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Personal Protective Equipment (PPE) Packet for

PUIs and COVID-19

Updated June 8, 2020

Table of Contents

Summary of Changes from Version 11.0 2

Personal Protective Equipment (PPE) Guidance 2

Patient Care or Procedure PPE Selection 3

Time Factors Related to Cleaning & Disinfection of Isolation Room and other Patient Care Areas following care of PUI or COVID-19

Full Face Shield Disinfection

PPE Stewardship

Summary of PPE Conservation Strategies 11

Caregiver Guidance for PPE Selection when Caring for Patient in Isolation 13

Contingency Tiered Approach Based on Inventory of PPE if Inventory is at Crisis Level 14

Optimizing Use of N95 Respirator 15

Performing a Respirator Seal Check 19

Examples of Aerosol Generating Procedures 20

Aerosol Generating Procedure Door Sign (2 sided) 21

Facial Hairstyles and Filtering Facepiece Respirators, NIOSH, CDC 2017 23

PPE At -a-Glance Guide to Donning PPE for PUI or COVID19 – No AGP 24

PPE At -a-Glance Guide to Donning PPE for PUI or COVID19 – AGP 25

PPE At -a-Glance Guide to Doffing PPE for PUI or COVID19 26

Prophylaxis and Treatment for Skin during Extended PPE Use 29

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Personal Protective Equipment (PPE) Guidance

Universal Masking Process:

To address asymptomatic and pre-symptomatic transmission, everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms are encouraged to wear a mask as described:

o All healthcare personnel are to wear a disposable, medical grade facemask If supply of disposable, medical grade masks are limited, provide these to personnel that

provide direct patient care Personnel that do not provide direct patient care may use non-traditional, cloth or other

reusable mask o As indicated in prior guidance, non-traditional cloth masks are not considered PPE and are not to be

used by healthcare personnel for work activities in which PPE is needed, e.g. aseptic procedures, risk of splashes to face, etc.

o For visitors and patients, a cloth facemask or other covering is appropriate.

Occupational Safety and Health Administration (OSHA) Compliance

OSHA has primary responsibility for ensuring the safety and health of the workforce by setting and enforcing

standards and by providing training, outreach, education and assistance. Every effort is made to ensure that we are

keeping our workers safe within our ministries. Strategies around respiratory protection include:

Respirator evaluation o Use NIOSH approved respirators that are not expired as supplies allow

Re-use/extend the use of non-expired respirators when supply is low o Only use expired respirators when those are all that is available

Expired N95 Respirators generally must not be used when HCP perform surgical procedures on patients infected with, or potentially infected with, SARS-CoV-2, or perform or are present for procedures expected to generate aerosols or procedures where respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction). Refer to the Use of Expired N95 Respirators Guidance.

o Careful evaluation of non-NIOSH approved respirators by surveying the literature and consensus from internal subject matter experts

Implementing strategies recommended by CDC and OSHA for optimizing and prioritizing N95 respirators

Performing initial fit-testing, where feasible, for each employee with the same model, style, and respirator provided for use.

Informing employees of the temporary suspension of the annual fit testing requirements in order to preserve supply of N95 respirators.

Explaining the importance of seal check to employees and providing needed assistance to ensure this objective is met. (i.e. use of PPE safety coaches or other colleagues trained in proper use of PPE (i.e. surgical techs) to help evaluate seal checks).

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CDC Recommendations

CDC updated recommendations is to use Standard and appropriate transmission-based precautions when caring for

person under investigation (PUI) and confirmed COVID-19. Therefore Droplet + Contact precautions along with

Eye Protection are to be ordered and used when caring for PUI or those with confirmed COVID-19. SARS-CoV-2,

the cause of COVID-19, is transmitted over short distance of up to 6 ft. from droplets that contain this virus when

those with COVID-19 cough or sneeze. There are certain aerosol generating procedures (AGPs) listed below which

likely release greater amount of respiratory secretions. Whenever possible personnel should wear a N95 respirator

or PAPR during these procedures or whenever entering the isolation room for these AGPs if running continuously,

e.g. high flow nasal cannula. It is important to note a cough, or a sneeze is not considered an AGP.

PPE Purchased by Colleagues

In areas where PPE is required (see table below), colleagues are required to wear PPE procured by MercyOne.

This assures all PPE used in clinical areas meets stringent quality and efficacy standards. Colleagues who work

outside of direct patient care and wish to obtain their own PPE may do so. Colleagues will not be reimbursed for

purchases made outside of our Procurement channels, and MercyOne is not responsible for maintenance of PPE

procured outside of these channels.

Patient Care or Procedure PPE Selection

Patient Care or Procedure Patient

Placement PPE

N95 Respirator or PAPR? Plus

additional comments

Direct patient care, e.g. inserting catheter, daily cleansing, emptying urinary drainage bag, oral care

Any private room

Mask

Eye Protection

Gown

Gloves

No

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Patient Care or Procedure Patient

Placement PPE

N95 Respirator or PAPR? Plus

additional comments

AGPs (AGPs – see Appendix):

Co-locate PPE near or in code cart nearest to patient, esp. N95 Respirator and eye protection, so readily available for code response team.

Minimize number of personnel in the room during code to essential team members.

Patient should not be moved to an Airborne Infection Isolation Room for an AGP. Moving the patient creates a higher risk after the procedure

Support services staff must not enter the room until sufficient time has passed for aerosols to clear (see AGP Procedure Notice in Appendix). IF support services must enter the room before the appropriate time has passed, colleagues must use the same PPE indicated for clinical staff. If Environmental Services (EVS) colleague is assigned to a high risk, cohorted, unit where the decision was made to require all colleagues wear N95 protection, The EVS colleague will also be fit tested and provided with an N95 mask.

Airborne infection isolation room (AIIR), if available If not available – any private

N95 respirator + eye protection or PAPR

Gown

Gloves

Yes Note: high flow nasal cannula is typically run continuously based on clinical need. If high flow is on and running wear N95 and eye protection or PAPR whenever entering patient's room. Post AGP procedure notice on door to room, keep door closed during the AGP. See AGP Procedure Notice in Appendix.

Obtaining nasopharyngeal or swab specimens for testing

Procedural mask and eye protection.

gown

gloves

During swab collection have patient keep mask over their mouth.

After collecting swab – have disposable tissue ready and give to patient to contain cough. Once cough subsides; have them put their mask back on.

No, except for high-volume areas (see next row).

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Patient Care or Procedure Patient

Placement PPE

N95 Respirator or PAPR? Plus

additional comments

Personnel in locations with high volumes of PUI and/or COVID-19+ patients (e.g. Emergency Departments, COVID units, dedicated testing facilities) Support services staff working in these locations must use the same PPE indicated for clinical staff. *Consideration should be given to units where full negative pressure is present and unit engineering allows for "clean" hallways, etc. Please consult your local infection

preventionist.

N95 Respirator and/or PAPR when entering an isolation room

Procedural mask when not in an isolation room, e.g. at central nurses station or in corridors outside patient rooms.

Eye protection

Gown

Gloves

Yes; observe and adhere to N95 Respirator Optimization guidelines.

Nebulized medication administration

Use MDI if available. If not use standard nebulizer treatment device and medication

Patient should not be moved to an Airborne Infection Isolation Room for nebulizer treatment. Moving the patient creates a higher risk after the procedure.

Support services staff working in these locations must use the same PEE indicated for clinical staff.

AIIR, if available otherwise any private room

For nebulized med: N95 respirator + eye protection or PAPR. If in a setting where N95 is not available wear mask and eye protection. Note: this procedure produces a high concentration of aerosols – PPE must be worn. Disinfect surfaces immediately around the patient after treatment is completed. For MDI = mask, eye protection, gown and gloves

Yes Post AGP procedure notice on door to room, keep door closed during the AGP. See AGP Procedure Notice in Appendix.

Therapy personnel in isolation rooms of COVID-19+ (i.e. respiratory therapist, physical therapy, etc.) mobilizing intubated patients

N95 Respirator and/or PAPR

Eye protection

Gown

Gloves

Yes

Therapy personnel in isolation rooms of COVID-19+ (i.e. respiratory therapist, physical therapy, etc.) mobilizing non-intubated patients

Procedural mask

Eye protection

Gown

Gloves

No

Personnel performing interventional/radiologic study (i.e. swallow evals, etc.)

Procedural mask

Eye protection

Gown

Gloves

No

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Patient Care or Procedure Patient

Placement PPE

N95 Respirator or PAPR? Plus

additional comments

Personnel performing screening at entrances to MercyOne facilities Colleagues are not required to change gloves between screenings and may perform hand hygiene as needed over gloves. Colleagues are to follow manufacturer IFUs for disinfecting thermometers. Touchless thermometers should be disinfected at the end of the shift

Mask appropriate to the colleague’s level of patient contact*

Gloves (1 pair/shift – change if soiled)

Hand sanitizer available

*Screeners at colleague only entrances are to wear cloth masks. Screeners at entrances used by patients are to wear surgical/procedural masks.

No

Personnel performing screening at entrances to non-healthcare facilities (eg. Manufacturing plants, meat packing plants, other non-healthcare locations, etc.) Colleagues are not required to change gloves between screenings and may perform hand hygiene as needed over gloves.

Surgical/procedural mask

Face shield*

Gloves (1 pair/shift – change if soiled)

Hand sanitizer available

* A face shield is not required by CDC guidelines, but is required by MercyOne due to the unknown risk in these settings.

NO

AGP = aerosol generating procedure MDI = metered dose inhaler PAPR = powered air purifying respirator CAPR = controlled air purifying respirator N95 Respirator = refers to the 3M branded respirator or other NIOSH-approved alternatives Source: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

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Time Factors Related to Cleaning & Disinfection of Isolation Room and other Patient Care

Areas following care of PUI or COVID-19

Environmental Cleaning Patient Care

Areas

Time lapse after patient vacates before entering to clean room PPE

N95 Respirator or PAPR

1. Airborne infection isolation room (AIIR)

If AGP performed during the 1.5 hours prior to discharge – leave the AGP alert on the door. Wait for 35 minutes before beginning discharge (terminal cleaning) [35 minutes is based on air changes/hour (ACH) = 12. If uncertain of air changes, contact facilities and apply CDC time factor to the appropriate ACH for the isolation room used.]

Mask; standard disposable procedure or surgical. Eye protection Gown Gloves

Only needed if terminal cleaning has to start before 35 minutes has passed since patient has left the room. If so, then wear N95 in place of mask, wear other PPE as indicated in PPE column to left

2. Standard Private room, e.g. med-surg unit with confirmed or PUI for COVID-19 Terminal (discharge) clean

If AGP performed during the 1.5 hours prior to discharge – leave AGP alert on door. If feasible have EVS wait 1 hour before starting discharge/terminal room cleaning. If unable to wait 1 hr., EVS will wear PPE listed under "PPE column"

If no AGP in 1.5

hours before discharge – wear PPE and start discharge cleaning as soon as patient has left the room

Mask; standard disposable procedure or surgical. Eye protection Gown Gloves

No – patient has been discharged and therefore source of virus is no longer present. Enter room with PPE that is identical to what nurse and others wear for care that does not involve a AGP, e.g. patient bath, checking IV pump, etc.

3. Any private room with non-COVID-19 patient

Immediate Gloves No

4. Treatment or Imaging room or area, e.g. CT scan room,

If no AGP performed, disinfect surfaces onto which patient was placed, directly touched

Gloves; no AGP

No. PUIs and COVID19 should remain in their isolation room except for essential clinical

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Environmental Cleaning Patient Care

Areas

Time lapse after patient vacates before entering to clean room PPE

N95 Respirator or PAPR

Interventional cardiology room

or in immediate surrounding area following routine procedures that are done for non-COVID19, e.g. disinfect exam/imaging table. No wait time needed. If AGP is performed apply wait time from CDC or wear PPE in PPE column

If AGP: mask, eye protection, gown and gloves.

need – e.g. CT scan. AGPs should be performed in an AIIR.

5. Non patient care areas

Immediate Glove No

Full Face Shield Disinfection After removal:

Put on clean gloves – obtain 1 disinfectant wipes

Hold the mask by the head piece for disinfection. Placing the mask on a flat surface may lead to cracks in the mask.

Wipe inside of shield and other areas, e.g. strap or ear loops with the disinfectant wipe, avoid foam area. Allow for appropriate dwell time.

Disinfect front (patient-facing) side of shield with the wipe. Allow for appropriate contact time for the wipe being used.

If shield is streaked or has a cloudy film, clean mask with soft, damp (with water) cloth or use an alcohol pad.

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PPE Stewardship The safety of our caregivers and patients is our highest priority. We have made the decision move to extended and reuse of existing personal protective equipment with the goal of protecting every caregiver, as they protect our patients. This approach which is only an option during times of significant PPE shortages, will help keep our caregivers safe. Caregiver are the most important part of our effort to support our communities during the COVID-19 outbreak.

PPE from Other Countries In an effort to ensure adequate supplies of PPE, MercyOne is working to source PPE produced in other countries, as well as domestically produced options. A list of other countries with standards verified as similar to NIOSH can be found here: https://www.osha.gov/memos/2020-04-03/enforcement-guidance-use-respiratory-protection-equipment-certified-under. See Appendix for additional detail.

Mask Conservation Mask Stewardship: System-wide supply of masks are in red status, meaning the quantity in our collective inventory is becoming very limited. Therefore, we are requiring the following strategies be deployed:

N95s are to be reserved for the scenarios outlined above in the Selection of PPE table.

Surgical masks (those with ties, rather than ear loops, depicted in Figure 1.0) are to be reserved for operative procedures. Procedural masks (depicted in Figure 2.0) are to be used in all other areas.

Assure supplies of disposable masks are secure and their deployment is overseen by colleagues rather than available in unsupervised areas, e.g. respiratory hygiene stations at points of facility entry.

o Important: masks do need to be available and provided to patients with symptoms of acute respiratory infection, e.g. fever + cough + shortness of breath. Colleagues at reception/registration can provide these upon request.

o Patients will be provided with standard procedural masks in the inpatient or ED setting.

Figure 1.0: Surgical Mask (with ties) Figure 2.0: Surgical Mask (with ear loops)

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If not involved in direct care, other health care personnel, e.g. support services – Food Services, Facilities Management, are not to enter the rooms of PUIs or those with confirmed COVID-19 except for an emergency.

o Direct care personnel should bundle activities to minimize the number of times a room is entered (e.g., check vital signs during medication administration, deliver food tray and perform room cleaning and disinfection while performing other care, etc.) and plan which activities will be performed at the bedside.

o Environmental services colleagues may enter patient rooms to provide more in-depth clean when a need is identified by a unit manager. EVS colleagues must wear appropriate PPE.

Continue to wear the same surgical mask (i.e., extended use), remove only used gloves and gowns, and perform hand hygiene between treating several patients with the same suspected or confirmed infectious disease diagnosis or exposure who are maintained in a confined area, e.g. PUIs. If the mask, gloves, or gowns become contaminated, replace them. Change gloves in between each patient. Change gown if visibly soiled.

If there are no state or local regulations requiring healthcare personnel wear a mask during their work shifts for those not able to receive seasonal influenza vaccine, suspend this policy and permit them to work without a continual wearing of mask throughout their work shift.

Limit the number of personnel that enter rooms used for patients on Contact or Droplet precautions (not PUI or COVID-19) during multidisciplinary rounds, training of nursing, medical students, etc., to conserve supply of masks and other PPE, e.g. gowns and gloves. Whenever possible designate a member of the multidisciplinary team to examine or interview the patient. The other members can remain just inside the entry to the room.

Discontinue contact precautions for patients with history of or colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococci (VRE). The exception for this would be if the site of detection of MRSA or VRE is not contained, e.g. wound with active drainage of purulent discharge.

Surgical Mask Conservation Prioritize surgical masks for selected activities such as:

o For provision of operative procedures o During care activities where splashes and sprays are anticipated.

Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html

Gown Conservation Gown Stewardship: System-wide supply of gowns are in red status, meaning the quantity in our collective inventory is becoming very limited. Therefore, we are requiring the following strategies be deployed:

Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19.

Limit the number of personnel that enter rooms used for patients on Contact or Droplet precautions (not PUI or COVID-19) during multidisciplinary rounds, training of nursing, medical students, etc., to conserve supply of masks and other PPE, e.g. gowns and gloves. Whenever possible designate a member of the multidisciplinary team to examine or interview the patient. The other members can remain just inside the entry to the room.

Discontinue contact precautions for patients with history of or colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococci (VRE). The exception for this would be if the site of detection of MRSA or VRE is not contained, e.g. wound with active drainage of purulent discharge.

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Switch to a reusable (i.e. washable) gown made of polyester or polyester-cotton fabric. Caregivers need to exercise caution not to touch the outside surface of gown during patient care. Plastic apron, if available, may be worn over reusable gowns.

Discontinue use of cloth gowns in areas where isolation gowns are not required.

Surgical gowns MUST be preserved and prioritized for surgical and other sterile procedures.

Use of gowns with an expiration beyond the manufacturer-designated shelf life may be considered.

Coveralls may also be used as a last resort but are best preserved for use in outdoor mobile clinics or other settings where temperature would allow. These coveralls or Tyvek suits can be difficult or uncomfortable to wear in warmer areas.

Other items that can be considered as a last resort for care of COVID-19 patients as single use. None of these options can be considered PPE, since their capability to protect HCP is unknown. These items include

o Disposable laboratory coats o Reusable (washable) patient gowns o Reusable (washable) laboratory coats o Disposable aprons o Combinations of clothing: 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 patient gowns or laboratory coats - Open back gowns with long sleeve patient gowns or laboratory coats - Sleeve covers in combination with aprons and long sleeve patient gowns or laboratory coats

Summary of PPE Conservation Strategies

No visitors allowed for PUI or COVID-19 (exceptions on case-by-case basis for end of life)

Essential personnel only in any care setting that requires PPE

Maintain 6 foot distance from PUI or COVID-19 when possible, avoid contact with items in patient room. For example, if patient only has a question – enter just inside the isolation room door and answer or identify if more assistance is needed. If so and direct contact is required – don PPE.

Use virtual methods for patient contact (e.g. remote communication via mobile phone), and batching visits into the room

In ambulatory care setting, e.g. primary care provider office, have patient call the office once arrived and have them remain in their car until the office is ready to receive them.

Hold all PPE in a central location with a gatekeeper responsible for ensuring appropriate distribution

Limit number of direct care providers needing to enter room of a PUI or COVID-19. Direct care team will provide support services like daily cleaning and disinfection of isolation room, waste removal and deliver food trays. EVS will provide discharge/transfer (terminal) cleaning of the room after the patient has been discharged.

Transport personnel should not enter the room for patients in isolation for PUI or COVID-19 patients, rather have nursing prep the patient and move onto stretcher and push patient to door and have receiving unit prepared in PPE so that transport does not have to wear PPE (prep includes disinfecting bed rails and covering with clean linen).

In the surgical environment: Extended use is appropriate for respirators for patients not in contact precautions

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N95 Respirator Conservation Strategies Extend Use/Continuous: refers to the practice of wearing the same N95 respirator or isolation mask for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.

N95 respirators or mask must be covered by a face shield

PPE should be discarded when any of the following criteria are met:

PPE becomes visibly soiled, wet, or damaged

PPE becomes hard to breathe through (masks/respirators)

Disinfect face shields after removing and before re-donning

Reuse: refers to reusing the same N95 respirator or isolation mask by the same caregiver multiple times. PPE is donned by the caregiver, removed after each use, then donned again for the next patient.

- When available, cover the N95 respirator with a face shield - PPE should be discarded when any of the following criteria are met:

- PPE becomes visibly soiled, wet, or damaged - PPE becomes hard to breathe through (masks/respirators) - Respirators and masks can be stored between use in a paper bag - Hand hygiene should be performed after both removing and donning during reuse - Face shields must be disinfected after each use

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Caregiver Guidance for PPE Selection when Caring for Patient in Isolation

Supply Item Who/When to

Use When/How to Reuse

When/How to Extend Use

Surgical or

Procedural Mask

Staff collecting specimen Staff caring for a patient with

respiratory symptoms Staff when splashes, spray,

splatter or droplets of blood or other body fluids are anticipated

Patients with respiratory symptoms to contain secretions

For patients with diseases know to have airborne transmission by not contact transmission (measles, mumps, etc.) respirators can be reused For patients in droplet precautions, reuse is only acceptable if a full face shield is worn over the mask/respirator “Last resort/short term: Use a standard mask over an N95 respirator when face shields are not available.”

Extended use is right strategy for cohorted settings Mask can remain on

caregiver until it becomes damp, damaged, visibly soiled, or hard to breathe through

N95

If PAPR/CAPR not available or appropriate: Staff during aerosol-generating

procedures on patients with suspected or confirmed infection

Staff when caring for patients in isolation for airborne disease (measles, chickenpox, TB, etc.)

Extended use is right strategy for cohorted settings Respirator can remain

on caregiver until it becomes damp, damaged, visibly soiled, or hard to breathe through

Face shield or

goggles

Staff collecting specimens for COVID-19

Staff during aerosol-generating procedures on patients with suspending or confirmed infection

Staff when splashes spray, or other body fluids are anticipated

Wipe inside and outside with hospital-approved disinfectant wipe between each use. May have to follow-up with damp cloth for streaking.

Perform hand hygiene before and after contact

Wipe inside and outside with hospital-approved disinfectant wipe after doffing-may need to follow with damp cloth if streaking.

Perform hand hygiene before and after contact

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Contingency Tiered Approach Based on Inventory of PPE if Inventory is at Crisis Level

Strategies for Crisis Capacity of

PPE (Regular and alternate products unavailable)

Possible Substitution

N95 respirator

• Extended use • Reuse • Assign staff that have recovered from

COVID-19 and have them wear an isolation mask to care for COVID-19 patients.

• Surgical mask • Elastomeric or industrial respirator • Non-surgical respirator, or

any filtration capacity above 95%

• PAPR

Isolation Gowns

• Prioritize gowns for use during AGP, high touch procedures, do not use when entering room if nothing is going to be touched.

• Use "safe/PPE free zone” just inside door to isolation room.

• Hazmat suits • Reusable linen gowns • Paper gowns

• Plastic aprons to cover critical zones • Lab coat or jacket • Waterproof sports gear • Last resort: any physical barrier

Isolation Mask

• Extended use • Reuse

• Non-fluid resistant procedure masks (blue cones)

• Use N95s, CAPRs, PAPRs, isometric respirators

• Utilize non-fit tested expired N95s in pharmacy sterile compounding with extended use/reuse

• Last resort: any physical barrier between patient and mucous membranes / homemade products

Surgical Masks

• Extended use • Reuse

• Last resort: homemade cloth masks

Eye protection

• Disinfect and reuse eye protection - assign to each caregiver during assigned shift. If disinfected can be used between personnel.

• Swim goggles/ snorkel goggles • Industrial face shields (for grinding

metal) • Industrial goggles, safety glasses,

etc. • Last resort: homemade face shields

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Optimizing Use of N95 Respirator N95 respirators or powered air purifying respirators (PAPRs) are recommended by CDC for use by colleagues and clinicians during aerosol generating procedures (AGPs) for PUI or confirmed COVID-19 along with eye protection. The supply of N95 respirators is in yellow status currently – meaning available inventory is limited - and likely to get even more so over the course of this pandemic. The Occupational Safety & Health Administration (OSHA), that enforces a respiratory protection standard for use of N95, has issued a temporary, emergency enforcement guidance that has been used to develop this optimization guide. At this time, we are requiring the following strategies be deployed:

Facemasks are an acceptable, effective alternative to protect personnel when the supply chain of respirators

cannot meet the demand as is true currently. During this time, prioritize use of respirators for procedures that are likely to generate respiratory aerosols; AGPs. For all other care, wear mask and eye protection.

If available, personnel should prioritize use of powered air purifying respirators (PAPRs) for AGPs or other care when indicated for PUIs or patients with COVID-19.

If limited amount of PAPRs are available, ask those with facial, especially full face shields, to shave and use N95. A Guide from NIOSHA on which facial hairstyles are compatible with N95s is posted on COVID19 web site and can be used as alternative to removal of all facial hair.

Assure supplies of N95 respirators are secure and their deployment is overseen by colleagues for appropriate clinical, patient care use.

Until further notice, suspend annual fit testing of N95 filtering facepiece respirators for personnel that were successfully fitted in the prior year to optimize supply for patient care needs.

o If feasible, fit test personnel who have not previously been fit tested to the model, make and size of N95 provided prior to their use for a PUI or patient with COVID-19.

NOTE: During this current response to pandemic and ongoing surge of PUIs – instruct colleagues to

use seal check. See seal check guide in the Appendix - following the IFU from the manufacturer of

the N95 instead of fit testing all colleagues when a different make and model of N95 is being

provided.

o Rationale: stockpiles of N95s are likely to be a different make and model and this may happen repeatedly – there is limited capacity of personnel that are trained to perform fit testing and currently the fit testing solutions are becoming scarce.

- If fit testing is determined to be feasible by the EHS and or occupational health team use qualitative method only.

Only essential personnel needed for direct patient care are to enter the room of a patient under investigation (PUI) or confirmed COVID-19.

Assure personnel perform fit check (for proper seal of the N95) prior to each use. If the colleague cannot achieve a seal:

o See a PPE Coach. The coach will assess whether the mask is damaged or faulty. If the mask is not damaged or faulty but the colleague cannot achieve a seal, the

coach will send the mask for reprocessing following local ministry guidelines. If the mask is damaged or faulty, the PPE Coach will discard the mask and report the

issues to Supply Chain for tracking. This applies to all N95 respirators.

o When needed, the PPE Coach will assist the colleague in identifying the appropriate respirator or alternative respiratory protection device (such as a PAPR or CAPR).

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Inform employees to notify Employee Health of changes in their physical condition (e.g., facial scarring, dental changes, cosmetic surgery, or obvious changes in body weight) that could affect fit of N95 respirator to which they were successfully fitted. Explain to personnel that, if their face shape has changed since their last fit test, they may no longer be getting a good facial seal and may not be adequately protected.

N95 respirators are NOT to be provided to personnel with facial hair (e.g. beard) that interferes with the functionality of the mask (see Facial Hairstyles and Filtering Facepiece Respirators, Appendix). Options for personnel with a beard are to use PAPR or remove facial hair during response to this pandemic and wear a N95 respirator.

If available, personnel need to use powered air purifying respirators (PAPRs) for AGPs.

The CDC has provided a list of all manufacturers and model numbers for N95s, as well as alternative approved manufacturers of N95 respirator equivalents. OSHA has also temporarily updated their enforcement guidelines.

The CDC has also published several strategies for mask conservation. o Extend the use of N95 respirators by wearing the same N95 respirator for repeated close contact

encounters with several different patients, without removing the respirator. o Implement limited re-use of N95 respirators for caregivers of patients with COVID-19 or PUIs. Note,

if the respirator is torn or splashed with body fluids – discard after removal when leaving the isolation room. Important aspects of re-use are:

If available, wear a full-face shield over the N95 respirator to minimize possible contamination during direct care.

When doffing, use care as the exterior of the N95 respirator is potentially contaminated. Place N95 respirator into a storage bag for next use. Perform hand hygiene prior to donning, and after doffing, mask.

Store N95 respirator in an unsealed paper bag with the name of the personnel.

Don gloves prior to removing mask from bag, be sure to put on gloves prior to any contact with exterior of the respirator.

Do not share the same disposable respirator between different healthcare personnel.

o Facilities that have no touch disinfection (NTD) devices, e.g. ultraviolet germicidal irradiation used for whole room supplemental disinfection, can use this equipment for disinfection of N95 respirators.

A procedure developed by Nebraska Medicine is available on Pulse COVID19 web pages.

Before beginning this process, review the instructions for use for both the N95 and the NTD

device to determine compatibility of the N95 with the method used and the disinfection cycle time to achieve disinfection. Please contact Mike Trachta, MercyOne System Logistics Section Chief.

Do not attempt to disinfect disposable N95 respirators with disinfectant wipes or other liquids

as the N95 face piece is made of a filter media that will be damaged if immersed in liquid.

System Office Logistics and Supply Chain are working on a commercial vendor that will provide sterilization of N95 respirators– this is underway in some ministries. It is

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recommended that ministries begin collecting used masks that have been inspected for obvious damage or soiling for colleagues only. Marked bins are available in designated areas for the collection of masks. Follow the instructions in your collection area.

o Use of N95 respirator equivalents approved under standards used in other countries that are similar

to NIOSH-approved N95 respirators are acceptable to use. A listing of respirators certified by other countries is available on CDC's COVID19 web site.

o Use N95 respirators beyond the manufacturer-designated shelf life. Only use expired respirators when those are all that is available. Expired N95 Respirators generally must not be used when HCP perform surgical procedures on patients infected with, or potentially infected with, SARS-CoV-2, or perform or are present for procedures expected to generate aerosols or procedures where respiratory secretions are likely to be poorly controlled (per OHSA). Expired N95s must be clearly marked and follow all guidance set forth in Use of Expired N95s.

o Colleagues participating in an N95 optimization strategy are asked not to wear makeup below the eye, as this will compromise the N95 and make it ineligible for re-use.

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Appendix

Signs and Job Aids

19

Source: Lippincott Nursing, procedures. Online.

20

Examples of aerosol generating procedures

Aerosol Generating Procedures Procedures performed on patient with known or suspected COVID-19 could generate infectious aerosols.

CPR

Sputum induction-not recommended

Open deep oral suctioning

Tracheal intubation/extubation

High flow nasal cannula/Airvo o An oxygen supply system capable of delivering up to 100%

humidified and heated oxygen at a flow rate of up to 60 liters per minute.

Bipap/CPAP

Nebulizer treatments

Chest physiotherapy

Tracheostomy

Bronchoscopy o Lab, in support of procedure, can wait outside of room for specimen handoff

NG Tube placement

CORONAVIRUS DISEASE 2019

(COVID-19)

21

AGP placard for door

22

Air changes/hour (ACH) and time required for airborne-contaminant removal by efficiency

Source: https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html

23

Facial Hairstyles and Filtering Facepiece Respirators, NIOSH, CDC 2017

24

PPE At-a-Glance Guide to Donning PPE for PUI or COVID19 – No AGP. Acknowledgement and thanks to Emory Health System that developed this resource.

Available at: https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious-communicable-diseases-program/covid-19-resources/conserving-ppe.html

25

PPE At-a-Glance Guide to Donning PPE for PUI or COVID19 – AGP! Acknowledgement and thanks to Emory Health System that developed this resource.

Available at: https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious-communicable-diseases-program/covid-19-resources/conserving-ppe.html

26

PPE At-a-Glance Guide to Doffing PPE for PUI or COVID19 Acknowledgement and thanks to Emory Health System developed this resource

Available at: https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious-communicable-diseases-program/covid-19-resources/conserving-ppe.html

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Donning and Doffing Process for Conversation of Gowns During Crisis

**Gowns are specific patient use only.**

Some gowns cannot be reused due to the material composition. Consult with your local

Infection Preventionist if you’re unsure whether a gown can withstand disinfecting wipes.

Always perform hand hygiene before donning PPE

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Updated Guidance for PPE Goal: Reduce Health Care Provider (HCP) exposures

Strategy: Identify zones, delineate tasks & PPE, HAND HYGIENE between tasks & zones

29

Prolonged Mask Use Prophylaxis and Treatment - Ears When expecting prolonged use of masks, the following steps are recommended for behind the ears care:

Skin injury prevention recommendations:

Consider a headband with buttons or an "ear saver" device to protect ears while wearing mask

Apply a hydrocolloid dressing (ex. DuoDERM®) behind the ears for those who are at high risk of skin breakdown from wearing a mask.

Apply a barrier film wipe (ex. Cavilon™ No Sting Barrier Film Wipe (1mL)) daily: o This product is intended to protect the skin from moisture, adhesives, and friction. Do not use on skin

that is not intact. o This product provides a clear coating of protection on the skin o It is a hypoallergenic, alcohol-free, no-sting formula o Apply per manufacturer's instructions

Skin Injury treatment recommendations (skin is not intact or not blanchable):

Consider consulting a wound ostomy nurse if skin breakdown occurs.

Apply a hydrocolloid dressing (ex. DuoDERM® Extra Thin Hydrocolloid dressing) o Apply per manufacturer's instructions o Change dressing per manufacturer instructions

Prolonged Mask Use Prophylaxis and Treatment - Face It is important to note that masks should not irritate your skin. If you experience discomfort outside of the below

scenarios, see your local Employee Health or Colleague Safety Department for guidance. When expecting

prolonged use of masks, the following steps are recommended for care of the face:

Bruising

A tight seal is necessary for the mask to protect the user. However, to relieve pain from bruising, users can apply

cool compresses for 20-30 minutes after their shift.

Eczema

For irritant contact dermatitis or allergic contact dermatitis, users should wash their face and apply hydrocortisone

ointment 1% to affected areas, followed by a barrier cream meant for chapped skin (ex. Vaseline, Aquaphor).

NOTE: Barrier creams may interfere with the fit seal on an N95 respirator. Apply after mask use only.

Acne

Wash or wipe sweat off the area as soon as the mask is removed. Consider a face wash with salicylic acid or

benzoyl peroxide. Do not wear cosmetics under an N95 respirator as this may exacerbate the issue.

Skin Breakdown

Wash with a gentle soap or cleanser. Apply a barrier cream meant for chapped skin (ex. Vaseline, Aquaphor). While

off-duty, consider a hydrocolloid dressing. NOTE: Barrier creams or padding may interfere with the fit seal on

an N95 respirator. Apply after mask use only.

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PPE from Other Counties

Source: https://www.osha.gov/memos/2020-04-03/enforcement-guidance-use-respiratory-protection-equipment-

certified-under