PPE Policy: Appendix I Clinical PPE Selection Certification

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1 PURPOSE The following list of procedures is meant to be the basis for a department/patient care units orientation concerning the use of personal protective equipment. However, it is not meant to be all inclusive for every department/patient care unit and must be supplemented for those special procedures carried out in that department/unit. This list is intended to cover personal protective equipment only and does not exclude the wearing of further barriers for protection of the patient. This document is designed to comply with OSHA 29 CFR Personal Protective Equipment Standard, and The Joint Commission EC STEPS TO COMPLETION 1. Manager: Customize the form as applicable by checking the appropriate procedures. 2. Manager: Review the entire list of procedures and the required PPE with your staff. 3. Manager: Review the procedures that apply to your unit and required PPE with your staff. 4. Once the review is completed, the manager must sign the Manager Signature page. The supervisor is required to sign the page and place it in his/her employee file. 5. Each employee must sign the Employee Signature page including the manager s signature. 6. Store each Employee Signature form in his/her employee file. 7. Place a master copy at a central location (ex. disaster manual) where the form is readily available as a reference to all staff at all hours. If a procedure requires an eye wash and/or shower present and you do not have one in the immediate area, contact OSHP at for an installation assessment. PPE DEFINITIONS Clinical Area / Unit Please consult with your nurse manager/supervisor for specific procedures and the appropriate PPE selection. Click here to access the document online! Revised, Rollout Page 1 of 8

2 Check if Applicable Procedure Gloves Gown Face Protection Special PPE Eye Wash Station / Shower Required 1. Performance of intravascular procedures including venipunctures, arterial and capillary sticks, flushing, and manipulation of intravenous catheters in order to obtain blood. 2. Flushing intravenous line when meeting any resistance. 3. Placement of arterial line and/or manipulation of any line under pressure. 4. Assisting with or performance of procedures in which a sharp instrument is used to manipulate tissue, including, but not limited to the following: Debridement Removal of eschar Incision and Drainage Suturing Lacerations Small without bleeding Large with possibility of bleeding 5. Assisting with or performing insertion of devices or catheters into a body cavity in which potentially infectious body fluids are encountered (e.g. central venous lines, paracentesis, sigmoidoscopy, bronchoscopy, NG tube insertion, etc.) Exception: Indwelling urinary catheters. 6. Performing or assisting in procedures in which tissue is irrigated: If shielded device is used If small irrigation If large area or irrigation or irrigation is under pressure Revised, Rollout Page 2 of 8

3 Check if Applicable Procedure Gloves Gown Face Protection Special PPE Eye Wash Station / Shower Required 7. Personnel at field in the operating suites, delivery rooms, or special procedure rooms. Note: Impervious boots and leggings if massive amounts of body fluids are anticipated. 8. Performing vaginal or rectal exams Note: Glove cuffs must cover hands, wrist, and forearm that may touch lining of vaginal cavity. 9. Handling newborns before or during first bath. 10. Intubation and extubation of patients 11. Performing oral suctioning or administering mouth care 12. Performing open tracheal, endotracheal, or nasotracheal suctioning. 13. Manipulation of tracheotomy or therapy performed on patient with tracheotomy in which provider is in direct line of tracheotomy 14. Manipulating containers that contain body fluids Small volumes that do not produce splashing (e.g. urinary drainage bags, emesis basins) Large volumes that may produce splashing 15. Dressing changes: Use of PPE varies according to size of wound, amount of drainage, type of dressing used, cleaning procedure used and cooperation of the patient. Ranges from use of gloves only to gloves, gown, and full face protection. Revised, Rollout Page 3 of 8

4 Check if Applicable Procedure Gloves Gown Face Protection Special PPE Eye Wash Station / Shower Required 16. Assisting with treatment of trauma or other patient in which blood is freely present in the work area. Note: May require impervious boots and leggings also. 17. Collecting, preparing, and testing specimens. (All specimens are to be brought out of room and transported in leakproof containers with biohazard label provided in all areas.) (unless further PPE needed with above procedures) 18. Cleaning contaminated equipment: Wiping small equipment with disinfectant Wiping large equipment with disinfectant If brushes or pressurized liquid used in process 19. Handling of all dirty laundry and contaminated waste Note: May need to add a gown if possibility of touching clothing. 20. Bathing, toileting, feeding when mucous membrane, non-intact skin, and/or obvious soiling with body fluids is encountered. 21. Administration of enema or vaginal douche; Colostomy/Ileostomy care 22. Administering blood or blood products 23. Any other procedure or assistance with any other procedure where the potential for splashing of blood or other body fluids exists. 24. Working with, mixing Glutaraldehyde and Formaldehyde Revised, Rollout Page 4 of 8

5 PPE Policy: Appendix I Check if Applicable Procedure 25. Handling, disposing, transporting, and transferring of hazardous chemicals Refer to the Safety Data Sheet for chemicals requiring additional PPE 26. Handling hazardous pharmaceuticals as defined in the C-088A Handling of Chemotherapy and Other Cytotoxic Drugs Gloves Gown Face Protection Special PPE Eye Wash Station / Shower Required Procedures not listed above that require PPE should be noted below with a description and check mark. Please provide additional explanation, as needed, in the Optional Notes: Explanations and Considerations for PPE Selection section. Revised March 2014, Rollout March 2014 Page 5 of 8

6 Optional Notes: Explanations and Considerations for PPE Selection Revised, Rollout Page 6 of 8

7 MANAGER SIGNATURE By signing below I understand that the required personal protective equipment is to be worn during the applicable procedures. I know how to use PPE and how to access a Safety Data Sheet. I acknowledge I have reviewed this document with the employees of this unit. Manager Name (Print Legibly) Date Manager Signature Clinical Unit/Area The review and revision of this form was a collaboration of clinical and safety leaders within the Medical University Hospital Authority. The form has been adapted from Infection Control and Prevention by. DO NOT remove or discard any PPE forms of previous years from employee files. Revised, Rollout Page 7 of 8

8 EMPLOEE SIGNATURE By signing below I understand that the required personal protective equipment is to be worn during the applicable procedures. I know how use PPE and how to access a Safety Data Sheet. Employee Name (Print Legibly) Date Employee Signature Clinical Unit/Area The review and revision of this form was a collaboration of clinical and safety leaders within the Medical University Hospital Authority. The form has been adapted from Infection Control and Prevention by. DO NOT remove or discard any PPE forms of previous years from employee files. Revised, Rollout Page 8 of 8