ADVISORY:

This video is part of the Exposed: Infection Control Part 2 that was inadvertently not included in the editing. This is about the protocol of the donning and doffing of our PPE's to avoid cross contamination. Our PPE's and infection control materials and equipment can only protect us if we use and maintain them right.
If you missed our recent webinars on "Exposed: Infection Control Part 1 & 2 and Q& A Part 1” or just want to watch it again?
Click here to revisit the webinar:

Part 1: https://dmd.center/expose-covid-19-part-1
Part 2: https://dmd.center/expose-covid-19-part-2
YouTube Link Part 1: https://www.youtube.com/watch?v=GZw_Azr_a14
YouTube Link Part 2: https://www.youtube.com/watch?v=l_BJ8F7_85A
YouTube Link Q&A Part 1: https://youtu.be/Hbcu6vbhAhw
YouTube Link Q&A Part 2: https://youtu.be/vpqW8_h9guo
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ABOUT DONNING AND DOFFING:

As we go through our dental treatments, it is a known fact that we deal with a lot of aerosol and droplet producing procedures. This is the main cause of alarm of all dental practitioners as we all know that CoVid-19 virus can be transmitted precisely either through droplets and aerosols. Thus, personal protective equipment (PPEs) became very important and critical gear to all health care providers especially with dentists, dental hygienists and assistants, who are very vulnerable to this highly infectious disease while they practice their profession.

On this case all precautionary steps must be taken and PPEs become an SOP, however, these PPEs will not work if we don’t use and maintain them properly. Let’s deal with the PPEs, which are the head cap, face mask, protective eye wear, face shield, scrub, gloves and shoe cover. They are essentials that acts as our first line of defense from contracting this virus, however, they will all be for nothing if we don’t don (the act of putting it on) and doff (the act of getting it off) properly. These steps are as much as critical as the PPEs themselves because if they get contaminated or cross contaminated, you might as well have not worn any of them. So, let’s discuss this critical steps and be guided accordingly:

RESPIRATORY PROTECTION

  • The respirator protects us from the inhalation of droplets and particles.
  • There are different types of respirators that fit differently between users, the respirator requires a fitting test. They are the Half Face Respirator and Full Face Respirator.
    1. A Full-Face Respirator provides a higher level of protection than a Half Face. It has better sealing characteristics as it seals around the whole face rather than just around the nose and mouth. Since it covers the eyes and face, it also protects against liquid splashes and irritating vapours.
    2. A Half Face Mask can only cover nose and mouth and is required to be partnered with face shield.
  • Respirators should fit and create a tight seal in the face
  • A FFP3 respirator should be always be used when performing aerosol-generating procedures.
  • If FFP3 isn’t present, use an n95 Mask

MASKS (Surgical Masks, Face Mask and N95):

  • Face masks are used mainly as a physical barrier for the nose and the mouth from exhaling aerosols or droplets.
  • The mask should block large-particle droplets, splashes, sprays, or splatter that may contain germs (viruses and bacteria), keeping it from reaching your mouth and nose.
  • It is advice to wear n95 at all times when performing dental procedures.
  • If your mask is damaged or soiled, or if breathing through the mask becomes difficult, you should remove the face mask, discard it safely.
  • Reduce the amount of talking when wearing a mask or respirator. These actions will lower the amount of condensation produced within the mask or respirator, and extend its efficacy.
  • Do fit test. Most n95 will not give a good seal, especially in the chin area.
  • This causes a break in your PPE which increases the risk of getting infected.
  • Test the mask by doing positive pressure seal check.
  • Positive pressure seal check is done by breathing out in the mask. The mask should puff slightly away from your face and stay like that while you hold your breath for 10 seconds. If you find a leak, adjust the mask or straps and repeat the test until you get a good fit.
  • You may also check if the product is listed on NIOSH’s website as a NIOSH-certified N95 respirator.

EYE PROTECTION:

  • Goggles, or face shields, should be used to prevent virus exposure of the eye mucosa.
  • Goggles need to fit the user’s facial features and have to be compatible with the respirator.

BODY PROTECTION:

  • Long-sleeved water-resistant gowns should be used to prevent body contamination.
  • This PPE item does not need to be sterile unless it is used in a sterile environment ( treatment room).
  • If water-resistant gowns are not available, a single-use plastic apron worn over the non-water-resistant gown can be used.
  • Wear a surgical hair cap also. Exposed hair can also be contaminated. Advise girls to neatly tie their hair. The hair cap should also cover the ears

HAND PROTECTION:

  • Gloves should be used when managing suspected or confirmed COVID-19 patients.
  • It is suggested at least 3 layers of gloves. Use surgical sterile gloves as one of the layers of gloves on top of the gown (PPE), then wear another pair of clean gloves on top of it.
  • Gloves should extend through cuffs of the PPE avoiding skin exposure.
  • Avoid snapping of gloves during doffing procedure.
  • Hand hygiene is a must.

WEARING (DONNING) OF PPE:

Before wearing the PPE for managing case, proper hand hygiene should be performed following international recommendations. This is a critical aspect in this setting and should be performed using an alcohol-based solution in accordance with the manufacturer’s instructions.
Points to Remember Before Any Procedures:

  • Put PPE and bring all equipment needed for treatment before entering the treatment area.
  • Ensure that you are always adequately hydrated.
  • Check again: all jewelry, watches, lanyard, keychain, cellphone should be removed, placed in a sealed plastic zip lock container and stored away from patient area; if you have long hair, ensure hair is neatly tied in a bun.
  • Keep hands away from face, avoid touching PPE.
  • Avoid touching areas in the room.
  • Remove PPE at patient’s doorway or outside of the treatment area, and perform hand hygiene.
  • Remove the respirator outside of room after patient leaving the treatment area.
  • If hands are contaminated during PPE removal, stop and perform hand hygiene first then proceed with the PPE removal.
  • Proper disposal of soiled PPE should be contained on a hazardous waste bin.

Step 1: Perform Hand Hygiene

Handwash Steps
Step 2: Wear Your Gown

  • Fully cover torso from neck to knees, arms to end of the wrist and wrapped around the back.
  • Fasten in back of the neck and waist by tying a knot.
  • Seek assistance from your personnel, if not present use a mirror to check.
  • Put on another layer of booties.

Step 3: Mask and Respirator

  • Secure ties or straps. Have tightened to have a firm and comfortable fit.
  • If you cannot achieve a proper fit, position the straps crosswise.
  • Fit the metal nose clip to the nose bridge.
  • Fit snug to face and below chin.
  • Fit-check respirator Mask and Respirator.
  • Test the mask by doing positive pressure seal check.
  • Positive pressure seal check is done by breathing out in the mask. The mask should puff slightly away from your face and stay like that while you hold your breath for 10 seconds. If you find a leak, adjust the mask or straps and repeat the test until you get a good fit.
  • Use a FFP3 type of respirator for aerosol producing procedures.

Step 4: Googles

  • Place the goggles over the mask’s straps and ensure that the textile elastic strap fits snugly – but not too tightly.
  • Use tape to seal and secure spaces as needed.

Step 5: Gloves

  • When wearing gloves, it is important to extend the glove to cover the wrist over the gown’s cuffs.
  • For individuals allergic to latex gloves, an alternative option, for example nitrile gloves, should be available.

REMOVING (DOFFING) OF PPE

The removal (doffing) of the PPE is a critical and important step that needs to be carefully carried out in order to avoid self-contamination because the PPE could by now be contaminated.

Step 1: Removing of Gloves

The gloves are removed first because they are considered a heavily contaminated item followed by hand hygiene. Use of alcohol-based hand disinfectant should be considered before removing the gloves. The gloves should be removed following eight steps:
1. Pinch and hold the glove (with the other gloved hand) between the palm and wrist area.
2. Slowly peel the glove away from the wrist.
3. Turn the glove inside out covering the fingers.
4. With the now half-gloved hand, pinch and hold the fully gloved hand between the palm and wrist.
5. Peel the glove away from the wrist.
6. Turn the glove inside out and covering the fingers. Note* (Both hands should be half-gloved).
7.Remove the glove from one hand completely by grabbing the inside part of the glove and peeling it away from the hand, and do the same for the remaining half-gloved hand using the non-gloved hand, while always grabbing the inside part of the glove.
8. Dispose of the gloves in a biohazard bin.

Doffing Gloves Step 1Doffing Gloves Step 2Doffing Gloves Step 3
Step 2: Removing of Gown

  • Use a new pair of glove in removing the gown.
  • When using a gown with back closure , a second operator should assist in untying the backside of the gown.
  • The assistant should wear gloves and a surgical mask, which need to be removed after opening the gown.
  • After the gloves of the assistant are removed, hand hygiene should be performed using an alcoholic solution.
  • The assistant will remove the gown by grabbing the back of the gown and pulling it away from the body, keeping the contaminated front part inside the gown.
  • If your hands get contaminated during gown removal, immediately proceed with hand hygiene.
  • Single-use gowns can now be disposed of through a biohazard bin; reusable gowns have to be placed in a bag or container for disinfection.
  • Remove soiled gloves and immediately proceed with hand hygiene

Step 3: Removing of Googles

  • Use a new pair of gloves, proceed removing the googles.
  • Be aware that the outside of goggles or face shield are contaminated.
  • Using your thumb and pointing finger, grip the strap and slowly slide it upward or away from the face.
  • If your hands get contaminated during goggle or face shield removal, stop immediately and proceed with hand hygiene.
  • If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container.

Step 4: Removing of Mask and Respirator

  • DO NOT TOUCH the front of mask/respirator as it is contaminated.
  • Grasp bottom ties or elastics of the mask/respirator with your pointer finger and thumb, then the ones at the top, and remove without touching the front.
  • If your hands get contaminated during mask/respirator removal, immediately proceed with hand hygiene.
  • The goggles should be removed and either disposed if they are single-use, or placed in a bag or container for disinfection.
  • Successfully finish doffing by doing another hand hygiene procedure.

CONCLUSION

In conclusion, like everything else since CoVid-19 virus was discovered to have a human to human transmission last December 2019, there’s a new normal on how we do our practice. Sure, it will be a challenge, it will be difficult and it will take time, but, we are resilient and we can do it if we truly put our minds into it. As we’ve mentioned in the Exposed: Infection Control Part 1 &2 webinar, one of the solutions so we can defeat this CoVid-19 from further finding a new host and prolonging its existence is our change of habits and by being determined that we can change for the better than we used to. This is an opportunity for us to become better dentists to our patients and in practicing our profession.

Contributors:

Dr. Bryan Anduiza – Writer
Dr. Jean Galindez – Writer | Editor

References:

1. World Health Organization (WHO). Coronavirus disease 2019 (COVID-19). Situation report – 29 2020 [updated 19 February 2020; cited 2020 25 February]. Geneva: WHO; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf?sfvrsn=6e50645_2.
2. European Centre for Disease Prevention and Control (ECDC). COVID-19 2020 [internet, cited 2020 24 February]. Stockholm: ECDC; 2020. Available from: https://www.ecdc.europa.eu/en/novel-coronavirus-china.
3. World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak 2020 [cited 2020 24 February]. Geneva: WHO; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
4. European Centre for Disease Prevention and Control (ECDC). Outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): increased transmission beyond China – fourth update 2020 [cited 2020 24 February]. Stockholm: ECDC; 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/SARS-CoV-2-risk-assessment-14-february-2020.pdf.pdf.
5. European Centre for Disease Prevention and Control (ECDC). Safe use of personal protective equipment in the treatment of infectious diseases of high consequence 2014 [cited 2020 25 February]. Stockholm: ECDC; 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/safe-use-of-ppe.pdf.
6. European Centre for Disease Prevention and Control (ECDC). Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV) 2020 [cited 2020 25 February]. Stockholm: ECDC; 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protective-equipment-needs-healthcare-settings.pdf.
7. World Health Organization (WHO). WHO Guidelines on hand hygiene in health care 2009 [cited 2020 25 February]. Geneva: WHO; 2009. Available from: https://apps.who.int/iris/bitstream/handle

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