1.4 Additional Precautions and Personal Protective Equipment (PPE)

Certain pathogens and communicable diseases are easily transmitted and require additional precautions to interrupt the spread of suspected or identified agents to healthcare providers, other patients, and visitors (PIDAC, 2012). Additional precautions are used in addition to routine precautions and are defined by how a microorganism is transmitted (Perry et al., 2014).

Point of Care Risk Assessment (PCRA) is the first step in routine practices. As such healthcare workers should be doing this with all patients for all care at all times. It involves assessing the infection risk posed to themselves and others by the patient, a procedure or a situation. Personal protective equipment (PPE) is chosen based on that risk (Vancouver Coastal Health, 2017).

Types of Additional Precautions

There are three categories of additional precautions: contact precautions, droplet precautions, and airborne precautions (CDC, 2007).

Contact precautions are are the most common type of additional precautions. They are used in addition to routine practice for patients who are known or suspected to be infected with microorganisms that can be transferred by direct (touching) or indirect (shared equipment) contact. Types of organisms in this category are antibiotic-resistant organisms (AROs) such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamase (ESBL), Clostridium difficile (CDI), carbapenemase-producing organisms (CPO), diarrhea, and scabies. AROs are also known as multi-drug-resistant organisms (MDROs).

Droplet precautions are used in addition to routine practices for patients who are known or suspected to be infected with microorganisms that are spread through the air by large droplets. Types of organisms and unconfirmed conditions in this category include mumps, influenza, vomiting of unknown cause, norovirus, and unconfirmed cough.

Airborne precautions are used in addition to routine practices for patients who are known to have or are suspected of having an illness that is transmitted by small droplet nuclei that may stay suspended in the air and be inhaled by others. These particles can remain infectious for a long period of time when spread through the air. Types of organisms in this category include tuberculosis (TB), measles, chicken pox (varicella), disseminated zoster, and severe acute respiratory syndrome (SARS).

Special considerations:

• Signage and accommodation: Signs must state the type of precaution required for the patient and be displayed on the door or at the foot of the bed. Accommodation in a private room, or cohorting patients with the same type of infection, is acceptable. Private bathrooms are preferred.
• Personal protective equipment (PPE): PPE is clothing or equipment worn to protect staff from catching or transmitting an infection. Depending on the type of additional precaution, PPEs are required when performing patient care tasks and may consist of a mask, gown, gloves, face shield, and/or eyewear.
• Consistent communication: Patients on additional precautions must be clearly identified on their patient chart or requisitions to ensure all hospital personnel, departments, or other healthcare settings know what additional precautions to use.
• Visitor information: Visitors must be informed of the precautions and must wear the appropriate PPEs and follow the routine practices for healthcare settings. Visitors also must wear the same PPEs as the healthcare provider if providing direct care for the patient.
• Multiple additional precautions: Some microorganisms may be transmitted by more than one mode and, therefore, more than one additional precaution is needed. For example, a patient with suspected or confirmed Ebola virus disease (EVD) would be on contact and droplet precautions.
• Aerosol procedures: Aerosol-generating medical procedures (such as tracheostomy care, CPR, nebulized therapy) may increase risk of transmitting infectious agents. Airborne precautions should be initiated during specific procedures when a patient is suspected of having or confirmed to have TB.
• Equipment is patient specific (i.e., BP cuffs, stethoscopes, BGMs) and not used on others unless thoroughly cleaned. Ideally all patient equipment stays in the room with that patient.

Tables 1.1, 1.2, and 1.3. summarize the three categories of additional precautions.

Personal Protective Equipment (PPE)

Additional precautions require the use of personal protective equipment (PPE), which is equipment or clothing worn by staff to prevent the transmission of infection from patient to staff or to family member (PIDAC, 2012). All PPE must be applied and removed in a specific order to ensure the skin, nose, mouth, and eyes are covered to prevent transmission of infection to healthcare providers. Depending on the type of additional precaution or risk assessment, a gown, goggles, face shield, and mask (surgical or N95) may be used during patient care. Refer to Checklist 6 for steps to take when donning (putting on) PPE.

Checklist 6: Donning PPE Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: The selection of PPE is based on the nature of the interaction with the patient and the likelihood of transmission of infectious agents. PPE should be put on just prior to the interaction with the patient and should be removed immediately after the interaction, followed by hand hygiene. Donning of PPE is usually done outside the patient’s room. Patients may feel depressed or lonely when isolated in a room or experiencing decreased contact with healthcare providers. Support for individuals on isolation must be provided. Conversely, some patients may appreciate the privacy of an individual room.
Steps		Additional Information
1. Remove rings, bracelets, and watches. Perform hand hygiene.		This prepares hands for direct patient care.
2. Apply waterproof long-sleeved gown. Tie the neck and waist strings.		Waterproof gown prevents any potential cross-contamination from blood or body fluids onto forearms and body.
3. Apply mask. Remember different masks are required for different situations. Ensure the fit is secure with no air leaks. Secure the metal band around the nose and pull mask over chin as required.		Wearing a poor-fitting mask is the number one reason for exposure to pathogens for healthcare providers. Masks should be worn if provider is within two metres of a coughing or sneezing patient or if there is a potential for spray of secretions or excretions. Replace mask if it becomes wet or soiled.
4. Apply goggles or face shield.		Goggles or a face shield prevents accidental exposure to eyes, nose, and mouth. Goggles can be placed on top of eyeglasses. Prescription glasses are not an alternative to goggles as they do not protect the entire eye.
5. Apply non-sterile gloves over top of the cuff of the gown.		Non-sterile gloves ensure complete coverage of skin on arms for direct patient care.
Data source: Barratt, Shaban, & Moyle, 2011; PIDAC, 2012; PHAC, 2012b

See Checklist 7 for steps on how to doff (or remove) PPE.

Checklist 7: Doffing PPE Disclaimer: Always review and follow your agency policy regarding this specific skill.
Steps		Additional Information
1. Remove gloves.		Grasp outer edge of glove by wrist and peel away from hand, rolling the glove inside out. Roll it into a ball in gloved hand. With the bare hand, reach under the second glove and gently peel down off the fingers. Drop glove into garbage bin. Always perform hand hygiene after removing gloves. Gloves are not tear- or leak-proof. Hands may have been contaminated upon removal of the gloves.
2. Perform hand hygiene.		Use soap and water if hands are visibly dirty.
3. Remove gown.		Remove gown in a manner that does not contaminate clothing. Starting at the neck ties, pull the outer (contaminated) part forward and, turned inward, roll into a ball. Discard in appropriate receptacle bin.
4. Perform hand hygiene.		Always perform hand hygiene after removing gown. Hands may have been contaminated upon removal of the gown.
5. Remove eye protection or face shield.		Arms of goggles and the headband on the face shield are considered clean. Handle these only by the sides. The front of the face shield or goggles is considered contaminated. Dispose them according to agency policy. Ensure you are at least two meters from the patient when removing eyewear.
6. Remove mask or N95 respirator.		Ties, earlobe loops, or straps are considered clean and may be touched. If tied, remove bottom tie first, then top tie. Remove ear loops or straps by leaning forward to allow the mask to slip off your face. Masks are removed outside the patient room Dispose of the mask in the garbage bin.
7.  Perform hand hygiene.		This step reduces the transmission of microorganisms.
Data source: Barratt et al., 2011; Perry et al., 2014; PHAC, 2012b; Siegal et al., 2007

Blood or Body Fluid (BBF) Exposure

A blood and body fluid (BBF) exposure is defined as an exposure to potentially infectious body fluids or blood through the following methods: a puncture wound by a sharp object or needle (percutaneous exposure), from a body fluid/blood splash onto your mucous membranes (permucosal exposure) or exposure through eczema, an open wound/skin or scratch (non-intact skin exposure) (BCCDC, 2015).

Post-exposure management is only required when (1) percutaneous, permucosal, or non-intact skin is exposed to a BBF; (2) the exposure is to blood or potentially infectious body tissue or fluid; (3) the source is considered potentially infectious (e.g., patient is part of a high-risk group, exposure occurred in a high-risk setting, or patient has a positive test); and (4) the exposed person is considered susceptible to HIV, hepatitis B, or hepatitis C. Checklist 8 explains what to do if exposed.