Standard principles for the use of personal protective equipment

National Clinical Guideline Centre (UK)

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National Clinical Guideline Centre (UK). Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2. London: Royal College of Physicians (UK); 2012 Mar. (NICE Clinical Guidelines, No. 139.)

See 2017 Partial Update

Update information February 2017: A footnote was added to recommendation 22 linking to Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. A footnote linking to a safety alert on chlorhexidine was added to recommendations 1.4.3.1, 1.4.3.8, 1.4.4.1 and 1.4.4.11. Other footnotes were updated with references to revised or replaced British Standards and other regulations. August 2013: A clarification has been made to recommendation 22 on the disposal of used standard needles.

Update information February 2017: A footnote was added to recommendation 22 linking to Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. A footnote linking to a safety alert on chlorhexidine was added to recommendations 1.4.3.1, 1.4.3.8, 1.4.4.1 and 1.4.4.11. Other footnotes were updated with references to revised or replaced British Standards and other regulations. August 2013: A clarification has been made to recommendation 22 on the disposal of used standard needles.

Cover of Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care

Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2.

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7Standard principles for the use of personal protective equipment

7.1. Introduction

The updated review questions in this chapter are:

choice of gloves (latex, vinyl or nitrile)
when to wear aprons or gowns.

The evidence and text from the previous guideline that has been superseded by this update is included in Appendices D.6 and D.9.

No new review questions are included in this chapter. The recommendation about gloves conforming to CE standards has been moved to the top of the gloves section (section 7.2.1.1), to emphasise its importance.

Sections not updated in this chapter are:

when to wear gloves
gloves as single-use items
when to wear facemasks, eye protection and other facial protection.

The primary role of personal protective equipment (PPE) is to reduce the risk of transmission of microorganisms between patients, healthcare workers and the environment. The recommendations in this chapter are in line with Health and Safety requirements (Health and Safety Regulations 2002⁴, Health and Safety at work Act 1974¹).

Disposal of PPE is included in a separate general waste disposal chapter (see chapter 9).

This section discusses the evidence and associated recommendations for the use of personal protective equipment by healthcare workers in primary and community care settings and includes the use of aprons, gowns, gloves, eye protection and facemasks.

7.2. Infection Control Dress Code – protect your patients and yourself!

Expert opinion suggests that the primary uses of personal protective equipment are to protect staff and patients, and reduce opportunities for the transmission of microorganisms in hospitals⁹⁵^,²⁸¹. However, as more healthcare is undertaken in the community,¹⁵⁶^,¹⁸⁸^,²⁴⁵ the same principles apply. A trend to eliminate the unnecessary wearing of aprons, gowns and masks in general care settings has evolved over the past twenty years due to the absence of evidence that they are effective in preventing HCAI.⁹⁵

The decision to use or wear personal protective equipment must be based upon an assessment of the level of risk associated with a specific patient care activity or intervention and take account of current health and safety legislation.⁶²^,⁸⁶^,¹¹³^,¹¹⁴

7.2.1.1. Recommendation

10.: Selection of protective equipment must^x be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare workers’ clothing and skin by patients’ blood, body fluids, secretions or excretions. [2003]

7.3. Gloves: their uses and abuses

Since the mid-1980s the use of gloves as an element of personal protective equipment has become an everyday part of clinical practice for healthcare workers.³⁷^,⁴⁵^,⁸⁶^,⁹⁵^,¹⁰⁴^,¹³² Expert opinion agrees that there are two main indications for the use of gloves in preventing HCAI³⁷^,⁴⁵^,⁸⁶^,⁹⁵:

to protect hands from contamination with organic matter and microorganisms;
to reduce the risks of transmission of microorganisms to both patients and staff.

7.3.1. To glove or not to glove?

Gloves should not be worn unnecessarily as their prolonged and indiscriminate use may cause adverse reactions and skin sensitivity.⁴⁵^,²¹¹ As with all items of personal protective equipment the need for gloves and the selection of appropriate materials must be subject to careful assessment of the task to be carried out and its related risks to patients and healthcare practitioners⁴⁵^,²¹¹. Risk assessment should include consideration of:

who is at risk (whether it is the patient or the healthcare practitioner) and whether sterile or non-sterile gloves are required;
the potential for exposure to blood, body fluids, secretions or excretions;
contact with non-intact skin or mucous membranes during general care and invasive procedures.

Gloves must be discarded after each care activity for which they were worn in order to prevent the transmission of microorganisms to other sites in that individual or to other patients. Washing gloves rather than changing them is not safe and therefore not recommended.⁴⁵^,²¹¹

7.3.2. Do gloves leak?

A previous systematic review provided evidence that gloves used for clinical practice leak when apparently undamaged.²¹⁰ In terms of leakage, gloves made from natural rubber latex (NRL) performed better than vinyl gloves in laboratory test conditions. Revised standards (2000) relating to the manufacture of medical gloves for single-use have been devised and implemented.²⁸^–³⁰ These require gloves regardless of material to perform to the same standard.

Expert opinion supports the view that the integrity of gloves cannot be taken for granted and additionally, hands may become contaminated during the removal of gloves.³⁷^,⁴⁵^,⁸⁶^,⁹⁵^,²¹¹ Our systematic review found evidence that vancomycin resistant enterococcus remained on the hands of healthcare workers after the removal of gloves.²⁵⁷ Therefore, the use of gloves as a method of barrier protection reduces the risk of contamination but does not eliminate it and hands are not necessarily clean because gloves have been worn.

7.3.2.1. Recommendations

Recommendations	11. Gloves used for direct patient care: must^y conform to current EU legislation (CE marked as medical gloves for single-use)^z and should be appropriate for the task. [new 2012]
Relative values of different outcomes	The GDG agreed that healthcare worker preference and glove punctures were the most important outcomes for this recommendation.
Trade off between clinical benefits and harms	Although one study found that latex gloves had significantly fewer punctures compared to nitrile gloves, all single-use gloves that meet BS EN 455, (1–4 Medical gloves for single-use)³¹ are required to meet the same resistance to punctures or holes, irrespective of glove material. BS EN 455-2 specifies the requirements and gives test methods for physical properties of single-use medical gloves (i.e. surgical gloves and examination/procedure gloves) in order to ensure that they provide and maintain, when used, an adequate level of protection from cross contamination for both patient and user.
Economic considerations	The cost of gloves is the main economic consideration. If all gloves conform to European Community standards and there is no clinical reason to prefer one type of glove over another, the least costly option will represent the most cost-effective.
Quality of evidence	One low quality crossover trial with one outcome was identified. This study was downgraded due to study limitations including no randomisation and allocation concealment and a very low sample size of five dentists. See evidence review in section 7.4.
Other considerations	No evidence was identified for vinyl gloves, but the GDG considered that if they met the relevant CE standards they could be used. This recommendation is a ‘must’ as it is covered by legislation detailed in the footnotes in line with the guidance from the NICE Guidelines Manual (2009).¹⁸² The GDG made changes to the original recommendation based on a consensus decision that gloves should be fit for purpose or ‘appropriate for the task’ (allow enough sensitivity, for example to feel a vein to take blood), be the correct size and take any allergy into consideration. It was important in light of health and safety legislation to amend the recommendation to highlight the obligation for healthcare workers to use gloves that conform to the relevant European and British standard. This recommendation has been moved to the beginning of the gloves section as the GDG considered it to be very important. The evidence behind the recommendation was searched for under the type of glove material in question (section 7.4).

z: At the time of publication of the guideline [March 2012): BS EN 455 Parts 1 – 4 Medical gloves for single-use.

12.: Gloves must^y be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or to sharp or contaminated instruments. [2003]
13.: Gloves must^y be worn as single-use items. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient. [2003]

Recommendations	14. Ensure that gloves used for direct patient care that have been exposed to body fluids are disposed of correctly, in accordance with current national legislation^aa or local policies. (see chapter 9) [new 2012]
Relative values of different outcomes	The GDG considered the most important outcomes for making this recommendation to be the safe disposal of clinical waste as addressed in chapter 9.
Trade off between clinical benefits and harms	The likelihood of cross contamination is greatly reduced by the immediate disposal of gloves as clinical waste. Failure to comply with this recommendation could result in legislative action. Further recommendations for waste disposal are in chapter 9.
Economic considerations	If healthcare organisations are currently improperly disposing of clinical waste then compliance with this recommendation may be associated with implementation costs.
Quality of evidence	New guidance based on legislation⁷² informed this recommendation.
Other considerations	This recommendation is a ‘must’ as it is covered by legislation detailed in the footnote, in line with guidance from the NICE Guidelines Manual (2009)¹⁸². The GDG considered it important to update the original recommendation as a result of legislatory requirements in waste disposal and as part of the findings from the review question considered in chapter 9. The second half of the original recommendation has been removed (hands decontaminated after the gloves have been removed) as this is now included in the hand decontamination chapter, see recommendation 6.3.1.4.

aa: For guidance see (at the time of the publication of the guideline [March 2012]): ’Safe management of healthcare waste’ (2011); available from www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126345

7.4. Which types of gloves provide the best protection against healthcare-associated infections?

7.4.1. Review question

The following review question was prioritised to determine which type of gloves provides the best protection against infection. A wide variety of gloves are available and it was considered that there is currently variation in types of gloves used in practice. The GDG stated that hypersensitivity and user preference were the most important outcomes for this question. Polythene gloves were included in the search, however no studies were identified.

What is the clinical and cost effectiveness of healthcare workers wearing vinyl, latex or nitrile gloves on user preference and reduction of hypersensitivity, blood borne infections, glove porosity and tears?

7.4.1.1. Clinical evidence

One crossover trial was identified, comparing non-powdered nitrile gloves with non-powdered latex gloves.¹⁷⁷ This study was also included in the previous 2003 guideline for this review question. No evidence was identified for vinyl gloves.

See Evidence Table G.3.1, Appendix G, Forest Plots in Figure 14, Appendix I.

Table 22Non-powdered nitrile vs. non-powdered latex gloves - Clinical study characteristics

Outcome	Number of studies	Design	Limitations	Inconsistency	Indirectness	Imprecision
Glove punctures¹⁷⁷	1	Crossover	Very serious limitations^(a)	No serious inconsistency	No serious indirectness	No serious imprecision
Blood borne infections	0	RCT or observational studies
Glove porosity	0	RCT or observational studies
Hypersensitivity	0	RCT or observational studies
User preference	0	RCT or observational studies
Ability to perform task	0	RCT or observational studies

a: Not randomised and no allocation concealment. Very low sample size (5 dentists), likely to be underpowered.

Table 23Non-powdered nitrile vs. non-powdered latex gloves - Clinical summary of findings

Outcome	Non-powdered nitrile	Non-powdered latex	Relative risk	Absolute effect	Quality
Glove punctures	58/1020^(a) (5.7%)	19/1000^(a) (1.9%)	RR 2.99 (1.8 to 4.99)	38 more per 1000 (15 more to 76 more)	LOW

a: Numbers given are number of punctures from the total number of gloves used.

7.4.1.2. Cost-effectiveness evidence

No cost-effectiveness evidence was identified in the update search.

No economic evidence was identified in the previous 2003 guideline. The previous guideline included a table outlining the costs for each type of glove and recommends that ‘Healthcare personnel should be aware of the cost differential in gloves and should select the most appropriate for the activity.’ In the absence of any published cost-effectiveness analyses, current UK glove costs were presented to the GDG to inform decision making.

Table 24Glove costs

	Latex	Nitrile	Vinyl
Cost per 100 gloves (£)	3.70	5.31	2.35

: Source: Based on average NHS Supply Chain Catalogue¹⁸⁷ prices.

7.4.1.3. Evidence statements

Clinical	There is a statistically significant and clinically important decrease in glove punctures with latex gloves compared to nitrile gloves (LOW QUALITY). No studies were identified that reported blood borne infections, glove porosity, hypersensitivity, user preference or ability to perform tasks.
Economic	No relevant cost-effectiveness data were identified.

7.4.1.4. Recommendations and link to evidence

Recommendations	15. Alternatives to natural rubber latex gloves must^bb be available for patients, carers and healthcare workers who have a documented sensitivity to natural rubber latex. [2012]
Relative values of different outcomes	The GDG stated that hypersensitivity and user preference were the most important outcomes for this recommendation.
Trade off between clinical benefits and harms	The benefit of using non-latex gloves for those who have an allergy to latex (contact urticaria) is that they avoid allergic reactions and future adverse reactions by properly documenting their condition. This will require additional occupational health assessments.
Economic considerations	Because latex gloves are not a valid option for individuals with latex sensitivity, the comparatively greater cost of nitrile gloves is not a relevant consideration.
Quality of evidence	No clinical evidence found. One study compared latex to nitrile gloves, but healthcare workers with latex allergy were randomised to the nitrile group. No sensitivity to latex was reported by those healthcare workers using latex gloves.
Other considerations	The GDG thought that the latex sensitivity of anyone living with the patient should be taken into consideration when deciding which glove type to use. The Health and Safety Executive also provide information on the use of latex gloves.¹¹⁷ This recommendation is a ‘must’ as it is covered by legislation detailed in the footnote in line with guidance from the NICE Guidelines Manual (2009).¹⁸² A minor change has been made to the order of wording of this recommendation following update to the previous guideline.

bb: In accordance with current health and safety legislation (at the publication of the guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002, and Health and Social Care Act 2008.

Recommendations	16. Do not use polythene gloves for clinical interventions. [new 2012]
Relative values of different outcomes	The GDG stated that prevention of blood borne infections and bodily fluid contamination were the most important outcomes for this recommendation (and that hands are protected from harmful microorganisms).
Trade off between clinical benefits and harms	Stating that ‘powdered gloves should not be used’ has been removed from this recommendation as an update to the previous guideline. The recommendation in the previous guideline referred to latex powdered gloves that are associated with latex allergy. Corn starch used in powdered latex gloves is thought to be a source of latex sensitisation, because the natural rubber latex easily binds to it, transporting it through the skin and into the circulation. However, alternative powdered gloves are now available that are non-latex and thus avoid this problem. Although no evidence for the use of polythene gloves was identified as part of the update, GDG consensus was that polythene gloves are inappropriate for clinical use as they do not provide sufficient protection against microorganisms for healthcare workers or patients, and do not meet current British standards³¹ and as such should remain in the guideline as a ‘do not use’ recommendation.
Economic considerations	Although polythene gloves may be less expensive than other types of gloves, they are not appropriate for clinical interventions and do not represent a valid alternative to latex, nitrile, or vinyl gloves. If healthcare workers are currently using polythene gloves for clinical interventions, compliance with this recommendation will be associated with an implementation cost.
Quality of evidence	No clinical evidence was identified for polythene gloves.
Other considerations	Polythene gloves may be appropriate for other tasks (such as food preparation), but they are not suitable for clinical interventions.

7.5. When should plastic aprons or fluid repellent gowns be worn?

7.5.1. Review question

The following review question was prioritised to determine when a disposable apron should be worn or when a fluid repellent gown was more appropriate. This question was highlighted by dental practitioners during stakeholder consultation as an area that required updating. The GDG agreed that the prevention of blood, bodily fluid contamination and transfer of pathogenic microorganisms were important outcomes for this clinical question.

What is the clinical and cost effectiveness of healthcare workers wearing plastic aprons or fluid repellent gowns vs. no aprons or gowns, gloves only or standard uniform on the reduction of blood, bodily fluid and pathogenic microorganism contamination?

7.5.1.1. Clinical evidence

Two observational studies investigating contamination of uniforms when disposable plastic aprons were worn were included for this review question,³⁴^,⁹⁶ one of which was included in the previous 2003 guideline.³⁴ Two intensive care based, observational, before and after studies were included, comparing isolation procedures with gowns and gloves against isolation procedures with gloves alone in preventing the acquisition of vancomycin resistant enterococci (VRE).²¹⁶^,²⁴⁶

See Evidence Table G.3.2, Appendix G, Forest Plots in Figure 15–16, Appendix I.

Table 25Disposable aprons vs. no aprons - Clinical study characteristics

Outcome	Number of studies	Design	Limitations	Inconsistency	Indirectness	Imprecision
MRSA contamination of uniform (Care assistants; aprons worn when washing and changing)⁹⁶	1	Observational studies	Very serious^(a)	No serious inconsistency	No serious indirectness	Serious imprecision ^(b)
MRSA contamination of uniform (Care assistants; aprons worn when washing, changing and for meal assistance)⁹⁶	1	Observational studies	Very serious^(a)	No serious inconsistency	No serious indirectness	No serious imprecision
MRSA contamination of uniform (Nurses; aprons worn for dressing)⁹⁶	1	observational studies	Very serious^(a)	No serious inconsistency	No serious indirectness	Serious imprecision ^(b)
MRSA contamination of uniform (Nurses; aprons worn for dressing and biological sampling)⁹⁶	1	Observational studies	Very serious^(a)	No serious inconsistency	No serious indirectness	Serious imprecision ^(b)
Bacterial contamination of uniform³⁴	1	Observational studies	Very serious limitations^(c)	No serious inconsistency	Serious indirectness^(d)	No serious imprecision ^(e)
Bodily fluid contamination	0	RCT or observational

a: Study poorly reported. Not clear how the indications to wear aprons were allocated. Results were excluded for HCW who did not use aprons where indicated on more than 5 occasions per shift.
b: The relatively few events and few patients give wide confidence intervals around the estimate of effect. This makes it difficult to know the true effect size for this outcome.
c: Study poorly reported. Study conducted in 2 wards but no baseline data reported regarding care activities for each ward, patient characteristics (including numbers) or staffing in the 2 wards.
d: Study conducted in hospital population not primary or community care.
e: No standard deviation reported so confidence intervals are unknown, therefore unknown whether effect is precise or not.

Table 26Disposable aprons vs. no aprons - Clinical summary of findings

Outcome	Aprons	No aprons	Relative risk	Absolute effect	Quality
MRSA contamination of uniform (Care assistants; aprons worn when washing and changing)⁹⁶	15/43 (34.9%)	5/16 (31.3%)	1.12 (0.48 to 2.57)	38 more per 1000 (163 fewer to 491 more)	VERY LOW
MRSA contamination of uniform (Care assistants; aprons worn when washing, changing and for meal assistance)⁹⁶	7/80 (8.8%)	5/16 (31.3%)	0.28 (0.1 to 0.77)	225 fewer per 1000 (72 fewer to 281 fewer)	VERY LOW
MRSA contamination of uniform (Nurses; aprons worn for dressing)⁹⁶	7/22 (31.8%)	7/16 (43.8%)	0.73 (0.32 to 1.66)	118 fewer per 1000 (298 fewer to 289 more)	VERY LOW
MRSA contamination of uniform (Nurses; aprons worn for dressing and biological sampling)⁹⁶	2/20 (10%)	7/16 (43.8%)	0.23 (0.05 to 0.95)	337 fewer per 1000 (from 22 fewer to 416 fewer)	VERY LOW
Bacterial Contamination of uniform³⁴	Mean colony count in apron group: 59.40^(a)	Mean colony count in no apron group 44.80^(a)	N/R	N/R	VERY LOW

a: Only results for mean colony counts were provided in the paper. No details about standard deviation of results were provided.

Table 27Gowns and gloves vs. gloves alone - Clinical study characteristics

Outcome	Number of studies	Design	Limitations	Inconsistency	Indirectness	Imprecision
Vancomycin resistant enterococci (VRE) acquisition rate (cases per 100 days at risk)²⁴⁶	1	Observational	Serious limitations^(a)	No serious inconsistency	Serious indirectness ^(b)	No serious imprecision ^(c)
VRE acquisition rate (cases per 1000 MICU days)²¹⁶	1	Observational	Serious limitations^(a)	No serious inconsistency	Serious indirectness ^(b)	No serious imprecision ^(c)
Bodily fluid contamination	0	RCT or observational

a: Studies investigated impact of policy change over two consecutive periods of time. No blinding and so some bias due to changes in behaviour could have occurred.
b: Study conducted in hospital population not primary or community care.
c: No standard deviation reported so confidence intervals are unknown, therefore unknown whether effect is precise or not.

Table 28Gowns and gloves vs. gloves alone - Clinical summary of findings

Outcome	Gowns and gloves	Gloves alone	Relative risk	Absolute effect	Quality
VRE acquisition rate (cases per 100 days at risk)	1.8^(a)	3.78^(a)	N/R	N/R	VERY LOW
VRE acquisition rate (cases per 1000 MICU days)	9.0^(b)	19.6^(b)	N/R	N/R	VERY LOW

a: Results expressed as cases per 100 days at risk.
b: Results expressed as cases per 1000 MICU days.

7.5.1.2. Cost-effectiveness evidence

Two economic studies were identified through the update search. One was excluded because it did not include any relevant outcomes, used a costing method that is incompatible with the NICE reference case, and as it was undertaken from a Turkish perspective, was considered a non-relevant setting by the GDG.²⁰

Results of a cost analysis by Puzniak et al., (2004)²¹⁵ were presented to the GDG. The GDG were also presented with current UK gown and apron costs to inform decision making.

No economic studies were identified in the previous 2003 guideline.

Table 29Gowns vs. No gowns – Economic study characteristics

Study	Limitations	Applicability	Other Comments
Puzniak 2004²¹⁵	Potentially serious limitations^(a)	Partial applicability^(b)	ICU setting

a: Based on a before and after trial designed to assess the impact of a policy change, difficult to isolate the effect of gowns as was part of an intervention package.
b: USA hospital perspective; ICU isolation setting.

Table 30Gowns vs. No gowns – Economic summary of findings

Study	Incremental cost (£)	Incremental effects	ICER	Uncertainty
Puzniak 2004²¹⁵	Gowns cost £67 567 per year^(a)	58 cases of VRE colonisation and 6 cases of VRE bacteraemia averted with use of gowns	Net benefit of £382 914 associated with gowns	Results were robust under exploratory analysis

a: Annualised hospital-wide cost; cost of intervention included the healthcare worker time needed to don and doff gowns.

Table 31Gown and apron costs

	Sterile fluid impervious gowns	Sterile standard gowns	Standard plastic apron
Cost per gown/apron (£)	2.10 (disposable)	1.80 (+laundry/autoclave)	0.10 (disposable)

: Source: Based on average NHS Supply Chain Catalogue¹⁸⁷ prices.

7.5.1.3. Evidence statements

Clinical

It is uncertain whether there is any difference in mean bacterial colony count on uniforms when wearing an apron compared with not wearing an apron (VERY LOW QUALITY).
There is a statistically significant and clinically important reduction in MRSA contamination of care assistant uniforms when aprons were used for washing, and meal assistance in a long-term care facility compared with when no aprons were used (VERY LOW QUALITY).
There is a statistically significant reduction of uncertain clinical importance in MRSA contamination of nurses uniforms when aprons were used for dressing changes and biological sampling compared with when no aprons were used (VERY LOW QUALITY).
There was a statistically significant reduction of uncertain clinical importance in VRE acquisition when gowns and gloves were worn in isolation procedures compared to when gloves alone were worn (VERY LOW QUALITY).
No studies were identified that reported bodily fluid contamination.

Economic

Wearing a gown or apron is likely to be cost-effective where there is a risk of infection transmission to the healthcare worker or between patients (POTENTIALLY SERIOUS LIMITATIONS; PARTIALLY APPLICABLE).
No economic studies comparing gowns to aprons were identified.

7.5.1.4. Recommendations and link to evidence (2012)

Recommendations	17. When delivering direct patient care: wear a disposable plastic apron if there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions or wear a long-sleeved fluid-repellent gown if there is a risk of extensive splashing of blood, body fluids, secretions or excretions, onto skin or clothing. [2012]
Relative values of different outcomes	The GDG agreed that prevention of blood, bodily fluid and pathogenic microorganism contamination were important outcomes for this clinical question.
Trade off between clinical benefits and harms	Wearing disposable aprons and gowns should protect healthcare workers from becoming contaminated whilst providing care and is also in line with health and safety legislation.¹^,³^,⁴^,¹¹⁵ In turn, this should help prevent the spread of microorganisms to other patients. The GDG felt that potential clinical disadvantages may occur if the healthcare worker becomes reliant on the aprons to protect themselves and does not continue with other standard infection control best practice. The GDG considered that poor practice, such as not wearing a clean uniform or not wearing aprons for more than one patient care episode, should not occur.
Economic considerations	The cost of disposable aprons, cost of uniforms, cost of laundering uniforms, and consequences of infection were taken into consideration. The GDG agreed that the cost associated with apron use would likely be outweighed by the costs and consequences of not wearing an apron (staff time and resource use associated with changing and laundering soiled uniforms, and the risk of infection associated with exposure to blood, bodily fluid, excretions or secretions). The cost associated with fluid-repellent gown use should be considered relative to the risk of contamination associated with each episode of direct patient care. Where the risk of soiling or infection is high, the increased cost of a fluid-repellent gown is likely to be justified.
Quality of evidence	Four clinical studies were included. Two very low quality, poorly reported observational studies investigated uniform contamination when an apron was used compared to when no apron was used. Two very low quality comparative observational studies investigated the impact of changing isolation procedures in intensive care units on the acquisition of VRE. Both studies reported lower VRE acquisition rates in the periods when gloves and gowns were used compared to the periods when gloves alone were used. The GDG agreed the changes to the recommendation by consensus.
Other considerations	The GDG noted that before any task is started an assessment of the risks should be undertaken to identify the risks of contamination to healthcare workers. They noted that appropriate PPE should be selected based on the task required. Employers are obliged to ensure that suitable PPE is available and that there are proper facilities for its storage and disposal in line with current legislation. The GDG thought that employees should be adequately instructed and trained in the safe use of PPE, which includes appropriate donning, doffing and disposal procedures. However, they did not feel it was necessary to make a recommendation in this area as this is covered in recommendation 5.2.1.1. The GDG noted that healthcare workers should be protected from contamination of bodily fluids that could cause infection. The level of protection (disposable apron or full gown) should depend on the extent of potential contamination. The GDG acknowledged that ambulance staff wear aprons when required, but it is unusual to wear full gowns in the community. Full gowns are generally only available in exceptional circumstances, such as high risk transfers and/or previously known risks or scenarios, which are rare. The GDG considered that the recommendation is appropriate for the majority of healthcare workers in the community. The recommendation from the previous guideline explicitly stated that aprons or gowns should be used to protect against body fluid contamination with the exception of sweat. The GDG decided to remove ‘with the exception of sweat’ as, although they acknowledged that microorganisms in sweat were unlikely to be pathogenic, the exception was confusing and unnecessary. In addition, the brackets included in the recommendation made in the previous guideline which provided the example of ‘when assisting with child birth’ were removed as it was felt by the GDG to be unnecessary and may limit the reader’s interpretation of the recommendation.

Recommendations	18. When using disposable plastic aprons or gowns: use them as single-use items, for one procedure or one episode of direct patient care and ensure they are disposed of correctly (see chapter 9). [2012]
Relative values of different outcomes	The GDG agreed that prevention of blood and bodily fluid and pathogenic microorganism contamination were important outcomes for this clinical question.
Trade off between clinical benefits and harms	The GDG noted that wearing disposable aprons and gowns protect healthcare workers from becoming contaminated whilst providing care. This benefit is negated if bad practice is adopted such as wearing aprons or gowns between patients or wearing the same apron for different procedures on the same patient.
Economic considerations	The GDG agreed that any increased cost in apron and gown use associated with single-use of these items is outweighed by the cost and quality of life implications associated with infection transmission to healthcare workers and between patients.
Quality of evidence	The recommendation developed is in line with the available evidence which investigated the use of single-use items which were discarded after each patient use. The evidence that showed the use of gowns reduced the acquisition of VRE in intensive care units, provided gowns that were not re-used between patients. It is unclear from consideration of the evidence reviewed whether the available gowns were disposable items.
Other considerations	The GDG updated the recommendation from the previous guideline to highlight that plastic aprons or gowns should be changed between ‘individual episodes of patient care’ in order to prevent disposable aprons used for a patient being re-donned when providing care for that same patient at a later time. Appropriate disposal of aprons and gowns is a legal requirement. The GDG decided to separate the section of the recommendation which required the healthcare worker to dispose of plastic aprons as ‘healthcare waste’ as this is now considered in a separate recommendation (see chapter 9).

7.6. When is a facemask, eye protection or other facial protection necessary?

Our previous systematic review failed to reveal any robust experimental studies that suggested any clinical benefit from wearing surgical masks to protect patients during routine ward procedures such as wound dressing or invasive medical procedures.²¹¹^,²¹²

Personal respiratory protection is required in certain respiratory diseases, e.g., HIV-related or multiple drug-resistant tuberculosis²⁶⁰ and where patients who are severely immunocompromised are at an increased risk of infection. In these instances, surgical masks are not effective protection and specialised respiratory protective equipment should be worn, e.g., a particulate filter mask.¹¹³^,²¹²^,²⁶⁰

Our previous systematic review indicated that different protective eyewear offered protection against physical splashing of infected substances into the eyes (although not on 100% of occasions) but compliance was poor.²¹² Expert opinion recommends that face and eye protection reduce the risk of occupational exposure of healthcare practitioners to splashes of blood, body fluids, secretion or excretions.⁴⁵^,⁹⁵^,²¹¹

7.6.1.1. Recommendations

19.: Face masks and eye protection must^cc be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. [2003]
20.: Respiratory protective equipment, for example a particulate filter mask, must^cc be used when clinically indicated. [2003]

Footnotes

x: In accordance with current health and safety legislation (at the time of publication of the guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002, and Health and Social Care Act 2008.
y: In accordance with current health and safety legislation (at the publication of the guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002, and Health and Social Care Act 2008.
cc: In accordance with current health and safety legislation (at the time of the publication of the guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002, and Health and Social Care Act 2008.

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