The Importance of PPE Selection in Healthcare

PPE is used throughout health care, it is any form of equipment that will protect its user against health or safety risks whilst at work, which includes potential cross infection. Making the workplace safe means that organisations are responsible for providing instructions, procedures, training and supervision to encourage people to work safely and responsibly, including using PPE to protect themselves whilst working with individuals who are known to be or who are potentially unwell.

Organisations should be clear about when PPE is required and never deviate from the rules, for example telling a nurse that she needn’t wear gloves because the procedure will ‘only take a few seconds’ or telling a care assistant that he needn’t get an apron because ‘the individual’s symptoms have subsided’.

Deviation from the rules about PPE places everyone within a setting at risk, including any visitors who may enter it such as contractors or those in care homes who have come to see their family members.

When should PPE be used?

PPE should be used whenever there is a risk within a workplace to an employee’s health and safety. However, despite the fact that use of PPE is widespread in healthcare settings, the Health and Safety Executive maintains that, in general, its usage should only be as a last resort, at times when risks cannot be controlled in other ways.

In a healthcare setting, some examples of when it is necessary to use PPE of various kinds include:

• When using sharps or contaminated devices
• When carrying out personal care tasks with individuals
• When there is a risk of blood or bodily fluids splashing into the eyes and face
• When there is a risk of blood or bodily fluids spilling in greater amounts such as in an operating theatre
• When carrying out activities that risk infection transmission such as giving injections or carrying out moving and positioning.

This list is by no means exhaustive and it will change depending on the nature of the activity being carried out and the setting where it is being carried out.

The reasons behind PPE

In a healthcare setting, the main reason behind the use of PPE is to protect healthcare workers whilst performing specific tasks that may involve them coming into contact with any bodily fluid that may contain infectious agents, for example bacteria and viruses.

PPE therefore acts as a barrier which helps to minimise the potential spread of infection within a setting, which in turn protects not just healthcare workers but anyone else within the setting as well such as patients and any visitors.

All healthcare workers should use PPE when there is a chance that they may have contact with bodily fluids, no matter how small this chance may be.

Carrying out a risk assessment for PPE and infection control      

Employers are responsible for assessing risks and preventing exposure to hazards as far as this is reasonably possible and this includes any hazards that may necessitate the use of PPE such as bodily fluids.

The NHS base their risk assessment procedure on the Health and Safety Executive’s commonly used ‘Five Steps to Risk Assessment’, which is straightforward to follow and can be applied to infection control.

The five steps that are covered within this risk assessment are:

• Step 1 – Identify the hazards
• Step 2 – Decide who might be harmed and how
• Step 3 – Evaluate the risks and decide on precautions
• Step 4 – Record the findings and implement them
• Step 5 – Monitor performance and review.

Step 1 – Identify the hazards

Any procedure where an employee works with someone who has an infection (whether known or not) will have their risk of developing an infection increased.

The risk will vary greatly depending on the activity that is being undertaken; some areas of practice have a low risk of infection but in some areas, the risk remains consistently high.

With this in mind, all risks should be assessed in all situations where the employee may be exposed to blood or any other material that has the potential for cross infection.

Step 2 – Decide who might be harmed and how

Legislation concerning infection control covers all employees who work within an organisation as well as those people who are self-employed within the setting and those who work on behalf of an agency, such as bank staff and those who are provided by other companies to carry out services such as catering and cleaning.

Those employees who are directly involved with individuals who are unwell have the potential to be exposed to various risks when using them, which include:

• Clinical actions such as taking blood, fixing a cannula and giving a vaccination
• Ancillary actions such as cleaning, portering and ensuring that supplies are sterile
• Work carried out in a laboratory
• Work carried out in a mortuary.

Employees who use medical equipment and who are in direct contact with individuals who are unwell are the most at risk of infection, and examples of these roles include:

• Nurses
• Doctors
• Phlebotomists.

However, other staff, such as cleaning staff remain at risk, for example cleaners and other ancillary employees, who may be at risk of infection from equipment and linens which have not been disposed of properly.

Step 3 – Evaluate the risks and decide on precautions

It is recommended that the best way to evaluate risk is to compare the practice that is currently being carried out with what is known to be good practice. Any identified hazards that come about because of such a comparison should be assessed to see if it can be eliminated altogether or if it can only be controlled to ensure that the risk of harm remains as low as possible.

COSHH Regulations require that a hierarchical approach be followed to prevent the risk of infection:

1. Preventing the risk of exposure – The complete removal of a hazard
2. Controlling the risk of exposure – Through use of effective work practices
3. The control of exposure at source – Through use of work practice controls
4. Personal protective equipment (PPE) – Such as correct use of gloves and masks
5. Underpinned by administrative controls, information and training.

Administrative controls that limit the exposure to hazards

Administrative controls ensure that the correct information about good practice is accessible to all employees as well as ensuring that employees have access to training that is relevant to their role. Examples of administrative controls include:

• Ensuring that all staff are aware of their responsibilities in terms of health and safety
• A clear infection control policy is in place which covers prevention of injury and illness as well as follow-up treatment and follow-up information
• The removal of all unsafe equipment
• Safe systems of work are in place where there is a higher risk such as operating theatres
• Consistent information and training is provided to all employees concerning the correct use and disposal of medical equipment.

Specific risk assessment related to Covid-19

Initial risk assessments should be carried out by phone or another remote method before entering the clinical setting. PPE should be put on before the healthcare worker carries out an activity to ascertain if the individual has Covid-19.

If the healthcare worker cannot establish the risks posed before any form of care activity takes place then the recommendation is that they have access, in any setting, to aprons, respirators, eye protection and gloves so that these are ready and available to be worn at any time.

It is recommended that respirator masks should be worn if there is going to be or suspected to be prolonged interaction with an individual who has or who may have Covid-19.

Healthcare workers are advised that if there is any risk at all to themselves or to the individual that they should wear a fluid repellent surgical mask, with or without eye protection, determined by the individual healthcare worker.

Choosing the correct PPE for maximum effect

Healthcare workers should be trained to know what kind of PPE they need in relation to the task that they will be carrying out – this will be established by using the findings of a correctly carried out risk assessment.

However, healthcare workers also need to take into account the fit and comfort of PPE when they are selecting the correct items to use. PPE that fits well and is comfortable will not only encourage its use but is much more likely to keep the healthcare worker and thus everyone else safe from hazards.

Places of work should have written guidance in the form of a PPE policy that gives instructions about when to wear PPE and what type should be used. All healthcare workers should be aware of the content of this policy and should seek recommendations from a supervisor or manager if they are in any doubt at all about effective use of PPE.

Types of PPE that are commonly used

Here are the most common forms of PPE that are used in normal circumstances by most members of staff:

• Gloves: Gloves should be put on before any task where there may be contact with body fluid. They must then be removed immediately upon its completion. Employees should ensure that individuals are not allergic to latex before assisting with any procedure that involves direct contact with an individual, as most gloves that are used in a healthcare setting are made from this material and an alternative material must be made available by the employer.
• Overshoes: These are worn to prevent the transmission of infection via flooring. They are used most commonly in a clinical environment when employees are working with individuals who have had surgical procedures or those who may have been placed in isolation.
• Aprons: Aprons, like gloves, should be worn when carrying out any task where there is a possibility of coming into contact with body fluids. They should be removed immediately after the task has been completed and disposed of in the correct manner, in line with official guidance.
• Face shields including goggles: These are important when working with an individual who may have some form of infection, or where there is the possibility that the employee’s face or eyes may be splashed with some form of body fluid. Any form of surgical mask should cover the face and nose so that germs cannot be breathed in or out. Respirator masks form a tight seal around the mouth and nose and are used in cases where risk of infection is very high and/or when infection is/has the potential to be deadlier.

Single sessional use of PPE

Single sessional use of PPE refers to an instance where the healthcare worker is carrying out activities in a specific clinical setting or environment such as within a specific ward within a hospital.

The ‘session’ in relation to PPE ends when the healthcare worker leaves the specific setting or environment and so at this time, PPE would be removed and disposed of safely.

There is no set time for a session to take, as this will vary depending on the activities being undertaken. However, PPE should be removed and replaced if it becomes damaged during a session or if it is used beyond the time period that is given by the manufacturer.

Reusing PPE

Only items of PPE that have a manufacturer’s instruction to say that they are reusable should be reused. This does not, therefore, apply to single-use items such as gloves, overshoes and aprons.

Items of PPE that are sometimes reusable include:

• Surgical gowns or coveralls
• Laboratory coats
• Long-sleeve patient gowns
• Visors
• Goggles.

Even though some items of PPE are reusable, they still need to remain fit for purpose and should be disposed of if they become damaged or are beyond the recommended use-by date set by the manufacturer. They should be cleaned in line with local policy and should not, at any time, be reused in a way that would put the healthcare worker or others at risk.

Healthcare workers should know what items of PPE are single-use and what are reusable but if they are ever in any doubt, they should check with a supervisor or manager.

Problems associated with PPE

Just like with any safety system, the use of PPE is not perfect and there exist several different issues that can come about with PPE and its correct usage.

• Ill-fitting items: If an item of PPE is not worn correctly because it does not fit the user then its effectiveness will be compromised. It is often argued that most PPE is designed to fit men and that women therefore have problems with some items not fitting them correctly.
• Wrong choice of PPE: The choice of PPE will depend on the activity being undertaken and healthcare workers need to be confident that the PPE they choose will support health and safety measures and not put anyone at risk. For example, a healthcare worker may not wear a respirator mask when in prolonged contact with someone who has Covid-19 symptoms.
• Costs: The cost of PPE to public and private healthcare providers is usually in line with its demand; the more PPE that is needed, the more suppliers may charge. Restrictive costing can put settings under pressure to reduce the amount of PPE they use but this is a counter-productive measure as it increases the risk of the spread of infection, meaning that in the long term, the need for PPE will be even greater.
• Availability: At the outset of the Covid-19 outbreak, it was well publicised that the amount of PPE that was available to healthcare providers was not in line with what they needed and that people were being put at risk because of this. It is recommended that PPE is ordered well in advance using some form of predictor but, in unprecedented cases, being able to do this is not always straightforward.
• Authenticity: When demand for PPE is high, this can mean that unscrupulous suppliers will sell PPE that is not authentic or not in line with the correct standards. Settings should check the quality of the product before using it in a setting to ensure that to use it will not place people at risk.

Provision and maintenance of PPE

It is the legal responsibility of the employer to provide adequate PPE to employees whose responsibility it is then to use it appropriately and to make sure that it is properly maintained and disposed of as necessary.

Failure to provide PPE where it is needed not only puts people at risk of harm but it is also illegal in line with the PPE Regulations and the Health and Safety at Work etc. Act 1974.

When maintaining PPE, the following should be considered to ensure that it remains fit for purpose:

• Are there available replacement parts if it becomes damaged, for example filters in respirator masks?
• Are there replacement items available if PPE suddenly becomes unusable?
• Is it more cost effective to use single-use items?
• Ensure that PPE is checked regularly
• Any damage to PPE must be reported to a line manager immediately.

Maintenance of PPE may involve cleaning and storing it most effectively and settings should have a policy about how this should be carried out. For the most part, PPE should be cleaned by a professional cleaning agency so that it does not cause a hazard. PPE that is taken home is the responsibility of the healthcare worker and should be kept fit for purpose.

Storing PPE

When it is not in use, PPE should be properly stored, which means in a location that is clean and dry and where it can be easily accessed and not exposed to potentially damaging conditions.

The storing of PPE should reflect health and safety, so it should not be placed in an overflowing cupboard or on a high shelf; it should not be stacked and use should be made of tools like hooks and low shelving.

If PPE is stored for a considerable period of time, it must be checked to ensure that it remains within the manufacturer’s use-by date before it is worn.

Warning signs

In any setting where PPE is required there should be some form of signage to alert healthcare professionals to this requirement. Some signs will be generic and refer only to ‘PPE’ but some will be more specific and will state the kinds of PPE that should be worn, for example goggles or visors.

Anyone entering a setting where such a sign is visible should adhere to it; failure to do so not only puts that specific individual at risk but also anyone else who may enter the setting as well.

Since the outbreak of Covid-19, the use of warning signs about PPE has become more prevalent and their use is far more widespread. This means that in some settings, warning signs must now be adhered to by the general public who are also required to wear PPE (most often face coverings) when entering clinical settings like hospitals and GP surgeries.