Compliance with the standard principles of infection prevention and control (IPC) is the keystone of best evidence-based practice. All those who work in health and social care environments have responsibility for IPC and must follow a code of practice (Department of Health, 2015).
Standard IPC precautions must be applied by healthcare practitioners for all patient care activities, regardless of known or suspected infection status (Loveday et al, 2014). According to Bouchoucha and Moore (2018), poor compliance can become ‘generalised’, putting staff and patients at increased risk of infection. As nurses, you can only safeguard against risks if you know what those risks are (Cochrane, 2009).
The use of gloves, disposable aprons, facemasks and eye protection are the constituents of personal protective equipment (PPE). Using PPE is one of the standard IPC precautions and reduces the risk of acquiring contamination from potentially infectious body fluids and transmitting microorganisms via hands or clothing (Loveday et al, 2014; Wilson et al, 2015).
The decision to wear PPE is made following an assessment of the risks related to the activity to be undertaken. If no contact with blood or body fluids is involved, then PPE is usually not required. Practitioners are taught how to put on PPE during their general clinical skills education session (Figure 1). If you are unsure of how to put on PPE, you should contact your line manager, practice educator and/or the IPC team.
Facemasks and eye protection
For most nursing intervention facemasks and eye protection are not necessary. However, these pieces of protective equipment must be worn when there is a likelihood of accidental splashes from blood, body fluids, secretions and excretions to the face. If face protection is not worn, you may be exposed to conjunctival or mucosal splashes from blood or body fluids (Cochrane, 2009).
Where facemasks are required, in most instances an ordinary surgical facemask will suffice. However, some specific respiratory infections or aerosol-generating procedures require the use of specialised face masks, (usually FFP3 facemasks or respirators), for example, when undertaking bronchoalveolar lavage, and when patients have tuberculosis (TB) or severe acute respiratory syndrome (SARS). FFP3 facemasks afford protection against the inhalation of minute airborne particles.
Different brands of mask are available in many sizes. FFP3 masks and respirators have to be fitted correctly to afford the best protection. It is a legal requirement that wearers should be fit-tested, so that a satisfactory seal can be attained (Cochrane, 2009). NHS England (2013) stated:
‘Fit-testing should be carried out by a properly trained and competent fit tester.’
Your IPC team and/or occupational health department will direct you to your organisation's designated fit tester.
Remember that your IPC team will provide specialist knowledge and advice when you are caring for patients who have specific infection prevention and control requirements. Table 1 provides some insight into which masks should be worn and when and Table 2 provides recommendations for different types of facial protection.
| Facial protection should always be used when undertaking a procedure or task where splashes or aerosol could be created. Facemasks should be combined with a mask or visor and goggles for the eyes | |
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A surgical mask is recommended in most clinical situations, to provide adequate respiratory and facial protection, acting as a barrier to splashes and droplets |
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Specific respiratory infections, and aerosol-generating procedures, require the use of specialised facemasks. It is a legal requirement that the wearer of these masks and respirators should be fit tested |
| Eye/face protection should be worn by all members of the surgical team during all surgical procedures. Ordinary spectacles are not considered to be clinical eye protectors | |
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Recommended in most clinical situations to provide adequate facial protection, by acting as a barrier to splashes and droplets |
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Recommended if blood or body fluid contamination to the face/eyes is anticipated, for example, during surgical interventions, equipment decontamination or work in dental clinics |
Gloves
The wearing of gloves is not an alternative to hand decontamination. Put yourself in the patient's place and ask yourself ‘Where have that practitioner's hands been before they touched me?’ Before and after glove use, hands must still be washed, or an alcohol-based hand decontamination agent applied. When adorning PPE, gloves should be put on last (Cochrane, 2009). The selection of the appropriate glove material must be made following a risk assessment. This assessment should include: Are gloves necessary, Should the gloves be sterile or non-sterile? (Health Protection Scotland, 2018).
An overview on making the risk assessment for sterile versus non-sterile gloves is provided in Figure 2.
When wearing gloves, practitioners should be mindful not to touch anything outside of the ‘patient zone’, for example, own clothes/uniform, skin, hair etc. Anything touched outside of the patient zone presents a risk of contamination to the patient and/or the practitioner (Wilson et al, 2015).
Aprons
Disposable plastic aprons are single-use items, which are water repellent and impervious to microorganisms. They must be used solely for one procedure or a single episode of care (Cochrane, 2009). They must be worn when undertaking all direct care procedures with patients, when there is a likelihood of contact with blood, secretions, excretions or body fluids (Loveday et al, 2014). Similarly, they must be worn when handling soiled linen, used equipment or waste products (Wilson, 2015).
Not all aprons used in health care are disposable, for example the lead aprons that are worn by radiographers. Where reusable aprons made of heavy-duty polyvinyl chloride (PVC) or lead are used, they must be decontaminated after each activity in accordance with the manufacturer's decontamination guidelines and organisational policy.
In many organisations, aprons are colour-coded, with a particular colour used for a particular patient intervention, for example red aprons for administering a bedpan or commode. Colour coding, if used, is usually in line with National Specifications for Cleanliness (National Patient Safety Agency, 2010).
Removing PPE
A study (Mitchell et al, 2013) highlighted how practitioners often demonstrate different ways of removing disposable aprons. However, if they are removed incorrectly, this can lead to contamination or the transfer of microorganisms onto clothing (uniforms) and into the surrounding environment. Mitchell et al's study (2013) also found that a large number of medical staff demonstrated incorrect removal of PPE, while nurses and other healthcare workers were significantly better in their removal of PPE.
The correct sequence for removing PPE is gloves, followed by aprons, eye protection and then the facemask (Health Protection Scotland, 2018) (Figure 3).
As a nursing professional, you should endeavour to practice in a safe and competent manner (Nursing and Midwifery Council, 2018). Failure to comply with policy and best evidence-based practice could result in disciplinary action (Cochrane, 2009). You must constantly risk assess all your professional activities and adopt the standard principles for infection control practice with all patients and procedures. You must also comply with employers' policies, protocols and procedures.
Knowing how to use PPE correctly also equips you with transferable knowledge and skills relevant to all clinical practice arenas. This will ensure equitable, standardised care practices and minimise the transmission of infection.