Personal Protective Equipment

The Occupational Health and Safety Administration’s regulation on occupational exposure to bloodborne pathogens requires employers to identify employees and tasks that might put them at risk for exposure to blood and/or other body fluids, and to take appropriate measures to protect them 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 employer’s responsibility to provide appropriate PPE, ensure that it is used, and document and investigate any failure to comply. All employees should be trained in the appropriate protective attire to be worn for the tasks they perform and also in 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

The Emergency Care Research Institute’s 2022 List of Healthcare’s Top Ten Hazards include two that are specific to endoscopy: when poor duodenoscope processing ergonomics and workflow in endoscopy puts healthcare workers at risk; and when disposable gowns with insufficient barrier protection puts wearers at risk. Because of the potential for soaking 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 per ANSI/AAMI ST91:

• General-purpose utility gloves and a liquid-resistant covering with sleeves (for example, a backless gown or surgical gown). Processing personnel should use a glove style 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 Many companies offer longer length (18-inch) decontamination gloves. Exam gloves should not be used for decontamination. General-purpose utility gloves fitted at the wrist or above should be used. Note: The gloves should be designated as “decontamination gloves,” which are thicker and provide additional support from punctures.
• 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. Note: Masks with visors do not meet these criteria because a splash could occur from the top of the visor.
• 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 Shoe covers should be removed before leaving the scope-cleaning area in order to contain microorganisms and other contaminants (OSHA 29 CFR 1910.1030).
• Hearing protection. If noise levels exceed OSHA-permissible levels for the OSHA-designated time duration, hearing protection should be available (29 CFR 1910.95 g).

Reusable gloves, glove liners, aprons and eye-protection devices should be decontaminated according to the manufacturer’s written instructions for use (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).

Before leaving the cleaning area, employees should remove all protective attire, being careful not to contaminate the clothing beneath or their skin. Then they should perform appropriate hand hygiene. Designated areas with the necessary containers should be provided for donning and removing protective attire (ANSI/AAMI ST91). PPE should be located at the entrance to the decontamination area so staff and visitors can don it without walking through the area. In addition, PPE should be protected from contamination by keeping it in closed carts or bins.

A study by Kang, et al., discovered that healthcare personnel contaminated themselves in almost 80 percent of PPE simulations—an astonishing statistic. Therefore, endoscopy departments should establish competencies for donning and doffing PPE. Training and annual competency assessments should be documented in each employee’s record.

Donning (Applying) PPE

The CDC offers a poster with instructions for donning and doffing PPE. It does not include shoe covers, as the poster was developed during the Ebola outbreak; however, shoe covers were added in this listing below. When applying PPE, the recommended sequence is based largely on CDC guidelines.

1. Shoe covers should be donned Then wash your hands.
2. Gown should be donned
   • 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. Mask should be put on next; ensure it is properly adjusted to fit.
   • Some masks are fastened with ties, and others with else 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. Goggles or face shield should be donned next.
   • Position either the goggles or 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 feel snug but not tight. Note: Safety eyeglasses are not a substitute for goggles or a face shield.
5. Gloves are donned
   • Insert each hand into the appropriate glove and adjust as needed for comfort and 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. The areas that are 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. Shoe covers are considered to be the most contaminated pieces of PPE and are therefore removed first.
2. Gloves are removed 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. Goggles or face shield should be removed Because the outside of the goggles or face shield is considered contaminated, remove 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 designated waste receptacle.
4. Gown should be removed next. Unfasten the gown ties with the ungloved 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 toward 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 is next. 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 in a waste container.
6. Although not considered part of the PPE, the head cover should be removed last before leaving the decontamination area. Lift the head covering off the head by grasping it in the center and lifting it Discard in a waste container.
7. Thoroughly wash hands.

Personnel should remove PPE and head coverings when they leave the scope-cleaning room and then immediately wash their hands. A poster depicting the process of donning and doffing PPE can be obtained on the CDC website (www.cdc.gov) and placed in a prominent space in the endoscopy department. The type of PPE should be based on the potential for exposure. PPE samples should be obtained before purchasing or changing to another type of PPE to ensure it meets the requirements. However, the correct procedures for donning and doffing PPE are just as important and need to be addressed for staff safety.

For article references, visit www.EndoProMag.com.