(CPP) CENTER WIDE POLICY

Policy Title Personal Protective Equipment Policy

Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

1. Purpose:
1.1 To improve PPE usage and protect both Healthcare Workers (HCW’s) and patients from exposure to
infectious agent and reduce the opportunities for transmission of microorganisms in healthcare
facilities.
1.2 To outline the indications and technique for proper PPE usage.

2. Definition:
2.1 Personnel Protective Equipment (PPE) is a specialized clothing or equipment worn by an employee for
protection against infectious materials. The protective equipment includes gloves, gowns, apron, facial
protection and mask.
2.2 Barrier precaution –is another term for PPE. This refers to a variety of barriers and respirators used
alone or in combination to protect mucous membranes, airways, skin or clothing from contact with
infectious agents.

3. Policy:
3.1 Personal Protective Equipment must always be available in all departments to protect healthcare
personnel from exposure to infectious agents during healthcare activities.
3.2 Healthcare workers shall decide which Personal Protective Equipment is most appropriate for the
task/situation, depending on what Healthcare workers might be exposed to, e.g. blood/other body
fluids.

4. Procedure:
4.1 Use of Gloves:
4.1.1 Use gloves when anticipating direct contact with blood or body fluids, mucous membranes,
non-intact skin and other potentially infectious material.
4.1.2 During direct contact with patients who are colonized or infected with pathogens transmitted
by the contact route e.g., VRE, MRSA, RSV.
4.1.3 Use sterile gloves for procedures involving contact with normally sterile areas of the body. (e.g.,
any surgical procedure, , invasive radiological procedures, performs vascular access).
4.1.4 Use examination gloves for procedures that involve direct skin or mucous membrane contact
with blood or body fluid, and in clinical situations like the following:
4.1.4.1 Procedures involving contact with mucous membrane, non-intact skin, and potential
presence of highly infectious and dangerous organism.
4.1.4.2 IV insertion and removal.
4.1.4.3 Drawing blood
4.1.4.4 Handling and cleaning instrument, handling waste, cleaning blood spills.
4.1.5 General-purpose utility (rubber heavy duty) gloves shall be worn by
maintenance,housekeeping, or non-medical personnel.

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 (CPP) CENTER WIDE POLICY
Policy Title Personal Protective Equipment Policy
Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

4.1.5.1It maybe decontaminated and re-use if the integrity of the glove is not compromised.
4.1.5.2It must be discarded when they become peeled, cracked, discolored, torn or
punctured.
4.1.6 Do not wear the same pair of gloves for the care of more than one patient.
4.1.7 When wearing gloves, change or remove gloves during patient care when moving from a
contaminated body site to a clean body site within the same patient.
4.1.8 Change or remove gloves after touching a contaminated site and before touching a clean site or
the environment.
4.1.9 Change gloves as soon as they are torn or punctured.
4.2 Use of Gowns / Aprons:
4.2.1 Gowns/aprons are readily available in all working areas at all times.
4.2.2 Do not use gown routinely. Wear only once and then discard at the appropriate receptacle.
4.2.3 The gown shall be large enough to cover the clothing entirely to protect all areas of exposed
skin.
4.2.4 Securely tie tabs/ties to keep the gown/plastic apron in place while performing patient care
activities in the patient room/ procedure area.
4.2.5 Remove soiled gowns promptly before leaving the room and immediate work area when
contaminated with blood or body fluid
4.2.6 4.2.6 Wear a gown/plastic apron to protect skin and clothing during procedures that may
generate splashes aero-isolization of body substances and cause soiling of clothes
4.2.7 Sterile gowns are only necessary for performing invasive procedures such as central line
insertion, when changing dressings of patients with extreme extensive burns and in the
performance of procedures requiring sterile technique.
4.2.8 Wear fluid resistant gowns during any procedure where there is likelihood of splashes or
contamination with blood or other body substances.
4.2.9 Reusable items and non-disposable aprons should have clearly documented cleaning schedule,
(e.g. laundering must be checked for cleanliness before being donned).
4.3 Face, Mouth, Eye Protection:
4.3.1 Face Mask:(surgical- particulate respirators)
4.3.1.1 Wear surgical masks when blood, body fluids, secretions, excretions, and splashing
procedure is anticipated and when approaching patients on droplet precautions one
meter away.
4.3.1.2 Masks should fully cover the nose and mouth and prevent
4.3.1.3 Fluid penetration and should fit over the nose and mouth.
4.3.1.4 Discard mask once it has been worn, do not hang on the neck or keep on the pocket.
3.1.1 Use single use fit tested particulate respirators N95for Airborne Precautions that means for any
medical and patient care procedure that results in the production of airborne particlesAerosol
Generating Procedures (AGPs)(e.g. TB, Chicken Pox ,Measles ,SARS-CoV and MERS-CoV)

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 (CPP) CENTER WIDE POLICY
Policy Title Personal Protective Equipment Policy
Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

4.3.2 Eye Wear:

4.3.2.1 Wear protective eyewear when performing any procedure where there is likelihood of
splashing of blood or other body substances into the eyes.
4.3.2.2 Goggles shall fit particularly from the corners of the eyeacross the brow enough to
protect the eyes.
4.3.3 Face Shields:
4.3.3.1 Use to provide full-face protection against splashes and sprays to the face.
4.3.3.2 Wear face shields as alternative to goggles to provide furtherprotection to other facial
area.
4.3.4 Caps / Footwear:
4.3.4.1 During surgery, wear surgical caps to keep the hair and scalpcovered so that flakes of
skin are not shed into the wound.
4.3.4.2 Caps shall be large enough to cover all hair.
4.3.4.3 When providing care, wear closed-toed shoes to avoid contamination with blood or
other body fluids or potential injury from sharps.
4.3.4.4 Practice extreme care when donning/removing shoes anytimeduring care delivery to
avoid hand contamination.
4.4 PPE for transmission- based Precautions:
4.4.1 Contact Precautions – Gown and gloves for contact with patient or environment of care (e.g.,
medical equipment, environmental surfaces). In some instances these are required for entering
patient’s environment.
4.4.2 Droplet Precautions – Surgical masks within 3 feet away from the patient.
4.4.3 Airborne Infection Isolation – Particulate respirator (N-95).
4.5 Compliance with regards to PPE use (can only come through employee education)
4.6 Sequence Donning:
4.6.1 Gown:
4.6.1.1 Select appropriate type and size
4.6.1.2 Opening is in the back
4.6.1.3 Secure at neck and waist
4.6.1.4 If gown is too small, use two gowns:
4.6.1.4.1 Gown #1 ties in front
4.6.1.4.2 Gown #2 ties in back
4.6.2 Surgical Mask:
4.6.2.1 Place over nose, mouth and chin.
4.6.2.2 Fit flexible nose piece over nose bridge.
4.6.2.3 Secure on head with ties or elastic.
4.6.2.4 Adjust to fit.
4.6.3 N95 Respirator:
4.6.3.1 Select a fit tested respirator.
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 (CPP) CENTER WIDE POLICY
Policy Title Personal Protective Equipment Policy
Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

4.6.3.2 Place over nose, mouth and chin.

4.6.3.3 Fit flexible nose piece over nose bridge.
4.6.3.4 Secure on head with elastic.
4.6.3.5 Adjust to fit.
4.6.3.6 Perform a fit check.
4.6.3.6.1 Inhale – respirator should collapse
4.6.3.6.2 Exhale – check for leakage around face
4.6.4 Goggles:
4.6.4.1 Position goggles over eyes and secure to the head using the ear pieces or headband.
4.6.4.2 Adjust to fit comfortably.
4.6.5 Face shield:
4.6.5.1 Position face shield over face and secure on brow with headband.
4.6.5.2 Adjust to fit comfortably.
4.6.6 Gloves:
4.6.6.1 Don gloves last
4.6.6.2 Select correct type and size
4.6.6.3 Insert hands into gloves
4.6.6.4 Extend gloves over isolation gown cuffs
4.7 Sequence for removing PPE:
4.7.1 Gloves (1):
4.7.1.1 Grasp outside edge near wrist
4.7.1.2 Peel away from hand, turning glove inside-out
4.7.1.3 Hold in opposite gloved hand
4.7.2 Gloves (2):
4.7.2.1 Slide ungloved finger under the wrist of the remaining glove
4.7.2.2 Peel off from inside, creating a bag for both gloves
4.7.2.3 Discard
4.7.3 Goggles or Face Shield:
4.7.3.1 Grasp ear or head pieces with ungloved hands
4.7.3.2 Lift away from face
4.7.3.3 Place in designated receptacle for reprocessing or disposal.
4.7.4 Gown:
4.7.4.1 Unfasten ties
4.7.4.2 Peel gown away from neck and shoulder
4.7.4.3 Turn contaminated outside toward the inside
4.7.4.4 Fold or roll into a bundle
4.7.4.5 Discard
4.7.4.6 Wash hands (Refer to Hand Hygiene policy for proper technique)
4.7.5 Surgical Mask:
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 (CPP) CENTER WIDE POLICY
Policy Title Personal Protective Equipment Policy
Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

4.7.5.1 Untie the bottom, then top, tie

4.7.5.2 Remove from face
4.7.5.3 Discard
4.7.6 N95 Respirator:
4.7.6.1 Lift the bottom elastic over your head first
4.7.6.2 Then lift off the top elastic
4.7.6.3 Discard
4.7.6.4 Wash hands
4.7.7 How to Safely Use PPE:
4.7.7.1 Keep gloved hands away from face.
4.7.7.2 Avoid touching or adjusting other PPE.
4.7.7.3 Remove gloves if they become torn; perform hand hygiene before and after donning
new gloves.
4.7.7.4 Limit surfaces and items touched
4.7.7.5 If hands become dirty when removing gloves, goggles /face shield, gown wash hands
immediately.
4.8 Employees must be trained to know at least the following:
4.8.1 When/what PPE is necessary.
4.8.2 How to properly don, remove, adjust and wear PPE.
4.8.3 The limitations of the PPE.
4.8.4 Proper care, maintenance, and disposal of PPE.
4.9 Supervisors must ensure that each employee had received and understood the required training
through a written certification, which includes date of training. The certificate shall be kept at the
employee file.
4.10 Incident Reporting: Report adverse reactions (allergies, sensitivities) relating to the use of PPE to
immediate supervisors, which will be further, be reported to employee health clinic.

5. Responsibilities:
5.1 The responsibility of the Manager is to ensure that adequate resources are in place to allow
recommended infection prevention and control measures such as PPE to be implemented.
5.2 Supervisors:
5.2.1 Assure the adequacy of the PPE; proper fit protection, maintenance.
5.2.2 Ensure every employee knows howto use his or her PPE correctly.
5.3 Infection Control Staff:
5.3.1 Provide education for staff and management on this policy.
5.3.2 Act as a resource for guidance and support when advice on PPE is required.
5.3.3 Provide advice on individual risk assessments for PPE decisions.
5.4 All Staff: Must follow PPE policy and procedure and advice the patient/client or visitors of any infection

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 (CPP) CENTER WIDE POLICY
Policy Title Personal Protective Equipment Policy
Policy Number IPC-CWP-002 Version No. 1
Issue Date September 01, 2023 Effective Date September 15, 2023
Review Date September 01, 2026 New Revised
Applies to All Center Staff

control requirements with regards to the proper use of PPE.

6. Attachments:
6.1 N/A

7. References:
7.1 GCC Centre for infection Control, 3rd edition, 2018; Section2 – Standard infection control policy, ICM –
11- 03, Standard Precautions.
7.2 General Directorate for Infection Prevention and Control(GDIPC) May 2020.

Approvals:

Action Name Position Signature Date

Prepared by IPC Practitioner
Director of Nursing
Reviewed by P&QM Director
Medical Director
Prepared by Center Director

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