Personal Protective Equipment (PPE)Frequently Asked Question (FAQ) - For Internal Use Only

Current as of: June 19, 2020New items are highlighted.DISCLAIMER: COVID-19 information is rapidly changing and documents will be updated accordingly.

PPE General Questions1. Who should wear an N95 respirator?........................................................................3

2. What should be worn when collecting a nasopharyngeal swab for COVID-19 testing?......................................................................................................................3

3. Are cloth isolation gowns an acceptable alternative to disposable isolation gowns? 3

4. Can I wear a homemade cloth mask?.......................................................................3

5. Can Healthcare Workers Wear PPE brought from home?........................................3

6. Can an expired respirator be used?..........................................................................3

7. When can isolation precautions be discontinued?....................................................4

8. Can I wear PPE (i.e., goggles, gloves, or gown) in a non-clinical setting such as the cafeteria?...................................................................................................................4

9. What PPE should be worn by environmental services (EVS) personnel who clean and disinfect rooms of hospitalized patients with COVID-19?...................................4

10. How are we carefully managing our supply of PPE?.................................................5

11. What type of PPE should be worn when transporting a COVID-19 patient?.............5

12. Are two masks better than one?................................................................................6

13. Are we implementing extended use and/or reuse for N95s?.....................................6

14. Can PPE be reprocessed by disinfection or sterilization?.........................................6

15. Where do I go to find out more about employee health and human resources questions?.................................................................................................................6

16. Can EVS immediately terminally clean an isolation room after a suspect or confirmed COVID-19 patient has been discharged without waiting the allotted time for air clearance?.......................................................................................................6

PPE ReprocessingA. When will CommonSpirit begin reprocessing N95 masks?.......................................6

B. What will happen to the masks collected that were intended for Medline?...............7

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C. Why is CommonSpirit pursuing reprocessing of surgical masks?.............................7

D. Can all masks from patients and employees be reprocessed?.................................7

E. How many times can a mask be reprocessed, and how will they be removed from usage?.......................................................................................................................7

F. Will the reprocessed masks have an odor or smell?.................................................7

G. Are other options available for reprocessing N95 masks?........................................7

H. What chemicals are used by ASP, Steris and Battelle?.............................................8

I. Is vaporous hydrogen peroxide safer than the Ethylene Oxide (EtO) that is used by Medline?....................................................................................................................8

J. Is CommonSpirit considering gown reprocessing given the shortage?.....................8

K. Medline reprocessing includes the use of Ethylene Oxide (EtO), a known carcinogen. Does this process expose healthcare workers to EtO?.........................8

L. How does Medline guarantee that EtO is removed from the masks?........................8

M. Has CommonSpirit Health discussed reprocessing efforts with our national union leaders?.....................................................................................................................8

N. What is the new Steris reprocessing method?..........................................................9

O. Which CommonSpirit locations can use the new Steris Steam reprocessing method?....................................................................................................................9

P. Which types of masks can be reprocessed with the Steris steam method?..............9

Q. How many masks can be reprocessed with the Steris steam method and how frequently?.................................................................................................................9

R. How can my location begin using the new Steris steam reprocessing method?.......9

REFERENCES.................................................................................................................9

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1. Who should wear an N95 respirator?

When taking care of a suspect or confirmed COVID-19 patient that is undergoing an aerosol generating procedure (e.g., intubation, extubation, sputum induction, breathing treatment, open oral suctioning) all healthcare workers must wear an N95 respirator.

2. What should be worn when collecting a nasopharyngeal swab for COVID-19 testing?

The healthcare worker should wear an N95 respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown.

3. Are cloth isolation gowns an acceptable alternative to disposable isolation gowns?

Yes, reusable (i.e., washable) isolation gowns are an acceptable alternative. Gowns made of these fabrics can be safely laundered according to routine procedures and reused.

4. Can I wear a homemade cloth mask?

Yes, however a homemade cloth mask is not medical grade PPE and should not be worn while providing care for patients in isolation. Facility policy may allow cloth masks outside of patient care areas or when a facemask is not required for isolation precautions. Homemade cloth masks must be safely handled to avoid unintentional exposure and transmission of infection. Safe handling includes:

Clean hands before removing or touching mask Cloth masks should be in clean condition and washed after each shift Remove cloth masks immediately if soiled or becomes wet Do not wear cloth mask under a standard/surgical mask

5. Can Healthcare Workers Wear PPE brought from home?

Yes, however respirators and other personal equipment brought from home are considered non-medical grade and should be treated the same as homemade cloth masks. Their use is dictated by facility policy and may not be used when caring for patients in isolation.

6. Can an expired respirator be used?

Yes, the CDC/NIOSH believes that respirators should provide protection past their manufacturer-designated shelf life. Recommendations for their use include

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precautionary measures that should be taken prior to donning such as visual inspection, strap integrity and a seal check. Follow facility guidelines regarding the use of expired N95 respirators.

7. When can isolation precautions be discontinued?

A. For Patients with Confirmed COVID-19:

In the hospital setting, negative test results are preferred when considering discontinuation of isolation precautions for patients with confirmed COVID-19. This includes:

Negative tests results from at least two specimens collected ≥24 hours apart (total of two negative specimens)

If testing is not readily available, facilities may use a non-test-based strategy for discontinuation of transmission-based precautions or extend the period of isolation on a case by case basis in consultation with local public health authorities.

B. For Patients Suspected of Having COVID-19

The decision to discontinue isolation precautions relies on assessment by the physician and one negative test for COVID-19.

8. Can I wear PPE (i.e., goggles, gloves, or gown) in a non-clinical setting such as the cafeteria?

No, under typical conditions, all used PPE should be removed prior to leaving the patient room. If the supply of PPE becomes severely restricted, facilities may allow for extended use of facemasks. Gloves, gown, and eye protection should not be worn in a non-clinical setting. Care should be taken to avoid touching the outside surface of the mask which may be contaminated. Removal of facemasks prior to eating in any area should be done carefully and hand hygiene performed right after removal.

9. What PPE should be worn by environmental services (EVS) personnel who clean and disinfect rooms of hospitalized patients with COVID-19?

Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel to clean the room when the patient is there, they should wear the same recommended PPE when in the room as would physicians and nurses.

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Upon patient discharge, entry into the room should be delayed until a sufficient time has elapsed for enough air changes to remove potentially infectious particles (see below). EVS personnel may enter the room and should wear a gown and gloves when performing terminal cleaning. A facemask and eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or required based on the chemical they are using.

Air exchanges per hour

Time (mins.) required for removal 99%

efficiency

Time (mins.) required for removal 99.9%

efficiency2 138 2074 69 104

6+ 46 698 35 52

10+ 28 4112+ 23 3515+ 18 2820 14 2150 6 8

10.How are we carefully managing our supply of PPE?

This unprecedented public health crisis has stretched PPE supply chains like never before. As a result, we are closely managing our PPE supply and working around the clock to secure additional supplies. This includes ordering masks from other countries, as well as accepting donations from other organizations and the community. Please continue to be diligent and judicious in your use of PPE in order to conserve supplies, and if you have questions about proper usage, please direct them to your supervisor.

11. What type of PPE should be worn when transporting a COVID-19 patient?

Healthcare workers transporting patients that are suspect or known positive for COVID-19 need to wear appropriate PPE (e.g., standard mask, gown, gloves, and eye protection) if anticipating direct patient assistance may be needed upon transferring the patient.

12. Are two masks better than one?

No, layering masks does not provide any additional protection and may cause self-contamination upon removal if handled inappropriately.

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13. Are we implementing extended use and/or reuse for N95s?

Yes, extended use and reuse guidelines have been established by the Centers for Disease Control and Prevention (CDC). Implementing extended use and reuse is based on multiple variables within the facility, please refer to your local facility leadership to determine current protocol.

14. Can PPE be reprocessed by disinfection or sterilization?

Yes, CommonSpirit Health has been working with multiple vendors that are achieving FDA approval in reprocessing N95 respirators, standards masks, and eye protection. The health system is working to immediately launch these efforts to increase PPE supply to all facilities.

15.Where do I go to find out more about employee health and human resources questions?

Many staff members have raised questions regarding travel restrictions, paid time off, working from home and other significant topics. These questions are addressed in a frequently asked questions format and is constantly being updated. The employee health and human resources can be found by clicking here.

16.Can Environmental Services (EVS) immediately terminally clean an isolation room after a suspect or confirmed COVID-19 patient has been discharged without waiting the allotted time for air clearance?

Yes, however all PPE must be worn (e.g., mask, face shield, gown, gloves) similar to daily room cleaning if EVS has taken on this task.

PPE ReprocessingFrequently Asked Question (FAQ) - For Internal Use Only

A. When will CommonSpirit begin reprocessing N95 masks?

CommonSpirit hospitals can begin reprocessing N95s now if they have an ASP and/or Steris unit within their Sterilization Processing Department. Only non-cellulose N95s can be decontaminated. Instructions have been provided to hospitals. The previous mask reprocessing program with Medline will no longer be considered an option. Additionally, CommonSpirit finalized a contract with Battelle for third party N95 reprocessing by utilizing vaporous hydrogen peroxide.

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B. What will happen to the masks collected that were intended for Medline reprocessing?

The masks will be sent to Medline for reprocessing using EtO and donated as dust masks to first responders. They will be not designated as N95 masks.

C. Why is CommonSpirit pursuing reprocessing of surgical masks?

CommonSpirit Health is pursuing all channels for securing PPE for healthcare workers. Given the national concerns for adequate PPE, CommonSpirit is partnering with vendors to reprocess whenever possible. At this time hospitals at CommonSpirit Health have options. If a hospital has an ASP and/or Steris unit on site, they are able to reprocess non-cellulose N95s. CommonSpirit Health is also pursuing other options for reprocessing PPE.  Additional information will be shared as it is available.

D. Can all masks from patients and employees be reprocessed?

No, only masks that are used by employees can be reprocessed. If a mask has makeup, lipstick or other visible blemishes the mask will be rejected. Likewise, any mask with a hole, tear, torn strap or other damage will be rejected.

E. How many times can a mask be reprocessed, and how will they be removed from usage?

The FDA emergency use authorization specifies the number of reprocessing cycles allowed per vendor. Steris is approved for 10 cycles, whereas ASP is for two and Battelle for 20.  A marking will be established on the mask to determine the current cycle number. Masks should be disposed of regardless of cycle number if they do not fit properly (does not pass seal check) or if any physical damage is seen.

F. Will the reprocessed masks have an odor or smell?

No, the tie masks and ear loops won’t have a smell. The respirators maintain the original smell (similar to rubber).

G. Are other options available for reprocessing N95 masks?

In addition to internal ASP and/or Steris reprocessing, CommonSpirit finalized a contract with Battelle, an outside vendor, to reprocess non-cellulose N95 masks. Consult with your local leadership to determine current reprocessing methods utilized

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H. What chemicals are used by ASP, Steris and Battelle?

Both companies use vaporous hydrogen peroxide in their decontamination process.

I. Is vaporous hydrogen peroxide safer than the Ethylene Oxide (EtO) that is used by Medline?

No, it is also a substance that is known a carcinogen, similar to EtO. However, each company – Medline, Battelle, ASP and Steris – takes additional measures to remove the chemical agent from the masks once they are decontaminated.

J. Is CommonSpirit considering gown reprocessing given the shortage?

Yes, due to the ongoing demand for PPE, CommonSpirit is looking to ensure constant availability of gowns by procuring new product and identifying options for reprocessing as a last resort. This includes reprocessing of gowns via Medline using EtO. Any reprocessing of PPE is considered as a last resort with a primary focus on procuring new PPE.

K. Medline reprocessing includes the use of Ethylene Oxide (EtO), a known

carcinogen. Does this process expose healthcare workers to EtO?

The use of EtO has been a standard for sterilization in the industry, as over half of all sterile devices in industry are sterilized via EtO.

L. How does Medline guarantee that EtO is removed from the reprocessed gowns?

Medline is able to remove the EtO from products through an aeration process that takes place after reprocessing. This process is, at a minimum, a 9-hour long “air wash” cycle which takes place in large, industrial sized chambers. The chamber size and length of the aeration process is what allows the successful removal of EtO compared to the smaller EtO cabinets/modules with much shorter cycles that are commonly used in hospitals.

M. Has CommonSpirit Health discussed reprocessing efforts with our national union leaders?

Yes, our VP of Employee & Labor Relations, Scott Fuller has been in conversation with union leaders about the potential use of reprocessed items, e.g. N95 masks and gowns.

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N. What is the new Steris reprocessing method?

In addition to the standard Vaporous Hydrogen Peroxide method currently offered by Steris, the company recently received FDA Emergency Use Authorization to reprocess non-cellulose n95 masks with steam technology. This is an in-house decontamination method that uses Steris AMSCO Medium Steam Sterilizers.

O. Which CommonSpirit locations can use the new Steris Steam reprocessing method?

This option is limited to facilities that have the Steris equipment and opt to participate. Please contact your Facility Sterile Processing (SPD) leadership and local Administration for more details.

P. Which types of masks can be reprocessed with the Steris steam method?

Reprocessing with this method is limited to only 3M 1860, 3M 1860S and 3M 1804 NIOSH-approved N95 respirators only.

Q. How many masks can be reprocessed with the Steris steam method and how frequently?

This depends on the size of the machine. Small units can reprocess up to 108 masks at once, medium units can reprocess up to 144 and large units can reprocess up to 180. Regardless of the machine size, masks can only be reprocessed a maximum of 10 times.

R. How can my location begin using the new Steris steam reprocessing method?

Your facility SPD leader will need to have this approved locally and will work with Steris to have the sterilizers “programmed” to use the steam technology.

References

Collection of Diagnostic Respiratory Specimens: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html#collection

Strategies for Optimizing Supply of Gowns: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html

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A cluster randomized trial of cloth masks compared with medical masks in healthcare workers. MacIntyre, C.R., et al. (2015). BMJ Open. Retrieved from: https://bmjopen.bmj.com/content/bmjopen/5/4/e006577.full.pdf

Release of Stockpiled N95 Filtering FacePiece Respirators Beyond the Manufactured-Designated Shelf-Life: https://www.cdc.gov/coronavirus/2019-ncov/release-stockpiled-N95.html

Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance): https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

Distributed by Patient Safety National Office on June 19, 2020