9. THE PERSONAL PROTECTIVE EQUIPMENT (PPE)

All healthcare workers should be responsible for ensuring that they are equipped with the appropriate PPE before starting work duties in SARS designated areas. The PPE includes:

• N95 masks
• Gloves
• Disposable solid front gowns
• Eye protection (i.e. goggles)
• Shoe covers
• Hair cover or cap

The PPE reduces but does not completely eliminate the risk of transmission. PPE will only be effective if used properly and worn at all times whenever contact is possible.

Specifically, the following personnel ARE REQUIRED TO use and follow all recommendations on the proper use of PPE when working in the SARS-designated areas within their hospitals:

• All physicians, nurses and other health care workers who provide direct care to the SARS patients (keep to a minimum according to the patient’s condition)

• All support hospital staff including medical aides, cleaners, laundry personnel who will be working within the SARS-designated areas (keep to a minimum)

• All laboratory personnel who will be handling specimens from SARS patients and X-ray technicians who may be asked to get portable radiographs (keep to a minimum).

The sequence for putting on and removing the PPE is as follows:

PUTTING ON PPE: Do this in the changing room just before entering

the SARS designated-area.

1. Change from street clothes to hospital scrub suit.

2. Put on head cover.

3. Put on shoe covers. Tuck in the bottom of the pants into top ends of shoe cover.

4. Put on gown. Wear the gown properly by closing the back with the Velcro or tie-strings.

5. Put on the impermeable apron.

6. Put on gloves. Tuck sleeves of gown into the gloves.

7. Put on goggles and masks

REMOVING PPE: Do this in the changing room before leaving the SARS

designated area.

1. Wash gloved hands with >60% alcohol-based hand wash to remove soilage.

2. Remove shoe cover.

3. Remove apron and gown.

4. Dispose shoe cover, apron, and gown into the proper infectious/yellow biohazard trash bags.

5. Remove gloves and dispose into trash bins. Take care not to put hands on contaminated outside surface of gloves.

6. Wash ungloved hands with alcohol-based hand wash.

7. Remove goggles and put in a receptacle for cleaning before next use.

8. Remove mask and dispose into an infectious/yellow bag or store in plastic for reuse* (see discussion on Guidelines for N95 below)

9. Remove cap and dispose.

10. Wash hands with regular soap and water.

11. Preferably, take a full bath if with facilities.

12. Change to street clothes and wash hands before leaving SARS-designated area.

Do not leave the SARS-designated area and go to other areas in the hospital wearing the PPE. If the HCW has to leave temporarily the isolation areas, a full change of PPE must take place.

Guidelines for the N95 Mask

• Although the transmission of SARS appears to be predominantly by direct contact with large respiratory droplets, airborne transmission cannot be completely ruled out. This is the basis for the recommendation to use N95 masks in the care of patients with probable or suspect SARS.

• The N95 mask must be put on with clean hands.

• It is highly recommended that HCWs who would be required to use this equipment must have training to ensure that it is properly worn.

• There must be a proper seal between the sealing surface of the N95 mask and the wearer’s face. The mask must fit well over the mouth and nose area, the metallic bar adjusted over the bridge of the nose. Both elastic bands should be put behind the head to ensure a snug fit over the face.

• The mask must be worn during the entire time that the personnel is at the SARS area.

• Once the mask is worn in an area with suspect or probable SARS, the external surface of the mask must be considered to be potentially contaminated with infectious droplets. Do not touch the external surface of the mask. WHO recommends change of mask every 6-8 hours under the ideal setting.

• Because of the limited supply of the N95 mask in many areas, the CDC has given guidelines for possible re-use. Consider re-use only if the mask is not yet grossly soiled or physically damaged. Reuse may increase contamination therefore the practice of re-using N95 masks must be carefully weighed between the need of the HCW to have protective equipment and the increased risk of contamination.

• If N95 will be considered for re-use, the following precautions must be followed to decrease the risk of contamination:

The PPE reduces but does not completely eliminate the risk of transmission. PPE will only be effective if used properly and worn at all times whenever contact is possible.

Specifically, the following personnel ARE REQUIRED TO use and follow all recommendations on the proper use of PPE when working in the SARS-designated areas within their hospitals:

• All physicians, nurses and other health care workers who provide direct care to the SARS patients (keep to a minimum according to the patient’s condition)

• The N95 mask must be put on with clean hands.

• It is highly recommended that HCWs who would be required to use this equipment must have training to ensure that it is properly worn.

• There must be a proper seal between the sealing surface of the N95 mask and the wearer’s face. The mask must fit well over the mouth and nose area, the metallic bar adjusted over the bridge of the nose. Both elastic bands should be put behind the head to ensure a snug fit over the face.

• The mask must be worn during the entire time that the personnel is at the SARS area.

• Once the mask is worn in an area with suspect or probable SARS, the external surface of the mask must be considered to be potentially contaminated with infectious droplets. Do not touch the external surface of the mask. WHO recommends change of mask every 6-8 hours under the ideal setting.

• Because of the limited supply of the N95 mask in many areas, the CDC has given guidelines for possible re-use. Consider re-use only if the mask is not yet grossly soiled or physically damaged. Reuse may increase contamination therefore the practice of re-using N95 masks must be carefully weighed between the need of the HCW to have protective equipment and the increased risk of contamination.

• If N95 will be considered for re-use, the following precautions must be followed to decrease the risk of contamination:
• Consider putting a loose barrier over the N95 mask (i.e. plain surgical mask or a face shield). This barrier should not affect the proper sealed fit of the N95 mask.
• Discard the external surgical mask after each use into infectious/yellow bags. Wash hands after handling the surgical mask.
• Hang N95 masks in designated areas or keep in individual plastic bags. Do not reuse the plastic bags.
• Consider labeling masks to identify users.
• When putting on a re-used N95 mask, be careful not to touch the potentially contaminated outside surface.
• Wash hands after putting on re-used mask
• Discard the N95 mask when grossly soiled or physically damaged or deformed.

• If the HCW is going to leave the area, the mask must be removed with the rest of the PPE and either disposed into the infectious yellow bag or stored properly for re-use.

• Do not allow HCWs assigned to the SARS areas to go to other hospital areas with the mask hanging around the neck.

• In the event that N95 masks cannot be made available to all HCW in a facility, the available masks must be prioritized to HCWs who would have the highest risk of direct contact to the SARS patients. A plain surgical mask with snug fit is an alternative while awaiting N95 supplies. Plain masks can act as physical barriers to transmission (versus no mask) but are not as protective as N95 mask.

Guidelines for Gloves

• Disposable non-sterile gloves should be worn for all patient contact. Gloves are removed and discarded in biohazard bags after patient care is completed, or when soiled or damaged.

Guidelines for Disposable Gowns

• Disposable fluid-resistant gown should be worn for all patient care activity. Remove gowns after patient care is completed, or when soiled or damaged and discard in biohazard bags.

Guidelines for Eye Protection

• Goggles or face shields should be worn at all times in all types of patient care activities.

• The protective eye equipment should be well fit over the eyes and must not allow contact of infected material to the mucous membranes of the eyes thru its sides.

• Corrective eyeglasses alone are not appropriate protection.

Administrative Issues on PPE

• It is essential that provision of enough PPE is planned for and that these equipment are accessible to HCWs when the need arises.

• An infection control officer must be assigned the responsibility to monitor and supervise the proper use of PPE and its eventual disposal by HCWs so that protection is maximized and risk of transmission is minimized.