Personal Protective Equipment Donning & Doffing

Transcription

1 The following questions were brought forward at SASWH s instructor level training held in November and December Responses have been provided by the Ministry of Health. Abbreviations used in this document are: PPE = personal protective equipment HCW = healthcare worker TO = trained observer 1. Why is the hood removed after the gown? The principle in PPE removal is that you go from the dirtiest to the cleanest. Initially it was considered to remove the boots first; however the HCW needs to bend over the potentially contaminated gown in order to do that. Therefore, the gown should be removed first with the inner set of gloves before going to the cleaner area of the head. It would be highly unlikely that the hood would ever be more contaminated than the gown or the boots. The current PPE model is based on what is used in the University of Nebraska Bio-containment unit which is one of the sites that cares for Ebola patients. If there was contamination on the hood when the HCW came out of the room, it should be noted by the TO and absorbed and/or wiped off with a disinfectant wipe or wipes. To address this concern the surgical hood protocol has been amended to allow for 2 options: Option 1: This option is still the HCW removal over the head. Option 2: This option is for those HCW who find the fit of the hood very tight or there is a concern about contamination. Trained Observer will use scissors to make a lateral cut to the hood up to facial opening - being very careful not to harm HCW s face. HCW will grasp the top of the hood, opposite to the side where the hood was cut and pulls the hood up and off the head. Place hood carefully in waste receptacle. In addition, the TO would need to cross off what was not done on the checklist and add the alternative action that was taken. For example, if the removal of the hood required the use of scissors, this would be documented. 2. The hood slides forward over face/eyes and won t stay in place. What is the solution? The hood is meant to cover a good portion of the face; the N95 Respirator holds it in place below the mask while the face shield should help anchor it on the top. You may need to stretch out the facial opening a bit without tearing it, then pull it up and back off of your face. If this does not work for the size of your face, perhaps your facility may have some of the Cardinal hoods which will fit any size face but will not cover as much of your face. Using the Cardinal hood would require putting on the hood before the gown and after the N95 mask as yoke of the Cardinal hood goes under the gown. 3. When donning, can the N95 go on after the gown? Following the exact order of the donning process is not as critical as the doffing process. The outcome of proper doffing is to limit/reduce the amount of exposed skin. PPE being donned is not considered contaminated; there still is time for correction and checking before the HCW would enter a client room. With the Kimberly Clarke hood, the N95 respirator could go on after the gown because it does not impact the fit of the hood. However, for consistency in education and application of PPE, the steps are being maintained in a relatively similar manner in the event the Cardinal hoods are used. With the Cardinal hood, the N95 must go on first followed the hood and gown. as at December 23, 2014 Page 1 of 6

2 4. Why do we need to follow the doffing checklist? The order of doffing high risk PPE is very critical because the HCW is considered to be contaminated. Even if there are no obvious signs of contamination, under the direction of the TO the HCW will slowly and methodically follow each step of the checklist to reduce any chance of self or environmental contamination. 5. Grabbing boots from the inside (top) and rolling down can boots be grabbed from the outside? The principle followed with PPE removal is that we are in contact with the inside of the PPE (or least contaminated) rather than the outside which could potentially be contaminated. Roll boot covers from the inside out and down, using your gloves which should be clean enough to touch the inside of the boot. If there is a concern that the gloves became contaminated during the gown removal process, then the HCW should wipe down the gloves with the hospital grade disinfectant or remove gloves, perform hand hygiene and put on new gloves then remove boots. 6. Video: is anyone considering creating a video for the low and/or high risk Ebola PPE? At this time there are no plans to make a video of the low or high risk Ebola PPE training. Practice, demonstration and return demonstration are the key elements required in understanding the complicated process of donning and doffing PPE in a safe and appropriate manner. Even with practice the steps, in a high risk Ebola situation requires the assistance and step by step guidance of a Trained Observer. 7. Participants felt that gloves under the cuff of the gown is not the best practice. When practicing doffing and using 2 fingers under the cuff of the gown, there is a concern that you may contaminate your gloves from the gown. When reaching under the gloves you may come in contact with the skin of your arm. The 2 glove method, with one under the gown and the other over, are based on the protocols and PPE recommended for cases of suspected Viral Hemorrhagic including Ebola Virus Disease. All of the steps in the Saskatchewan protocol are based on current national and international Infection Control guidance documents (Centre for Disease Control, World Health Organization, Public Health Agency of Canada, Public Health England). Although the PPE may be familiar, the steps are more complicated to ensure a higher level of protection. Before removing the gown, a disinfectant wipe is used to clean any contamination that might have occurred to the inner gloves. This is an important step. With the glove you would just pinch or grasp the cuff enough to pull the gown over the glove. The glove should only be near the edge and not be in contact with your skin. Also the cuff of the gown was covered by the outer glove layer, so contamination of the cuff should be minimal. 8. Some suggested a preference of wearing the apron UNDER the gown (if an apron is used) and that it was to never be removed over the head. This is OR practice. The apron is an extra layer of protection that can be used in a care situation where there are high levels of body fluids (vomiting, diarrhea, etc.). This extra layer of impervious material will reduce the risk of body fluids soaking through the gown, and the apron covers the front of the HCW where most of the contact with the client or the client s environment occurs. Again as stated above, national and international guidance best practice documents were used to develop this process. The doffing protocol and checklist is being updated with more information about removing the apron safely. The apron should never be removed over the head. Depending on the style of apron available in the health region, the neck straps should be cut or untied by the TO and then folded inward by the HCW so as to prevent contact with the contaminated front of the apron. as at December 23, 2014 Page 2 of 6

3 9. Are there written procedures for donning and doffing coveralls or are there going to be? If there are procedures, where can these be located? At this time there are no written procedures of donning and doffing body suits. The protocol would depend on the style of the body suit chosen. If EMS services make a coordinated decision to move to that type of protective apparel then a protocol and teaching tools would be developed. 10. As a trained observer, can I observe more than one healthcare worker at a time? In a real life care situation, the role of the TO is much more than ensuring the steps of donning and doffing are done correctly. The TO is meant to be a Team Leader or Coach who is responsible to monitor the HCW in the care environment. They must also proactively look for issues that may arise as well as to monitor care techniques or episodes of PPE failure and guide the HCW in corrective action or instruction. The TO must establish a one on one connection that will facilitate personal communication so as to keep the HCW calm and confident. If two HCWs were planning to be in the patient room at the same time, the best way is for the TO to review each HCW individually. 11. Do completed checklists for high risk Ebola need to be signed off? Do they need to be kept or would the log book be enough? Using a log to track all HCWs going into the room of the patient with suspected or confirmed Ebola Virus Disease is a requirement. Using the checklist to ensure all the steps in the donning and doffing process is recommended. Whether the checklist needs to be filled in and signed off is a decision that should made by (regional) leadership and training teams. Depending on the space allocation and standard work processes, the checklist may be used as either a guide or an actual checklist. The CDC recently released additional education modules that focus on the role of the TO and they are now describing the checklist as a memory tool, to be used as a guide and not a tick box. Use it to direct actions and sensitize yourself and your team members to risks and safe practices. Keeping in mind the CDC donning and doffing steps are similar but not the same as those in Saskatchewan, these modules can be viewed: How long do checklists need to be retained? How your health region/employer decides to use the checklist, will determine if they should be retained. The checklist is not meant to become part of the patient s chart as it has recording HCW safety and compliance with proper donning and doffing processes. Once the high risk care situation has ended, the checklists could be placed in biomedical waste and quarantined until the official diagnosis has been determined. 13. Can you add to the doffing procedures for high risk Ebola some steps for having the healthcare worker assist the trained observer in doffing their PPE? The gown isn t always easy to remove by yourself. The doffing procedure is to be used as a guide, not an absolute step but step. If the HCW is having problems putting on or adjusting PPE, the TO can assist as necessary and must ensure that the HCW s PPE is in place and intact, fits properly and allows for freedom of motion. as at December 23, 2014 Page 3 of 6

4 14. Can we use the healthcare worker donning and doffing procedures (the ones with pictures) as the trained observer s checklist and then add the signature, date and time information? If you feel that option will work better for your (regional) team, then please do so. These tools were developed to provide a consistent training method for Ebola preparedness that is consistent with the PPE that is available in our province. 15. Can you add the order for the trained observer to don and doff their PPE to the current checklists? Yes. We hope to have that tool available soon, but would most likely be a separate sheet. 16. Can you add information on using a bucket with a lid in the anteroom to the trained observer checklist? No, that would be a very specific regional or facility process which should be incorporated into your standard work tools. 17. Why does the trained observer need to wear PPE while the healthcare worker is donning their PPE when no one would be deemed contaminate at this time? In the situation where the HCW is donning PPE, nothing should be contaminated so the TO would not need to have on PPE. Real life may not be as clear cut, depending on how your donning and doffing areas are set up. The CDC modules referred to Question 6, have the TO in regular scrubs assisting the HCW with donning, in an area separate for the patient room, but also shows an example of the TO with PPE and a TO assistant. It will really depend on your physical resources and space. The purpose of having the TO wear their PPE for the training exercises is to become familiar with what PPE would if required if needed. It would be important to do a risk assessment in the context of your facility to determine if the TO needs to wear PPE for the donning. Please consider the risk inconsistency in PPE training for the TO, as it is better to be over protected that under protected. 18. The trained observer and the healthcare worker need to be consistent with either one or two sets of gloves. We need one complete document on this. We plan to release some documents that focus on the TO PPE. In response to some questions posed, SASWH incorporated the sequence (as per the CDC guidelines) for two sets of gloves for the trained observer. Depending upon the employer s decision to use either one or two pairs of gloves, the appropriate sequence would be followed. 19. The trained observer would be considered at low risk as they are not in direct contact with a client. For low risk procedures, the healthcare worker doesn t use shoe covers (booties). So why would the trained observer have shoe covers being low risk, and yet the healthcare worker in low risk doesn t need shoe covers? A low risk care assessment indicates the patient suspected of having Ebola has no imminent potential high risk symptoms or high risk procedures, therefore we would not be expecting blood and body fluids to be present on the patient or in the patient environment (therefore no shoe covers needed). as at December 23, 2014 Page 4 of 6

5 The HCW providing high risk or inpatient care to a patient suspected to have Ebola, may inadvertently contaminate the floor in the doffing area, so the TO wears shoe covers as an enhanced precaution to ensure that their shoes do not become contaminated. 20. Can wipes be used to clean off regular shoes? HCW providing work in a high risk care environment are to wear dedicated washable shoes meaning that they must be fluid resistant, closed toe and heels, plastic or rubber soles ( See donning PPE High Risk page 1) 21. Shoe covers are not impermeable is this true? If they are not impermeable, why are they used? The shoes covers and the knee high boot covers are not impermeable and not rated by the same process used for other types of PPE like isolation gowns and masks. The shoe covers are fluid resistant SMS material (Spunbound Meltblown Synthetic) used in the OR for protection against contaminated fluids. The boot cover is also rated as fluid resistant with a Polyethylene coating on the shoe portion and SMS material for the boot. They are being used to protect the HCW and TO shoes from being contaminated with blood or other body fluids. It is also expected that if blood or body fluids was on the floor of the patient room that it would be contained and managed expediently as all blood and body fluids should be so that staff are not walking into this area of contamination. 22. How long is a N95 mask good for once it becomes moist/wet from respiration/condensation? This is not my area of expertise and would depend on the type of mask and be very specific to the person wearing it he type of activity that the HCW is performing while wearing it. This may be a question that would be best asked of the manufacturer/distributor of the specific mask in question. 23. How long should our gloves or shoes be on contact with the wipes, to ensure we have disinfected properly? In order for cleaner/disinfectant to be effective, the wiping process must physically remove any contamination that may remain on the door, shoes, gloves or any other piece of equipment you want to disinfect. Once the contamination is removed, the disinfectant will continue to work as long as the surface remains wet. The contact time required for maximum effectiveness depends on the type of disinfectant product your region/employer is using for their Ebola management plan. The Ebola virus is an enveloped virus which is highly susceptible to all hospital grade disinfectants. To ensure a higher level of effectiveness, only disinfectants that kill both enveloped and non-enveloped viruses or a have a General Virucide Claim (disinfectant with registered claims for Poliovirus, Adenovirus, Parvovirus or Hepatitis A) should be used and would be considered effective against Ebola viruses. 24. If we are reusing the hoods, do we "clean" the hoods with wipes? If so, what kind? Can we use a hood, turn it inside out and use it for another staff member? It is not recommended that hoods are re-used during the training process. An option may be to obtain less expensive, alternative hoods such as surgeon hoods, and only for training purposes. Information on alternative hoods for training purposes has been shared with regional infection control practitioners. as at December 23, 2014 Page 5 of 6

6 25. I ve seen trainers and instructors read from their materials. Shouldn t they have the information memorized so that they don t need to use the checklist or the procedures with pictures? Trainers and instructors are encouraged to use the resources and to have the checklist in their hands as they go through the procedures. Some trainers and instructors might have the procedures or other information on a PowerPoint or even posted to a wall in the training room. The purpose of reading the materials and using the procedure sheets and checklists is to ensure each step is covered. It is not the expectation that any trainer or instructor know the material by heart or have it memorized. 26. If working with a solid wood door on the patients room, how would the TO communicate with the HCW? Would the TO enter but NOT assist with patient care, staying closer to the door as TO is supposed to constantly monitor the HCW to ensure no breaches in PPE. Choosing a room best suited to provide care that is safe for HCWs as well as the patient, is an important part of Ebola Contingency planning. If the room is less than ideal (i.e. a solid wood door) then more care needs to be taken in developing the work flow or standard of care to be performed. Ebola Viral Disease is not airborne like TB or Measles which require a closed door for Airborne Precautions. The closed door recommendation is important for several reasons, but needs to be looked in the context of care. During the time of Triage and Initial Clinical assessment, closing the door will help to isolate the patient suspected of having Ebola from other patients and HCWs, until it can be determined whether they do in fact meet the criteria. Once the patient is determined to be a real suspect case, they would be transferred ASAP to a designated facility where the room access should be more ideal. If it is determined that the patient s symptoms meet the high risk criteria, as long as no aerosol generating medical procedures (AGMPs) are being performed, the TO could stand in the doorway and observe but not go into the patient environment; the TO would be like a door to stop unprotected access or the patient from leaving). If there were some areas of the room that the TO could not see, then perhaps mirrors could be put in place. If an AGMP is required, then another HCW would need to be in the room and the door would need to be closed for the procedure as well as a post procedure time which would depend on what the Air Exchange Rate was or if the room was in Negative pressure. If you require additional clarity, please contact: Gwen Cerkowniak, RN BSN CIC Ministry of Health, Patient Safety Unit Provincial Infection Control Coordinator (Central) SCC 401 Acadia Drive Saskatoon, SK S7H 3V5 Phone ( 306) Fax (306) gwen.cerkowniak@saskatoonhealthregion.ca as at December 23, 2014 Page 6 of 6