Sl.No.	Topic
*	PPE: Requirement calculator
1	Personal Protective Equipment (PPE)
2	Components of PPE
2a	Re-use of N95 mask
3	Donning of PPE
4	Removal of PPE
5	Respiratory Protection
6	Rational use of PPE: Updated guidelines (15 th May 2020
6	Rational use of PPE : Old guidelines
7	Safe management of a dead body
8	Autopsy Guidelines

Personal Protective Equipment (PPE)

Personal Protective Equipments (PPEs) are protective gears designed to safeguard the health of workers by minimizing the exposure to a biological agent.

Components of PPE

Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover and shoe cover. Each component and rationale for its use is given in the following paragraphs:

Face shield and goggles

Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets generated by cough, sneeze of an infected person or during aerosol generating procedures carried out in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another likely scenario. Hence protection of the mucous membranes of the eyes/nose/mouth by using face shields/ goggles is an integral part of standard and contact precautions. The flexible frame of goggles should provide good seal with the skin of the face, covering the eyes and the surrounding areas and even accommodating for prescription glasses.

Masks

Respiratory viruses that includes Coronaviruses target mainly the upper and lower respiratory tracts. Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents human infection. Contamination of mucous membranes of the mouth and nose by infective droplets or through a contaminated hand also allows the virus to enter the host. Hence the droplet precautions/airborne precautions using masks are crucial while dealing with a suspect or confirmed case of COVID-19/performing aerosol generating procedures. Masks are of different types. The type of mask to be used is related to particular risk profile of the category of personnel and his/her work. There are two types of masks which are recommended for various categories of personnel working in hospital or community settings, depending upon the work environment:
1. Triple layer medical mask
2. N-95 Respirator mask

Reuse of N95 : guidelines by AIMS

Triple layer medical mask

A triple layer medical mask is a disposable mask, fluid-resistant, provide protection to the wearer from droplets of infectious material emitted during coughing/sneezing/talking

.

N-95 Respirator mask

An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit.

Such mask should have high fluid resistance, good breathability (preferably with an expiratory valve), clearly identifiable internal and external faces, duckbill/cup-shaped structured design that does not collapse against the mouth.

If correctly worn, the filtration capacity of these masks exceeds those of triple layer medical masks. Since these provide a much tighter air seal than triple layer medical masks, they are designed to protect the wearer from inhaling airborne particles.

Gloves

When a person touches an object/surface contaminated by COVID-19 infected person, and then touches his own eyes, nose, or mouth, he may get exposed to the virus. Although this is not thought to be a predominant mode of transmission, care should be exercised while handling objects/surface potentially contaminated by suspect/confirmed cases of COVID-19. Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis among health workers. However, if nitrile gloves are not available, latex gloves can be used. Nonpowdered gloves are preferred to powdered gloves.

Coverall/Gowns

Coverall/gowns are designed to protect torso of healthcare providers from exposure to virus. Although coveralls typically provide 360-degree protection because they are designed to cover the whole body, including back and lower legs and sometimes head and feet as well, the design of medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in the back, coverage to the mid-calf only).

By using appropriate protective clothing, it is possible to create a barrier to eliminate or reduce contact and droplet exposure, both known to transmit COVID-19, thus protecting healthcare workers working in close proximity (within 1 meter) of suspect/confirmed COVID-19 cases or their secretions.

Coveralls and gowns are deemed equally acceptable as there is a lack of comparative evidence to show whether one is more effective than the other in reducing transmission to health workers. Gowns are considerably easier to put on and for removal. An apron can also be worn over the gown for the entire time the health worker is in the treatment area. Coveralls/gowns have stringent standards that extend from preventing exposure to biologically contaminated solid particles to protecting from chemical hazards.

Shoe covers

Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal protection and decontamination.

Head covers

Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head and neck while providing clinical care for patients. Hair and hair extensions should fit inside the head cover.

Re-use of N95 mask : AIMS guidelines

1. You have been provided with five N-95 masks. You have also been provided with 4 small brown covers numbered 1,2,3& 4 as well and a large brown cover. (If not ask your indenting official to collect it from PRO.
2. Place each N-95 mask in separate small paper bags and mark both the mask and the bag as 1,2,3, and 4. Fifth mark is being issued as a reserve.
3. On day 1, wear the mask no.1 when you step out for duty. Learn to wear the mask correctly. This is very important. The Infection control team in your area will explain the method to you.
4. After you return home, place the used N-95 in paper bag no.1 & let it dry out for 4 days. Sunlight is not necessary. DO NOT THROW AWAY THE MASK.
5. On day 2, use mask number 2 when you go for duty. After you return home, place the used N-95 in paper bag no.2 & let it dry out for the next 4 days.
6. Do the same for day 3 and day 4.
7. Use the N-95 mask no. 1 on day 5 again. For eg. if you start using mask no.1 on Wednesday 8th April, it is available for reuse on Sunday 12th April' 2020.
8. Repeat the exercise until all 4 masks have been used 5 times as recommended by CDC, Atlanta, USA.. All four will be used up in 20 days (in this example on Monday 27th April 2020) .
9. These "personal use" N-95 masks will not be treated and reused.
10. Bring all 4 masks in the big brown bag, throw them in the yellow waste bin in your ward/ area or posting are report to the indenting nurse.
11. You will be issued OS new N-95 masks, after 20 days.

STANDARD OPERATING PROCEDURE (SOP) for extended use of N-95 masks for personal safety of Health Care Workers (HCW) at AIIMS.
No. F.79/COVID-19/2020-Estt.(H.)
Dated: 08.04.2020

Donning of PPE

Donning (putting on) PPE:

Steps of donning PPE:

1. Remove home clothes, jewelry, watches, electronic etc. and wear clean hospital scrubs
2. Wash hands with soap and water
3. Wear shoe covers – tie lace infront of the shin
4. Wear first place of gloves- smaller than 2nd pair, comfortable size, could be sterile or unsterile
5. Wearing gown-
Gowns- Put on a clean disposable non-permeable gown prior to entry into the patient room or are, do not remove paper strip attached at end of lace( will be required while tying lace at the end), wear by holding at shoulder end of gown, arm sleeves of gown should cover the gloves at wrist. identify the ends of lace by attached paper card, remove the paper card and tie the lace at back snuggly without wrapping all around the waist. Decontaminate the gown if it becomes soiled. Remove gown only in designated doffing area and discard the gown before leaving patient care area
7. Wear the mask - N95 mask with respirator is preferable, hold the opened mask in right hand with straps facing towards face, put on mask by placing lower strap behind the neck passing below ears. (strap should be in contact with skin), then place the upper strap over back of head. On the sides, straps should be above ear, check for snug fit of mask. There should be no more than minimal air leak from sides
8. Wear eye piece- Adjust the strap according to required size, open the ports at upper end to prevent fogging while wearing, upper end N95 mask should be covered by eye piece
9. Wear the hood- Hood should lay over the gown without leaving any open space.
10. Wear 2nd pair of the gloves-Should be of larger size than 1st pair, should cover free end of arms of gown. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene
11. Gown fitness check: Take help of companion for fitness check.

Removal of PPE

Steps of doffing:

To be performed only in the designated area, check for any leak or soiling in PPE before doffing. If any, disinfect the area before doffing. Doffing room should have 2chairs. One labelled “dirty” and the other “clean”. All the PPE must be discarded in the yellow bin
1. Disinfect the hands wearing gloves like hand hygiene procedure
2. Remove shoe covers only by touching the outer surface, and perform hand hygiene
3. Remove outer gloves. Again, perform hand hygiene
4. Remove hood and again perform hand hygiene
5. Remove gown slowly. hold the gown at the waist and pull. Without touching the outer surface, remove by with a rolling inside out technique. Perform hand hygiene again
6. Remove eye piece by holding the straps, and perform hand hygiene
7. Remove inner gloves and perform hand hygiene
8. Wear another pair of sterile /unsterile gloves
9. Remove mask- Do not touch exposed surface of mask. First remove lower strap of mask, remove mask holding upper strap in a slow and steady pace (as to not generate aerosols)
10. Perform hand hygiene
11. Sit over clean chair and clean your shoes with alcohol swabs
12. Remove last pair of gloves and perform hand hygiene

Respiratory Protection

Use respiratory protection, i.e as follows:

i. Medical mask to be worn by patients always
ii. A disposable N95 respirator to be worn by Health Care Providers (HCPs).

Disposable respirators should be removed and discarded in designated bags after exiting the patient’s room or care area. Perform hand hygiene after discarding the respirator Points to be noted pertaining to care

1. Face shield maybe a better option than eye piece (if available)
2. If any leak found in PPE while caring for infected patients, caring doctor should be quarantined
3. Label gown with name after wearing for identification

Rational use of PPE: Updated on 15th May 2020

1. About this guideline

This guideline is for health care workers and others working in Non COVID hospitals and NonCOVID treatment areas of a hospital which has a COVID block. These guidelines are in continuation of guidelines issued previously on ‘Rational use of Personal Protective Equipment’ (https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf). This guideline uses “settings” approach to guide on the type of personal protective equipment to be used in different settings.

2. Rational use of PPE for Non COVID hospitals and Non-COVID treatment areas of a hospital which has a COVID block The PPEs are to be used based on the risk profile of the health care worker. The document describes the PPEs to be used in different settings.

2.1.Out Patient Department

S.No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Help desk/ Registration counter	Provide information to patients	Mild risk	Triple layer medical mask Latex examination gloves	Physical distancing to be followed at all times
2	Doctors chamber	Clinical management	Mild risk	Triple layer medical mask Latex examination gloves	No aerosol generating procedures should be allowed.
3	Chamber of Dental/ENT doctors/ Ophthalmology doctors	Clinical management	Moderate risk	N-95 mask Goggles Latex examination gloves + face shield	Aerosol generating procedures anticipated. Face shield, when a splash of body fluid is expected
4	Pre- anesthetic check-up clinic	Pre-anesthetic check-up	Moderate risk	N-95 mask Goggles* Latex examination gloves	* Only recommended when close examination of oral cavity/dentures is to be done
5	Pharmacy counter	Distribution of drugs	Mild risk	Triple layer medical mask Latex examination gloves	Frequent use of hand sanitizer is advised over gloves.
6	Sanitary staff	Cleaning frequently touched surfaces/ Floor	Mild risk	Triple layer medical mask Latex examination gloves

#All hospitals should identify a separate triage and holding area for patients with Influenza like illness so that suspect COVID cases are triaged and managed away from the main out-patient department.

2.2.In-patient Department (Non-COVID Hospital &Non-COVID treatment areas of a hospital which has a COVID block)

S.No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Ward/individual rooms	Clinical management	Mild risk	Triple layer medical mask Latex examination gloves	Patients stable. No aerosol generating activity.
2	ICU/ Critical care	Critical care management	Moderate risk	N-95 mask Goggles Nitrile examination gloves +Face shield	Aerosol generating activities performed. Face shield, when a splash of body fluid is expected
3	Ward/ICU /critical care	Dead body packing	Low Risk	Triple Layer medical mask Latex examination gloves
4	Ward/ICU/ Critical care (Non-COVID)	Dead body transport to mortuary	Low Risk	Triple Layer medical mask Latex examination gloves
5	Labor room	Intra-partum care	Moderate Risk	Triple Layer medical mask Face shield Sterile latex gloves Coverall N-95 mask*	Patient to be masked in the Labor room, if possible. *If the pregnant woman is a resident
6	Operation Theater	Performing surgery, administering general anaesthesia	Moderate Risk	Triple Layer medical mask Face shield (- wherever feasible) Sterile latex gloves + Goggles N-95 mask*	Already OT staff shall be wearing For personnel involved in aerosol generating procedures *If the person being operated upon is a resident of containment zone
7	Sanitation	Cleaning frequently touched surfaces/ floor/ changing linen	Low Risk	Triple Layer medical mask Latex examination gloves

2.3.Emergency Department (Non-COVID)

S.No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Emergency	Attending emergency cases Emergency	Mild risk Emergency	Triple Layer medical mask Latex examination gloves Emergency	No aerosol generating procedures are allowed Emergency
2		Attending to severely ill patients while performing aerosol generating procedure	High risk Full complement of PPE (N-95 mask, coverall, goggle, Nitrile examination gloves, shoe cover)

2.4.Other Supportive/ Ancillary Services

2.5.Pre-hospital (Ambulance) Services

Points to remember while using PPE

1. Standard precaution to be followed at all times
2. PPEs are not alternative to basic preventive public health measures such ashand hygiene, respiratory etiquettes which must be followed at all times.
3. Always follow the laid down protocol for disposing off PPEs as detailed in infection prevention and control guideline available on website of MoHFW.
In addition, patients and their attendants to be encouraged to put on face cover.
In case a COVID-19 patient is detected in such Non-COVID Health facility, the MoHFW guidelines for the same has to be followed (Available at:
https://www.mohfw.gov.in/pdf/GuidelinestobefollowedondetectionofsuspectorconfirmedCOVID19ca se.pdf)

Rational use of PPE : Old guidelines