OSHA’s regulation on occupational exposure to bloodborne pathogens requires employers to identify tasks and positions that might put employees at risk for exposure to blood and/or other body fluids, and to take appropriate measures to protect those employees from exposure. The regulation includes requirements for appropriate personal protective equipment (PPE). The type of PPE might vary according to the tasks to be performed. According to OSHA, however, the PPE selected must “not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (29 CFR 1910.1030).
The use of PPE is not optional.
It is the responsibility of the employer to provide the appropriate PPE, ensure it is used, and document and investigate failure to comply. All employees should be trained in both the appropriate protective attire to be worn for the tasks they perform and the potential health and disciplinary consequences if they fail to do so. This training should be documented and routinely verified as part of departmental competencies.
Recommended PPE
Because of the potential for soaking of clothing, splashing, and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the scope cleaning area includes the following items (ANSI/AAMI ST91 2021):
- General-purpose utility gloves and a liquid-resistant covering with sleeves (for example, a backless gown or surgical gown). Processing personnel should use a style of glove that prevents contact with contaminated water. Gloves that are too short, do not fit tightly at the wrist, or lack cuffs might allow water to enter when the arms move up and down. Exam gloves should not be used for decontamination. General-purpose utility gloves fitted at the wrist or above should be used.
- A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit. When there is a possibility that attire can become soaked with blood or other potentially infectious material, as when items are being washed by hand, a Level 4 gown (as defined by ANSI/AAMI PB70) should be used.
- A fluid-resistant face mask and eye protection. PPE used to protect the eyes from splash could include goggles, full-length face shields, or other devices that prevent exposure to splash from all angles.
- Fluid-protective shoe covers with slip-proof bottoms. Shoe covers are recommended when there is the potential for shoes to become contaminated with blood or other body fluids. Shoe covers should be removed before leaving the scope cleaning area in order to contain microorganisms and other contaminants (OSHA 29 CFR 1910.1030).
Reusable gloves, glove liners, aprons and eye-protection devices should be decontaminated, according to the manufacturer’s written IFU, at least daily and between employees. If the integrity of an item has been compromised, it should be discarded. Personnel should remove torn gloves and thoroughly wash their hands before donning new gloves. They should remove PPE worn during processing and wash their hands. Before handling disinfected endoscopes, personnel should don clean PPE (ANSI/AAMI ST91).
The PPE should be located as close to the entry of the scope decontamination room (if a two-room design) or at the entry to the soiled area of the scope processing room (in a one-room design). It is important that staff or visitors (e.g., service personnel) do not have to walk through the decontamination or soiled areas to don PPE. In storage, PPE should be protected from contamination (e.g., on a covered cart, in covered tote bins).
PPE should always be used in the scope cleaning area and when handling contaminated items. Not only is PPE required (OSHA), but just as important is the need to know how to appropriately don (apply) or doff (remove) the PPE to ensure staff is protected and do not contaminate themselves or their clothing. In an observational study published in the American Journal of Infection Control, JaHyun Kang and associates discovered that healthcare personnel contaminated themselves in almost 80 percent of the PPE simulations. Eighty percent.
Before leaving the cleaning area, employees should remove all protective attire—being careful not to contaminate the clothing beneath or their skin—and wash their hands. Per ANSI/AAMI ST91, designated areas with the necessary containers should be provided for donning and removing protective attire.
Staff members are not always educated and trained in the proper sequence for donning and doffing PPE. This information should be documented in the employee’s orientation guide.
According to the Centers for Disease Control, the correct sequence for donning and doffing PPE is as follows. This recommended sequence is based largely on 2004 CDC guidelines; however, the document does not address shoe covers.
Donning (Applying) PPE
1) The shoe covers should be donned first. Then wash your hands.
2) The gown should be donned next.
To don a gown, first select the appropriate type for the task and the right size. The gown should open in the back. Secure the gown at the neck and waist.
3) The mask should be put on next and should be properly adjusted to fit.
Some masks are fastened with ties, and others with elastic. If the mask has ties, place the mask over your mouth, nose and chin. Fit the flexible nosepiece to the form of your nose bridge. Tie the upper set of ties at the back of your head and the lower set at the base of your neck.
4) The goggles or face shield should be donned next.
Position either the goggles of the face shield over your face and/or eyes and secure it to your head using the attached earpieces or headband. Adjust it to fit comfortably. Goggles should feels snug but not tight.
NOTE: Safety eyeglasses are NOT a substitute for goggles or a face shield.
5) Gloves are donned last.
Insert each hand into the appropriate glove and adjust as needed for comfort and dexterity. If you are wearing an isolation gown, tuck the gown cuffs securely under each glove to provide continuous barrier protection for your skin.
Doffing (Removing) PPE
To remove PPE safely, it is first necessary to identify which sites are considered “clean” and which are considered “contaminated.” In general, the shoe covers, the outside front and sleeves of the gown, and the outside front of the mask and goggles or face shield are considered contaminated, regardless of whether there is visible soil. The outside of the gloves is also contaminated. Areas considered clean are the parts that will be touched when removing PPE: the inside of the gloves; the inside and back of the gown, including the ties; and the ties, elastic or earpieces of the mask and goggles or face shield. The sequence for removing PPE is intended to limit opportunities for self-contamination.
1) The shoe covers are considered the most contaminated pieces of PPE and are therefore removed first.
2) The gloves are next.
With a gloved hand, grasp the opposite glove and peel the glove off.Hold the removed glove in the gloved hand. Carefully slide the fingers of the ungloved hand under the top of the remaining glove (at the wrist) and peel that glove off over the first glove removed. Discard the gloves.
3) The goggles or face shield
Because the outside of the goggles or face shield is considered contaminated, remove the goggles or face shield by grasping the earpieces or headband. Using ungloved hands, grasp the “clean” earpieces or headband and lift them away from your face. If the goggles or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the waste receptacle.
4) The gown
Unfasten the gown ties with the ungloved hands. Slip your hands underneath the gown at the neck and shoulder and peel away the gown from your shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull your hand into the sleeve, grasping the gown from the inside. Reach across and push the sleeve off the opposite arm. Fold the gown towards the inside and fold or roll it into a bundle. (Only the “clean” part of the gown should be visible.) Place the gown into a waste or linen container, as appropriate.
5) The mask
Do not touch the front of the mask to remove it. Untie the bottom tie and then, using the upper tie, lift off the mask. Discard it into a waste container.
6) Although not considered part of the PPE, the head cover should be removed last before you leave the decontamination area.
Lift the head covering off the head by grasping it in the center and lifting it upward. Discard in a waste container.
7) Thoroughly wash hands.
This procedure should be followed when personnel leave the scope cleaning room, and personnel should immediately wash their hands. Additional information on the removal of PPE can be found in Lisa Casanova’s PPE protocol published in the journal Emerging Infectious Diseases, which provides CDC’s recommendations. A poster depicting the process of donning and doffing PPE can be obtained on the CDC website (www.cdc.gov) and posted in your department.
PPE is required to protect staff members from an exposure to blood and/or body fluids. The type of PPE should be based on the potential for an exposure. Samples should be obtained before purchase or changing to another type of PPE to ensure it meets with the requirements. However, the correct procedures for donning and doffing PPE are just as important and need to be addressed for staff safety.
