Additional precautions and protective equipment

Routine practices apply to everyone. Some infections need more. In health care and long-term care, additional precautions are added for people known or suspected to have infections spread by contact, by droplets or by the airborne route, or by organisms that are hard to treat. This lesson explains the three main types of additional precautions, how protective equipment is selected for them, how to put it on and take it off without contaminating yourself, and how these ideas apply in settings outside health care.

Additional precautions

The precautions are chosen by the way the infection spreads, and often started as soon as an infection is suspected, before laboratory confirmation. Signs at the room entrance tell staff and visitors what is required without revealing the diagnosis.

In Canada, the Public Health Agency of Canada's guideline on routine practices and additional precautions and provincial guidance, such as PIDAC documents in Ontario, set the details. A point-of-care risk assessment can add protection beyond the minimum, for example wearing an N95 respirator for an aerosol-generating procedure on a patient with a respiratory infection.

Aerosol-generating procedures, such as intubation, open suctioning of airways, bronchoscopy and some dental procedures, produce more small particles and are usually done with respirators, in rooms with good ventilation and with as few people present as possible.

Choosing protective equipment

Protective equipment protects only when it is the right item, fits, is put on before exposure and is taken off without self-contamination. Studies of health care workers using fluorescent markers or harmless viruses on their equipment show that skin and clothing often become contaminated during removal. That is why the sequence and technique matter as much as the equipment.

Putting on and taking off

The Canadian sequence widely taught in health care is shown below. Some employers use variations; follow your workplace's procedure and practise it until it is automatic.

Some principles apply whatever the exact sequence:

• put on equipment before entering the room or starting the task, not after exposure has begun;
• remove the most contaminated items, usually gloves and the gown front, first;
• touch only the clean parts: the inside of gloves after the first glove is off, the ties of the gown, the band or ear loops of the mask;
• take off gloves using the glove-in-glove technique, peeling the first glove off with the other gloved hand and the second with a bare finger slid under the cuff;
• remove the respirator outside the room for airborne precautions, after the door is closed;
• clean hands between steps when hands may be contaminated, and always at the end;
• dispose of single-use items in the right container immediately.

Glove use in practice

Gloves are the most used and most misused item. Common problems include wearing the same gloves for several tasks or several people, touching clean surfaces such as door handles, phones and keyboards with contaminated gloves, wearing gloves when they are not needed, and skipping hand hygiene because gloves were worn. Overuse also creates waste and can increase skin problems. A simple rule helps: wear gloves when you expect to touch blood, body fluids, mucous membranes, non-intact skin or contaminated items; take them off as soon as that task is done; clean your hands.

Natural rubber latex gloves can cause allergies, from skin irritation to life-threatening reactions, in workers and patients. Many organizations have switched to nitrile gloves, which give good barrier protection without latex proteins. Where latex is still used, powder-free, low-protein gloves reduce the risk.

Planning supplies

During outbreaks and pandemics, protective equipment can run short, as it did in early 2020. Planning supplies by estimating how much each unit uses, called the burn rate, helps purchasing and helps show whether stock will last.

# PPE burn rate for one long-term care unit during a respiratory outbreak (illustrative)
residents_on_precautions = 12
entries_per_resident_per_day = 10     # care visits by all staff
items_per_entry = {"gloves (pairs)": 1, "gowns": 1, "medical masks": 0.5, "eye protection (disposable)": 0.5}
days = 14
stock = {"gloves (pairs)": 2000, "gowns": 1400, "medical masks": 900, "eye protection (disposable)": 600}
entries = residents_on_precautions * entries_per_resident_per_day
for item, per in items_per_entry.items():
    daily = entries * per
    need = daily * days
    status = "OK" if stock[item] >= need else f"short by {need - stock[item]:.0f}"
    print(f"{item:<30} {daily:5.0f}/day, {need:6.0f} for {days} days, stock {stock[item]:5d}: {status}")

gloves (pairs)                   120/day,   1680 for 14 days, stock  2000: OK
gowns                            120/day,   1680 for 14 days, stock  1400: short by 280
medical masks                     60/day,    840 for 14 days, stock   900: OK
eye protection (disposable)       60/day,    840 for 14 days, stock   600: short by 240

In a shortage, health agencies may allow strategies such as extended use of masks and eye protection or reprocessing of some items, but these are temporary measures within agency guidance, not a substitute for adequate stockpiles. Many provinces, states and health systems now keep strategic stockpiles and track supplies after the lessons of the COVID-19 pandemic.

Outside health care

Workplaces outside health care rarely use formal transmission-based precautions, but the same reasoning applies. A first responder treating someone with a cough wears a mask and eye protection and puts a mask on the patient if possible. A dental office uses eye protection and masks for routine care and adds respirators when the risk assessment calls for them. A cleaning company sends staff to a home with a known C. difficile infection with gowns, gloves and a sporicidal disinfectant. A laboratory follows the containment level and biosafety practices for the agents it handles. A home care worker visiting a client with influenza wears a medical mask and eye protection within close range. In every case, the starting point is a risk assessment of the task, the likely exposure and the available controls, with equipment as the last layer.

Signs, visitors and communication

Precaution signs work only if people read and follow them. Good signs are posted at the entrance to the room or bed space, use pictures as well as words, list the equipment needed in the order it is put on, and avoid naming the infection, which protects the patient's privacy. Supplies of the listed equipment should be stocked right outside the room, with a waste container for removed items inside or at the exit according to the procedure. Visitors who will have close contact should be shown how to put on and remove equipment and how to clean their hands, and they should be told why the precautions matter. In long-term care, where residents may live with precautions for weeks, staff should balance infection control with residents' quality of life and dignity, for example by allowing safe visits and activities rather than isolating people longer than necessary.

Precautions should be reviewed regularly and removed when they are no longer needed, according to the criteria in the guidance for each disease, such as a set number of days after symptoms end or negative test results. Keeping precautions longer than necessary wastes equipment, adds work and can harm patients by limiting care, mobility and social contact. A daily review by the care team, prompted by a checklist, keeps precautions accurate.

Finally, protective equipment protects only the people who wear it correctly. Watching a colleague put on and take off equipment and giving friendly feedback, sometimes called a buddy check, catches mistakes such as an exposed neck, a mask under the nose or a contaminated glove touching the face. Many hospitals adopted trained observers for high-risk situations, such as caring for patients with viral hemorrhagic fevers, after experience showed that removal errors were common even among experienced staff.