Personal protective equipment against potential Ebola virus exposure: higher risk – described video
Transcript - Personal Protective Equipment - Higher Risk Exposure
Use of Personal Protective Equipment when Caring for a Person Under Investigation for Ebola Virus Disease in a First Nations or other Community Health Facility
This training video is based on advice from the Public Health Agency of Canada's Infection Prevention and Control Expert Working Group.
TEXT ON-SCREEN: 'Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings (Date Modified: 2015-05-19). Canada.ca/EBOLAVIRUS'.
Dr. Tom Wong, Chief Medical Officer of Public Health, Health Canada's First Nations and Inuit Health Branch, provides remarks on-screen.
"My colleague, Dr. David Butler-Jones, and I would like to tell you about this very important initiative to help keep our health care workers safe and ensure they are prepared for infectious disease threats including Ebola or other hemorrhagic fevers.
Health Canada is pleased to collaborate with the Royal College of Physicians and Surgeons of Canada and the Public Health Agency of Canada to bring you these training videos. They will show how to put on and take off the personal protective equipment needed when caring for patients suspected or confirmed to have Ebola Virus Disease, in a First Nations community health setting.
Training and repeated practice is necessary to ensure when personal protective equipment is used, it is done so in a correct and safe way. These videos are to be used along with the in-person training."
Dr. David Butler-Jones, Senior Medical Officer, Heath Canada's First Nations and Inuit Health Branch, provides remarks on-screen.
"These videos are an important part of infection prevention and control training - both now and in the future - to help refresh and maintain these essential skills on an ongoing basis. We recommend watching these videos regularly as a reminder of the important skills learned during in-person training.
Our goal is to ensure health care workers in First Nations communities are prepared for any serious communicable disease event, including the Ebola Virus Disease.
We hope you find these videos a valuable contribution towards our efforts to protect and be protected when dealing with potential risks."
Recommended personal protective equipment donning and doffing processes where there is a higher risk of exposure to blood or other bodily fluids.
Please note that the sequences for donning and doffing may vary according to the type of personal protective equipment in use at your health facility and based on the point-of-care risk assessment.
A risk assessment approach should be used before, and during, every interaction with a patient under investigation for Ebola Virus Disease to support the use of additional infection prevention and control measures where indicated.
TEXT ON-SCREEN: Text on the left side of the screen reads: 'Lower Risk: Earlier or convalescing stage of EVD; Contained bodily fluids; Good hygiene; Capable of self-care'.
TEXT ON-SCREEN: Text on the right side of the screen reads: 'Higher Risk: Later stages of EVD, involving copious fluid loss; Uncontained bodily fluids; Poor hygiene; Incapable of self-care (due to physical condition, age or cognitive impairment)'.
Lower risk text fades away, as higher risk text on right side of screen remains highlighted.
DONNING sequence
This video segment demonstrates the DONNING sequence of personal protective equipment for higher risk of exposure to blood or other bodily fluids.
Wide shot of equipment cart in designated clean area, followed by close-up of each listed item of personal protective equipment.
The recommended personal protective equipment used in the following higher-risk scenario, as per the point-of-care risk assessment, includes: fluid-resistant foot and leg coverings, a fluid-resistant mask (or respirator, if performing an aerosol-generating medical procedure), a fluid-resistant head and neck covering, a fluid-impermeable gown, a fluid-impermeable apron, a faceshield, and double gloves.
STEP 1: Prepare for donning enhanced personal protective equipment in a designated clean area
Healthcare worker and trained monitor demonstrate preparation for the donning process as follows.
You, the health care worker, together with the Trained Monitor:
- Perform self-care, such as hydrating and going to the washroom.
- Remove all personal items such as stethoscope, cell phone, jewellery, identification tag, pens, and other items.
- Pull hair back and away from your face and neck and secure it in place.
- Ensure that your fingernails are trimmed to prevent tearing of gloves.
- Perform hand hygiene, thoroughly and effectively, using alcohol-based hand rub, or soap and water if hands are visibly soiled.
(* Note: The proper technique and complete hand hygiene procedure is being demonstrated in this step. Subsequent hand hygiene steps have been abbreviated.)
Close-up of health care worker's hands performing World Health Organization's Hand Hygiene Technique with Alcohol-Based Formulation.
- Ensure that you have all the personal protective equipment required.
- Inspect the personal protective equipment for defects and appropriate size.
Most importantly, be attentive and careful, and take your time in donning the personal protective equipment.
Supporting you is a Trained Monitor whose role is to assist, assess, and document your appropriate selection, use, removal and disposal of personal protective equipment.
The Trained Monitor reads aloud all steps throughout the donning procedure and ensures all steps are performed properly.
Close-up of English and French wall posters listing steps of donning sequence of personal protective equipment for higher risk of exposure to blood or other bodily fluids, followed by close-up of clipboard with donning checklist on blue absorbent pad-covered side table.
STEP 2: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DONNING STEP 1.
Close-up of trained monitor pumping alcohol-based hand rub into health care worker's hands, then own hands.
- Use alcohol-based hand rub.
Trained monitor and health care worker perform hand hygiene facing each other.
STEP 3: Put on fluid-resistant foot and leg coverings
Trained monitor hands foot and leg covering to seated health care worker.
If needed, sit down (on a stool or other surface) in the designated clean area.
Ensure that:
- Your shoes are compatible with the coverings, and allow for easy removal.
- The foot and leg coverings are long enough to cover your legs below the gown.
- And fit securely to avoid the risk of tripping.
Trained Monitor checks off Step 3 of donning checklist on clipboard.
STEP 4: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DONNING STEP 1.
Close-up of trained monitor pumping alcohol-based hand rub into health care worker's hands, then own hands.
Close-up of trained monitor and health care worker performing hand hygiene, facing each other.
STEP 5: Put on fluid-resistant mask
(if an aerosol-generating medical procedure is not being performed)
- Mould the metal piece to the bridge of your nose with three fingers simultaneously on both sides.
Masked health care worker turns face both ways, as trained monitor inspects each side for proper fit.
Gaps between the face and mask are visible on both sides.
The trained monitor indicates the mask doesn't fit properly.
- Ensure that your nose, mouth, and chin are fully covered with minimal gap between the mask and your face.
If there is a gap between the mask and your face, make a knot in each ear loop to tighten it.
The health care worker removes mask, ties a knot in each ear loop and moulds it back on face.
Masked health care worker turns face both ways, as trained monitor inspects each side for proper fit.
Gaps are no longer visible and trained monitor approves the fit.
*Note that masks with attached visors are not suitable.
ALTERNATE STEP 5: Put on respirator
(instead of a face mask, if an aerosol-generating medical procedure is being performed)
Close-up of health care worker inspecting respirator and stretching elastic bands.
- Confirm that proper fit-testing was completed, as per your jurisdiction's or organization's policies and procedures.
Health care worker cups front of respirator in palm of hand, then places upper and lower elastic bands over knuckles of hand.
- Place elastic bands, as per user instructions, to hold the respirator in place.
Health care worker positions respirator over nose and mouth, and lifts elastic bands over head.
The Trained Monitor can position the elastic bands properly to ensure a secure fit.
- Perform a seal check to assess adequate fit.
STEP 6: Put on fluid-resistant head and neck covering
- Ensure that the head and neck covering covers all of your hair and ears, and extends past your neck and shoulders.
Health care worker puts on head and neck covering, and trained monitor fastens the ties at the back of the health care worker's head.
- Secure the ties at the back of your head.
The Trained Monitor can help fasten the ties at the back of your head.
The Trained Monitor verifies that the covering fits securely and comfortably around your face.
STEP 7: Put on inner gloves
Health care worker receives one glove at a time from trained monitor.
- Ensure that the gloves are durable and fit appropriately for the task.
- Examine the gloves for intactness and proper fit.
STEP 8: Put on fluid-impermeable gown
Facing each other, trained monitor assists the health care worker to put on gown.
- Ensure that the gown is cuffed and long enough to cover from your neck to below your foot and leg coverings, and also to your wrists (including sleeves).
- Fasten the gown securely at the neck and waist.
If the gown has two sets of waist ties: Tie the inner tie first, followed by the outer tie, with edges overlapping to completely cover your clothing, both front and back.
The Trained Monitor can help fasten the gown at your neck and waist to ensure that no clothing is visible.
The Trained Monitor ensures that:
- Your inner gloves fit securely under the gown cuffs.
- And that the ties of the head and neck covering are also under the gown.
Gowned health care worker turns around in circle, as trained monitor inspects front and back for proper fit.
STEP 9: Put on fluid-impermeable apron
Trained monitor hands apron to health care worker.
- Don the apron to the front of your body for additional protection against exposure to patient blood or bodily fluids.
The Trained Monitor ties the apron slightly adjacent to, but away from, the gown ties to ease doffing.
*Do not tie the apron at the front.
STEP 10: Put on faceshield
Close-up of trained monitor handing faceshield to health care worker.
- Ensure that the faceshield is long enough to prevent splashing underneath and that it fits over your prescription eye glasses, if wearing.
- Secure the strap at the back of your head.
- Adjust the faceshield to ensure that no skin is exposed, as directed by the Trained Monitor.
Faceshielded health care worker turns around in circle, to allow trained monitor to inspect for proper fit.
*Note that eye glasses are not suitable eye protection.
STEP 11: Put on outer gloves
- Ensure that the gloves are durable and fit appropriately for the task.
- Fit them securely over your gown cuffs.
The Trained Monitor can help position the outer gloves over your gown cuffs.
- Examine the gloves for intactness and proper fit.
The DONNING procedure for higher risk of exposure to blood or other bodily fluids is now complete.
Health care worker and trained monitor demonstrate as follows.
To ensure proper fit of personal protective equipment, perform a few range of motion exercises, such as looking up and down, bending forward at the waist and extending arms above your head.
Health care worker turns around in circle.
The Trained Monitor inspects front and back to ensure proper fit of personal protective equipment - that is, all skin and clothing are completely covered.
Close-up of fully donned health care worker, moving from feet to head, with trained monitor inspecting from behind.
You are now appropriately attired to provide care to a patient suspected or confirmed to have Ebola Virus Disease, where there is a higher risk of exposure to blood or other bodily fluids.
Close-up of French and English signs on room door, stating "ISOLATION PRECAUTIONS. STOP. DO NOT ENTER. PLEASE SEE THE NURSE".
If, at any point while providing care to the patient, you have any difficulties or unintended breaches with your personal protective equipment (such as fogging of the faceshield or tearing of the gloves), OR unprotected exposure to blood or other bodily fluids, you should: stop providing patient care after ensuring the patient is safe, leave the patient room, and calmly and methodically remove your personal protective equipment.
Then, as required, follow your health facility's Ebola exposure management plan and put on a new set of personal protective equipment before continuing patient care.
DOFFING sequence
This video segment demonstrates the DOFFING sequence of personal protective equipment for higher risk of exposure to blood or other bodily fluids.
STEP 1: Prepare for doffing enhanced personal protective equipment in a designated soiled area located immediately outside the patient room
Infographic appears on-screen, indicating there is higher risk of exposure to blood or other bodily fluids.
The Trained Monitor performs a point-of-care risk assessment and dons the personal protective equipment required, ahead of time, in order to safely assist you, the health care worker, as soon as provision of care is completed.
Close-up of fully donned health care worker, with soiled apron, opening door and exiting patient room into designated soiled area, marked on wall and floor by red tape.
A waste receptacle and a wipeable chair is located in the soiled area.
French and English signs on door state "ISOLATION PRECAUTIONS. STOP. DO NOT ENTER. PLEASE SEE THE NURSE".
After leaving the patient room, you step into and remain in the designated soiled area right outside the patient room to remove and immediately discard your personal protective equipment, including respirator (if used) into a designated sturdy no-touch leak-resistant biohazard waste receptacle located there.
Trained monitor waits in designated clean area, which contains clean equipment cart, donning and doffing wall posters, as well as side table with gloves, hand sanitizer, clipboard, pen and scissors.
Like health care worker, trained monitor is fully donned in personal protective equipment for higher risk of exposure to blood or other bodily fluids.
In the following demonstration, as the health care worker is visibly soiled, the point-of-care risk assessment indicates higher risk of exposure to the Trained Monitor. Therefore, the personal protective equipment used by the Trained Monitor mirrors that of the health care worker.
The Trained Monitor remains in the designated clean area the entire time while helping the health care worker in the doffing process.
Close-up of trained monitor and health care worker's feet in designated clean and soiled areas, marked on floor by red tape.
The Trained Monitor reads aloud all steps throughout the doffing process and ensures that you are attentive, careful, and taking your time to reduce your risk of self-contamination.
Close-up of wall poster listing steps of doffing sequence of personal protective equipment for higher risk of exposure to blood or other bodily fluids, moving from top to bottom.
- Inspect your personal protective equipment for visible contamination, cuts or tears.
Health care worker turns around in circle, as trained monitor inspects for contamination.
Most importantly, be attentive and careful, and take your time in doffing your personal protective equipment to reduce the risk of self-contamination.
STEP 2: Remove outer gloves
Facing each other, trained monitor inspects health care worker's gloves.
- Use glove-to-glove technique to remove gloves away from your body, taking care not to contaminate inner gloves, as follows:
- Grasp the outside edge near your wrist and peel it away, rolling the glove inside-out.
- Then reach under the glove on your other hand and peel it away.
- Discard both gloves immediately into the designated waste receptacle.
STEP 3: Remove apron
Loop your thumbs onto the neck strap, being careful to minimize contact with your gown and not touch the head and neck covering.
To reduce your risk of self-contamination, the Trained Monitor then:
- Carefully cuts the neck strap at the back with disposable blunt scissors.
- Discards the scissors into the designated sharps receptacle in the designated soiled area.
- And undoes the waist ties.
You then:
- Pull the two fragments of the cut neck strap forward, away from your body.
- And remove the apron, without contaminating yourself, rolling it from inside to outside.
- Discard the apron immediately into the waste receptacle.
The Trained Monitor:
- Removes and immediately discards outer gloves into the same waste receptacle, and puts on new gloves.
STEP 4: Remove gown
To reduce your risk of self-contamination, the Trained Monitor:
- Unties the outer waist tie to open your gown at the back and expose the inner tie.
- Then unties your inner tie at the back.
- And unfastens your gown at the neck, gently pushing the gown off your shoulders, being careful not to touch the inside of your gown.
You then:
- Reach under the gown cuff of one sleeve and gently slide it over your hand.
- With your hand covered by the gown cuff, pinch the gown cuff of your other sleeve to remove it.
- Pull and remove your gown without touching your skin or clothing, or agitating the gown unnecessarily.
- Turn the gown inside-out on itself, and roll it up.
- Discard the gown immediately into the waste receptacle.
The Trained Monitor:
- Removes and immediately discards outer gloves into the same waste receptacle, and puts on new gloves.
STEP 5: Remove inner gloves
- Use glove-to-glove/skin-to-skin technique to remove gloves away from your body, as follows:
- Grasp the outside edge near your wrist and peel it away, rolling the glove inside-out.
- Then reach under the glove on your other hand and peel it away.
- Discard both gloves immediately into the waste receptacle.
STEP 6: Perform hand hygiene
… thoroughly and effectively
- Use alcohol-based hand rub.
The Trained Monitor pumps it into your hands without touching you.
(* Note: The proper technique and complete hand hygiene procedure is being demonstrated in this step. Subsequent hand hygiene steps have been abbreviated.)
Close-up of health care worker's hands performing World Health Organization's Hand Hygiene Technique with Alcohol-Based Formulation.
STEP 7: Put on gloves
Trained monitor hands glove to health care worker.
- Examine the gloves for intactness and proper fit.
STEP 8: Remove faceshield
- Bending forward from the waist, grab the strap toward the back and pull it over your head, ensuring that the bottom of the faceshield does not touch yourself.
- Gently allow the faceshield to fall forward.
Slow-motion of health care worker removing faceshield and discarding into waste receptacle.
- Avoid touching the front of the faceshield to prevent contaminating yourself.
- Discard the faceshield immediately into the waste receptacle.
If you wear prescription eye glasses, be careful not to drop them when removing the faceshield.
STEP 9: Remove gloves
- Use glove-to-glove/skin-to-skin technique to remove gloves away from your body.
- Discard both gloves immediately into the waste receptacle.
STEP 10: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DOFFING STEP 6.
Trained monitor pumps alcohol-based hand rub into health care worker's hand.
STEP 11: Put on gloves
Health care worker receives glove from trained monitor.
- Examine the gloves for intactness and proper fit.
STEP 12: Remove head and neck covering
- Unfasten the ties at the back of your head.
- Bend forward from the waist.
- Pinch the top of and gently pull the covering away from your face, while holding the ties in the same hand. (This is especially important if the ties hang past the bottom of the covering when undone.)
- Discard the head and neck covering immediately into the waste receptacle.
*Remember NOT to touch your face or hair.
STEP 13: Remove gloves
- Use glove-to-glove/skin-to-skin technique to remove gloves away from your body.
- Discard both gloves immediately into the waste receptacle.
STEP 14: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DOFFING STEP 6.
STEP 15: Put on gloves
- Examine the gloves for intactness and proper fit.
STEP 16: Remove mask OR respirator
- Grasp the mask loops (or respirator straps) from behind your ears (or head).
- Pull them forward off your head, bending forward from the waist to allow the mask (or respirator) to fall away from your face.
- Avoid touching the front of the mask (or respirator) to prevent contaminating yourself.
- Discard the mask (or respirator) immediately into the waste receptacle.
If you wear prescription eye glasses, be careful not to drop them when removing the mask (or respirator).
STEP 17: Remove gloves
- Use glove-to-glove/skin-to-skin technique to remove gloves away from your body.
- Discard both gloves immediately into the waste receptacle.
STEP 18: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DOFFING STEP 6.
STEP 19: Put on gloves
- Examine the gloves for intactness and proper fit.
STEP 20: Remove foot and leg coverings
- Sit down (on a swivel stool or other wipeable surface) in the designated soiled area.
- Roll down and pull off the covering of the leg closest to the designated clean area, without contaminating yourself, or agitating the covering unnecessarily.
- Slowly pivot the clean (uncovered) foot into the adjacent designated clean area.
- Discard the foot and leg covering immediately into the waste receptacle.
- As just described, remove the other covering, slowly pivot the second foot into the designated clean area, and discard the foot and leg covering immediately into the waste receptacle.
The Trained Monitor can help you remove the foot and leg coverings if needed.
STEP 21: Remove gloves (while seated)
Health care worker remains seated on chair in designated soiled area, with both feet planted in designated clean area.
- Use glove-to-glove/skin-to-skin technique to remove gloves away from your body.
- Discard both gloves immediately into the waste receptacle.
STEP 22: Perform hand hygiene
… thoroughly and effectively, as demonstrated in DOFFING STEP 6.
Trained monitor pumps alcohol-based hand rub into health care worker's hands.
STEP 23: Exit designated soiled area
With health care worker's feet already in designated clean area, the health care worker stands up from chair located in designated soiled area.
Remember to perform self-care, as required.
Trained monitor and health care worker are facing each other in designated clean area.
Trained Monitor checks off last steps of doffing checklist on clipboard.
The Trained Monitor doffs personal protective equipment, as appropriate, and discards all materials contaminated or potentially contaminated during the doffing process into the waste receptacle.
The DOFFING procedure for higher risk of exposure to blood or other bodily fluids is now complete.
"Hi. I'm Erin Henry, Director of the Communicable Disease Control Division in the First Nations and Inuit Health Branch of Health Canada.
These videos were developed to complement comprehensive in-person training and practice sessions provided to health care professionals working in First Nations on-reserve health facilities across Canada.
It is important to remember that in order for personal protective equipment to be effective, you must receive prior training in selecting and using the equipment based on the point-of-care risk assessment.
This includes using and practicing the correct techniques for donning and doffing, discarding into designated waste containers, and effective hand washing to minimize the risk of transmission.
The information presented in the videos is based on currently available scientific evidence, and may be reviewed and revised as new information becomes available. What is key is that all techniques shown are based on infection prevention and control principles and precautions to guide you in protecting yourself, your patients, colleagues, and others."
For further information, please visit canada.ca/ebolavirus and royalcollege.ca/ebola.
This video is made possible by a joint collaboration between Health Canada, the Royal College of Physicians and Surgeons of Canada, the Public Health Agency of Canada, and IPAC Canada.
Credits appear on-screen.
Spokespeople:
- Dr. Tom Wong
- Dr. David Butler-Jones
- Erin Henry
Nurse Demonstrators:
- Andrea Coady
- Tyla Turman
Project Team:
- Véronique Cantin
- Sabrina Chung
- Andrea Coady
- Amy Harik
- Erin Henry
- Fanie Lalonde
- Kathleen Lydon-Hassen
- Denise Taylor
- Tyla Turman
Special Advisors:
- Glenn Barton
- Katherine Defalco
- Diego Garcia
- Angèle Landriault
- Dr. Anne Matlow
- Patricia Piaskowski
- Infection Prevention and Control Expert Working Group, PHAC
- IPAC Canada Expert Review Panel
A message from the Government of Canada.
© Her Majesty the Queen in Right of Canada, represented by the Minister of Health, 2015. All rights reserved.