STERILE PROCESSING MANUAL Policy & Procedure TITLE: Dress Code and Personal Protective NUMBER: Equipment (PPE) Sterile Processing Department (SPD) Effective Date: March 2014 Page 1 of 6 Applies To: Holders of Sterile Processing Manual POLICY 1. The Sterile Processing Department (SPD) is a restricted area of the hospital. All healthcare facility staff with access to this area is required to strictly adhere to the SPD dress code in the interest of safety and infection control. 2. SPD staff working in the Operating Room areas is to adhere to the SPD Dress Code/Personal Protective Equipment (PPE) policy. 3. Staff non-compliance will be addressed through the Capital Health disciplinary process. (Refer to CH 08-045 formerly:ch 40-045) Corrective Action ) PROCEDURE 1. Clothing 1.1. Dress beginning with the head covering, and continue the application of PPE down the body, taking care to prevent the scrub pants from dragging on the floor. 1.2. Wear a clean uniform consisting of a facility laundered scrub type top and pants, or disposable scrub type top and pants. 1.3. Change clothing at the end of each shift and immediately if it becomes soiled or wet. 1.3.1. Dispose of soiled or wet uniforms into the laundry immediately. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
Dress Code and PPE SPD Page 2 of 6 1.4. If required for warmth, wear facility laundered reusable cover gowns over the uniform. Note: These cover gowns are to be worn in SPD areas only. 1.5. When transporting contaminated items, wear garments with appropriate barrier qualities for the job function and the task at hand, over the uniform (tied to completely cover the uniform underneath). 1.5.1. When leaving the department or facility, wear a freshly laundered, buttoned lab coat or warm up, to cover the uniform. 1.5.2. Change into street clothes whenever leaving the health care facility or when traveling between buildings. Note: Lab coats are not permitted in the department. Exception: 10A, and 11A - VG Site. When transporting clean OR goods between 10A OR, 11A OR and SPD. Using Centennial elevators, wear a clean scrub suit and no cover gown or lab coat. In all other instances, adhere to Procedure Statement 1.5.1. 2. Covering 2.1. Cover all head and facial hair, with the exception of eyebrows and eyelashes, with a clean disposable cap. Change the disposable cap whenever returning to the department, and when the cap becomes soiled. Note: The disposable hair covering is designed to cover all head and facial hair. 2.2. Ensure that any lesions are covered. 3. Shoes 3.1. Wear shoes that are clean, well maintained, keep the feet safe and dry, have a nonskid sole, are sufficiently durable to prevent foot injury if a device is dropped, are closed-toe and have no open holes. 4. Jewelry 3.1.1. Ensure that clog type shoes if worn - have a back strap. Note: The only acceptable jewelry is a plain band. Exceptions: Medic-Alert bracelets may be worn in the department.
Dress Code and PPE SPD Page 3 of 6 4.1. Remove or contain all piercing. 4.2. For safety reasons, do not wear badges, keys, or pens around the neck on lanyards. 5. Nails 4.2.1. Clip badges inside the pocket on scrub shirts for identification purposes. 5.1. Keep nails and cuticles clean, short and well manicured. 5.2. Do not wear artificial nails or nail polish (Refer to Artificial Fingernails IC 06-015) 6. Personal Effects 6.1. Do not keep personal effects/devices in the department, including but not limited to cell phones or pagers unless it s a hospital issued device. (Refer to Wireless Communications Devices Etiquette in the Patient Care Environment CC 01-070) 7. Decontamination Areas 7.1. Wear: 7.1.1. A clean uniform 7.1.2. Hair covering 7.1.3. Disposable foot coverings or designated footwear 7.1.4. Face shield 7.1.5. Gloves, appropriate to the task to be performed Refer to Appendix A Personal Protective Equipment. 7.2. Upon leaving the decontamination areas, remove all PPE and deposit into yellow biohazardous bags, or laundry as appropriate. Removal of Personal Protective Equipment Note: All staff working in ALL decontamination areas of the Sterile Processing Department is to safely and properly remove personal protective equipment (PPE) 7.3. Remove PPE as per Appendix B.
Dress Code and PPE SPD Page 4 of 6 8. Service Personnel and Visitors 8.1. All service personnel and visitors to reprocessing areas: 8.1.1. wear protective attire or PPE appropriate to the type of area, their activity in that area, and the amount of time they will be in that area (e.g. a cover gown and a hair covering for a walk through visitor). 8.1.2. remove the protective attire or PPE and wash hands on exiting the area. REFERENCES CSA (2008) Decontamination of Reusable Medical Devices Z314.8-08. CSA (2001). Effective Sterilization in Health Care Facilities by the Ethylene Oxide Process Z314.2-01. CSA (2009) Effective Sterilization in Health Care Facilities by the Steam Process (Z314.3-09) Health Canada (1998). Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. (Document is located at the bottom of the page.) RELATED DOCUMENTS Policies CC 01-070 Wireless Communications Devices Etiquette in the Patient Care Environment CH 08-045 (formerly:ch 40-045) Corrective Action CH 08-095 (formerly:ch 40-095) Dress Standards CH 20-055 (formerly:ch 80-055) Personal Protective Equipment (PPE) IC 06-015 Artificial Fingernails Q100-030-00 Cellular Phones and Two-Way Radios Appendices Appendix A PPE Appendix B Removal of PPE * * *
Dress Code and PPE SPD Page 5 of 6 Appendix A Personal Protective Equipment Wear waterproof aprons over a cover gown or waterproof gowns; discard when leaving the area. Change torn/compromised gloves immediately and wash hands thoroughly before donning new gloves. At a minimum, for face protection wear a disposable face shield that covers the entire face and neck areas. Wear full shoes, covered with disposable foot coverings or dedicated footwear Upon leaving the decontamination areas, remove all PPE and deposit into yellow biohazardous bags, or laundry as appropriate.
Dress Code and PPE SPD Page 6 of 6 Appendix B Removal of Personal Protective Equipment Remove and discard protective shoe covers and sleeveless disposable apron. Remove all gloves and discard. Wash hands. Carefully untie neck ties of protective gown, taking care to avoid touching uniform or neck. Remove face shield or goggles from the back of head. Take care to avoid touching the front of the face shield or goggles. Remove protective gown, turning gown inside out; immediately place in laundry. Remove facemask, if worn; handle by ties only. Wash hands with soap and water immediately after removing PPE.