Healthcare PPE Procedure

HEALTHCARE PPE PROCEDURE

Document Control

Procedure Owner:    Department:

Effective Date:    Review Frequency:

Purpose

This procedure establishes mandatory requirements for selection, use, care, training, and monitoring of personal protective equipment (PPE) to prevent transmission of infectious agents and reduce exposure risk to staff, patients, and visitors. Compliance with this procedure is a condition of continued access to clinical areas.

Scope

Applies to all clinical staff, ancillary personnel, contracted staff, volunteers, patients, and visitors in facility-controlled clinical and procedural environments. Specific task-based PPE requirements are set forth below.

Definitions

"PPE" means gloves, gowns, masks, respirators, eye protection, face shields, and other barrier devices used to reduce exposure. "Donning" means putting on PPE. "Doffing" means removing PPE in a manner that minimizes contamination.

PPE Requirements (by task)

The following PPE selection applies unless overridden by a documented, task-specific risk assessment authorized by the Infection Prevention Lead.

Standard PPE Items (check items required for this interaction): Gloves (disposable) Isolation Gown Surgical Mask N95/Respirator (fit-tested required) Eye Protection (goggles) Face Shield Shoe Covers Other:

Donning and Doffing Procedure

Personnel must don PPE in the following sequence unless clinical circumstance dictates alternative order: perform hand hygiene; put on gown; put on mask/respirator; place eye protection; put on gloves. Doffing must be performed to avoid self-contamination: remove gloves; perform hand hygiene; remove gown; perform hand hygiene; remove eye protection; remove mask/respirator last; perform final hand hygiene.

Training Required: I have received training in donning and doffing for the PPE items checked above.    Date of Last Training:

Responsibilities

Supervisors are responsible for ensuring PPE availability, verifying staff competency, and documenting training. Staff are responsible for using PPE as required, inspecting PPE prior to use, reporting breaches immediately, and complying with fit-testing requirements where applicable.

Supervisor Name:    Supervisor Contact:

Exposure, Breach, and Non-Compliance Reporting

Any suspected PPE breach or exposure must be reported immediately to the Supervisor and Infection Prevention. The facility will investigate and take corrective action; documentation will be retained as part of the incident record.

Incident Contact:    Reporting Method:

Recordkeeping and Audits

Records of PPE training, fit testing, and incident reports shall be maintained in the employee or patient safety file for a minimum period consistent with facility policy. Routine audits will be conducted to confirm compliance and adequacy of supplies.

Training Record Location:

Patient / Individual Information

Insurance Information

Medical History (relevant to PPE/Isolation)

Notification, Risks, and Right to Decline/Withdraw

I have been informed of the PPE measures that will be used during my care and the clinical rationale for those measures. I understand there are benefits to PPE use (reduced transmission risk) and potential burdens (communication barriers, skin irritation). I understand I may decline or withdraw consent for non-emergent interventions and that my decision will be documented and may require alternative clinical arrangements.

Patient/Individual Acknowledgement: I acknowledge I was informed and had the opportunity to ask questions.

If signed by guardian or representative, indicate relationship:

Authorization Expiration & Review

This acknowledgement and any authorization herein shall expire on:    Next Scheduled Policy Review:

Acknowledgment and Certification

By signing below, I certify that the information provided on this form is true to the best of my knowledge, I understand the PPE procedure and my responsibilities, and I agree to comply with PPE requirements while in clinical areas unless medically exempt with documented authorization. I understand noncompliance may result in denial of access or clinical services until compliance is restored.

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