Which activity does the nurse carry out while maintaining a zone of personal distance

Section 5. Designating Areas for PPE Donning and Doffing

• Ensure that areas for donning and doffing are designated as separate from the patient care area (e.g., patient’s room) and that there is a predominantly one-way flow from the donning area to the patient care area to the doffing area.
• Confirm that the doffing area is large enough to allow freedom of movement for safe doffing as well as space for a waste receptacle, a new glove supply, and ABHR used during the doffing process. If using a PAPR with external belt-mounted blower, confirm that there is an area or container designated for collecting PAPR components for cleaning and disinfection, as well as routine maintenance.

Facilities should ensure that space and layout allow for clear separation between clean and contaminated areas. Separate the space into distinct areas and establish a directional, one-way flow of care, moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where potentially contaminated PPE is removed and discarded). The direction of flow should be marked (e.g., signs on the floor) with visible signage; temporary plastic enclosures can be added if necessary. Existing anterooms to patient rooms have been used for doffing but in many cases are not ideal because of their small dimensions. As an alternative, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window) and provided that the healthcare worker doffing PPE can hear the instructions of the trained observer.

Whenever possible, close the end of the hallway of a ward or ICU to through traffic, thereby restricting access to the patient’s room to essential personnel who are properly trained in recommended infection prevention practices for caring for patients with Ebola. Designate two adjacent rooms, located on either side of the patient’s room, to be cleared of equipment and furniture and used as donning and doffing areas. Glass-enclosed rooms or other designs (e.g., wide glass doors, windows, video monitoring) to observe ongoing care in the patient room and activity in the doffing area are preferred. The path from the room of the patient with Ebola to an external doffing room should be as short as possible and clearly defined and/or enclosed as a contaminated area that is cleaned frequently along with the doffing area. If areas are reconfigured, the facility should make certain the space remains compliant with all applicable building and fire codes.

Post signage to highlight key aspects of PPE donning and doffing, including

• Designating clean areas vs. contaminated areas
• Reminding healthcare workers to wait for a trained observer before removing PPE
• Listing each step of the doffing procedure
• Reinforcing the need for slow and deliberate removal of PPE to prevent self-contamination
• Reminding healthcare workers to disinfect gloved hands in between steps of the doffing procedure, as indicated below.

Designate the following areas with appropriate signage

1. PPE Storage and Donning Area

This is a clean area outside the patient room (e.g., a nearby vacant patient room, a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers don PPE before entering the contaminated area and the patient’s room. Do not store potentially contaminated equipment (e.g., PAPR components that have not been cleaned and disinfected), used PPE, or waste removed from the patient’s room in the clean area. If waste must pass through this area, it must be properly contained.

2. Patient Room

Use a single-patient room, preferably with a private bathroom; a covered bedside commode with bagging of human waste is an alternative approach. Plan ahead for the need to store many bags of regulated medical waste before their secondary containment. Additional guidance on waste management can be accessed at Ebola-Associated Waste Management and www.osha.gov/Publications/OSHA_FS-3766.pdf [PDF – 6 pages]. The door to the patient room should be kept closed. Any item or healthcare worker exiting this room should be considered contaminated.

3. PPE Doffing Area

Designate an area near the patient’s room (e.g., anteroom or adjacent vacant patient room that is separate from the clean area) where healthcare workers leaving the patient’s room can stand to doff and discard their PPE. Alternatively, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window and provided that the healthcare worker doffing PPE can hear the instructions of the trained observer). Do not use this designated area within the patient room for any other purpose. Stock gloves in a clean section of the PPE removal area accessible to the healthcare worker while doffing.

In the PPE removal area, provide supplies to disinfect PPE and perform hand hygiene and space to remove PPE, including an easily cleaned and disinfected seat where healthcare workers can remove boot or shoe covers. If space allows, designate stations around the perimeter of the doffing room where each piece of PPE will be removed, moving from more contaminated to less contaminated areas of the room as PPE is doffed. Provide leak-proof disposable infectious waste containers for discarding used PPE. Provide a container to collect all reusable PAPR components. Frequently clean and disinfect the PPE removal area, including after each doffing procedure has been completed. One way such cleaning may be achieved is by having another healthcare worker who has just donned their full PPE clean the doffing area, moving from cleaner to dirtier areas within the doffing area, before entering the patient’s room.

Facilities should consider making showers available for use for the comfort of healthcare workers after doffing PPE at the end of their shift; the heat from wearing PPE is likely to cause significant perspiration.

Section 6. Selecting PPE for Healthcare Workers Who Care for Patients with Ebola

This section outlines several PPE combinations and how they should be worn. The key to safely wearing PPE is consistent and correct use reinforced by repeated training and practice. Variations in PPE used to care for patients with Ebola should be avoided within a facility. A facility should select and standardize the PPE to be used by all healthcare workers who are directly interacting with patients with Ebola. OSHA’s Bloodborne Pathogens standard requires employers to establish a written Exposure Control plan designed to eliminate or minimize employee exposures and should include procedures for donning and doffing the PPE ensemble that is chosen. The protocol must be reviewed by staff who participate in Ebola care and the trained observer should ensure the protocol is adhered to.

Airborne transmission of Ebola has not been documented in hospitals or households during any of the human outbreaks investigated to date. However, certain procedures (e.g., bronchoscopy, endotracheal intubation) might create mechanically generated aerosols that could be infectious. Such aerosol-generating procedures require additional precautions. Experience in the care of patients hospitalized with Ebola in the United States indicates that the level of care may change unexpectedly and could require an aerosol-generating procedure. Because there might not be time for staff to leave the room to don proper PPE for an aerosol-generating procedure, CDC recommends that all healthcare workers entering the room of a patient with Ebola wear respiratory protection that would protect them during an aerosol-generating procedure. This would include a NIOSH-certified, fit-tested N-95 or higher respirator, or a PAPR.

Safety and comfort are both critical for healthcare workers wearing PPE while caring for patients with Ebola. Standardized attire under PPE (e.g., surgical scrubs or disposable garments and dedicated washable footwear) helps the donning and doffing process and eliminates concerns of contaminating personal clothing. Footwear should be closed-toe, soft-soled, washable, and have a closed back. If facilities elect to use different PPE from what is outlined below (e.g., coveralls with either an integrated hood or a surgical hood with integrated full face shield), they must train healthcare workers on how to use each type of PPE type and ensure that donning and doffing procedures are adjusted and practiced accordingly. Extra layers of PPE are not advised because they can reduce comfort, field of vision, and mobility and increase the risk of error and injury while adding no meaningful protection for the wearer.

In this guidance, impermeable gowns and coveralls indicates that the material and construction have demonstrated resistance to synthetic blood and simulated bloodborne pathogens. In contrast, fluid-resistant indicates a gown that has demonstrated resistance to water or a coverall that has demonstrated resistance to water or synthetic blood. These categories reflect the currently available U.S. product specifications; specific test methods that assess resistance for these products are listed in Table 1. When purchasing gowns and coveralls, facilities should follow specifications in Table 1 to ensure they select gowns and coveralls as described in Sections 5 and 6 below.

Table 1. Specifications for impermeable and fluid-resistant gowns and coveralls

*Testing by an ISO 17025 certified third party laboratory is recommended.

For more details, refer to technical document “Considerations for Selecting Protective Clothing used in Healthcare for Protection Against Microorganisms in Blood and Body Fluids”, which provides a more detailed explanation of the scientific evidence and national and international standards, test methods, and specifications for fluid-resistant and impermeable protective clothing used in healthcare.

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