfluenza Entry to avian influenza isolation room / area No anticipated patient contact Hand hygiene Assess risk for Gloves Gown Eye protection (if patient contact within 1 meter possible) Particulate respirator w orn If not available, wear tight fitting surgical mask No surgical m ask on patient
PPE and Avian I nfluenza Avian influenza-infected patient < 1 m eter contact w ith patient Hand hygiene Gloves Gown
Particulate respirator Eye protection Surgical mask on patient when outside isolation room
PPE and Avian I nfluenza
Perform ance of aerosol-generating procedure on avian influenza-infected patient Hand hygiene Gloves Gow n and w aterproof apron if not fluid-resistant Hair cover is optional Particulate respirator If not available, wear tight fitting surgical mask and face shield Eye protection Negative air pressure room , side room s or other closed single-patient areas w ith m inim al staff present
PPE for postm ortem Should be done in negative pressure room Scrub suits Disposable , w aterproof, long-sleeved gow ns particulate respirator/ surgical m ask face shields/ goggles Autopsy gloves or tw o pairs of gloves Disposable cap Boots
PPE Recom m endations for Avian I nfluenza I nvestigations
I nvestigations in the Com m unity Considerations Level of suspicion Well-informed community members Community members with symptoms Close contact (< 1 meter)
PPE Recom m endations for Avian I nfluenza I nvestigations
I nvestigations on a Farm
PPE Coveralls or gown with apron Heavy duty gloves that can be disinfected Goggles and N-9 5 respiratory masks Heavy boots that can be disinfected, or foot covers that can be discarded Considerations Availability of PPE for farm workers
Heavy duty gloves Heavy boots Goggles and N-95
PPE for cullers
Basic Principles w hen using PPE
Avoid any contact with areas of the body that are not covered by PPE (i.e. hand face contact) when wearing PPE Avoid hand contamination of clothing under the PPE or skin when removing PPE. All PPE must be removed and disposed of appropriately before leaving or immediately on leaving the isolation room. Ensure your hands are washed or disinfected immediately after removing your PPE. Avoid any contact between those in the isolation room/ area wearing potentially contaminated PPE and people, equipment
Avoid where possible the reuse of PPE items as the risk of contamination to the user or the environment is increased with reuse of potentially contaminated PPE
General Recommendation Limited resource situation ( phase 4,5,6)
OPD
Separate OPD Triage
IPD
Single isolation ( neg. pressure room)
MASK
N95 ( or other eqivalent) Tightly fitting surgical masks N95 – for aerosol – producing procedures
Glove
Contact Reserved for – contact with blood/ body fluid, aerosol – producing procedures
Gown
Contact Reserved for aerosol – producing procedures, pediatric, extensive contact Face protection Contact, aerosol – producing procedures Contact, aerosol – producing procedures
Adapted from: WHO. Avian Influenza, including Influenza A(H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities. 24 Apr 2006.
Disposable PPE
( eg. Masks, gloves, hair cover, disposable gown)
Should be properly discarded as infectious waste Non – disposable PPE
( eg. Goggles, face shields, gown ( cloth), boots)
Should be cleaned and disinfected as infectious waste
Place directly into a specific w aste bag ( red – coloured) Contain in a m anner that prevent bursting during transport Laundry personnel should use standard precautions and perform hand hygiene Non - Disposable PPE should be w ash and dry according to routine facility ( separate laundry) Disposable PPE should be destroyed by incineration
Surveillance system s
: self reporting, m anagem ent, self-isolating
each tim e they start duty
w ith I LI and w ho have cared for AI -infected patient : HCW s w ith serologic evidence of AI A( H5 N1 ) infection
→ be prioritized for the care of AI A ( H5 N1 ) patients
Occupational Health Recom m endations
Adapted from: WHO. Avian Influenza, including Influenza A(H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities. 24 Apr 2006
WHO Interim Infection Control Guideline for Health Care Facilities. 24 Apr 2006
WHO Interim Infection Control Guideline for Health Care Facilities. 24 Apr 2006