PPE and Hand Hygiene

Implementation Date: 11/2021

Date of Last Revision: 6/24/2023

Next Review Due: 6/23/2026

 

Reviewed by VTH Administrative Team: 11/2021

Reviewed by VTH Board: N/A

 

Reviewed & Approved by Hospital Director: 11/2021

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

The intent of this policy is to provide the outlines of the processes for utilizing PPE for any activities involving hazardous drugs, to provide protection for those handling the drugs. This is applicable to all personnel handling, preparing, dispensing, or administering hazardous drugs.

Appropriate PPE must be worn for any activities that involve hazardous drugs. Appropriate PPE must still be worn when a CSTD is being utilized.

Guidelines

Appropriate and required PPE must be donned when involved in an activity that includes hazardous drugs.

*When doing an activity in which spills or leaks are possible, don a chemotherapy gown and respiratory protection*

• Gloves: Powder-free nitrile, polyurethane, neoprene, or latex material. Gloves must meet ASTM D6978 standards (i.e., be chemotherapy protective).
• Gowns: Disposable, lint-free, and rated to resist chemotherapy. Must have long sleeves and elastic or knit cuffs. No open front (fastened in the back) and without seams or closures that could allow HD exposure
• Eye / Face Shields: Must be worn any time there is a risk of splashes or spills. Goggles should be worn with face shields when full eye and face protection is needed.
• Respirators: For most activities requiring respiratory protection: A fit-tested, NIOSH-certified, N95 is sufficient protection for airborne particles; however, N95 respirators do not offer protection against gases or vapors.
  • When there is a risk of respiratory exposure to HDs (including large spills and known risk of exposure to vapors and gases), wear an appropriate full-facepiece, chemical cartridge-type respiratory, or powered air-purifying respirator (PAPR).
• Shoe, sleeve, hair, and facial hair covers: Required to be lint-free and made from disposable materials. Sleeve covers should be polyethylene-coated polypropylene or other laminate with closed cuffs and no seams, openings, or closures that would allow exposure.

Procedure (if applicable)

1. Inspect PPE for defects and tears before use. Do not reuse gloves, gowns, shoe covers or any other disposable PPE.
   
   
2. Wash hands with soap and water after removing the gloves.
   
   
3. Change gloves after 30 minutes of normal wear. Should change immediately if damaged or contaminated.

• • When double gloving, place one glove under the gown cuff and one over. (Regardless of the thickness of the glove, staff must use double gloves when handling concentrated forms of hazardous drugs).

4. Change gowns when leaving the handling area, after a spill or splash, or after two to three hours of continuous use. Gowns worn in the HD handling areas must not be worn to other areas.
   
   
5. When compounding HDs, a second pair of shoe covers must be donned before entering the C-SEC and doffed when exiting the C-SEC. Remove shoe covers after cleaning a spill.
   
   
6. Dispose of all disposable PPE in a hazardous waste container after use.
   
   
7. For non-disposable PPE, decontaminate and clean after use and take care to properly dispose of the materials used to decontaminate this equipment.
   
   

HD Formulation	Activity	Double chemotherapy gloves	Protective gown	Eye/face protection	Respiratory protection	Ventilated engineering control
Intact tablet or capsule	Administration from unit-dose package	*single glove can be used, unless spills occur*	no	no	no	N/A
Tablets or capsules	Cutting, crushing or manipulating tablets or capsules; handling uncoated tablets	YES	Yes	No	Yes, if not in a control device	Yes, if possible
	Administering	No *single glove can be used, unless spills occur*	no	Yes, if potential vomiting	No	N/A
Oral liquid drug or feeding tube	Compounding	YES	YES	Yes, if not in a control device	Yes, if not in a control device	YES
	administration	YES	YES	Yes, if potential vomiting		N/A
Topical drug	administration	YES	YES	Yes, if potential splashing	Yes, if inhalation potential	N/A
SQ/IM injection from vial	Preparation (withdrawal from vial)	YES	YES	Yes, if not in a control device	Yes, if not in a control device	YES, BSC OR CACI
	Administration from prepared syringe	YES	YES	Yes, if potential splashing	No	N/A
Withdrawing/ mixing IV / IM solution from vial or ampule	Compounding	YES	YES	No	No	Yes, BSC or CACI; use of CSTD recommended
	Administration from prepared solution	YES	YES	Yes, if potential splashing	no	N/A ; CSTD if dosage form allows
Solution for irrigation	Administration	YES	YES	YES	YES	N/A
Powder/ aerosol treatment / solution for inhalation	Aerosol administration	YES	YES	YES	YES	N/A
	Administration	YES	YES	Yes, if potential splashing	Yes, if inhalation potential	N/A
Spills	Cleaning	YES	YES	YES	YES	N/A
Drug-contaminated waste	Disposal and cleaning	YES	YES	Yes, if potential splashing	Yes, if inhalation potential	N/A
Drugs and metabolites in body fluids	Disposal and cleaning	YES	YES	Yes, if potential splashing	Yes, if inhalation potential	N/A

Definitions and abbreviations (if applicable)

HD : Hazardous Drug

PPE : Personal Protective Equipment

CSTD : Closed System Transfer Device

NIOSH : National Institute for Occupational Safety and Health

ASTM : American Society for Testing and Materials International

C-SEC : Secondary engineering control ; Room where the C-PEC is placed

C-PEC : Primary engineering control ; Hood

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.