Personal Protective EquipmentPE Guidance for COVID-19 in Long- Term Care Settings

Implement strategies to optimize current personal protective equipment (PPE) supplies even before shortages occur, including bundling patient/resident care and treatment activities to minimize entries into patient/resident rooms.

Additional strategies might include:

•  Extended use of respirators, face masks, and eye protection (face shield or goggles), which refers to the practice of wearing the same respirator or face mask and eye protection (face shield or goggles) for the care of more than one patient/resident (e.g., for an entire shift).
•  Care must be taken to avoid touching the respirator, face mask, or eye protection (face shield or goggles). If this must occur (e.g., to adjust or reposition PPE), health care personnel (HCP) should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others.
•  Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact patient/resident care activities that provide opportunities for transfer of pathogens to hands and clothing of HCP.
•  If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different patients/residents unless it is for the care of patients/residents with confirmed COVID-19 who are cohorted in the same area of the facility and these patients/residents are not known to have any co-infections (e.g., Clostridioides difficile or C. diff).

NOTE: Extended use of gowns on the COVID-19 unit is only recommended during patient/resident care activities and, as such, gowns should not be worn in areas like nurses’ stations, clean utility rooms, or break rooms. If not enough gowns are available, reuse the gown and hang them somewhere with the most contaminated surfaces facing inward.

General PPE tips:

• Re-use of PPE means putting on and taking off PPE and then putting it back on again. Re-use potentially can lead to self-contamination, especially when putting the PPE back on again.
• Extended use of PPE is using PPE for an extended period and not removing it in between the care of patients/residents.
• If a new patient/resident case is identified, HCP should wear all recommended PPE (masks, eye protection [face shield or goggles], gowns, and gloves) for the care of all patients/residents on the affected floor (or potentially the entire facility).
• Used PPE should not leave the building.
• HCP should not wear used PPE during times of eating and drinking. These items should be stored in a separate area.

N95s

• Do not reuse more than five times.
• Always discard N95s that become grossly contaminated or damaged.
• If there is a limited supply, prioritize the use of N95s for:
  
  • the care of COVID-19 patients/residents,
  • the case of symptomatic patients/residents awaiting testing, and
  • during any aerosol-generating procedures for all patients/residents, including nebulizer therapy, CPAP/BiPAP.

Consider the following for N95 masks:

• Assign HCP several N95s so they can be stored in an individual paper bag and not reused for at least 72 hours following the last use.
• HCP should wear clean gloves anytime they put or take off the mask and should perform hand hygiene after glove removal.
• If the HCP touches the mask, glove removal and hand hygiene should be performed immediately.

Surgical masks

• HCP do not need to wear both N95 and surgical masks. If they want to wear both, the surgical mask should be placed over the N95, not the other way around. In this case, the surgical mask may reduce the amount of contamination to the N95; however, this practice may deplete your stock.
• Do not reuse surgical masks beyond several days. If you must re-use, store them in a paper bag and leave within the facility. Always replace surgical masks that become contaminated or damaged.
• HCP should wear clean gloves anytime they put on or take off the mask and perform hand hygiene after glove removal.
• If HCP touch the mask, glove removal and hand hygiene should be performed immediately.

Cloth face masks

Cloth masks are not considered PPE and should not be used by HCP with direct patient/resident care responsibilities. Reserve cloth masks for patients/residents to wear if they can tolerate it. Encourage them to don the mask if they must leave the room or when HCP provide care to them when feasible. These masks need to be laundered.

• Because cloth face coverings can become saturated with respiratory secretions, care should be taken to prevent self-contamination.
• The masks should be changed if they become soiled, damp, or hard to breathe through, laundered regularly (e.g., daily and when soiled).
• Hand hygiene should be performed immediately before applying the mask and after removing.  Perform hand hygiene after contact with a cloth face covering.
• Facilities also should provide training about when, how, and where cloth face coverings can be used (e.g., frequency of laundering, guidance on when to replace, circumstances when they can be worn in the facility, importance of hand hygiene to prevent contamination).

Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses.

PPE patient/resident care recommendations

• The PPE recommended when caring for a patient/resident with known or suspected COVID-19 includes:
  1. Respirator or face mask (cloth face coverings are NOT PPE and should not be worn for the care of patients/residents with known or suspected COVID-19 or other situations where a respirator or facemask is warranted).
  2. Put on an N95 respirator (or higher-level respirator) or face mask (if a respirator is not available) before entry into the patient/resident room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators.
  3. N95 respirators or respirators that offer a higher-level of protection should be used instead of a face mask when performing or present for an aerosol-generating procedure.
  4. Disposable respirators and face masks should be removed and discarded after exiting the patient/resident’s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or face mask.
  5. If reusable respirators (e.g., powered air-purifying respirators [PAPRs]) are used, they must be cleaned and disinfected according to the manufacturer’s reprocessing instructions before re-use.
  6. When the supply chain is restored, facilities with a respiratory protection program should return to the use of respirators for patients/residents with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care of patients/residents with pathogens for which a respirator is recommended, should implement a respiratory protection program.
• Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.

Eye protection

• Wear a disposable face shield that covers the front and sides of the face or goggles upon entry to the patient/resident room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply.
• Personal glasses are NOT considered adequate eye protection.
• Remove eye protection (face shield or goggles) before leaving the patient/resident room or care area.
• You can use the same eye protection for all patients/residents on a designated unit, but they need to be cleaned and disinfected when leaving the unit and then stored in a clean area away from other PPE.
• Reusable eye protection must be cleaned and disinfected according to the manufacturer’s reprocessing instructions before re-use.
• Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.
• HCP should wear clean gloves anytime they put on or take off the eye protection and perform hand hygiene after glove removal.
• If HCP touch the eye protection, glove removal and hand hygiene should be performed immediately.

Gloves

• Put on clean, non-sterile gloves upon entry into the patient/resident room or care area.
• Change gloves between each patient/resident, with hand hygiene performed after removal.
• Change gloves if they become torn or heavily contaminated.
• Remove gloves and perform hand hygiene before entering common spaces like nurses’ stations and break areas.
• Remove and discard gloves when leaving the patient/resident room or care area and immediately perform hand hygiene.

Gloves are not a substitute for hand hygiene.

Gowns

• Put on a clean isolation gown upon entry into the patient/resident room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linens before leaving the patient/resident room or care area.
• Disposable gowns should be discarded after use.
• Cloth gowns should be laundered after each use.
• Used gowns should not be worn in common spaces like nurses’ stations and break areas.
• HCP that do not provide direct patient/resident care do not need to wear gowns.
• Ideally, gowns are for one-time use and disposed of after each patient/resident contact.
  
  • If you do not have an adequate supply to do so, then gown use should be extended, prioritized, or re-used. For more information, refer to the Centers for Disease Control and Prevention (CDC) guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gow and the guidance below.
• Extended use of gowns means using the same gown for multiple patients/residents without removing and should only be used on COVID units and if individuals are not co-infected with another pathogen, such as C diff.
• Do not extend the use of gowns in other areas.
• Ideally, cloth gowns are laundered after every use.
• Prioritization of gowns means using gowns only during certain activities or for certain patients/residents.
• Ideally, disposable gowns are disposed of after use for these activities. Example of prioritization could be:
  
  • Care of symptomatic patients/residents awaiting testing.
  • Care for any exposed roommates.
  • Aerosol-generating procedures, which include nebulizers (also should include N95 use).
  • Care activities where splashes and sprays are anticipated.
  • High-contact patient/resident care activities provide opportunities for the transfer of pathogens to the hands and clothing of HCP when:
    • dressing
    • bathing/showering
    • transferring
    • providing hygiene
    • changing linens
    • changing briefs or assisting with toileting
    • device care
    • wound care
• Re-use of gowns means putting on and taking off the gown multiple times. It is likely the least ideal way to use gowns as it may pose an increased risk of self-contamination to the HCP while putting on and taking off the gown. If this must occur:
  
  • One gown should be dedicated for one patient/resident.
  • One gown should be dedicated to one HCP.
  • You could consider hanging used gowns inside the patient/resident rooms near the entrance so they do not need to enter the common areas like breakrooms.
  • Dispose of the reused gown at the end of every shift.
  • Consider using cloth gowns or cloth alternatives, which may be easier to re don and be less prone to damage.
  • Cloth gowns should be collected at the end of each shift and then laundered.

PPE strategies to consider by unit type

COVID unit

1. Required PPE
   
   • N95 if available (extended use) or face mask (extended use).
   • Eye protection (extended use) face shield or goggles.
   • Gowns ideally disposed of or laundered (if cloth) after every use. If unable to dispose of gowns (in waste or laundry), then extended use or re-use of gowns may be implemented, except gowns should not be worn in common areas.
   • Gloves for each patient/resident interaction.
2. Place signage at the entrance to the COVID-19 care unit that instructs HCP to wear eye protection (face shield or goggles), and an N95 or higher-level respirator (or face mask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering patient/resident rooms.
3. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum, this should include the primary nursing assistants and nurses assigned to care for these patients/residents.
4. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area separate from HCP working in other areas of the facility.
5. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit.
6. Assign dedicated environmental services (EVS) staff to work only on the COVID-19 unit.
7. Ensure high-touch surfaces in staff break rooms and work areas are frequently cleaned and disinfected (e.g., each shift).

Non-COVID-19 units while considered exposed

1. Required PPE
   
   • Surgical masks, unless N95 is warranted
   • N95 for symptomatic patients/residents or during aerosol-generating procedures
   • Gloves for each patient/resident interaction
   • Prioritization of gowns as noted above
   • Eye protection (face shield or goggles) for the care of all patients/residents

Non-COVID unit if the building is at least 14 days from the last positive patient/resident/HCP case and now likely if negative tests are acquired

1. Required PPE
   
   • Surgical masks
   • Eye protection (face shield or goggles), gowns, and gloves per Standard Precautions

Observation unit for unknowns (admission/readmission)

1. Required PPE
   
   • Surgical masks, unless N95 is warranted
   • N95 for symptomatic patients/residents or during aerosol-generating procedures
   • Eye protection (face shield or goggles) for the care of all patients/residents
   • Gloves for each patient/resident interaction
   • Prioritization of gowns as noted above

Recovery where patients/residents have met criteria to discontinue transmission-based precautions

1. If they are fully recovered and back to baseline
   1. Required PPE
      • Face mask
      • Eye protection (face shield or goggles), gowns, and gloves per Standard Precautions
2. If Transmission-Based Precautions have been discontinued, but the patient/resident has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room.
   1. Required PPE
      • N95 if available
      • Eye protection (face shield or goggles)
      • Gowns ideally disposed of or, if  cloth, laundered after every use
      • Gloves

Last Updated:  7/22/2020