• Standard infection prevention and control precautions should always be used when delivering care to all patients.

• All staff should have access to required personal protective equipment; gloves, aprons, gowns, masks (surgical and FFP3) and eye protection.

• Personal protective equipment choice is based on an assessment of risk.

• A Quick Guide to PPE selection is on pages 6-7 of this guideline.

• This guidance should be followed in conjunction with the guidance in the National Infection Prevention and Control Manual (NHSE 2024) (and references therein) Chapters on Standard IPC and Transmission-Based Precautions

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

This document provides guidance on the use of personal protective equipment (PPE) for prevention and control of infection, as one of the Standard IPC Precautions (NHSE 2024) , to enable Trust staff to select PPE based on assessment of the risk of transmission of micro-organisms to the patient, and the risk of contamination of the healthcare worker’s clothing and skin by patients’ blood, body fluids, secretions and excretions (Loveday at al 2014).

The appropriate and consistent use of personal protective equipment can help protect the wearer from exposure to blood, body fluids and chemical and reduce the risk of cross-infection. The inappropriate wearing of PPE can result in a waste of resources, missed hand hygiene opportunities and may result in an increased risk of cross-transmission (Wilson & Loveday 2014, WHO 2009).

2.1 PPE Risk Assessment

Before undertaking any procedure, staff should assess any likely exposure to blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated. Staff must ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken, in line with Standard IPC Precautions (NHSE 2024).

2.2 PPE General Principles

• accessible and located close to the point of use;

• stored to prevent contamination in a clean/dry area until required for use (expiry dates must be adhered to). PPE for healthcare professionals providing care in the community and domiciliary care providers must be transported in a clean receptacle;

• single-use only items unless specified by the manufacturer;

• changed immediately after each patient and/or following completion of a procedure or task; and

• disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.

• Discarded if damaged or contaminated.

Reusable PPE items, e.g. non-disposable goggles/face shields/visors must be decontaminated after every use, according to the manufacturer’s instructions.

2.3 PPE for Transmission-Based Precautions (TBPs)

Standard IPC precautions may be insufficient to prevent cross transmission of specific infectious agents. Therefore, additional precautions TBPs are required to be used by staff when caring for patients with a known or suspected infection or colonisation. Clinical judgement and decisions should be made by staff on the necessary precautions. This must be based on the:

• suspected or known infectious agent

• severity of the illness caused

• transmission route of the infectious agent

• care setting and procedures undertaken

TBPs are categorised by the route of transmission of infectious agents (some infectious agents can be transmitted by more than one route). Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

2.3.1 Droplet precautions

Used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.

2.3.2 Airborne precautions

Used to prevent and control infections spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.

2.3.3 High Consequence Infectious Disease (HCID) precautions

Please refer to the NIPCM (NHSE 2024) Addendum on HCID PPE. Refer to the UKHSA (2023) list of HCIDs which require implementation of HCID-level PPE.

2.4 Quick Guide to PPE selection

2.5 Process for Donning and Doffing of PPE

Refer to the NIPCM (NHSE 2024) Appendix 6 for the process for safe donning (putting on) and doffing (removing) of PPE.

Gloves must be:

• Worn when exposure to blood and/or other body fluids, non-intact skin or mucous membranes is anticipated or likely

• Changed immediately after each patient and/or after completing a procedure/task even on the same patient

• Changed if a perforation or puncture is suspected

• Appropriate for use, fit for purpose and well-fitting

• Never decontaminated with ABHR or soap between use.

• Hand hygiene must be carried out immediately following the removal of gloves. Gloves are not a substitute for hand hygiene, and hand hygiene must always be performed following the removal of gloves (WHO 2009).

• Gloves should only be worn when indicated. Inappropriate, prolonged or indiscriminate use can lead to missed opportunities for hand hygiene, risk of cross-infection an importantly and increased risk of developing contact dermatitis and/or exacerbating pre-existing skin problems.

• GLOVES ARE MARKED AS ‘SINGLE USE’ - they must not be reprocessed.

• Gloves must conform to the relevant quality standards (European Community (CE marked)).

• Gloves must be stored as per manufacturer’s instructions and be available in a range of sizes.

• Double-gloving is not recommended for routine clinical care.

3.1 Types of Clinical Gloves

• The choice of glove should be made following a risk assessment of:

• task to be performed

• anticipated contact and compatibility with chemicals and to cytotoxic drugs

• latex or other sensitivity

• glove size required

• Any suspected sensitivity to natural rubber latex gloves in healthcare personnel must be reported immediately to the Occupational Health Department.

• Sensitivity to natural rubber latex in any patient must be documented, and alternatives to latex gloves must be available.

• Midwives attending labour in the birthing pool must have access to long (gauntlet style) gloves.

• Powdered and polythene gloves must not be used in healthcare activities (Loveday et al 2014).

3.2 Sterile Gloves or Clean Examination Gloves?

(See also: IPC30 Principles of Asepsis)

The choice of sterile or clean examination gloves should be made on a risk assessment of whether the procedure can be carried out without touching key parts or key sites (those parts of the patient or equipment, that if contaminated, provide a direct route for transmission of pathogens between the procedure and the patient) (Rowley et al 2010).

The risk assessment will vary according to the complexity of the task and the skill/ expertise of the staff member carrying out the task.

Examples of clinical glove use

- Sterilised Gloves

• Operating Theatre and Ward surgical/invasive procedures

• Complex wound dressing procedure

• Vaginal examination (ruptured membranes, delivery, following surgery)

• Insertion of central vascular devices

- Clean Examination gloves

• Direct contact with blood or body fluids

• Direct contact with mucous membranes and non-intact skin

• Handling hazardous chemicals (such as disinfectants)

• Cleaning spills of blood or body fluids

• Cleaning dirty/used patient equipment/instruments

• Handling soiled linen

• Cytotoxic drugs (vinyl gloves to be used)

Provide a physical barrier between clothing/ skin and prevent contamination and wetting of clothing/ uniforms during clinical tasks.

• Should be only be worn if contamination of clothing or uniform with body substances is anticipated or splashing is likely.

• Plastic aprons must be worn as single use items for each clinical procedure or episode of patient care and then discarded.

• Plastic aprons must be stored safely so they do not accumulate dust (RCN 2022).

• Fluid-repellent gown or coverall must be worn during procedures likely to cause extensive splashing of body substances onto the body, e.g. major surgical, obstetrical procedures and endoscopy.
• Gowns should be worn when a disposable apron provides inadequate cover for the procedure/ tasks being performed.
• Routine use of gowns is not recommended in general clinical areas.
• Gowns must be changed between patients.
• If gowns are worn for sessional use during the care of a patient undergoing aerosol-generating procedures, the gown should be short-sleeved to enable effective hand hygiene between patient care activities.
• Gowns must be sterile when worn in operating theatres and for insertion of central venous catheters, insertion of peripherally inserted central catheters, insertion of pulmonary artery catheters and spinal, epidural and caudal procedures.

• Eye protection must be worn during procedures likely to cause splashing of body substances into the eyes, mouth or nose, e.g. major surgical procedures, childbirth, intra-arterial puncture, AGPs, and if manually cleaning instruments.

• Eye protection must cover the full peri-orbital region and wrap around the side of the face.

• Eye protection must be removed or changed in accordance with manufacturer’s instructions, if vision is compromised through contamination with blood or body fluids, if the integrity of the equipment is compromised, at the end of a clinical procedure/task and/or prior to leaving the dedicated clinical area.

7.1 Fluid-resistant surgical facemasks (FRSM)

Surgical face masks are required as a means of source control, eg to protect the patient from the wearer during sterile procedures such as surgery; and to protect the wearer when there is a risk splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa.

Fluid-resistant surgical facemasks (FRSM) are worn as part of droplet precautions. The purpose of FRSM is to prevent respiratory droplets being expelled into the environment by the wearer, and to provide protection against splashes/ droplets of blood or body fluids to the nose and mouth. If there is a high risk of splashing, a face visor is recommended. Surgical facemasks are not designed for high filtration efficacy or to seal tightly to the face.

FRSM must be:

• worn if a full-face visor is not available for spraying or splashing

• worn with eye protection if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated or likely (Type IIR)

• worn to protect patients from the operator as a source of infection, eg when performing surgical procedures or epidurals or inserting a central vascular catheter (CVC) (Type II or Type IIR)

• well-fitting and fit for purpose, fully covering the mouth and nose (manufacturers’ instructions must be followed to ensure effective fit and protection)

• removed or changed at the end of a procedure/task

• if the mask’s integrity is breached, eg from moisture build-up after extended use or from gross contamination with blood or body fluids

• in accordance with manufacturers’ specific instructions.

• transparent face masks may be used to aide communication with patients in settings where FRSM Type IIR are used as personal protective equipment. They must meet the standards set by the national Transparent facemask technical specification.

7.2 Respiratory Protective Equipment (RPE)

Respiratory Protective Equipment (RPE) ie, a filtering face piece (FFP) must be considered when a patient is admitted with a known/suspected infectious agent/disease spread wholly or partly by the airborne route (including COVID-19) and when carrying out aerosol generating procedures (AGPs, Section 8) on patients with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

Respirators are designed to protect the wearer from airborne particles. They are made to defined national standards or the similar European standards FFP2 or FFP3. The standards define the performance required of the respirator, including filtration efficiency. When worn correctly, they seal firmly to the face, thus reducing the risk of leakage.
Where an unacceptable risk of respiratory infectious disease transmission remains following risk assessment, it may be necessary to consider the extended use of FFP3s for patient care in specific situations. The risk assessment should include evaluation of the ventilation in the area, operational capacity, vaccination status of healthcare workers, and prevalence of infection.

• Healthcare staff who are required to wear respirators for tasks with patients, must have been ‘fit-tested’ to ensure the mask is the appropriate size and type to provide protection, and carry out a ‘fit-check’ every time that mask is donned. Fit testing is advised to be repeated a minimum of every two years.

• Staff who are trained to ‘fit test’ their staff, must attend a ‘train the trainer’ session every 3-years to ensure best practice is being followed.

• Passed fit tests must be recorded on the Electronic Staff Record (ESR).

• In the event of no FFP3 masks having the required fit a staff member’s face, they are advised to not undertake high risk procedures with patients suspected or confirmed to have a respiratory-spread infectious disease, unless a PeRSO respirator hood is available for use.

• PeRSO hoods are available in areas of high RPE use (such as Critical Care/ ITU, MADU, and Emergency Department Resus). Follow the guidance for PeRSO respirators use and decontamination on the trust intranet (IPC microsite, in the Fit Testing folder).

• Valved respirators and PeRSO hoods must not be worn during procedures that require surgical aseptic non-touch technique, as there is no expiratory valve.

The list below (NHSE 2024) are the procedures demonstrated through evidence, to generate a significantly high number of respirable aerosols, and are associated with an increased risk of respiratory infection transmission:

• tracheal intubation and extubation (removed from national AGP list in July 2022 – currently under Trust review)

• tracheostomy procedures (insertion or removal)

• awake* bronchoscopy (including awake tracheal intubation)

• dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills)

• induction of sputum

• respiratory tract suctioning

• awake* ENT airway procedures that involve respiratory suctioning

• awake* upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs beyond the oro-pharynx

• surgery or post-mortem procedures (like high-speed cutting / drilling) likely to produce aerosol from the respiratory tract (upper or lower) or sinuses.

*Awake including ‘conscious’ sedation (excluding anaesthetised patients with secured airway).

Where AGPs are medically necessary for patients with known or suspected infections, they should be undertaken in a negative-pressure room if available or in a single room with the door closed. The time required to wait prior to decontamination of rooms in which AGPs take place, is dependent on the ventilation of that room (air changes/ hour).

Only the minimum number of required staff should be present, and they must all wear AGP PPE as described. Entry and exit from the room should be minimised during the procedure.

NERVTAG (NHSE 2022) advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.

Visitors do not routinely need to wear PPE unless they are assisting with direct care activities where there is the potential for exposure to blood or other bodily excretions/secretions, or risk of exposure to specific infectious diseases. They must clean their hands-on arrival and prior to leaving.

Patients may be required to wear PPE for prevention of spread of specific infectious diseases; for example, wearing a fluid repellent surgical facemask to prevent the spread of respiratory infectious diseases (such as COVID-19, TB, influenza) on transfer from source isolation. The aim of this is to minimise the dispersal of respiratory secretions, reduce both direct transmission risk and environmental contamination. A mask should not be worn by patients if there is potential for their clinical care to be compromised (for example, when receiving oxygen therapy via a mask). Physical distancing must be promoted.

Staff who have direct contact with patient blood or body fluids must be immunised against Hepatitis B.

Cuts and abrasions in any area of exposed skin should be covered with a waterproof dressing. Health-care workers with open areas on their hands or forearms (e.g. exudative lesions/weeping dermatitis) must seek advice from the Occupational Health department and avoid all direct patient care, food handling or handling of patient-care equipment until the condition resolves.

• Staff must be trained and competent to collect and handle the specimen safely and have up to date immunisation cover.

• Wear appropriate personal protective equipment based on assessment of the risk associated with the procedure.

• Hand hygiene must be carried out in line with the ‘5 Moments for Hand Hygiene’ (WHO 2009).

• All specimens must be in an approved, leak proof container. Ensure the lid is on correctly (i.e. tight). This should then be placed within a sealable polythene bag (with request form attached).

• Avoid contamination of the outside of the container and request form as this places laboratory staff at risk.

• Do not use clips or staples as these may puncture the bag.

• It is critical to provide accurate clinical details on microbiology test requests, to ensure:

• samples are tested

• the most appropriate processing of samples

• correct assessment of the clinical relevance of results

• adequate protection of laboratory staff from potentially hazardous organisms

• safe handling of samples in the laboratory Important clinical details include:

• Travel history

• Suspicion of high-risk pathogens

• Recent/ current antimicrobial treatment

• High-risk occupational information

Monitoring of this guideline is via the annual IPC audit programme.

Department of Health 2013 HTM 00-09 Infection Control in the Built Environment. The Stationary Office. London. https://www.england.nhs.uk/publication/infection-control-in-the-built-environment-hbn-00-09/

Loveday HP, Wilson JE, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M, 2014b epic3: National Evidence-based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infections. 86S1 (2014) S1–S70. Available at: https://www.journalofhospitalinfection.com/article/S0195-6701(13)60012-2/pdf

NHS England 2022 A rapid review of aerosol generating procedures (AGPs). An assessment of the UK AGP list conducted on behalf of the UK IPC Cell. Available at: https://www.england.nhs.uk/wp-content/uploads/2022/04/C1632_rapid-review-of-aerosol-generating-procedures.pdf

NHS England 2024 National Infection Prevention and Control Manual for England. Available at: https://www.england.nhs.uk/publication/national-infection-prevention-and-control/

RCN 2022 Tools of the trade: guidance for health care staff on glove use and the prevention of work-related contact dermatitis. Available at: https://www.rcn.org.uk/Professional-Development/publications/tools-of-the-trade-uk-pub-010-218

Rowley S, Clare S, Macqueen S, Molyneux R 2010 ANTT v2: An updated practice framework for aseptic technique British Journal of Nursing 19 (5): S5-S11.

UK Health Security Agency 2024 High consequence infectious diseases (HCID) webpages. Available at: https://www.gov.uk/guidance/high-consequence-infectious-diseases-hcid

World Health Organisation 2009 Glove Use Information Leaflet WHO, Geneva. Available at: https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/infection-prevention-and-control/hand-hygiene/tools/glove-use-information-leaflet.pdf

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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