Download Policy for Personal Protective Equipment for use

Policy for Personal Protective Equipment for use in
Healthcare. Infection Prevention and Control.
This policy identifies the appropriate personal protective
equipment for staff to use at the required times and for the defined
care delivery procedures and processes. This document forms
part of the mandatory requirements as identified within the Health
and Social Care Act 2008.
Key Words:
Infection Prevention and Control
Personal Protective Equipment
Version:
Adopted by:
4
Infection Prevention and Control
Committee
Date adopted:
January 2015
Main author
Antonia Garfoot
Name of responsible committee Infection Control Committee
Quality Assurance Committee
Date issued
January 2015
Review date
August 2017
Expiry date
January 2018
Target audience
All LPT staff
Type of policy:
(tick appropriate box)
Clinical
Non-clinical
√
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PPE policy
Contribution List
Key individuals involved in developing the document
Name
Amanda Hemsley
Antonia Garfoot
Una Willis
Fiona Drew
Mel Hutchings
Designation
Senior Nurse Advisor Infection Control
Senior Nurse Infection Control
Senior Nurse Infection Control
Infection Control Nurse
Infection Control Nurse
Circulated to the following individuals for consultation
Name
Infection Control
Committee
Equality Team
Adrian Childs
Di Postle
Dr Leverment
Emma Wallis
Claire Armitage
Michelle Churchard
Samantha Pearson
Louise Carpenter
Katie Willitts
Paul Williams
Fran Guerra
Kathy Feltham
Neil Hemstock
Janet McNally
Sarah Clements
Linda Bull
Sarah Latham
Bernadette Keaveney
Dr. Philip Monk
Designation
Leicestershire Partnership Trust
Integrated Equality Service
Directorr of Infection Prevention & Control / Chief Nurse
Trust Lead for Professional Standards
Occupational Health Physician
Lead Nurse CHS
Lead Nurse AMHS
Senior Advisor LDS
Service Manager AMHS
In-patient Lead AMHS
Nurse Specialist FYPC
Team Manager Eating Disorders
Senior Matron
Lead Nurse MHSOP
Lead Nurse FYPC
Team Manager
Matron Loughborough & Hinckley
Matron Coalville Community Hospital
Matron Evington Centre
Health Safety and Security Manager
Consultant Communicable Disease Public Health England
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Contents
Version control and summary changes
4
Definitions that apply to this policy
5
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Summary
Introduction
Purpose
Justification for the document
Personal and Protective Equipment for use in Healthcare
Training
References and associated documents
6
6
7
7
7
10
11-12
Appendix 1: Guidelines for the use and disposal of Personal and
Protective Equipment
13
Appendix 2: National colour coding poster
14
Appendix 3. Process for Donning and Doffing (removal) of PP 15-17
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PPE policy
Version Control and Summary of Changes
Version
Date
Version 1
March 2008
Version 2
Version 3
September
2010
August 2011
Version 4
August 2014
Comments
(description change and amendments)
Infection control policy for the use of Personal
Protective Equipment.
Guideline review and amendments
Harmonised in line with LPT LVCRCHS LCCHS
(Historical organisations)
Review of policy
For further information contact: Infection Prevention and Control Team
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PPE policy
Definitions that apply to this policy
Blood borne
A blood-borne disease is one that can be spread by
contamination by blood.
Due Regard
Having due regard for advancing equality involves:
• Removing or minimising disadvantages suffered by
people due to their protected characteristics.
• Taking steps to meet the needs of people from protected
groups where these are different from the needs of other
people.
• Encouraging people from protected groups to participate
in public life or in other activities where their participation
is disproportionately low.
HCW
Health Care Worker
Infection
This is an organism present at a site and causes an
inflammatory response or where the organism is present in
a normally sterile site.
Infectious
Caused by a pathogenic microorganism or agent that has
the capability of causing infection
Inoculation
Inoculation is the placement of something that will grow or
reproduce, and is most commonly used in respect of the
introduction of a serum, vaccine, or antigenic substance into
the body of a human or animal, especially to produce or
boost immunity to a specific disease
Organisms
This is defined as any living thing, in medical terms we refer
to bacteria and viruses as organisms.
Pathogen
An agent that causes disease, especially a living
microorganism such as a bacterium, virus, or fungus
Personal Protective
Equipment (PPE)
Specialised clothing or equipment worn by employees for
protection against health and safety hazards
Single-use Device
(SUD)
A SUD is a device that is intended for one use or on an
individual patient during a single procedure, or episode of
care
Standard
Precautions
Precautions designed preventing the transmission of bloodborne diseases such as human immunodeficiency virus,
hepatitis B, and other blood borne pathogens when first aid
or health care is provided. The precautions are designed to
reduce the risk of transmission of microorganisms from both
recognized and unrecognized sources of infection
LPT
Leicester Partnership Trust
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1.0 Summary of Policy
This policy has been developed to give clear guidance to staff in relation to the
procedure for the use of Personal Protective Equipment by Leicestershire
Partnership Trust (LPT) It describes the process for ensuring the delivery of
effective infection prevention and control education and training for all relevant
staff groups and is compliant with the NHSLA Standards and Care Quality
Commission registration
Further guidance for healthcare workers and other staff work in prisons and places of
detention can be found in Prevention of Infection & Communicable Disease Control
in Prisons & Places of Detention – A Manual for Healthcare Workers and other Staff.
2.0
Introduction
The principles of protection against blood and body substance are under pinned
by the Health and Safety at Work Act (1974). This is reinforced by the Control of
Substances Hazardous to Health (COSHH) Regulations (as amended 2002),
which require employers to assess the risks associated with the handling of
hazardous substances, including pathogenic micro- organisms and legislation
from the Health & Safety Executive (HSE) relating to personal protective
equipment (PPE) at work. The Personal Protective Equipment Regulations
(1992)
Everyone involved in providing care within the hospital and community setting
should be educated about standard precautions and trained in hand
decontamination, the use of personal protective equipment and the safe disposal
of sharps (NICE 2012).
The risk of acquiring blood-borne pathogens can be minimised by treating blood
and other body substances from all patients as potentially infectious and taking
precautions to minimise the risk of exposure of non-intact skin or mucous
membranes to blood and body substances. Selection of personal protective
equipment must be based on an assessment of the risk of transmission of
microorganisms to/from the patient, and the risk of contamination of the
healthcare practitioners' clothing and skin by patient's blood, body fluids,
secretions or excretions, (NICE 2012,CG).
The greatest risk of transmission of blood borne viruses is from inoculation
injuries, but it is also known to have occurred following splashing of blood onto
mucous membranes or damaged skin.
In addition to prevention of exposure to blood-borne pathogens it is recognised
that healthcare workers (HCWs) should be protected against other pathogens
carried in body fluids/solids. The use of personal protective equipment will
minimise the spread of infection if used in the management of all body
substances.
Healthcare workers have a professional responsibility to ensure that
personal protective equipment is worn appropriately. (Appendix 1)
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3.0
Purpose
The purpose of this policy is to provide staff employed by Leicestershire Partnership
Trust (LPT) with a clear and robust process for the use of Personal Protective
Equipment. This policy applies to all permanent employees including medical staff
who work for LPT including those on bank, agency or honouree contracts.
All health professionals should ensure they work within the scope of their
professional code of conduct.
4.0
Justification for Document
Risk management provides a solid foundation for clinical governance to improve and
assure the quality of clinical services for patients (DoH 1999). The use of personal
protective equipment to prevent exposure to blood and other body fluids is one
example of risk management relating to infection control (NICE 2003); equipment is
worn for the task intended /episode of care and then removed. Personal protective
equipment is not a substitute for safe systems of work but is complementary to them.
The general principles of personal protective equipment are:



5.0
Prevent HCW becoming a vehicle of transmission of pathogens
Prevent bodily substances coming into contact with non- intact skin and
mucous membranes
Prevent bodily substances coming into contact with intact skin
Personal Protective Equipment for use in Healthcare
The use of personal protective equipment aims to prevent the transmission of
blood- borne viruses and other pathogens.
After removal of any item of personal protective equipment, it must be disposed of
as clinical waste (in the health care setting). In patients' own homes where there is
no clinical waste collection and there is only a small amount of PPE then this can be
disposed of in household waste. It should be placed into a waste bag then placed
into the household waste bag (double bagged). Clinical waste bags must not be
disposed of in household waste bags. For larger amounts of PPE waste the
responsibility of its disposal sits with the practitioner who has produced it, it should
be disposed of at the designated waste collection point for that staff member.
Please refer to the LPT policy for the management of waste.
Hands must always be washed with liquid soap and water following removal of PPE.
If soap not available decontaminate with alcohol sanitiser at wash hands at the
earliest opportunity.
Employers must ensure that there are adequate stocks of personal protective
equipment readily available at all times.
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Gloves
The aim of wearing gloves is to:

protect hands from contamination by organic matter and
micro- organisms

protect hands from chemicals that may cause an
adverse reaction on the skin

reduce the risk of cross-infection by preventing the transfer
of organisms from staff to patients, patient to staff and
environment to staff. (NICE 2003)
Disposable, well fitting, good quality, single-use sterile or non-sterile powderfree, nitrile gloves should be worn for contact with body substances or items
contaminated by them, mucous membranes and non-intact skin.
Please refer to the LPT Glove Policy.
Gloves must be changed:



after contact with each patient
after different procedures for the same patient and
at the end of each activity.
If wearing gloves, then aprons must also be worn at the same time (NICE 2003).
Gloves must be removed by holding at the cuff and peeling the glove over the
hand, then fold the second glove off the hand over the first glove, enclosing the
first glove within the second glove and disposing of the gloves into the
designated bin for clinical waste (NICE 2012)
Hands should be decontaminated following the removal of gloves by hand washing
(As outlined in the Hand Hygiene Policy).
Gloves for clinical use are designated 'single use' and must never be re-used
(NICE 2012). Washing gloves not only reduces the barrier properties of the
glove but is also re-processing which is not permitted.
Disposable Plastic Aprons
Disposable plastic aprons are protective equipment and must be worn to protect
the wearer's clothing/uniform. The appropriate colour coded apron should be
worn. (Appendix 1)
Disposable plastic aprons are worn in the following circumstances.
 When there is a risk of contamination with blood or body fluids.
 For direct contact with a patient when providing personal or
clinical care.
 During invasive procedures and minor surgery.
 For cleaning activities.
 Whenever gloves are worn.
The apron should be put on at the beginning of the activity i.e. patient contact or
cleaning, and then removed at the end. Aprons should be single use for close
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patient contact (including contact with babies and children) surgery, or patient
treatment.
White coats must not be worn.
Following completion of the above procedures(s) the apron must be removed and
discarded into a clinical waste bin (NICE 2003). In patients own homes where there is
no clinical waste collection then dispose of in household waste. It should be placed
into a waste bag then placed into the household waste bag (double bagged). Clinical
waste bags must not be disposed of in household waste bags
One disposable plastic apron should not come into contact with more than
one patient
Micro-organisms will survive for a sufficient time to allow cross-infection to occur if
the apron is worn in caring for more than one patient.
Staff must not leave the clinical area or patient’s home wearing disposable plastic
aprons.
Masks
General surgical facemasks must be worn:
 During procedures likely to cause splashing of body substances
into the mouth or nose of the HCW.
 By staff during procedures when an aerosol from body fluids may
be created.
 By staff to protect the patient from potential shedding of
microorganisms from the HCW during minor surgery.
FFP3 Masks are not required for general nursing care but should be used in the
event of a pandemic influenza (as per protocol)
Masks must only be handled by their strings and should be handled as little as
possible. They must NOT be worn around the neck or be removed from the face
except when they are to be discarded. If the mask becomes contaminated with body
fluids then it must be changed immediately.
Masks must never be reused and should be changed between each patient, once
removed they must be disposed of into a clinical waste bin. In patients' own homes
where there is no clinical waste collection then waste must be bagged and returned
to the centre for disposal.
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Eye Protection / Face Visors
Goggles, visors or protective spectacles must be worn to protect the eyes from;

Aerosol or splash contamination from body substances/parts e.g. nails
surgery, bladder washouts.

Aerosol or splash contamination from chemicals
Eye protection must fit correctly and be comfortable to wear. It must allow for
uncompromised vision.
Some of these items may not be disposable. The appropriate method of
decontamination must be implemented before re-use (see manufacturer’s
instructions or LPT Cleaning and Decontamination Policy).
Prescription spectacles are inadequate protection unless fitted with side
protectors and therefore eye protection/face visors should be worn over the top
of spectacles.
Forearm Protection
Forearm protection should be available for use in areas that there is a risk of injury. It
should be used in conjunction with a detailed plan of care to minimise injuries from
scratches and bites. Forearm protection is intended for single use and should be
disposed of as clinical waste. Arm protection must remain fitted at the wrist, keeping
hands free to undertake hand hygiene.
6.0
Training
There is a need for training identified in this policy. In accordance with the
classification of training outlined in the Trust Human Resources and Organisational
Development Strategy this training has been identified as mandatory and role
development training.
The course directory e source link below will identify: Who the training applies to,
delivery method, the update frequency, learning outcomes and a list of available
dates to access the training.
http://www.leicspart.nhs.uk/Library/AcademyCourseDirectory.pdf
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7.0
References and associated documents
LPT policies via intranet. The website can be accessed at http://www.leicspart.nhs.uk/
Centres for Disease Control. Recommendations for the prevention of HIV
transmission in health care settings. MMWR 1987; 37: 24.
Centers for Disease Control and Precautions. Hospital Infection Control Advisory
Committee. Guideline for isolation precautions in hospitals. Infect ContrHosp
Epidemiology 1996; 17: 53-80.
Department of Health. Control of Substances Hazardous to Health (COSHH)
Department of Health. Immunisation against infectious disease. London:
HMSO,1992.
Health and Safety Executive (HSE) (1992) the Personal Protective Equipment
Regulation.
Hospital Infection Society. Acquired immune deficiency syndrome: recommendations
of a working party of the Hospital Infection Society. J Hosp Inf 1990; 15:7-34.
Infection Control Nurses Association 2003 Protective Clothing Guidelines.
Lynch P, Jackson MM, Cummings MJ, Stamm WE. Rethinking the role of isolation
practices in the prevention of nosocomial infections. Ann Int Med 1987;107:243-46.
Medical Devices Bulletin SN 9825 June 1998
National Institute for Clinical Excellence (NICE). Infection Control: Work Wear
Personal Protective Equipment Policy (2007)
National Institute for Clinical Excellence (NICE). Infection Prevention and Control of
healthcare – associated infections in Primary and Community Care (March 2012)
Olsen RJ, Lynch P, Coyle MB, Cummings J, Borete T, Stamm WE. Examination
gloves as barriers to hand contamination in clinical practice. J Am Med Ass 1993;
270 (3): 350-53.
Royal College of Nursing. Universal Precautions. London: RCN, 1993.
Saghafi L, Raselli P, Francillon C, Francioli P. Exposure to blood during various
procedures: results of two surveys before and after implementation of universal
precautions. Am J Inf Contr 1992; 20 (2): 53-57.
UK Health Departments. Guidance for clinical health workers: protection against
infection with HIV and hepatitis viruses. Recommendations of the Expert Advisory
Group on AIDS. London: HMSO, 1990.
Prevention of Infection & Communicable Disease Control in Prisons & Places of
Detention – A manual for Healthcare Workers and other Staff. August 2011. ©
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Health Protection Agency. HPA Gateway Reference: HPA11-02.DH Gateway
reference: 16314.
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Appendix 1
GUIDELINES FOR THE USE AND DISPOSAL OF PERSONAL PROTECTIVE EQUIPMENT
GENERAL PRINCIPLES: To prevent the transmission of blood-borne viruses and to prevent the transmission of other
Pathogens.
•
•

Gloves
Must be worn:
• When in contact with
body fluids and
substances
• Mucous membranes
Prevent HCW becoming a vehicle of transmission
Prevent body substance contact with non-intact skin and mucous membranes
Prevent body substance contact with
Disposable plastic aprons
• For direct contact with a
patient when providing personal
or clinical care
• For cleaning activities and bed
making
Aprons must be worn if wearing
gloves
Gloves must be changed after
contact with each patient and
at the end of each procedure
Surgical face Masks
• Procedures likely to cause
splashing of body substances into
the mouth and nose of the HCW
• Procedures when an aerosol
from body fluids may be created
• To protect the patient from
exposure to risk of infection from
HCW
Eye Protection (or
face visors)
• Aerosol or
splash
contamination of
body substances
• Aerosol or
splash
contamination from
chemicals
Arm protection
•Procedures likely to
cause probable
scratching / biting to
HCW
Single use items should not come
into contact with more than one
patient, and be disposed of after
use
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Personal Protective Equipment must be disposed of into a clinical waste bin
Appendix 2
National Patient Safety Agency
National colour coding scheme for
hospital cleaning materials and equipment
All NHS organisations should adopt the colour code below for cleaning materials. All cleaning
items, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves, should
be colour coded. This also includes those items used to clean catering departments.
Bathrooms, washrooms,
showers, toilets, basins
and bathroom floors
General areas including
wards, departments, offices
and basins in public areas
Yellow
Catering departments, ward
kitchen areas and patient food
service at ward level
Isolation areas
Appendix 3
Process for the donning and Doffing (removal) of PPE
The risk of acquiring blood-borne pathogens can be minimised by treating blood and other body
substances from all patients as potentially infectious and taking precautions to minimise the risk of
exposure of non-intact skin or mucous membranes blood and body substances . Personal
protective equipment (known as PPE) is specialised clothing or equipment worn by employees for
the protection against health and safety hazards. Selection of personal protective equipment must
be based on an assessment of the risk of transmission of microorganisms to/from the patient, and
the risk of contamination of the healthcare practitioner clothing and skin by patients’ blood, body
fluids, secretions or excretions.
Healthcare workers have a professional responsibility to ensure that person Protective
equipment is worn appropriately
Donning and D o f f i n g ( removal) of PPE
Putting on and removing Personal Protective Equipment
The level of PPE used will vary based on the procedures being carried out and not all
items of PPE will always be required. Standard Infection Control Precautions (SIPs)
apply at all times. The order given here for putting on PPE is practical but the order for
putting on is less critical than the order of removal.
Donning PPE
a) Gown (or apron [as shown] if not Aerosol
Generating Procedure [AGP])
•
Fully cover torso from neck to
knees, arms to end of wrists, and
wrap around the back
•
Fasten at back of neck and waist
In order to wear a FFP3 mask, you should have been FIT tested before to know that the mask works.
b) FFP3 respirator (or surgical mask if not Aerosol
Generating Procedure [AGP])
•
Secure ties or elastic bands at
middle of head and neck
•
Fix flexible band to nose bridge
•
Fit snug to face and below chin
Fit-check respirator
•
24 November 2014
Donning and removal of PPE
c) Goggles or face shield
(Aerosol Generating Procedure
[AGP] and as appropriate after
risk assessment)
•
Place over face and eyes adjust to fit
d) Disposable gloves
•
24 November 2014
Extend to cover wrist and gown if worn
Donning and removal of PPE
Doffing PPE
Removal (Doffing) of PPE
The order for removing PPE is important to reduce cross contamination so
the order outlined below always applies even if not all items of PPE have
been used:
a) Gloves
Assume the outside of the glove is contaminated
•
Grasp the outside of the glove
with the opposite gloved hand;
peel off
•
Hold the removed glove in gloved hand
Slide fingers of the ungloved hand under
the remaining glove at wrist
•
Peel second glove off over the first glove
•
Discard appropriately
a
b) Gown or apron
Assume the gown / apron front and
sleeves are contaminated:
•
•
Unfasten or break ties
Pull gown / apron away from the neck and shoulders, touching
the inside of gown only
•
Turn the gown inside out
•
Fold or roll into a bundle and discard appropriately
c) Goggles or face shield
Assume the outside of the goggles or face
shield is contaminated:
•
•
•
To remove, handle by head band or
ear pieces
Discard appropriately
d) Respirator or surgical mask
Assume the front of respirator / surgical
mask is contaminated:
•
•
Untie or break bottom ties, flowed by top ties or
elastic and remove by handling ties only
Discard disposable ones appropriately
24 November 2014
Donning and removal of PPE
Perform hand hygiene immediately after removing PPE. To minimise crosscontamination, the order outlined above should be applied even if not all items of PPE
have been used. Clean hands thoroughly immediately after removing PPE.
24 November 2014
Donning and removal of PPE