The COVID-19 epidemic continues to evolve locally. In response to the growing number of regional cases, effective immediately, LVHN will implement the following standard for the use of personal protective equipment (PPE) for its employees. In order to assure the protection of our patients and colleagues at the greatest risk for exposure AND to assure that we maintain an adequate supply of PPE, it is imperative that colleagues comply with these standards.

Always perform careful hand hygiene BEFORE and AFTER putting on or taking off masks and protective eyewear to prevent self-contamination.

  1. Non-Patient Facing Colleagues – No PPE recommended. This group includes all employees who do not come into close contact with patients in the inpatient or outpatient setting. Close contact is defined as prolonged contact within six feet for more than two minutes.
  2. All Patient-Facing Colleagues – Recommend extended use surgical facemask and protective eyewear (face shields or goggles) during work hours. N-95 masks are not appropriate for routine use – our current supply dictates that we use these masks only in appropriate, high-risk situations (see below).
    1. Gloves should be worn for direct patient contact
    2. Gowns are not recommended for routine patient care – these must be conserved for high-risk contacts.
    3. Examples
      1. Providers/Clinicians with Direct Patient-Facing Care Responsibilities such as physicians, APCs, nurses, physical therapy, registrars, pharmacists, food service, technical partners, MAs, PSRs, etc.
      2. Colleagues in these groups who are working remotely or at locations that do not bring them into immediate contact with patients should NOT be wearing PPE.
  3. Patient-Facing Colleagues in Situations with Risk of Aerosolization of COVID – recommend extended use N95 respirators/masks, protective eyewear and gowns.
    1. Examples of these situations include:
      1. Inpatients on Enhanced Droplet precautions during an aerosol generating procedure (such as intubations, endoscopy, bronchoscopy, nebulizer treatments without actuator, etc.)
      2. Ambulatory patients undergoing an aerosol generating procedure
      3. Patients critically ill on Airborne Precautions
    2. Extended N95/respirator masks can be covered with surgical facemask to reduce likelihood of soiling and allow for more prolonged usage.
    3. Gowns should be worn during these procedures.

In order to conserve our current supply of PPE, we will be significantly reducing the number of colleagues who interact directly with patients. All teams – inpatient and outpatient – will be critically evaluating their current structure to significantly limit the number of colleagues who have direct contact with patients daily. We will be dramatically reducing surgeries and other procedures, focusing only on urgent procedures, as part of our strategic plan to reduce unnecessary PPE usage.

Extended Use Surgical Facemasks and N95 Respirators/Masks: When to discard and replace

  • Replace mask if it does not maintain its fit and function, becomes damaged or breathing becomes difficult.
  • Discard masks that become contaminated with blood, respiratory or nasal secretions, or other bodily fluids.
  • Follow requirements for limited reuse when mask is removed for periods of time (e.g. breaks, lunches, while off the unit). See below.
  • Discard after your shift. (This is subject to change based upon our supply).

Reuse of Surgical Facemasks and N95 Respirators/Masks during Your Shift

  • Cover the N95 respirator with a surgical facemask during aerosol generating procedure to prevent contamination.
  • Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal.
  • Avoid touching the front of the N95 or surgical facemask while wearing. Perform hand hygiene if contact with the front of the mask is experienced.
  • Avoid touching the inside of the N95 respirator or surgical facemask when taking off and putting on prior to disinfecting your hands.
  • Perform careful hand hygiene before and after touching or adjusting the N95 respirator or surgical facemask (if necessary, for comfort or to maintain fit) during use.

Storing Surgical Facemasks and N95 Respirators/Masks between Uses

  • Store N95 respirators or surgical facemasks in a designated personal container (preferable) or paper bag between uses.
    • Do not store N95 respirator or surgical facemasks with other masks to minimize potential cross-contamination
    • Clearly label the container/bag with the name of the person using the N95 respirator or surgical facemask – do not share.
    • Dispose or clean storage containers regularly with a hospital approved disinfectant.

Employee “Bring Your Own” Surgical Masks and N95 Respirators/Masks

  • Employees are permitted to wear their own personal N95 respirator provided it is NIOSH approved ONLY as appropriate.
  • The employee will be responsible to assure they are familiar with the instructions for use associated with their N95 respirator or surgical facemask.
  • The employee will be responsible to maintain the cleanliness of their N95 Respirator/Mask or surgical facemask.
  • Always perform careful hand hygiene before and after putting on or taking off N95 Respirators/Masks and surgical facemasks to prevent self-contamination.

Protective Eyewear

Eye protection is required in addition to N95 respirator/mask or surgical facemasks and should be worn for the duration of the shift by patient-facing colleagues.

  • Perform hand hygiene BEFORE and AFTER putting on or taking off the eye protection
  • Disinfect with a hospital-approved disinfectant between uses
  • Eye glasses are not personal protective equipment. Place goggles over the eye glasses.


Copyright © 2020 Lehigh Valley Physician Hospital Organization, Inc./Valley Preferred, All rights reserved.

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