Personal Protective Equipment (PPE)

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PPE is the last line of defense and least effective method of control against a hazard and does NOT take the place of engineering or administrative controls. Effective use of PPE relies on the user and is only used until better controls can be identified and implemented.

Selection of PPE depends on the potential risk of exposure to a hazard. Examples of PPE by body areas include:

• Eyes (e.g., safety glasses, goggles, laser protective eyewear)
• Ears (e.g., ear plugs or muffs)
• Face (e.g., face shield)
• Hands (e.g., exam gloves, chemotherapy gloves)
• Feet (e.g., shoe coverings)
• Torso/body (e.g., fluid resistant gowns, impervious splash suit, laser protective clothing)
• Lungs/respiratory tract (e.g., N95 filtering facepiece respirator, elastomeric half-mask respirator, powered air- purifying respirator (PAPR), surgical mask, and protective shields and barriers

Personal protective equipment (PPE) came into the spotlight at the height of the COVID-19 pandemic, but these important materials and practices have been protecting healthcare providers for years. Regulation of PPE standards usually falls to the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA). The availability, application, and disposal of PPE play an essential role in a healthcare system's ability to care for patients safely. [1] Part of standard precautions, PPE provides a barrier to minimizing workplace hazards that healthcare providers encounter from harmful exposures. Chemical, biological, radiological, and nuclear contamination threats are encountered throughout healthcare. This article discusses the application of PPE in relation to healthcare. See Table. Personal Protective Equipment Clinical Presentations and Recommended Precautions.

Issues of Concern

Types of Personal Protective Equipment

Commonly worn PPE includes a gown, gloves, masks, respirators, and face shields or goggles. Understanding the limitations and proper wearing of PPE is essential to ensuring safe practices. Specific gloves offer differing levels of standards for infection prevention. One commonly used metric in glove safety evaluation is the acceptable quality level (AQL). A lower AQL means a higher quality glove with less micro-perforation potential and fewer pinholes in the glove product. The FDA generally recommends a minimum AQL level of 1.5 for surgical gloves and 2.5 for medical exam gloves.[2] 

Surgical procedural evidence supports using two layers of gloves as an infection prevention technique.[3][4] Surgical procedures also necessitate using sterile gloves, which have been treated to eliminate microbes.

The availability of appropriate gowns can prevent the spread of infection. Medical gowns follow the American National Standards Institute (ANSI), the Association of the Advancement of Medical Instrumentation (AAMI), and the Food and Drug Administration's (FDA) ANSI/AAMI PB70 standards for medical gowns. The ANSI/AAMI PB70 has four levels of fluid barrier protection.[5] 

USP 800 guidelines promote safety by outlining gown standards for handling hazardous drugs. Following suggested guidelines for PPE in the appropriate setting, whether using sterile gowns for surgery or non-sterile gowns for contact exposure, will ensure the safety of both healthcare workers and patients.[6][7] 

Loosely woven cloth masks provide the least respiratory protection, while National Institute for Occupational Safety and Health (NIOSH) approved respirators offer the most protection.[8][9] A key component of mask protection involves the proper fitting of masks.[10] All healthcare workers should be fit tested if required to use respirators, including N95 masks.[11][12] 

If fit testing cannot be completed, then a NIOSH-approved powered air purifying respirator (PAPR) can be considered based on institutional and local regulatory requirements.[13][14][15] The COVID-19 pandemic created a high demand for face coverings with limited consistent standards comparing different products. The American Society for Testing and Materials (ASTM) and NIOSH updated barrier face covering standards, ASTM F-21, allowing comparison between different barrier face coverings.[16] 

Standard Precautions

Standard precautions serve as a framework all healthcare providers should follow as part of an initial approach to limiting exposure. These preventative steps should be considered for every patient encounter.[17][18][19][20]

 Standard precaution components are listed here:

• Hand hygiene, including hand washing, regardless if gloves are worn, before and after contact with a patient or bodily fluids [21] [22] [23]

• Appropriate use of PPE, including gown, gloves, and eye protection, especially if there is a risk of bodily fluid exposure

• Respiratory/cough etiquette to prevent droplet transmission of respiratory pathogens

• Patient placement with consideration for single patient rooms and routes of transmission for specific infectious agents

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Infection Prevention

PPE infection prevention recommendations can be categorized into specific transmission-based precautions. Following these recommendations, in addition to standard precautions, can protect healthcare providers and patients from disease infection. Clinical presentations giving concern for certain organism exposures require different standards of transmission prevention.[24][25] Please see Table 1.[26][27] 

Contact precautions require the use of a gown and gloves in clinical situations involving organisms spread by direct or indirect contact with a patient or patient's environment. For example, clinical scenarios involving wound drainage, fecal matter, or other bodily discharge exposure would suggest using contact precautions.[28][29] 

Droplet precautions should be utilized in respiratory illness where close mucous membrane contact or respiratory droplet exposure may occur. Droplet precautions should include standard precautions, eye protection, and a mask. Generally, pathogens requiring droplet precautions do not remain infectious over extended distances. Eye protection and an N-95 mask or higher-level respirator should be utilized with standard precautions in the setting of airborne precautions. Airborne pathogens have long-distance exposure potential that necessitates the need for special air handling and ventilation systems. These ventilation systems should meet the Architects Facility Guidelines Institute standards for airborne infection isolation rooms. Easily visible signs should be placed outside patient rooms and contact zones listing the required PPE for a specific patient encounter.[26]

Chemical and Nuclear Personal Protective Equipment

Healthcare providers may come into contact with harmful chemicals as part of day-to-day activity. Whether in the form of cleaning, pharmaceutical, or contamination, exposures are a risk at several points throughout regular workplace flow. In the event of exposure to workplace-stocked chemicals, Material Safety Data Sheets (MSDS) should be referenced for information specific to each chemical. Standard PPE should be utilized in the setting of chemical handling as defined by OSHA and CDC. Considerations should be made for areas of safe chemical handling, including adequate ventilation, safe handling areas, cleaning work surfaces, and spill procedures. In the scenario where a healthcare provider must enter a contaminated area with appropriate hazardous materials (HAZMAT), PPE must be utilized.[30][31][32] 

HAZMAT equipment PPE recommendations follow OSHA standards as outlined by Levels A, B, C, and D. Different levels of protection are offered in each guideline, from the highest level of protection, Level A, including self-contained breathing apparatus (SCBA) to Level D least protective including standard precautions and appropriate work uniform. Level A PPE should be utilized when the hazardous substance requires the highest level of eye, skin, and respiratory protection.[33][34] 

Level A PPE guidelines are also followed when entering areas of poor ventilation or when a substance has not yet been identified as appropriate for a lower level of protection. Level B PPE provides protection in areas requiring a high level of respiratory protection, including scenes with less than 19.5% oxygen or incompletely identified vapors/gasses. Level C PPE protection is appropriate in situations necessitating air-purifying respirators and contaminants which will not cause adverse harm through exposed skin. Level D PPE would be utilized when no known hazard is present in the atmosphere and contact or inhalation with hazardous levels is precluded by work functions. Other PPE may be included as defined by specific sceneries and OSHA recommendations. Part of the appropriate response to chemical exposure also includes decontamination processes in addition to proper disposal of used PPE.[35]

Recommendations for nuclear hazardous materials come from OSHA guidelines regarding events involving chemical, biological, radiological, or nuclear (CBRN) agents.[36] Recommendations for specific exposure risks can be found in relation to the area of contamination. Three zones of contamination are outlined in the recommendations, with the red zone being the area of most significant contamination and the green zone being the area of lowest contamination. Level A OSHA protection is usually recommended in a red zone. Yellow zone area of contamination PPE needs should be decided with consideration for air monitoring results, skin contact risk, and proximity of the event. Green zone contamination with CBRN agents is unlikely to occur.

OSHA Defined PPE

• Level A: positive pressure full face-piece SCBA, encapsulating covering chemical protective suit, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe, disposable protective suit/gloves/boots

• Level B: positive pressure full face-piece SCBA, chemical-resistant clothes with hood, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe

• Level C: air purifying respirator, chemical-resistant clothes with hood, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe

• Level D: gloves, coveralls, chemical-resistant boots/shoes with steel toe, safety glasses or chemical splash goggles

Radiologic PPE

Exposure to ionizing radiation can present a significant long-term health risk to healthcare providers. PPE should be available for healthcare providers working within radiation-exposure settings. Of particular importance, dose reduction with exposure to x-ray and gamma radiation can be achieved with proper PPE.[37][38][39] Providers practicing with X-ray and gamma radiation exposure, especially fluoroscopy and other image-guided procedure devices, should have access to a lead apron/vest, lead-lined glasses, lead-lined cap, and lead protection collar.[40][41][42][43] 

Dose monitoring is required by OSHA Ionizing Radiation standards for workers who enter a high radiation area or restricted area or receive a dose in any calendar quarter more than 25% of the appropriate occupational limit.[44][45][46][47] OSHA standards for monitoring radiation exposure can be followed by wearing a person's passive dosimeter for exposure dose evaluation.[48][49]

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