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By Rose Hoban

As the number of coronavirus-related hospitalizations grows in North Carolina, so have the concerns about having adequate amounts of personal protective equipment (PPE) for health care workers.

“Those on the front lines of the COVID-19 pandemic are concerned that the lack of adequate PPE endangers not only themselves, but their patients and families as well,” reads a statement from Patrice A. Harris, a physician and the president of the American Medical Association. “Physicians and frontline health care workers across the country are pleading for more personal protective equipment (PPE), doing everything they can to raise awareness of this crisis.”

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PPE is required when treating COVID-19 patients because it’s understood that the virus spreads through droplets as people talk, laugh, cough and sneeze. The droplets could land on a patient’s bed, bedside table, wall, floor or any other equipment in the room. So that means health care providers need to cover their hands, clothes, but particularly their mouths, noses and eyes.

It’s not uncommon for medical personnel to wear PPE on a regular basis when treating many types of respiratory infections and those ways of covering up are not just for the providers’ protection but help protect patients too, especially those who are immunocompromised.

Ideally, patients designated for “respiratory precaution” are placed in a room where the air conditioning or heating ventilation exhausts directly to the outside, rather than being circulated around the hospital. These “negative pressure” rooms came into widespread use in hospitals in the 1980s, when tuberculosis made a resurgence in the U.S.

“What’s unusual is having to do this on potentially a large group of patients is something we don’t do frequently,” said pulmonologist Brad Drummond, who’s on the faculty of the medical school at UNC Chapel Hill and works in the hospital there.

As hospitals brace for a surge, there have been a lot of questions about the shortage of PPE supplies to protect health workers on the front lines of this pandemic. How do masks and other PPE work? Can they be reused safely? Are homemade mask donations helpful? How many are actually needed?

How do you wear PPE?

Doctors, nurses and other health care providers have to “don” and “doff” PPE each time they go into a patient’s room. It’s not like throwing on a sweater, it takes time to follow all of the steps.

“You can’t rush it, and there are situations where we need to get into a room expeditiously,” Drummond said, such as when a patient requires emergency care such as resuscitation.

“We still have to go through the steps, because if you don’t, it puts us at risk.”

He also said that in order to reduce the risk of contamination, he can’t bring in his cell phone or even his pager into the room. Instead, he and his colleagues at UNC are using a type of walkie talkie that clips onto their clothing in order to communicate back to the nurses’ station on the floor.

“It’s muffled, you have to enunciate a little bit more,” because of the presence of tight-fitting masks, Drummond said, but it means workers don’t have to go in and out of patient rooms continually putting on the PPE and taking it off again.

“We’re having to evolve… how we use these technologies to help, kind of on the fly,” he said.

Steps to donning Personal Protective Equipment:
  • Clean hands
  • Put on gown
  • Put on N95 mask
  • Check N95 mask for fit
  • Put on face shield/goggles
  • Put on gloves to cover the cuffs of the gown

What about taking the PPE off afterward? 

Drummond said it’s when health care workers take off their personal protective equipment that they really put themselves at most risk of getting contaminated.

The order is very prescribed. For example, when doffing the gown and gloves, it’s important to turn them inside out so the contaminated parts don’t touch the skin.

“Having another person who’s outside the room, visually watching you almost as a monitor making sure that if you do do something out of order, that they will stop you before you get to a place where you’re about to contaminate yourself,” he said.

An example of the powered air respiratory (PAPR) device used for personal protection by health care workers (PPE). This device, which circulates air around the heads of health care personnel allows for easier breathing than using an N95 mask. Photo courtesy: 3M company

The problem comes when all the beds are filled and all the workers slammed with work.

“We may not have one person to just stand there. They may need to be doing care for someone else,” he said.

In China, they wore total bodysuits. Are the gowns U.S. health care workers using enough? 

Drummond said that because the mode of transmitting COVID-19 is droplets, the most important thing is to protect a health care worker’s mouth, nose and eyes, all of which have mucous membranes that allow for the virus to get past the body’s protective outer layers

He said that Chinese doctors who wore those white “bunny suits” during the initial outbreak in Wuhan may have been able to use them, in part, because the Chinese make much of the world’s personal protective equipment and were able to scale up local manufacturers.

“And this is my speculation, but it may not have been clear initially what the mode of transmission is,” Drummond said. “So that really drove full PPE, versus now that we have a better understanding of the mode of transmission.

“Obviously more is always better, but you reach a point of diminishing returns, because the more time you have to put it on and take it off, the less care time you can provide.”

He said that the understanding now is that an N95 mask, along with a face shield to protect the eyes and a gown and gloves with good precautions is sufficient to protect health care workers.

Many hospitals are now also providing their workers with several sets of scrubs, so that they can change out of them at the end of the day, leave them to be cleaned at the hospital laundry, and wear street clothes home.

Can you make PPE last longer?

A strategy for stretching out the lifespan of protective supplies is to group many patients with COVID-19 into wards where everyone is infected, Drummond said. This way, a health care worker can put on their PPE and then go in and out of multiple rooms without worry of cross-contamination.

“We’ve cohorted, or placed, a lot of patients on the same units within the hospital,” concurred James Wyatt, the chief medical officer at Cone Health in Greensboro.

Wyatt also said that the masks can be reused, so long as they’re not too soiled either from spatters or use.

“We’re asking for most of our physicians who are using those or other personnel, to put it in a very clean bag after they’ve used it, seal it, with their name on it, with the number of times it’s been used on the outside, and then keep count,” he said.

According to the National Institute of Occupational Safety and Health, respirators can function within their design specifications for eight hours of continuous or intermittent use.

Why are N95 masks better than cloth masks?

N95 masks received their name because they filter 95 percent of particles the size of a virus, said David Weber, head of infection control at UNC Health in Chapel Hill.

“They actually make N100 which are 100 percent filters, but they’re more difficult and uncomfortable to wear,” he added.

Not everyone can wear the same N95 masks. In fact, health care workers need to be fitted to their masks based on the shape and size of their faces.

“We all get fitted every year to see what type of N95 mask we should wear, because there’s different shapes and we all have different facial structure,” Drummond said.

Once the correct shape mask has been identified, the metallic nose bridge needs to be formed into the shape to create an airtight seal over the wearer’s face. Fitted correctly, if a person blows out air forcefully, you should not feel any air coming out from the edges of the mask. To keep that mask fitting well, the elastic can’t be stretched out.

When the mask is on correctly, it can be difficult to communicate, Drummond said.

Can N95 masks be reused?

In recent years, health care has moved toward using every item only once and then discarding it. However, health care providers have been reusing N95 masks for some time, according to the CDC’s website.

The masks can be used for a handful of times so long as they don’t get wet or soiled. Between uses, they must be stored in a paper bag that allows for airflow that allows for condensation inside the masks to dry out.

But as concerns about COVID-19 have grown, more institutions have explored ways to disinfect the masks between use.

Researchers at Duke found a way to clean and reuse N95 masks. Photo credit: Shawn Rocco, Duke Health

Last week, Duke University announced it was using a novel technique to disinfect masks, using aerosolized hydrogen peroxide, which “permeates the layers of the mask to kill germs, including viruses, without degrading the mask material.”

This process was studied, tested and published in 2016 but not put into widespread use, according to Duke Health press release.

Does ultraviolet light work on N95 masks?

Another way that hospitals have moved to decontaminate masks is to expose them to ultraviolet light. But not just any UV light.

UV light has long been known to kill germs. In particular short-spectrum UV light — known as UVC — is used to disinfect hospital spaces, equipment and even drinking water.

Greensboro-based Cone Health has been using UV light to disinfect their masks by stringing them up on a clothesline and exposing them to UV light on both sides for five minutes each, a protocol developed by Nebraska Medicine.

Workers label the masks with their names and a tick mark for each time the mask has been used. They can reuse the masks until the elastic stretches out and no longer provides a tight fit.

N95 masks that have been decontaminated using short spectrum ultraviolet (UVC) light. Photo courtesy Nebraska Medicine

Are my DIY mask donations useful?

A cloth mask or a “surgical mask” like those seen frequently on people on the street, or sewn by volunteers, don’t really do much to filter out particles or viruses.

“The cloth, first it has to be tight-fitting, and then the weave pattern of the cloth has to be such that it actually filters out viruses,” Weber said. “It’s probably better than nothing, but it’s certainly not as good as an FDA-approved mask or an OSHA-approved N95.”

“There’s ventilation all the way around,” said Sheila Natarajan, a Charlotte physician who’s coordinating donations of personal protective equipment to area facilities. “While it protects people from being exposed in large degree to the wearer’s droplets, it does not protect a healthy individual from aerosolized droplets.”

Some providers have been wearing homemade fabric masks over surgical or N95 masks in an attempt to prolong its lifespan, according to Natarajan.

“It protects them from being soiled,” she said. But it doesn’t keep the masks from getting damp from condensation when someone wears them for any length of time.

Cloth masks can be a “last resort” in cases where approved N95 masks are not available, according to the CDC.

“However, homemade masks are not considered PPE, since their capability to protect [health care personnel] is unknown,” reads the CDC webpage. “Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”

Natarajan said she hoped that North Carolina never gets to that point.

“I hope we never get to the place where we have to use them for providers because that means we’ve run out of everything,” she said.

Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...

4 replies on “PPE 101: How does personal protective equipment work?”

  1. Please describe the steps for people to use when “doffting” the PPEs. I see people in stores wearing gloves, and not washing their hands after removing them. I see people wearing gloves and masks, touching their faces. I think that asking people to use useless masks and wasting ppes gives them a false sense of security, especially without the education to use them properly and safely.

  2. N95 Respirator Limitations as PPE
    If you are care-taking, visiting or are in contact with an individual that is COVID-19 positive or are suspected to be positive, please do not be under the false impression that if the individual with COVID-19 is wearing an N95 Respirator, that you are protected also. Personal Protective Equipment is just that, it protects the person wearing it, not the people around them. If you research N95 Respirators, you will find that many are equipped with a cooling valve, which simply allows air to flow out easier when exhaling by passing through a flap or valve and bypassing the maximum filtration while minimizing heat buildup and the chances of the respirator from becoming dislodged from the facial seal. These respirators are designed and rated by their efficiency to filter particulate while inhaling not exhaling. That being said, any protection is better than no protection as long as you are aware of the limitations and are not unknowingly misusing it.

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