17 June 2020

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How to put and remove Personal Protective Equipment to avoid Coronavirus infection

Authors: S. Chirico, L. Breschi

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After months of emergency caused by the Coronavirus epidemic, we find ourselves living a completely different reality from what we were used to and having to take several precautions. Especially in the dental field (which is what concerns us) the risk of contagion and infection with coronavirus is very high and for this reason guidelines have been established to be respected.
These guidelines provide for the use of devices for individual protection, such as: disposable caps, surgical masks and FFP2 / FFP3, disposable gowns, application of double disposable gloves, visors and boot covers. The best way for healthcare professionals to prevent SARS-CoV-2 infection is not only to protect themselves with appropriate devices, but also to have training and proven expertise in putting on and removing personal protective equipment (PPE).
 The steps in which the PPE is worn and removed are delicate phases, with a risk of contagion that should not be underestimated absolutely, so they must be carried out calmly and carefully.  

The article published on The New England Journal of Medicine focused on this aspect and described in detail the adequate system of dressing and undressing of PPE that can avoid contagion from Coronavirus disease.   The PPE  used to prevent contagion from SARS-CoV-2 includes: gloves, disposable gown, disposable cap, FFP2 (N95) or higher mask and visor or face mask. If the FFP2 masks are not available, the surgical ones combined with a face mask are to be considered an acceptable alternative. Disposable overalls or full coveralls must be resistant to fluids and must cover the body at least from the neck to the calf.
The gloves should extend to cover the cuffs of the lab coat. Disposable gowns with integrated thumb hooks can help protect the sleeves and wrists under the gloves.  

Procedure for putting PPE Wear PPE in the operating room 
Before wearing them, you must tie long hair and remove personal items such as jewelry, watches etc.
If you are wearing eyeglasses, make sure they are placed firmly on your face. Eyeglasses alone are not enough for eye protection, they must always be combined with visors or protective face masks.
Before handling any PPE, wash your hands with soap and water or clean your hands with an alcohol-based hand sanitizer.
Visually check the integrity of all devices. If possible, ask the assistant to watch carefully while wearing PPE to check that no mistakes are made in the dressing technique.
Put on the disposable gown with the assistant with the back fastenings.
When inserting the template, model the flexible nasal strip around the bridge of the nose with both hands so as to make it adhere as much as possible, which does not bother in the subsequent phases and which remains firm, to avoid having to readjust it during the operating phases, which would increase the risk of contagion.
Then put on the cap and the face shield and adjust the elastic strap to ensure a perfect fit.
If you wear glasses, make sure they are positioned correctly and firmly to minimize the need to readjust them during patient treatment.
Disinfect your hands with an alcohol-based disinfectant and put on the gloves by extending the cuffs over the sleeves of the lab coat. Now it will be possible to start with patient treatment.      

Procedure for removing PPE 
 Correct removal and disposal of contaminated PPE represent the most difficult challenge in preventing exposure to pathogens.
Whenever possible, ask the assistant to observe while the PPE is removed to be sure not to make any mistakes during the removal that must be done in the operating room.
Let's see the various steps: remove the gloves correctly. Grasp the outside of a glove on your wrist with one hand, pull the glove from your hand, with the contaminated outside folded inside. Then hold the removed glove in the gloved hand. Slide a finger of the hand without a glove under the strap of the remaining glove and gently pull it so that it is turned upside down, forming a bag for the other glove and throw away; disinfect hands; remove the gown correctly. Undo the closure at the waist first. Better get help from the assistant to unfasten the back of the lab coat.
Then detach the gown from the body, rotating the gown inside by wrapping it so that only the inside of the gown remains visible.
Discard the lab coat; remove the visor. It is particularly important to carry out this phase correctly to avoid contamination of the eyes and mucous membranes when removing facial PPE. Tilt your head forward and lift the visor by the strap above and away from the head, without touching the visor itself. If you wear prescription glasses, make sure that the glasses are not contaminated when removing PPE; remove the template N95. To minimize the possibility of contamination, avoid contact with the mask itself, touching only the laces; disinfect hands.    

For additional information: Personal Protective Equipment and Covid-19