Personal Protective Equipment

Personal protective equipment (PPE) refers to equipment worn by workers to prevent workplace injury and occupational disease. In health care, commonly used PPE includes gloves, masks, eye protection, gowns, bouffant head covers, surgical caps, booties, and respirators. 

While PPE is an important aspect of protection from pathogens encountered in the workplace, several other controls must be in place for an effective exposure control plan to be implemented and sustained. PPE is considered the last line of defense in the health and safety hierarchy of controls, as shown in the following image. 

Members must be trained in the components of their site’s biological agent exposure control plan which includes information and training in the safe use of PPE. If a member has questions about PPE at their workplace, they should be encouraged to follow these steps: 

1. Contact supervisor or manager. The supervisor or manager has access to workplace infection control, safety and public health resources to ensure the member has an answer to your question.
2. If the supervisor or manager cannot answer the member’s questions, the site Joint Occupational Health and Safety Committee  (JOHSC) should be notified and the issue should be added to the next meeting agenda for discussion and action. 
3. If the issue is not resolved at the JOHSC level, or if urgent support is required, the member may contact the BCNU Safety and Support Line to get immediate support from union staff. 

If the issue is not imminent, report this as an unsafe condition to your employer and identify the undue hazard to your health and safety at work. Share as many details as possible so your manager has a full picture of the situation. 

Your employer is legally required to investigate unsafe conditions that are reported to them and ensure that any necessary corrective action is taken without delay in accordance with Section 3.10 of the OHS Regulation:

3.10 Reporting unsafe conditions

Whenever a person observes what appears to be an unsafe or harmful condition or act the person must report it as soon as possible to a supervisor or to the employer, and the person receiving the report must investigate the reported unsafe condition or act and must ensure that any necessary corrective action is taken without delay.

Examples of unsafe conditions might be not knowing how to access appropriate PPE for a work process, not having the training to use the PPE correctly, not being fit-tested for respirator use, or not knowing what PPE to use in which situations. 

You first should report your concern and any suggestions you have to correct the problem to your manager verbally. Then send a follow-up email documenting your conversation.

If the issue is imminent, report this as an unsafe condition to your employer and identify the undue hazard to your health and safety at work. Share as many details as possible so your manager has a full picture of the situation. Should you feel that there is an undue hazard to you or others, you may refuse unsafe work. Contact the BCNU member safety and support line at 1-800-663-9991 (press 1), available Monday - Friday from 0900 - 1700.

During the COVID-19 pandemic, health-care facilities must follow direction from the BC Centre for Disease Control (BCCDC) and the BC Provincial Health Officer, Dr. Bonnie Henry. This means: 

1. Contact and droplet precautions must be used by health-care workers for all interactions with clients with a suspected, presumed or confirmed COVID-19 diagnosis. In relation to PPE, contact and droplet precautions include gloves, face shield or goggles, gowns, and surgical masks.

2. Airborne precautions must be used by health care-workers involved in aerosol-generating procedures (AGMPs). In relation to PPE, airborne precautions include respiratory protection such as the N-95 respirator mask, elastomeric respirator or powered air purifying respirator (PAPR). The BCCDC has published supporting Guidance for Respiratory Protection. AGMPs include but are not limited to: 

   • Intubation, extubation and related procedures

   • CPR with bag valve mask ventilation

   • Bronchoscopy and bronchoalveolar lavage

   • Sputum induction

   • Nebulized therapy

   • High concentration oxygen therapy

   • Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)

   • Open airway suctioning

   • Nasopharyngeal aspirates, washes and scoping

   • Autopsies involving respiratory tissues

BCNU fully supports the right of nurses and other clinicians to use their judgment and conduct point-of-care risk assessments to determine what level of PPE they feel they require when providing care to a patient.

Routine, contact, droplet and airborne precautions are used in health-care settings. A combination of these precautions can be used depending on routes of transmission of applicable athogens. 

Ultimately, the clinician must determine which precautions to use by conducting a risk assessment at the point of care. In the absence of unequivocal scientific evidence, the precautionary principle should be applied when determining the appropriate precautions to use in the workplace.

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REQUIREMENTS FOR PERSONAL PROTECTIVE EQUIPMENT

Depending upon the suspected nature of pathogen transmission, progessively more PPE may be needed.

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WHAT ARE ROUTINE PRECAUTIONS?

Routine (or standard) precautions in health care are a system of infection prevention and control measures used to prevent communicable disease transmission and must be used for every patient care interaction in all care delivery settings. Routine precautions involve a health care provider conducting a point-of-care risk assessment, engaging in hand and respiratory hygiene, using appropriate PPE dependent on the situation (such as the use of gloves) and risk reduction strategies. Education of health-care providers, client/patient, family and visitors in routine precautions is crucial to ensure the risk of transmission is minimized.

Additional resources can be found at:

The Government of Canada’s Infection Prevention and Control for COVID-19: Second Interim Guidance for Acute Healthcare Settings

British Columbia Provincial Infection Control Network Respiratory Infection Outbreak Guidelines for Health care Facilities (PDF) 

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WHAT ARE CONTACT PRECAUTIONS?

Contact precautions form the lowest level of PPE commonly used in health-care settings. These must be used for patients suspected or known to have an infection with increased risk for contact transmission. Contact precautions include but are not limited to the following: 

•  Ensuring appropriate patient placement

•  Limiting transport and movement of patients

•  Using disposable or dedicated patient care equipment whenever possible

•  Prioritizing cleaning and disinfection of environment

•  Additional PPE for contact precautions: gloves and gown

Health Canada: Personal protective equipment against COVID-19: Medical gloves

Health Canada: Personal protective equipment against COVID-19: Medical gowns

MEDICAL GLOVES

All medical gloves in Canada must meet design, testing and manufacturing standards set by Health Canada and are considered Class II medical devices. 

Medical gloves must be produced by licensed manufacturers and have appropriate labels in accordance with Section 21 of the Medical Devices Regulation.

Due to the high demand for gloves through the COVID-19 pandemic, Health Canada has allowed the importation and sale of medical gloves that don’t meet labeling requirements. Federal Minister of Health Patty Hajdu issued an interim order on March 18, 2020 respecting the importation and sale of medical devices for use as a way to fast track approval of medical gloves in Canada.

If you are wondering if your gloves are safe to use, confirm that they are licensed and labelled appropriately here.  

Additional resources can be found at: Health Canada: Personal protective equipment against COVID-19: Medical gloves

MEDICAL GOWNS

All medical gowns in Canada can be only be manufactured, imported or sold by licensed companies, and are considered Class I medical devices. Medical gowns must be fluid resistant and are rated on their ability to resist fluid as defined by the Association for the Advancement of Medical Instrumentation (AAMI). 

• Level 1 gowns are used for standard precautions and simple procedures 
• Level 2 gowns are used for minimally invasive surgery  
• Level 3 gowns are used for open GI surgery
• Level 4 gowns are used for open-heart and trauma procedures

To meet COVID-19 pandemic demands, Health Canada is allowing the importation and sale of medical gowns that have not been approved.

Additional resources can be found at: Health Canada: Personal protective equipment against COVID-19: Medical gowns

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WHAT ARE DROPLET PRECAUTIONS?

Droplet precautions must be used for patients suspected or known to be infected by pathogens transmitted by

respiratory droplets (via coughing, sneezing or talking). Droplet precautions include, but are not limited to: 

• Placing mask on patient

• Ensuring appropriate patient placement

• Limiting transport and movement of patients

• Using disposable or dedicated patient care equipment whenever possible

• Prioritizing cleaning and disinfection of environment

• Using additional PPE for droplet precautions: surgical mask and eye protection

EYE PROTECTION

Eye protection may include safety glasses, goggles or face shields. According to BCCDC guidelines, goggles or face shields are required during the conduct of AGMPs on patients suspected, presumed or confirmed to be COVID positive. Eye protection provided to a worker in BC must meet the requirements set out in either the:  

CSA Standard Z94.3-15, Eye and Face Protectors, or 

ANSI Standard ANSI/ISEA Z87.1-2015 Occupational and Educational Personal Eye and Face Protection Devices.

Eye protection must protect both the front and sides of the eye and must fit the worker properly while not interfering with the wearing of other PPE or visual aides such as glasses. 

Read about eye protection here: Centers for Disease Control - Eye Safety: Eye Protection for Infection Control

SURGICAL, MEDICAL OR PROCEDURAL MASKS

Surgical, medical or procedural masks must be worn to prevent large droplets and splashes from entering the mucous membranes of the mouth and nose. They must be tested to prove a high level of protection against infection and should meet requirements in at least one of the following standards:  

• American Society for Testing and Materials F2100 or 
• EN 16483 Type IIR (European Standard)

The American Society for Testing and Materials classifies medical masks in the following way: 

• Level 1 (Low) - venous pressure splash
• Level 2 (Moderate) - arterial pressure splash
• Level 3 (High) - high-velocity procedures, orthopedic surgery

Surgical, medical or procedural masks do not form a complete seal around the wearer’s face and should not be worn if there is concern about pathogen transmission through airborne means.

Visit Health Canada for additional information on surgical, medical or procedural masks.

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WHAT ARE AIRBORNE PRECAUTIONS?

Airborne precautions must be used for patients known or suspected to be infected with pathogens transmitted by the airborne route. Examples of pathogens known for airborne transmission are tuberculosis and measles. COVID-19 can become airborne, especially during aerosol generating medical procedures (AGMPs).

Airborne precautions include but are not limited to the following:

• Placing mask on patient
• Ensuring appropriate patient placement
• Limiting transport and movement of patients
• Using disposable or dedicated patient care equipment whenever possible
• Prioritizing cleaning and disinfection of environment
• Restricting susceptible health care workers from entering room of associated patients
• Using additional PPE for airborne precautions: NIOSH approved N-95 or higher-level respirator. 

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RESPIRATORS – WHAT ARE THEY AND WHAT ARE THE DIFFERENT TYPES?

A respirator is a personal protective device that is used by workers to prevent inhalation of hazardous airborne particles, gases or vapours. It requires a close facial fit in order to block out either 95%, 99% or 99.97% of airborne particles from entering the respiratory tract. Most biological agents, such as bacteria or viruses, including COVID-19, are considered particles and thus can be filtered by particulate respirators. 

Particulate respirators can either be disposable or reusable and are rated N, R or P based on level of resistance to oil. The N stands for “Not resistant to oil,” the R stands for “Resistant to Oil” and the P refers to the respirator being Oil-Proof. In health care, there is little-to-no risk of airborne oil particles. This is why respirators with the N rating (e.g. N-95) are commonly used by health-care workers. R- and P-rated respirators may be used, but in a health-care setting, they are no more protective against biological agents than N-rated respirators. 

The most common respirator in a health-care setting is the disposable N-95 respirator mask. This type of disposable particulate respirator requires a close facial fit in order to block 95% of airborne particles from entering a person’s respiratory tract. 

Reusable respirators (often referred to as elastomeric respirators) were previously uncommon in BC healthcare settings, but their use is becoming increasingly more common during the COVID-19 pandemic. Reusable models are easily identified by their large side cartridges and are often manufactured out of more durable materials such as silicone, thermoplastic or rubber.

Reusable respirators offer a similar protection factor to disposable respirators and are available in half or full facepiece models. Users must be fit-tested and trained on a reusable respirator prior to use.

Powered air purifying respirators (PAPRs) are devices that provide the wearer with a supply of purified air. They are reusable and provide the highest level of protection. PAPRs are not commonly used in BC.

Specialized training is required prior to the use of a PAPR.

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WHAT IF I AM ASKED TO WEAR A NEW TYPE OF RESPIRATOR?

Provincial stockpiles of standard models of disposable respirators are being augmented by alternate respirator models.

Presently, all respirators must be approved by the National Institute for Occupational Safety and Health (NIOSH) or equivalent prior to use in BC. A list of approved respirators can be found here: Centers for Disease Control - NPPTL - NIOSH-Approved Particulate Filtering Facepiece Respirators

From the WorkSafeBC guideline on respirators: G8 .33(2)-1 Approved respirators

WorkSafeBC has also deemed the following filtering facepiece types from other countries acceptable as an equivalent to NIOSH approved N95 respirators:

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The alternative particulate filtering facepiece respirators listed above are considered acceptable by WorkSafeBC for protection against airborne particulates, like biological agents, where a risk assessment deems that an N95 is appropriate. 

When using any respirator, the employer must ensure each of the following:

• Workers are fit-tested to the make, model, and size of respirator; can perform user seal checks; and know how to don and doff the respirator properly

• Workers visually inspect the respirator before use to check for defects or damage to the straps, nose clip, or filter material

• Workers are informed of any limitations of the respirator stated by the manufacturer

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MY EMPLOYER HAS PROVIDED ME WITH AN EXPIRED RESPIRATOR. WHAT SHOULD I DO?

If you are unsure of the safety of any PPE you have been provided, please reach out directly to your supervisor or manager as the first step.

From the WorkSafeBC guideline on respirators: G8 .33(2)-1 Approved respirators

As part of pandemic and emergency planning, many organizations have stockpiled particulate respirators, such as N95 filtering facepiece respirators. Many of the manufacturers of these respirators have provided a manufacturer-designated shelf life. In times when supply issues are critical like a pandemic, employers may have to use respirators beyond the ‘expiry date.’ A NIOSH study has indicated that these respirators may meet the performance standards if the manufacturers’ storage recommendations are followed.

WorkSafeBC accepts the use of these ‘expired’ NIOSH-approved particulate respirators with the following provisions:

• The expired respirators can only be used in an emergency and should only be used as a last resort

• The employer uses them in accordance with the manufacturer’s instructions, including instructions relating to the use of expired respirators

• The respirators have been stored in accordance with the manufacturer’s instructions

• The workers are informed of their use

• The employer must ensure the following precautionary measures are followed:

• Workers must visually inspect the respirator to determine if its integrity has been compromised;

• Before use, the worker checks that components such as straps, nose clip, and foam material did not degrade, which can affect the quality of the fit and seal

• Workers have been fit tested to the respirator, and can perform user seal checks and know how to don and doff the respirator properly

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MY EMPLOYER HAS PROVIDED ME WITH A REPROCESSED N-95 RESPIRATOR MASK. WHAT SHOULD I DO?

The science behind reprocessed N-95 respirator masks is inconclusive. BCNU is not in support of any of its members using a reprocessed N-95 respirator mask at this time. 

Health-care employers may ask you to place a disposable respirator aside for future reprocessing. 

Read Health Canada’s April 8, 2020 notice about reprocessed N-95 respirator masks. 

Some types of PPE are designed to be reused such as elastomeric respirators or safety goggles. To ensure the safe use of reusable PPE, it must be disinfected in accordance with manufacturer’s instructions prior to reuse. 

Other types of PPE, such as surgical masks or disposable gowns, are not designed to be reused. In an effort to conserve rapidly depleting stocks of PPE, the BC Ministry of Health issued a directive to all health authorities on March 29, 2020 stating that all health-care and support workers must extend the use of donned PPE (except gloves) by wearing the same PPE throughout their entire shift, and only changing when absolutely necessary (for example when items are damaged or visibly soiled). The directive also emphasizes the importance of a health-care worker’s PPE risk and point-of-care assessment prior to every patient or client interaction.

If you are unsure of the safety of the PPE you have been provided, please reach out directly to your supervisor or manager to get clarification as a first step. Contact BCNU if you are still unsure.

You should bring the issue directly to your supervisor or manager. Consider documenting the conversation or following up in an email. You have the right to know any risks that are present in your workplace and have the right to ask questions about your safety. If your question is not completely answered or is extremely urgent, you can contact BCNU directly.

Call the BCNU member safety and support line at 604-433-2268 (press 1), or dial toll-free at 1-800-663-9991 (press 1). This phone line is available to all nurses who require urgent assistance from 0700 - 2300, seven days per week.