3.2 PPE & Transmission-Based Precautions

PPE & Transmission-Based Precautions

Personal Protective Equipment (PPE) and Transmission-Based Precautions form the second critical line of defense in healthcare infection control. While hand hygiene eliminates pathogens from the skin, protective barriers prevent healthcare personnel from acquiring or spreading infections during resident care. In long-term care environments, nursing assistants must understand when, why, and how to utilize specialized equipment to shield themselves and vulnerable residents from contagious pathogens.

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Standard Precautions

Standard Precautions represent the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status, in any setting where healthcare is delivered. Standard Precautions are grounded in the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.

Core Components of Standard Precautions

1. Hand Hygiene: Performed before and after resident contact and immediately after glove removal.
2. Gloves: Worn whenever contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items is anticipated. Gloves must be changed between dirty and clean procedures on the same resident.
3. Gowns: Worn during procedures likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to protect skin and clothing.
4. Masks & Eye Protection (Goggles/Face Shields): Worn during procedures likely to generate splashes, sprays, or droplets of blood or body fluids (e.g., suctioning, oral care with heavy coughing).
5. Respiratory Hygiene / Cough Etiquette: Covering coughs with tissues, prompt disposal, and offering masks to symptomatic individuals.
6. Environmental Disinfection & Equipment Care: Properly cleaning, disinfecting, or disposing of reusable resident care equipment between residents.

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Transmission-Based Precautions (Expanded Precautions)

When Standard Precautions alone are insufficient to prevent the transmission of highly contagious pathogens, facilities implement Transmission-Based Precautions. These precautions are categorized into three distinct tiers based on the pathogen's mode of transmission: Contact Precautions, Droplet Precautions, and Airborne Precautions.

1. Contact Precautions

Contact Precautions are initiated to prevent the spread of infectious agents transmitted by direct skin-to-skin contact or indirect contact with contaminated environmental surfaces and medical equipment.

• Common Indications: Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), Clostridioides difficile (C. diff), scabies, impetigo, and major uncontained wound drainage.
• Required PPE: Clean gown and gloves must be donned before entering the resident's room.
• Room Assignment: Single-resident private room preferred, or cohorted with a resident infected with the exact same organism.
• Dedicated Equipment: Dedicated medical equipment (blood pressure cuff, stethoscope, thermometer) must remain in the room and be disinfected upon discharge.
• Special Measures: For C. diff or Norovirus, hands must be washed with soap and water upon exiting, and environmental surfaces must be disinfected with a sporicidal agent (such as sodium hypochlorite/bleach).

2. Droplet Precautions

Droplet Precautions prevent transmission of pathogens spread through large respiratory droplets generated during coughing, sneezing, talking, or procedures like suctioning. Respiratory droplets are large (>5 micrometers) and travel short distances, typically falling to the ground within 3 to 6 feet.

• Common Indications: Influenza, Pertussis (whooping cough), Bacterial Meningitis, Mumps, Rubella, and Mycoplasma pneumonia.
• Required PPE: A surgical mask is required prior to entering the room. Eye protection (goggles or face shield) is added if working within 3 to 6 feet of the resident.
• Room Assignment: Private room required unless cohorting. Spatial separation of at least 3 to 6 feet must be maintained between residents if cohorted.
• Resident Transport: If the resident must leave the room for essential tests, the resident must wear a surgical mask during transport.

3. Airborne Precautions

Airborne Precautions protect against infectious agents transmitted via small droplet nuclei (<5 micrometers) or dust particles containing pathogens. These microscopic particles remain suspended in air currents for extended periods and can travel long distances throughout ventilation systems.

• Common Indications: Active Tuberculosis (TB), Measles (Rubeola), Varicella (Chickenpox), and Disseminated Herpes Zoster (Shingles).
• Required Room: An Airborne Infection Isolation Room (AIIR) equipped with special negative air pressure that exchanges air 6 to 12 times per hour and exhausts air directly outdoors or through High-Efficiency Particulate Air (HEPA) filtration. The room door must remain closed at all times.
• Required PPE: Healthcare personnel must wear a fit-tested N95 respirator (or Powered Air-Purifying Respirator [PAPR]) prior to entering the room. CNAs must undergo annual fit testing to ensure a tight seal around the face.
• Resident Masking: The resident must wear a surgical mask during essential transport outside the room.

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Step-by-Step PPE Sequences (CDC & Headmaster Skill Standards)

The order in which PPE is donned (put on) and doffed (taken off) is critical to prevent contamination of skin, clothing, and environment.

Donning (Putting On) PPE Sequence

Before entering the resident care area, don PPE in the following order:

1. GOWN -> 2. MASK / RESPIRATOR -> 3. GOGGLES / FACE SHIELD -> 4. GLOVES

2. Gown: Select appropriate size. Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten neck and waist ties securely.

3. Mask or Respirator: Place mask over nose, mouth, and chin. Fit flexible nosepiece over nose bridge. Secure ties or elastic bands behind head or ears. Ensure fit-tested N95 forms a tight seal.

4. Goggles or Face Shield: Position over eyes and face; adjust headband for a comfortable fit.

5. Gloves: Don clean gloves. Extend glove cuffs over the wrists of the isolation gown to eliminate exposed skin.

Doffing (Removing) PPE Sequence

PPE must be removed at the doorway or immediately outside the resident room (except respirators, which are removed outside the room).

1. GLOVES -> 2. GOGGLES / FACE SHIELD -> 3. GOWN -> 4. MASK / RESPIRATOR

2. Gloves (Most Contaminated): Using gloved hand, grasp outside cuff of opposite glove and peel off, turning inside out. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove cuff and peel off over first glove, creating a glove-inside-glove package. Discard in trash.

3. Goggles or Face Shield: Handle by ear pieces or head strap only (the cleanest part). Lift away from face and place in designated receptacle.

4. Gown: Unfasten ties taking care not to touch front of gown. Pull gown away from neck and shoulders touching inside of gown only. Turn gown inside out and roll into a bundle; discard in waste container.

5. Mask or Respirator: Grasp bottom ties/elastics, then top ties/elastics without touching front of mask. Lift away from face and discard.

6. HAND HYGIENE: Perform hand hygiene immediately after removing all PPE!

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Comparison of Transmission-Based Precautions

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Clinical Scenario: PPE Sequence in Practice

Scenario: CNA Marcus is preparing to enter room 212 to assist a resident with suspected active Pulmonary Tuberculosis. Marcus puts on clean gloves, dons a surgical mask, pulls a gown over his arms, and enters the room with the door left slightly ajar.

Clinical Evaluation: Marcus committed three high-risk infection control violations:

1. Wrong Respirator & Masking: TB requires a fit-tested N95 respirator, not a standard surgical mask, because TB is carried in airborne particles that penetrate surgical masks.
2. Incorrect Donning Sequence: Gloves must always be put on last after gowning, masking, and putting on eye protection, with glove cuffs pulled over gown sleeves.
3. Environmental Hazard: Leaving the AIIR room door open allows airborne TB bacilli to escape into the hallway ventilation system, exposing residents and staff.