Personal Protective Equipment

PPE, for personal protective equipment, has become a rather common acronym in the lexicon of health care providers. The acronym has been common in fire services, emergency medical services (EMS), and the military for quite some time. Essentially, PPE helps to ensure that individuals are safe from physical hazards that they may encounter in their work environment. PPE may be used to protect workers from general environmental threats (e.g., temperature extremes and noise), specific work-related threats (e.g., industrial equipment and falls from elevated work areas), or threats faced in an emergency situation (e.g., hazardous chemical and infectious agents). No equipment is appropriate for all individuals and threats: rather, equipment must be selected and properly used according to the setting of use and the level of risk.

The critical problem with most PPE, particularly in regard to chemically protective suits and respirators, is that with higher levels of protection come not only higher prices and required training levels but also a higher physiological and physical burden to the user. Thus a structured approach to assessment of risk and selection of proper equipment is important to achieve a reasonable level of protection in relation to the hazard.

In this chapter we review the concepts of PPE, including recent lessons learned, types of respirators, key regulations, and issues in the selection of PPE for emergency medical care and decontamination operations.

Historical perspective

Previously PPE for medical providers received little attention short of the “standard precautions” of gloves, with the addition of simple masks, eye protection, and barrier precautions, as needed for respiratory and contact precautions. A number of events have highlighted the importance of PPE for first responders and health care workers. The 2003 Severe Acute Respiratory Syndrome (SARS) Epidemic, the 2009 H1N1 Influenza Pandemic, the 1995 Tokyo Subway Sarin Attack, the 1995 Murrah Federal Building Bombing in Oklahoma City, and the terrorist attacks of September 2001 are some examples of situations in which the lack of proper PPE or the improper use of it resulted in adverse health effects for health care providers. Such events and adverse outcomes have focused attention on PPE as a critical issue in routine emergency department operations and disaster response.

In March 1995, a crude form of the nerve agent sarin was released in the Tokyo subway system on separate cars bound for a common downtown station. This attack resulted in 12 deaths and more than 4000 persons presenting to the hospital for medical evaluation. None of the casualties was decontaminated before treatment or transport. Retrospectively, 135 prehospital and 100 hospital personnel reported symptoms consistent with nerve agent exposure. Fortunately, none required emergency treatment. Eleven physicians caring for the sickest victims (including one in cardiac arrest and one in respiratory arrest) were most affected, and six of them required treatment with specific antidote. All recovered fully and did not have to cease their patient care efforts because of symptoms. Approximately 80% of victims self-referred to hospitals, which is consistent with U.S. experiences, indicating that few victims of chemical contamination events undergo decontamination before arrival at a medical facility. ^,This has caused most jurisdictions to reconsider historical plans that contaminated patients would not be in contact with medical care personnel until they were “clean.” EMS and hospital personnel need to be prepared for contaminated patients presenting directly to them and recognize that in certain situations PPE may be required to safely provide care.

SARS posed unique risks and challenges to health care workers. This novel viral agent with incompletely defined transmission characteristics was controlled in 2002, with aggressive quarantine measures and use of PPE. In the first wave of SARS in Toronto, 79.2% of all cases were acquired in a health care setting. Aggressive use of PPE, including N95 masks, barrier precautions, and gloves, was generally effective at preventing spread, although during one difficult and prolonged intubation attempt, at least 6 providers contracted SARS from a patient, despite complying with PPE recommendations. This case led to recommendations that higher levels of PPE may be required during procedures that are likely to generate aerosols or provoke coughing, such as intubation, airway suctioning, positive pressure ventilation, and nebulized treatments. Many of the lessons learned from the SARS epidemic, including the importance of appropriate respiratory PPE and compliance programs, were later applied to the 2009 H1N1 Influenza Pandemic. Even so, H1N1 took a toll on health care workers, and analysis of both of these events has led to future improvements for disaster preparedness.

The National Institute for Occupational Safety and Health (NIOSH) and the RAND Corporation produced a comprehensive “lessons learned” report, summarizing issues from the 2001 terrorist bombings at the World Trade Center (WTC), anthrax incidents, and the 1995 Oklahoma City Murrah Federal Building Bombing. The report, titled Protecting Emergency Responders: Lessons Learned from Terrorist Attacks, describes in detail many of the challenges responders faced ( Box 46-1 ).

Box 46-1

Historical Hazards Faced by Responders to Terrorism Events

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Physical hazards including fires, burning jet fuel and explosions, rubble piles with sharp rebar and heated metal, falling debris (which resulted in the death of a nurse in Oklahoma City), hazardous materials, electrical hazards, structures prone to collapse, heat stress, exhaustion, and respiratory irritants
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Heat-related seizures while wearing chemically protective suits
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Eye injuries (usually related to particulate exposure), which accounted for 12% of all WTC disaster response worker injuries
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Potential for secondary hazards, including explosive devices and chemical, biological, and radioactive agents
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PPE shortcomings:
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  Heavy helmets hindered performance
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  SCBA was heavy and cumbersome
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  SCBA face pieces fogged (reducing visibility), and the equipment hindered verbal and radio communication
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  SCBA air bottle made it difficult to enter small spaces, and the limited air supply (up to 1 hour) necessitated leaving the operation to exchange the air bottle
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  Air tanks and/or filters were not interchangeable between teams, and teams worked under different standards
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  PAPR filters became clogged and were uncomfortable for long-duration use. Many workers instead opted to use dust masks (which offered little protection and caused nose-bridge chafing) or to wear the masks/hoods around their necks (“neck protectors”)
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  Use of respirators made it difficult for workers to communicate with each other, often resulting in users breaking the face seal to talk
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  Turnout gear (the common protective garments used by firefighters) increased heat stress and physical fatigue
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  At the WTC, the rubble pile was so hot in places that it melted the soles of workers’ boots; providing wash stations to cool the boots resulted in wet feet and serious blisters for many workers; some 440 WTC disaster response workers sought treatment for blisters
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  Steel-reinforced boots (soles and toes) protected against punctures by sharp objects but conducted and retained heat, which contributed to blisters and burns
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  Structural firefighting gloves worked well until they got wet and hardened, reducing their dexterity
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  WTC disaster response workers did not consistently protect their hands against potential hazards such as human remains and bodily fluids
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  Safety glasses were readily available but often were open at the sides and did not offer adequate protection against airborne particles
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  Goggles were uncomfortable, hindered peripheral vision, tended to fog, and did not fit well in conjunction with half-face respirators
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  Many disaster response workers at the WTC (especially law enforcement officers) did not consistently use hearing protection, even around heavy machinery, because they needed to hear their radios and voices and listen for tapping when they were searching for survivors
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Most volunteers at the WTC, Pentagon, and Oklahoma City did not receive pre-event training on PPE and hazardous materials
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Although firefighters generally received detailed pre-event training, this was less true for law enforcement officers
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Accurate “real-time” hazard information was not readily available, especially during the anthrax incidents
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Protection from falls was available at some sites (in the form of ropes and harnesses) but was inconsistently used

It is clear from the WTC events that a large number of jurisdictions responding, conflicting messages regarding use of PPE and safety of the environment, unavailability of appropriate PPE, poor design characteristics of current PPE models, and lack of a plan to implement respiratory precautions can complicate a response and potentially place providers at risk. WTC responders continue to suffer respiratory symptoms attributable to exposures at “ground zero.”

Current practice

Hazard Vulnerability Analysis

Selection of appropriate PPE begins with an analysis of the hazards that responders may encounter, as well as an assessment of responders’ roles and responsibilities. Hazard vulnerability analyses (HVA) are required for community emergency planning grants and are required of health care facilities that are accredited by The Joint Commission, previously known as the Joint Commission on Accreditation of Health Care Organizations (JCAHO). ^,The HVA uses a numerical ranking of factors for specific threats (e.g., chemical release), including the risk of the event occurring, the current preparedness for the threat, and the risk to life. The numerical score determines the gravity of each threat to the community. Each community’s HVA will reflect the unique risks that must be considered by its emergency responders. Choice of PPE may be affected by factors within the HVA, such as

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Population density of the community and surrounding area
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High- or moderate-risk terrorist targets in the community (e.g., government buildings, centers of commerce, or other symbolic sites)
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Chemical hazards posed by community industry (e.g., use of cyanide and hydrofluoric acid in the electronics industry)
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Risk of transportation incidents and major transportation routes, particularly highways and railroads
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Proximity of health care facilities, schools, or other key locations to these potential targets and industrial and transportation hazards
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Frequency of hazardous materials (HazMat) incidents in the community
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Resources available to respond to HazMat incidents (e.g., rapid access to on-site decontamination may decrease, but not eliminate, contaminated persons leaving the scene)

Defining the Agency and the Facility Role

Stakeholders in emergency response, including EMS, fire and rescue, and law enforcement agencies, emergency management teams, and health care facilities, must clearly define the responsibilities of each entity and the support and resources that each may need or offer during an emergency, particularly one involving a HazMat release.

The EMS role in a HazMat event may vary depending on jurisdictional planning and the availability of resources. Fire services personnel may or may not be able to provide treatment in a “warm zone” (i.e., the area of reduced contamination outside of the immediate release zone) depending on their training. Nonfire-based EMS personnel may require PPE to triage and treat victims in the warm zone. In the event of a mass chemical exposure, victims will likely self-refer to visible ambulances, call for emergency assistance from locations removed from the site of release, or make their way to hospitals, by-passing organized EMS and fire services altogether. This movement of contamination on the bodies of patients essentially causes a “migrating” warm zone, resulting in contamination of previously clean (“cold”) areas. This migrating contamination may require protective equipment for EMS responders and hospital personnel, and appropriate plans and equipment should be in place. The roles and responsibilities of the responders, as well as the equipment required, need to be defined and drilled in advance of an incident.

Hospitals usually have relied on fire services for patient decontamination at the hospital. These resources, however, are often deployed to the scene of the event and are thus unavailable to support the hospital. Most hospitals have recognized the need for at least some internal capacity for patient decontamination and are equipping their teams with PPE appropriate for decontaminating self-referred patients and the means to decontaminate patients prior to entry into the emergency department (ED). In some instances, the hospital teams integrate with community HazMat teams, necessitating additional training and equipment as the mission then changes from a defensive decontamination response at the health care facility to an offensive response at the scene of release.

Risks to Providers

Even though HazMat releases seldom cause serious traumatic injury in the absence of concomitant explosions, the potential exists for both scene responders and hospital receivers to suffer serious consequences of exposure. The Agency for Toxic Substance and Disease Registry (ATSDR) maintains a multistate voluntary accounting of hazardous substance releases. The National Toxic Substance Incidents Program (NTSIP), which replaced the Hazardous Substances Emergency Events Surveillance (HSEES) database in 2010, currently collects data from seven states on HazMat events. From 1993 to 2001, 44,015 events were recorded in the database: 3455 (7.8%) of the incidents caused injuries, and 74% of victims were transported to a health care facility. In another analysis of HSEES data, only 5% of victims required admission to a health care facility, with the vast majority of patients presenting with self-limited respiratory symptoms. In 2011, the NTSIP reported 3128 separate incidents, resulting in 62 fatalities and an additional 1115 ill or injured patients. Carbon monoxide, chemicals for illicit methamphetamine production, paints/dyes, and petroleum products were the most common offending agents. A review of these events found that 344 of the patients were employees or first responders whose illness and injuries could have been prevented with appropriate PPE.

HSEES data from 2003 to 2006 shows that of 33,157 documented events, secondary contamination of facilities and providers occurred in 15 (0.05%) cases, resulting in illness in 17 providers. Of these secondary contamination victims, only two had employed any PPE when the contamination occured. Even though secondary contamination events are relatively rare, they pose significant risk to health care providers and to the entire health care system because emergency departments and transport vehicles may be closed or taken out of service for proper decontamination. Events resulting in emergency department evacuation and/or provider illness are especially serious in situations of “off-gassing,” where toxic gases are released from contaminated patients and/or their clothing. The most serious of these incidents involve patients with suicidal ingestions of organophosphate pesticides. Exposures to these patients have caused at least one provider to require intubation and receive aggressive treatment with specific antidote because of contact with pesticide in emesis and vapors during patient resuscitation. Patients who have ingested organophosphate may “off-gas” for days and present an ongoing risk to health care workers. In conjunction with the information from the Tokyo Subway Sarin Attack and the chemical terrorism risk posed by these agents, it is clear that these pesticides present a substantial risk of toxicity from secondary exposures.

Limited research is available to document the degree of the off-gassing that occurs from the bodies and clothing of contaminated patients. ^,Clothing removal and control may be expected to remove 90% of the contaminant and thus should be a priority. ^,Ideally, this should take place in an open-air environment.

Chemical Protective Equipment

Providers may not initially recognize a chemical release when they arrive at a scene. Even though structural firefighting ensembles with self-contained breathing apparatus (SCBA) offer some chemical protection that may be sufficient for victim rescue, the incident commander must determine what actions are appropriate for any given situation and maintain a high level of suspicion that a HazMat situation is present. Protective suits, gloves, boots, and appropriate respiratory protection must be donned as soon as possible when a chemical threat is recognized.

The Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency define four basic levels of PPE for HazMat scene responses ( Table 46-1 and Fig. 46-1 ; OSHA standard 29 CFR 1910.120, Appendix B). Generally, as the level of protection increases (Level A being the highest level), so do the weight, cost, and physiological burden of the appropriate PPE. Increasing protection also generally means decreasing mobility, dexterity, and scope of vision. Inherent risks to PPE include trip and fall hazards, reduced ability to complete tasks, heat stress, anxiety, and seizures. ^,Cardiovascular demand is dramatically increased as ensemble weight and heat retention increase. PPE must be selected on the basis that it does not impose unnecessary risks to the provider while at the same time offering an appropriate margin of safety against the hazard. Because the selection of PPE usually revolves around the selection of the respiratory component, various types of respirators must be reviewed. Each respirator has an assigned protection factor that reflects the degree of protection afforded to the user. Simply put, 1/protection factor equals the amount of exposure for the wearer. For example, a provider wearing a powered air-purifying respirator (PAPR) with an assigned protection factor (APF) of 1000 is exposed to 1/1000 the level of contaminant as compared with wearing no protection.

Table 46-1

Categories of PPE

From Agency for Toxic Substances and Disease Registry. Emergency Medical Services Response to Hazardous Materials Incidents. Available at: http://www.atsdr.cdc.gov/mhmi-v1-2.pdf .

LEVEL	BRIEF DESCRIPTION	ADVANTAGES	DISADVANTAGES
A	Completely encapsulated suit and SCBA	Highest level of protection available for both contact and vapor hazards	• Expense and training requirements typically restrict use to HazMat response teams • Lack of mobility • Heat and physical stresses • Limited air supply • Fit-testing requirements
B	Encapsulating suit or junctions/seams sealed, and SAR or SCBA	High level of protection adequate for entry into unknown environments	Same as for Level A • SAR hose may pose a trip hazard or become dislodged
C	Splash suit and APR (note APR and PAPR considered equivalent in classification despite significant difference in protection)	• Significantly increased mobility • Less physical stress • Extended operation time with high levels of protection against certain chemical hazards • No fit testing required for hood type	• Not adequate for some high-concentration environments, less-than-atmospheric-oxygen environments, or high levels of splash contamination • Expense and training moderate
D	Usual work clothes	• Increased mobility • Less physical stress • Extended operation time • More fashionable	• Offer no protection against specific hazards • Expense and training minimal