Ebola Virus Disease (EVD) Risk Assessment and Personal Protective Equipment

Transcription

1 Version 2.0: Nov. 6, 2014 Document will be updated as new information is available. Ebola Virus Disease (EVD) Risk Assessment and Personal Protective Equipment Transmission of Ebola virus occurs when non-intact skin or mucous membranes have direct or indirect contact with blood or body fluids of an infected person. Appropriate infection control measures like proper use and removal of Personal Protective Equipment (PPE), environmental cleaning (approved hospital grade disinfectant such as broad spectrum virucide product or proven efficacy against Adenovirus type 5, Bovine Parvovirus, Canine Parvovirus and Poliovirus types 1) and waste management and are essential for safe practice. There is no risk of transmission during the incubation period (i.e. when no symptoms are present). Symptoms of EVD include: acute fever (> 38 C), headache, joint and muscle aches, abdominal pain, weakness, diarrhea, vomiting, lack of appetite, rash red eyes, hiccoughs, cough, chest pain, difficulty breathing, difficulty swallowing, bleeding inside or outside of the body. Low risk symptoms include acute fever (>38 C), headache, joint and muscle aches, weakness and abdominal pain. High risk symptoms include: bleeding, diarrhea or vomiting. Trained observers are required to monitor PPE donning and doffing steps when patient symptoms and/or care activities are determined to be a potential High Risk. The decision to upgrade to a higher level of protection is based on your assessment of risk in each situation. Conduct the following risk assessment to assess the PPE you require: Risk of EVD Patient is being monitored by Public Health for potential EVD symptoms, but has no symptoms (no symptoms = no risk) In the past 21 days patient: (1) has been in a country with widespread transmission of EVD OR cared for, come into contact with body fluids, or handled clinical specimens from an individual known or strongly suspected to have Ebola; and (2) has LOW risk symptoms In the past 21 days patient: (1) has been in a country with widespread transmission of EVD OR cared for, come into contact with body fluids, or handled clinical specimens from an individual known or strongly suspected to have Ebola; and (2) has HIGH risk symptoms OR requires a high risk procedure (cardiopulmonary resuscitation, central line insertion, procedures that result in copious amounts of body fluid contamination) or aerosol generating medical procedures (including intubation and related procedures, open respiratory /airway suctioning, high- frequency oscillatory ventilation, nebulized therapy, non-invasive positive pressure ventilation) Routine practices as for all patients PPE Required Nitrile Gloves Fluid resistant Mask Level 4 fluid resistant gown with knitted cuffs or thumb loops Full face shield YES NO NO YES YES NO YES YES YES Increase PPE to: N95 Respirator, Fluid resistant head cover, Double gloves, impervious boot covers Please note this risk assessment and the following instructions on how to properly use PPE are recommendations from the Government of Saskatchewan. Individuals transporting EVD patients to and from acute care centers require different procedures and different PPE. Page 1

2 DONNING PPE High Risk Patient *High risk: Patient is confirmed to have Ebola Virus Disease OR Patient is suspected to have Ebola Virus Disease AND has high risk symptoms such as bleeding or uncontrolled diarrhea or uncontrolled vomiting; or is unstable and requires a high risk procedure such as an aerosol generating medical procedure (includes intubation, open respiratory/airway suctioning, high-frequency oscillatory ventilation, nebulized therapy, non-invasive positive pressure ventilation), cardiopulmonary resuscitation, central line insertion, or any procedure that could potentially result in copious amounts of body fluid generation or exposure PPE Storage and Donning Area An area outside of the patient room (e.g., nearby vacant patient room or a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers (HCW) can don PPE under the guidance of a trained observer before entering the patient room Post appropriate signage indicating room designation and purpose Pre-Donning Activities Ensure that all required personal protective equipment and supplies are available and in the size required for the healthcare worker Ensure you are signed into log book Remove all personal items (i.e. jewelry, watches, cell phones, lanyards, pagers, pens) Ensure longer hair is tied back Remove personal clothing and change into scrubs and dedicated washable shoes (fluid resistant footwear-closed toe and heels, plastic or rubber soles) Hydrate (no drinking or eating is allowed in patient care area) Ensure trained observer is available to monitor, assist (if required), and document the steps of the donning checklist with you Ensure trained observer document the steps of the donning checklist with you Trained observer PPE The trained observer will don surgical gown, shoe covers, face shield, and gloves *If using the high risk PPE donning protocol, you must ensure that a trained observer is present to monitor PPE donning and to document the steps on the PPE donning checklist* Move slowly; do not rush, when putting on PPE before entering the patient room Page 2

3 1. Hand hygiene Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 2. Knee high boot covers Sit on a clean chair, if available Place boot cover on toes of foot and pull up 3. Hand hygiene Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 4. N95 respirator Use your appropriate fit-tested size Place over nose, mouth and chin Flexible nose piece is fitted over bridge of nose Secure on head with elastics: bottom elastic first at the base of the neck, then top elastic at the crown of your head Perform a seal-check 5. Surgical hood Ensure smooth fit around face and neck without causing restrictions Trained observer may assist with neck tie if difficult to reach Page 3

4 6. Nitrile gloves Either regular length or extended length nitrile gloves First set of gloves worn under gown cuffs Inspect for tears 7. Surgical gown Gown should be rated as Level 4 for moderate to high level of fluid resistance Ensure gown fits over the yoke of the hood Gown is securely fastened at the neck, waist, and back using all Velcro/ties provided Trained observer may assist with ties, if required 8. Full face shield Place face shield over the N95 respirator and surgical hood Adjust to fit Ensure there is an overlap to protect the forehead 9. Extended cuff nitrile gloves Second set of gloves worn over gown cuffs Inspect for tears 10. Inspection Trained observer inspects PPE for gaps and adjusts if necessary Conduct range of motion activities (e.g., move your arms, legs and neck) to ensure PPE stays intact. The goal is for the PPE to be secure and the staff care provider to be comfortable Avoid touching your face or adjusting PPE once in the patient care environment Page 4

5 Trained Observer Checklist for PPE Donning - High Risk Done 1. Trained Observer (TO) is available and has changed into required PPE: a. Surgical gown, shoe covers, face shield and gloves 2. TO is ready to monitor the steps of the PPE donning checklist and will assist healthcare worker (HCW) as required 3. HCW has completed the following pre-donning activities: a. Changed from personal clothing to scrubs and washable footwear b. Removed all personal items (e.g., jewelry, watches, cell phones, pagers, pens, lanyards, stethoscopes) c. Signed into log book d. Hydrated and recently used the washroom e. Tied or pulled longer hair back f. Ensured all required PPE are available in the sizing appropriate for HCW fit 4. Perform hand hygiene (See page 18) 5. Put on boot covers sit on clean chair or stool, if available a. Place boot cover on toes of foot and pull up leg 6. Perform Hand Hygiene 7. Put on N95 respirator: a. Place over the nose, mouth and chin b. Flexible nose piece is fitted over bridge of nose c. Secure on head with elastics: bottom elastic first at the base of the neck, then top elastic at the crown of your head d. HCW performs seal-check 8. Put on surgical hood: a. Ensure smooth fit around face and neck without causing restrictions b. TO may assist with neck tie if difficult to reach 9. Put on inner gloves (regular or extended length nitrile) 10. Put on surgical gown: a. Ensure gown fits over the yoke of hood b. Gown is securely fastened at the neck, waist and back using all Velcro/ties provided c. TO may assist with ties if required 11. Put on face shield over the N95 respirator and surgical hood: a. Adjust to fit b. Ensure there is an overlap to protect the forehead 12. Put on the outer 2 nd pair gloves: a. Long cuff nitrile gloves that fit over the cuff of the gown 13. TO verifies that all pieces of PPE are in place and all skin areas are covered 14. HCW reaches and bends over to ensure PPE stays in place while in motion Date/Time Healthcare Worker Trained Observer Page 5

6 DOFFING PPE High Risk Patient *High risk: Patient is confirmed to have Ebola Virus Disease OR Patient is suspected to have Ebola Virus Disease AND has high risk symptoms such as bleeding or uncontrolled diarrhea or uncontrolled vomiting; or is unstable and requires a high risk procedure such as an aerosol generating medical procedure (includes intubation, open respiratory/airway suctioning, high-frequency oscillatory ventilation, nebulized therapy, non-invasive positive pressure ventilation), cardiopulmonary resuscitation, central line insertion, or any procedure that could potentially result in copious amounts of body fluid generation or exposure PPE Doffing Area Designate an area in close proximity to the patient room (e.g., anteroom or adjacent vacant room) that is separate from the clean area where healthcare workers (HCWs) leaving the patient s room can doff and discard their PPE Alternatively, some steps of the PPE removal process may be performed in a clearly designated area of the patient s room near the door, which ensures that all doffing steps can be seen and supervised by the trained observer (e.g., through a window so that the instructions of the trained observer can still be heard) Provide supplies for disinfection of PPE (hospital grade approved disinfectant wipes) and for hand hygiene Provide a space for sitting, parallel to the doffing pad, that can be easily cleaned and disinfected, where the HCW can remove boot covers Provide leak-proof infectious waste containers for discarding used PPE If a hallway is being used outside the patient room, construct physical barriers to close hallway to traffic (thereby creating an anteroom) Post appropriate signage indicating room designation and purpose Pre-Doffing Activities (HCW) Ensure the trained observer is available to monitor, assist (where required), and document the steps of the PPE doffing checklist with you Pre-Doffing Activities (trained observer) Don shoe covers, gown, face shield, and gloves to assist HCW with removal of PPE Prepare a doffing pad that is marked section 1 and section 2 Read aloud each step of the PPE doffing procedure to the HCW and provide reminders to avoid reflexive actions that may put them at risk, such as touching their face PPE items shall be removed slowly and carefully and discarded one piece at a time in a handsfree waste receptacle Page 6

7 1. Disinfect outer gloves Use a hospital grade disinfect wipe to clean outer gloves prior to opening the door to the patient room 2. Clean door handle Use a new hospital grade disinfectant wipe to clean the door handle before opening the door 3. Inspect HCW steps out of the patient room onto section 1 of the doffing pad Trained observer visually inspects PPE for visible contamination or tears before doffing process is started If any PPE appears contaminated, HCW will clean and disinfect area using a hospital grade disinfectant wipe 4. Remove outer gloves Minimize direct contact with inner gloves Grasp outside edge of glove near the wrist and peel away, rolling the glove inside out Slide 1 or 2 fingers under the wrist of the remaining glove and peel away Discard immediately into waste 5. Disinfect inner glove Use a hospital grade disinfectant wipe to clean inner gloves 6. Remove gown Remove gown in a manner that prevents contamination of clothing and skin Trained observer will carefully unfasten top tie first, then outside waist tie, then inside waist tie Slide 2 fingers under cuff of gown and pull hand into gown. Using the hand that is covered, grab the opposite sleeve of gown and pull away from body over hand. Continue folding the gown Page 7

8 inward on to itself and rolling it away from you until it becomes small enough to discard Place into waste receptacle 7. Remove knee high boot covers 8. Remove inner gloves 9. Perform hand hygiene Sit on a clean chair (if available) Remove boot covers one at a time by rolling down and outward, lifting your heel first and then your toes Step out of the boot covers one at a time onto section 2 of the doffing pad Trained observer will discard boot covers into waste receptacle If chair is not available, then the HCW will roll the top of the boot covers out and down, and the trained observer can help pull the boot covers down and hold while the HCW steps on to section 2 of the doffing pad Grasp outside edge of glove near the wrist and peel away, rolling the glove inside out Slide 1 or 2 fingers under the wrist of the remaining glove and peel away Discard immediately into waste Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 10. Put on new gloves When hands are dry, put on a new pair of gloves 11. Remove face shield The front of the face shield is considered contaminated Handle only by the rear strap and pull it up and over the head gently, allowing the face shield to fall forward Place in waste receptacle Page 8

9 12. Remove gloves 13. Perform hand hygiene Grasp outside edge of glove near the wrist and peel away, rolling the glove inside out Slide 1 or 2 fingers under the wrist of the remaining glove and peel away Discard immediately into waste Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 14. Remove surgical hood Trained observer will undo the surgical hood ties and gently pull off of HCW s head Place hood carefully in waste 15. Perform hand hygiene Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 16. Remove N95 respirator The front of the respirator is considered contaminated Lift the bottom elastic over your head first, then the top elastic up and over your head Pull forward off the head bending forward to allow respirator to fall away from the face Place respirator carefully into waste Page 9

10 17. Perform hand hygiene Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 18. Put on new gloves When hands are dry, put on a new pair of gloves 19. Clean shoes If a second chair is available, HCW may sit and clean the tops, sides, and bottoms of each shoe using hospital grade disinfectant wipes (use one wipe for each shoe) If a second chair is not available, the trained observer will wipe the top, sides, and bottoms of each shoe As each shoe is cleaned, the HCW steps off the doffing pad on to the floor 20. Remove doffing pad Trained observer rolls up doffing pad and places in waste receptacle 21. Remove gloves 22. Perform hand hygiene Grasp outside edge of glove near the wrist and peel away, rolling the glove inside out Slide 1 or 2 fingers under the wrist of the remaining glove and peel away Discard immediately into waste Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled Page 10

11 Trained Observer Checklist for PPE Doffing - High Risk Done 1. Trained observer (TO) is available to supervise proper PPE removal by reading aloud each step of the procedure 2. TO has on a surgical gown, shoe covers, face shield and gloves 3. TO will prepare a doffing pad that is marked section 1 and section 2 and ensure a chair is available 4. Prior to removal of PPE, TO will remind the healthcare worker (HCW) to avoid reflexive actions that may put them at risk, such as touching their face, and to perform each step done slowly and carefully 5. HCW uses a hospital grade disinfectant wipe to clean outer gloves prior to opening the door to patient room 6. Using a new disinfectant wipe, the healthcare worker will clean the door handle before opening the door 7. HCW steps out of room onto section 1 of the doffing pad 8. TO visually inspects HCW s PPE for visible signs of contamination, cuts or tears before doffing process is started. If any PPE is potentially contaminated, HCW to clean and disinfect area using a hospital grade disinfectant wipe 9. If apron was used, HCW to remove carefully to prevent contact with outside of apron 10. HCW removes outer glove carefully to minimize contact with inner gloves: a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 11. HCW performs inner glove disinfection with hospital grade disinfectant wipe 12. Gently remove gown in manner that avoids contamination: a. Trained observer will carefully unfasten top tie first, then outside waist tie, then inside waist tie b. Slide 2 fingers under cuff of gown and pull hand into gown. Using the hand that is covered, grab the opposite sleeve of gown and pull away from body over hand. Continue folding the gown inward on to itself and rolling it away from you until it becomes small enough to discard c. Place into waste receptacle 13. If chair is available, a. Remove boot covers one at a time by rolling down and outward, lifting your heel first and then your toes b. Step out of the boot covers one at a time onto section 2 of the doffing pad c. Trained observer will discard boot covers into waste receptacle If chair is not available, a. HCW will roll the top of the boot covers out and down, and the trained observer can help pull the boot covers down and hold while the HCW steps on to section 2 of the doffing pad Page 11

12 14. HCW removes inner gloves and TO removes gloves in a manner that avoids contamination of hands: a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 15. HCW and TO perform hand hygiene with hand sanitizer (See page 18) 16. When hands are dry, both HCW and TO put on a new pair of gloves 17. HCW removes the face shield: a. The front of face shield is considered contaminated b. Handle only by the rear strap and pull it up and over the head gently, allowing the face shield to fall forward. c. Place in waste receptacle 18. HCW removes gloves in a manner that avoids contamination: a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 19. HCW performs hand hygiene with hand sanitizer (See page 18) 20. TO removes surgical hood: a. TO will undo the surgical hood ties and gently pull off the top of HCW s head b. Place in waste receptacle 21. TO removes gloves in a manner that avoids contamination: a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 22. TO performs hand hygiene with hand sanitizer (See page 18) 23. When hands are dry, TO to put on a new pair of gloves 24. HCW removes the N95 respirator: a. The front of the respirator is considered contaminated b. Lift the bottom elastic up and over your head first, then the top elastic up and over your head c. Pull forward off the head, bending forward slightly to allow respirator to fall away from face d. Place respirator carefully into waste receptacle 25. HCW performs hand hygiene with hand sanitizer (See page 18) 26. When hands are dry, HCW to put on a new pair of gloves 27. If a second clean chair is available, a. HCW sits on chair and uses a hospital grade disinfectant wipe to clean the top, sides and bottom of each shoe (one wipe for each shoe) b. As each shoe is cleaned, the HCW steps off the doffing pad on to the floor If second chair is not available, a. TO will use a hospital grade disinfectant wipe to clean the top, sides, and bottom of each shoe b. As each shoe is cleaned, the HCW steps off the doffing pad on to the floor 28. HCW removes gloves in a manner that avoids contamination: Page 12

13 a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 29. HCW performs hand hygiene with hand sanitizer (See page 18) 30. TO rolls up doffing pad and places in waste receptacle 31. TO removes gloves in a manner that avoids contamination: a. Grasp outside edge of glove near the wrist and peel away, rolling the glove inside-out b. Slide 1 or 2 fingers under the wrist of remaining glove and peel away c. Gloves are discarded into waste receptacle 32. TO performs hand hygiene with hand sanitizer (See page 18) 33. If shift is over, proceed to change area to remove scrubs and have a shower if that is the facility protocol Date/Time Healthcare Worker Trained Observer Page 13

14 DONNING PPE Low Risk Patient *Low Risk Encounter with a patient suspected to have Ebola Virus Disease who is mildly symptomatic: mild fever, fatigue, headache, sore throat, muscle pain. The decision to upgrade to a higher level of protection is based on your assessment of risk in each patient care situation. If risk is high, use the high risk protocol. The use of a trained observer is not required for a low risk encounter; however, HCWs are encouraged to request assistance, if needed. The trained observer checklist for donning PPE is not required for a low risk encounter. Ensure you are signed into the log book prior to entering patient room. Move slowly; do not rush, when putting on PPE before entering the patient room. 1. Hand hygiene Perform hand hygiene (See page 18) Alcohol-based hand rub (ABHR) is preferred Soap and water is used when hands are visibly soiled 2. Surgical gown Gown should be rated as Level 4 for moderate to high level of fluid resistance Gown is securely fastened at the neck, waist, and back using all Velcro/ties provided 3. Mask Fluid resistant surgical/procedure mask Place mask over nose, mouth, and chin Secure ties or loops Adjust flexible nose piece over the bridge of your nose using both hands 1. Page 14

15 4. Full face shield Place face shield over the mask Ensure there is an overlap to protect the forehead 5. Nitrile gloves Single glove provides adequate protection for low risk encounter Either regular length or extended length nitrile gloves Pull gloves over the cuffs of the gown Inspect for tears 6. While wearing PPE Avoid touching your face or adjusting PPE once in the client care environment Minimize contact with contaminated environmental surfaces Should the risk encounter change while providing patient care, the HCW should leave the patient area, safely remove all personal protective equipment, and begin using the high risk protocol for further patient encounters Page 15

16 DOFFING PPE Low Risk Patient *Low Risk Encounter with a patient suspected to have Ebola Virus Disease who is mildly symptomatic: mild fever, fatigue, headache, sore throat, muscle pain. The use of a trained observer is not required for a low risk encounter; however, HCWs are encouraged to request assistance, if needed. The trained observer checklist for doffing PPE is not required for a low risk encounter. Personal protective equipment should be removed in a designated doffing area (e.g., anteroom or in patient s room near the door) and discarded into an appropriate waste receptacle. Remove personal protective equipment slowly and carefully. 1. Disinfect gloves Clean gloves using a hospital grade disinfectant wipe before touching the door handle 2. Inspect Inspect PPE for visible contamination or tears Remove any obvious contamination with a hospital grade disinfectant wipe 3. Remove gloves Grasp outside edge of glove near the wrist and peel away, rolling the glove inside out Slide 1 or 2 fingers under the wrist of the remaining glove and peel away Discard immediately into waste 4. Remove gown Remove gown in a manner that prevents contamination of clothing and skin Carefully unfasten ties Slide 2 fingers under cuff of gown and pull hand into gown. Using the hand that is covered, grab the opposite sleeve of gown and pull away from body over hand. Continue folding the gown inward on to itself and rolling it away from you until it becomes small enough to discard Place into waste receptacle Page 16

17 5. Perform hand hygiene Alcohol-based hand rub (ABHR) is preferred (See page 18) Use soap and water if hands are visibly soiled 6. Remove face shield The front of the face shield is considered contaminated Handle only by the rear strap and pull it up and over the head gently, allowing the face shield to fall forward Place in waste receptacle 7. Remove mask Ties/straps are considered clean and may be touched with hands Untie the bottom tie first, then the top or grasp straps with both hands Pull forward off the head, bending forward to allow mask to fall away from face Place in waste receptacle 8. Perform hand hygiene Alcohol-based hand rub (ABHR) is preferred (See page 18) Use soap and water if hands are visibly soiled Page 17

18 Preferred Hand Hygiene Procedure using Alcohol-based Hand Rub Version 2.0: Nov. 6, 2014 Document will be updated as new information is available. Page 18

19 PPE Ordering Information for Saskatoon Health Region Employees and Physicians Version 2.0: Nov. 19, 2014 Document will be updated as new information is available. SKU DESCRIPTION VPC UOP VENDOR CAP DISPOSABLE BOUFFANT 24" LVL 3-4 PATH 263-PM4-728 BOX OF 100 STEVENS COMPANY FULL FACE SHIELD VENTED LVL 3-4 PATH BOX OF 24 PRIMED CANADA FULL FACE SHIELD NON-VENTED LVL 3-4 PATH PPR-053 CASE OF 100 BIO NUCLEAR DIAGNOSTIC INC MASK LASER SURGICAL LVL 3-4 PATH 145PG BOX SCHAAN HEALTHCARE SURGICAL HOOD LVL 3-4 PATH A4381 CASE OF 100 CARDINAL HEALTH LINEN GOWN DISP XL A9041 LVL 3-4 PATH A9041 CASE OF 20 CARDINAL HEALTH LINEN GOWN DISP EL A9041EL LVL 3-4 PATH A9041EL CASE OF 20 CARDINAL HEALTH SHOE COVER KNEE HIGH LVL 3-4 PATH 263-PM4-430 CASE OF 150 STEVENS COMPANY SHOE COVER KNEE HIGH XL LVL 3-4 PATH 263-PM4-430XL CASE OF 150 STEVENS COMPANY GLOVE EXAM NITRILE 12" CUFF X-SMALL 145PMS-1105#K BOX OF 100 SCHAAN HEALTHCARE GLOVE EXAM NITRILE 12" CUFF SMALL 145PM6-1106#K BOX OF 100 SCHAAN HEALTHCARE GLOVE EXAM NITRILE 12" CUFF MEDIUM 145PM6-1107#K BOX OF 100 SCHAAN HEALTHCARE GLOVE EXAM NITRILE 12" CUFF LARGE 145PM6-1108#K BOX OF 100 SCHAAN HEALTHCARE GLOVE EXAM NITRILE 12" CUFF SIZE X-LARGE 145PM6-1109#K BOX OF 100 SCHAAN HEALTHCARE Page 19