Using Personal Protective Equipment

List of high-contact care activities   

High-contact care activities should not involve reuse or extended use of PPE. These high-contact resident care activities may increase transfer of pathogens to the hands or clothes of providers:

• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use
• Wound care

Develop a process for decontamination and reuse of PPE such as face shields and goggles.

• Decontaminate if face shield or goggles become visibly soiled during course of care.
• Decontaminate between uses.
• Use proper doffing techniques when removing for decontamination.
• Follow manufacturer instructions for any product that is used for decontamination.
• Make necessary PPE available in areas where resident care is provided. 
• Post signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE. 
• Make PPE, including surgical facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room. 
• Position a trash can near the exit inside any resident room to make it easy for employees to discard PPE. 
• Encourage staff to review appropriate donning and doffing of PPE outlined in the PCHD video and CDC signage.
• If your facility is concerned about a potential or imminent shortage of PPE, email the Pima County Emergency Operations Center, EOCLogistics@Pima.Gov, and they will assist you in registering for a PPE Request account. 

Disinfection and cleaning-specific guidance

• Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas. 
• Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high- touch surfaces and shared resident care equipment. 
• Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. 
• Refer to the EPA list for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2. 
• ADHS PPE Contingent Use Guidelines
• CDC questions and answers on PPE

Types and Uses of Face Masks

• Understanding the difference between surgical masks and N95 respirators
• Reuse or extended use of surgical masks may occur when worn in a common area for multiple resident encounters, when those residents have the same diagnosis or exposure.
• Some masks received from the Strategic National Stockpile could be expired. These masks may be used, however prioritize for staff who do not provide direct resident care.
• For expired masks, please check that the elastic holds the mask on securely.

N95 respirators 

• Reuse or extended use has been authorized by the CDC, please follow the checklist for optimizing the supply of respirators 
• In the event of low supplies, respirators that are not NIOSH-approved, or even not performing adequately for healthcare delivery, can be used.
• Acceptable methods for decontamination and reuse of N95 masks 
• Of note, N95s with an exhaust valve do not provide source control and will release potentially infectious respiratory droplets into the facility as the user exhales through the valve. 
• Register for respirator (i.e. N95) decontamination with the Battelle Critical Care Decontamination System™ (Battelle CCDS™).

Cloth face coverings for residents and visitors

• As part of universal source control efforts, staff should wear a facemask at all times while they are in the healthcare facility.
• Facemasks are generally preferred over cloth face coverings for staff as facemasks offer both source control and protection for the wearer against exposure from others.
• Facemasks should be prioritized for staff, and then for residents with symptoms of COVID-19 (as supply allows).
• Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required.
• Some staff whose job duties do not require PPE (e.g., clerical personnel) might continue to wear their cloth face covering for source control while in the healthcare facility.
• Other staff (e.g., nurses, physicians) might wear their cloth face covering for part of the day when not engaged in direct resident care activities, only switching to a respirator or facemask when PPE is required.
• To avoid risking self-contamination, staff should consider continuing to wear their respirator or facemask (see “extended use” above) instead of intermittently switching back to their cloth face covering.
• Staff should remove their respirator or facemask and put on their cloth face covering when leaving the facility at the end of their shift. They should also be instructed that if they must touch or adjust their facemask or cloth face covering they should perform hand hygiene immediately before and after.

Gowns

• Reuse or extended use of cloth isolation gowns, which are usually made of polyester-cotton fabrics, may be safely laundered according to routine procedures and reused.
• Extended use of isolation gowns (disposable or cloth) may occur such that the same gown is worn by the same staff member when interacting with more than one resident, if those residents are known to be infected with the same infectious disease, and they are housed in the same location (i.e. COVID-19 residents residing in an isolation cohort).
• This can be considered only if there are no additional co-infectious diagnoses transmitted by contact (such as C. difficile) among residents.
• If the gown becomes visibly soiled, it must be removed and discarded as per usual practices.  
• In the event that no gowns are available, the CDC (accessed May 16, 2020) provides ideas on alternative clothing options that can be considered as a last resort for care of COVID-19 residents as single use. However, none of these options can be considered PPE, since their capability to protect HCP is unknown. Preferable features include long sleeves and closures (snaps, buttons) that can be fastened and secured.
  • Disposable laboratory coats
  • Reusable (washable) resident gowns
  • Reusable (washable) laboratory coats
  • Disposable aprons
  • Combinations of pieces of clothing can be considered for activities that may involve body fluids and when there are no gowns available:
    • Long sleeve aprons in combination with long sleeve resident gowns or laboratory coats
    • Open back gowns with long sleeve resident gowns or laboratory coats
    • Sleeve covers in combination with aprons and long sleeve resident gowns or laboratory coats”

The CMS toolkit (accessed May 16, 2020) gives this recommendation: To increase the supply of personal protective equipment (PPE) at the nursing home level, visit hardware stores, which have large supplies of PPE (coveralls to supplement gowns, eye protection, face shields, shoe covers, masks, and gloves) 
Purchasing reusable cloth gowns that can be laundered is likely the most sustainable solution during this shortage. The CDC does have some recommendations on extended use and laundering.