Personal Protective Equipment

PPE Types and UsesCopy Link!

Updated Date: December 19, 2020
Literature Review:
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Tool
: PPE Training Online Module

This section covers professional PPE for healthcare workers. Wearing Face Masks and Shields covers public use.

Standard recommended PPE for care of suspected, probable, and confirmed COVID-19 patients or infectious material includes gown, gloves, eye protection, and N95 respirator or medical mask. Adapted from WHO.

Item

Description

Performance Standards

Gown

  • Single-use, long sleeve, ties in back, length to middle of lower leg
  • Reusable gowns should meet performance standards before and after laundering, up to the maximum suggested number of laundry cycles
  • Some areas including the operating room and labor and delivery may require higher levels of fluid resistance.
  • EU PPE Regulation 2016/425 and EU MDD Directive 93/42/EEC
  • FDA Class I or II medical device, or equivalent
  • EN 13795 any performance level, or
  • AAMI PB70 all levels acceptable, or equivalent

Particulate Respirator

(Type N95 or greater)

Mask that covers the nose and mouth and filters particles (minimum 94-95%) without collapsing against the mouth. Some are tested for fluid resistance

  • Minimum "N95" respirator according to FDA Class II, under 21 CFR 878.4040, and CDC NIOSH
  • Minimum "FFP2 according to EN 149, EU PPE
  • Regulation 2016/425 Category III, or equivalent

Medical/Surgical Mask

Mask that covers the nose and mouth and filters minimum 98% of droplets

  • EU MDD Directive 93/42/EEC Category III or equivalent
  • EN 14683 Type II, IR, IIIR
  • ASTM F2100 minimum level 1 or equivalent

Eye Protection

(Face Shield or Goggles)

Face Shield: Made of clear plastic and completely covering the sides and length of the face. Fits snugly against the forehead with an adjustable band to tighten around the head. May be re-usable (when disinfected) or disposable

Face Shield :

  • EU PPE Regulation 2016/425
  • EN 166
  • ANSI/ISEA Z87.1

Goggles: Made of clear plastic and encloses eyes and surrounding areas; should have good seal with the skin of the face. Flexible PVC frame fits all face contours. Some have adjustable bands to secure goggles to the face. Indirect venting avoids fogging. May be re-usable (when disinfected) or disposable

Goggles :

  • EU PPE Regulation 2016/425
  • EN 166
  • ANSI/ISEA Z87.1 or equivalent

Gloves, Non-sterile/ Examination

Nitrile, powder and latex-free free single-use gloves. Ideally should have longer cuffs, reaching above the wrist so there is no gap between a gown and glove. Sizes: small, medium, large

  • EU MDD Directive 93/42/EEC Category III
  • EU PPE Regulation 2016/425 Category III
  • EN 455
  • EN 374
  • ANSI/ISEA 105,
  • ASTM D6319 or equivalent

Other Particulate Respirators

KF94 masks are similar in appearance to N95s and are able to filter 94% of particles according to standards of the South Korean government. A limited 2020 study demonstrated that KF94s provide protection from particles produced by coughing patients similar to the protection provided by N95s (Kim et. al.). KF94s have not been approved for healthcare worker use in the United States.

Powered Air Purifying Respirators (PAPRs)

PAPR are battery-powered respiratory protection devices that provide a higher filtration factor than N95s and other non-powered respirators. Air is blown through filter cartridges and into a breathing zone created by a tight or loose-fitting facepiece, hood, or helmet. User-friendly guidance on PAPR is available at this CDC site. International certification and regulatory standards for PAPR in healthcare settings are in slow development because PAPR are primarily certified for industrial applications (Licina et al). To be used in United States healthcare settings, PAPR must meet National Institute for Occupational Safety and Health (NIOSH) requirements. Lists of NIOSH approved PAPR are available here.

PAPR are among the most expensive forms of respiratory protection because of their battery components.There are no clinical trials available to evaluate the protective efficacy of PAPR in comparison to other forms of respiratory protection in healthcare settings, but reasonable application of the precautionary principle in consideration of their superior filtration capacities makes them attractive devices for protection against aerosols (Licina et al).

In some settings, available PAPR are reserved for healthcare workers who have failed fit seal tests or are otherwise unable to wear fitted respirators. Use of PAPR in operating rooms and other areas with sterile fields is controversial because air is not filtered upon exiting PAPR breathing zones. However, statistical differences between surgical masks and PAPR in protecting sterile fields has not been noted (Howard et al).

Seal (Fit) TestingCopy Link!

All N95 masks rely on a close seal to the face to ensure that all air is filtered through the mask. Ideally, qualitative fit testing should be performed to ensure a correct fit for each individual; this should be done annually for each type of N95. In addition, each time an N95 is used, the provider should perform a seal check, then adjust the position of the mask on their face if there is not a good seal.

Tool: Video Describing How to Perform a Seal Check

PPE During Clinical CareCopy Link!

Updated Date: September 24, 2020

PPE Recommended During Direct Care Delivery

Gown

Gloves

Particulate respirator or PAPR

Medical/ surgical mask

Eye protection (goggles or face shield)

Comments

Droplet Precautions

X

X

X

X

Airborne Precautions

X

X

X

X

Aerosol generating procedures; COVID positive or suspected

X

X

X

X

Some settings recommend apron in addition to gown

General patient care, not COVID positive or suspected

X

X

+/-

Some institutions with high rates of community spread recommend eye protection for all clinical encounters

Aerosol generating procedures; not COVID positive or suspected

X*

X

X*

X

*When high rates of community spread are present and supplies allow, consider gown and particulate respirator use for all aerosol generating procedures

Staff Supporting Care Delivery

Administrative staff

Administrative staff should wear masks at all times; some institutions recommend eye protection for any patient interaction; plexiglass barriers can be used as an alternative

Cleaning staff

When entering a clinical area, PPE should match the PPE needed for clinical care delivery above. In addition, some cleaning supplies may require higher levels of protection from splashes or heavier gloves. When in non-patient care areas, mask is recommended

Transporters

When entering a patient care area or directly interacting with a patient, PPE should match the PPE needed for clinical care delivery above.

PPE During TestingCopy Link!

Updated Date: September 24, 2020

Recommended Personal Protective Equipment (PPE) Euring COVID-19 Testing

Test type

Sample

PPE

Antigen (Ag) RDT

Nasopharyngeal Swab or Deep sputum

N95, Gloves, Gowns, Face Shield

RT-PCR

Nasopharyngeal Swab or Deep Sputum

N95, Gloves, Gowns, Face Shield

Antibody (IgM/IgG) RDT

Whole Blood, Serum, Plasma

Masks, Gloves, Gowns. If Concern for Active (not past) Infection, Follow Local guidance for suspected COVID cases

Donning and DoffingCopy Link!

Updated Date: December 19, 2020

Putting on (donning) and taking off (doffing) PPE correctly is very important. Contamination of mucous membranes while removing PPE can expose the wearer to the virus.

Order of Donning

Order of Doffing

1. Perform hand hygiene*

2. Don gown

3. Don mask

4. Don eye protection

5. Don gloves, ensuring wrists covered

1. Remove gloves

2. Perform hand hygiene

3. Remove gown

4. Perform hand hygiene

5. Remove eye protection

6. Perform hand hygiene

7. Leave the treatment area

8. Remove mask

9. Perform hand hygiene

10. Wash hands with soap and water

*When using alcohol-based hand sanitizer, allow to dry before continuing.

Tool: WHO Infographic for Donning/Doffing PPE
Tool:
Donning Technique Video
Tool:
Doffing Technique Video
Tool
: PPE Training Online Module by Lifebox

DecontaminationCopy Link!

Updated Date: December 19, 2020

  1. Disinfecting Reusable PPE and Equipment:
  1. For most reusable items (for example, thermometers): 70% ethyl alcohol
  2. Reusable face shields can be soaked in sodium hypochlorite 0.5% for 1 hour and left in a clean, open space to dry for at least 1 hour.
  1. Decontaminating N95 Masks: Facilities may consider decontaminating N95 masks when they are in short supply. Different techniques have different levels of efficacy, and some techniques are not effective. Vaporized hydrogen peroxide, UV-C chambers and humid heat are methods that have been implemented by health care facilities. N95decon.org has an Overview of decontamination methods and In-depth Guidance on multiple methods of decontamination. Note that Alcohol and sodium hypochlorite should not be used on N95 masks as they degrade filtration efficacy.
  2. Disinfecting Surfaces: See Disinfection and Cleaning.
  3. Washing Fabric: if reusable gowns are used, they should be machine washed with warm water at 60-90° C and laundry detergent. Laundry can then be dried according to routine procedures.
  1. If machine washing is not possible:
  1. Soak linens in hot water and detergent or soap in a large drum. Use a stick to stir and avoid splashing.
  2. Empty dum and soak linens in 0.05% chlorine for approximately 30 minutes.
  3. Rinse with clean water and allow linens to dry fully in sunlight.

Conservation of PPECopy Link!

Updated Date: December 20, 2020

It is critical to conserve PPE where possible as stock remains limited globally. Local stocks and availability may vary greatly, and individual institutions or local governments may have detailed guidance for the use of PPE that differs from what is presented here. These are some general strategies that can be used to try to conserve PPE while still maximizing patient and healthcare worker safety (adapted from WHO, United States Centers for Disease Control (CDC). To ensure that global PPE shortages do not negatively impact care of any kind of patient (including TB patients and surgical patients), it is important to conserve the use of PPE in all clinical areas.

Tool: PPE Consumption Tool

Institutional PoliciesCopy Link!

  1. Decrease length of hospital stay for patients, if safe to do so
  2. Limit total personnel and visitors in treatment areas
  3. Temporarily suspend routine fit testing for N95s for employees with no COVID contact
  4. Use N95 respirators beyond the manufacturer’s shelf life for training/testing
  5. During known shortages:
  1. Develop policies for extended use of N95 respirators:
  1. Extended use refers to wearing the same respirator for repeated close contact encounters with different patients without removing the respirator between patients. CDC guidelines for extended use can be found here.
  1. Limited Reuse of N95s:
  1. Reuse refers to use of the same respirator by the same health care worker for multiple encounters and doffing it between encounters. Contact transmission may be possible with reuse. Reuse of N95s for care of tuberculosis patients is preferred over reuse of N95s for care of COVID patients because tuberculosis is not transmissible through contact.
  1. When N95 supply is limited, prioritize the use of N95s for high-risk activities, such as aerosol generating procedures.
  1. Do not stop striving to optimize PPE. Institutions remain responsible for safety even while engaging in pragmatic strategies to adapt to crises.

Care Provider ChoicesCopy Link!

  1. Minimize the number of unnecessary aerosol generating procedures. Examples:
  1. Use metered-dose inhalers (MDIs) instead of nebulizers
  2. Do not use humidification with venturi masks
  1. Plan patient care to minimize PPE use. Examples:
  1. Cluster interventions: e.g. take vital signs and give medications at the same time
  2. Time medication administrations so that interventions can be clustered (medications due at the same time)
  3. Choose medications with daily dosing or oral dosing instead of frequent IV dosing
  4. Where possible, use long-acting or scheduled protocols in lieu of protocols requiring frequent assessments and administrations for things like alcohol withdrawal and diabetic ketoacidosis
  1. Arrange patient care areas, equipment, and daily staffing assignments so that caregivers do not need to don and doff PPE as frequently. Examples:
  1. Monitors, IV pumps outside of doors
  2. Where appropriate and possible, use technology (such as phones) to communicate with patients and consultants and minimize caregiver exposure

Equivalents and AlternativesCopy Link!

  1. Due to global PPE shortages, using substitutes for N95 masks may be necessary.
  2. The CDC and the National Institute for Occupational Safety and Health provide extensive guidance on selection and use of N95 equivalents, including an updated list of approved respirators as well as counterfeit respirators.

When Recommended PPE is Not AvailableCopy Link!

Updated Date: December 19, 2020

In addition to taking all possible steps to expand PPE supply and return to normal operations, crisis strategies when recommended PPE is not available are listed below. It should be noted that none of these strategies are sufficient to protect health care workers, and these should be strategies of last resort. In addition, consider excluding healthcare workers at increased risk for SARS-COV complications from patient contact.

  1. Maintain a minimum 1 meter distance whenever possible to avoid inhalation of droplets
  2. If gloves are not available, continue vigorous hand hygiene. Wash hands frequently for more than 20 seconds each time. Avoid touching face, mucus membranes, and surfaces.
  3. When face shields or goggles are not available, use alternate eye coverings, such as glasses, to cover the eyes. If performing an aerosolizing procedure that would normally require an N95, consider:
  1. A double medical mask
  2. Remaining out of direct alignment with the patient’s nose and mouth
  3. Use ventilation and portable HEPA filtration where possible to reduce ambient virus
  4. Consider ventilated headboards for some AGPs if available

InnovationCopy Link!

While official PPE products are preferable, in instances of shortages some people may be able to create PPE alternatives by repurposing existing medical or household supplies, using 3D printers, or using innovative methods for extending the use of existing supplies. Though some have emergency use authorizations or preliminary testing data, very few of these have been officially tested and the level of protection they afford is unknown.

Tool: Frames to Enable Reuse and Improved fit of Respirators

Tool: Snorkel/Scuba Mask Face Shields with Anesthesia Filters

Tool: Elastomeric Mask Adaptations (Source 1 and Source 2)