Approved by EVMS AOHSC 5/13/20

Masking and Hand Hygiene Requirements

The following requirements are in effect and shall continue until further notice. 

  1. Universal Masking (approved by EVMS Medical Group 5/11/2020).  All employees and students will adhere to the CDC recommendation for universal masking and/or wearing cloth face coverings in all public settings. Masking protects your EVMS community, not just you. See https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html
    • EVMS Medical Group implemented source control for everyone entering a healthcare facility (i.e. healthcare personnel, patients, visitors and vendors), regardless of symptoms on 4/29/2020. All patients, visitors, and vendors entering EVMS Medical Group facilities are asked to wear a face covering or a mask. Individuals without a face covering or a mask will be issued one at the building’s entry point.
    • EVMS employees who are required to wear a respirator or a surgical or medical face mask as outlined in the Respirator, Medical Masking, and Non-Medical Masking  Guidelines below and/or the EVMS Respiratory Protection Plan must strictly adhere to the donning and doffing procedure as well as strictly adhere to the use and reuse procedures for different masks.
    • Face coverings or cloth masks are not PPE, but are an administrative control as a safe work practice when used with other controls like social distancing.  As such, employees and students are required to use face coverings or masks while in common and shared areas like break rooms, lunchrooms, conference rooms or bathrooms. Masks may be removed for eating, provided that a distance of 6 feet or more from another employee is maintained. Areas should be disinfected following eating.
  2. Hand Hygiene (approved by EVMS Medical Group 5/1/2020).  Meticulous hand hygiene is mandatory using Alcohol Based Hand Rubs in the clinical settings or hand washing procedures while in a non-clinical setting (see Hand Hygiene Guidelines).

Respirator, Medical Masking and Non-Medical Masking Guidelines

Tight Fitting Respirators

Filtering Face Piece Respirators (FFR)/N95 (approved by EVMS Medical Group 04/06/2020).  FFR/N95 are tight-fitting masks that reduce exposure to particles and are evaluated, tested and approved by the National Institution for Occupational Safety and Health (NIOSH). FFR/N95s are considered PPE.*

  1. Recommended Use.  For providers, residents, and clinical staff (medical assistants and nursing staff) in accordance with the EVMS Respiratory Protection Plan.  Use of an N95 respirator requires fit testing and may be reused (See guidelines for re-use).
  2. Reuse.   Reusing disposable filtering face piece respirators (FFRs) has been suggested as a contingency capacity strategy to conserve available supplies for healthcare environments during a pandemic by the CDC.    

The pathogens on the filter materials of the FFRs may be transferred to the wearer upon contact with the FFR during activities such as adjusting the FFR, improper doffing of the FFR, or when performing a user-seal check when re-doffing a previously worn FFR. A study evaluating the persistence of SARS-CoV-2 (the virus that causes COVID-19) on plastic, stainless steel, and cardboard surfaces showed that the virus is able to survive for up to 72-hours [1]. One strategy to mitigate the contact transfer of pathogens from the FFR to the wearer during reuse is to issue five respirators to each healthcare worker who may care for patients with suspected or confirmed COVID-19. The healthcare worker will wear one respirator each day and store it in a breathable paper bag at the end of each shift. The order of FFR use should be repeated with a minimum of five days between each FFR use. This will result in each worker requiring a minimum of five FFRs, providing that they put on, take off, care for them, and store them properly each day.  

Healthcare workers should treat the FFRs as though they are still contaminated and follow the precautions outlined in our reuse recommendations. If supplies are even more constrained and five respirators are not available for each worker who needs them, FFR decontamination may be necessary. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Procedure for Donning FFR/N95 (see also How to Put On (Don) Daily PPE in the Outpatient Setting):

  1. Perform hand hygiene (wash hands or use alcohol based sanitizer).
  2. Put on a pair of clean exam gloves.
  3. Remove your previously used N95 mask from your labeled paper bag by only touching the straps or the outermost rim of the N95 mask.
  4. Inspect N95 to determine that it is intact (check components – straps, nose bridge, nose foam material).
  5. Care should be taken not to handle the front or insides of the N95 mask.
  6. If contact occurs, place N95 mask on top of bag, remove gloves, perform hand hygiene and put on new pair of gloves.
  7. Place N95 mask on face by only touching the straps and the outermost rim of the N95 mask.
  8. Perform seal check by only by touching outermost rim of N95 mask.
  9. Throw the paper bag away-do not reuse paper bag.
  10. Remove gloves and perform hand hygiene.
  11. If necessary put on clean exam gloves.

Procedure for Doffing and Storage of N95 Mask:

  1. Remove all isolation PPE except the N95 mask.
  2. Exit the patient room with N95 mask on (if used in exam room), otherwise can be worn for up to 8 hours.
  3. Perform hand hygiene and put on clean exam gloves.
  4. Obtain new/clean paper bag.
  5. Label with user’s name and date.
  6. Open bag for ease of N95 mask placement.
  7. Remove the N95 mask by only touching the straps or the outermost rim of the N95 mask.
  8. Place N95 mask in the labeled paper bag, handling only the straps or the outermost rim of the N95 mask.
  9. Remove gloves.
  10. Perform hand hygiene.
  11. Close bag by folding over itself two times.
  12. Take care to not fold, bend or crush the N95 mask inside the bag.
  13. Perform hand hygiene.

The N95 is good for 5 uses as long as not contaminated with blood, respiratory/nasal secretions, or other body fluids – don on, don off = 1 use.

Loose-Fitting Medical Masks

Loose-fitting medical masks do not prevent leakage around the edge of the mask, but may provide fluid resistance as outlined below.  Loose-fitting medical masks are considered PPE.*

Medical face mask (procedure mask) (approved by EVMS Medical Group on 04/06/2020). A medical face mask or procedure mask, is a mask, with or without a face shield, that covers the user’s nose and mouth and may or may not meet fluid barrier or filtration efficiency as outlined by the mask manufacturer.

  1. Recommended Use.  
    • Procedure masks should be provided to symptomatic patients at the point of check in (lobby screening) if not already masked (source control).
    • Healthcare workers working with patients will wear procedure masks and can wear for extended use (1 shift) without removing the facemask between patient encounters.
  2. Reuse. Procedure masks should be removed and discarded daily or if soiled, damaged, or hard to breathe through. Healthcare worker should take care not to touch their mask and if they touch or adjust the mask, they must immediately perform hand hygiene. Healthcare workers should leave patient areas if they need to remove the procedure mask.

Surgical Mask.  A surgical mask is a mask that covers the user’s nose and mouth and provides a physical barrier to fluids and particulate materials. Surgical masks meet certain fluid barrier protection standards and Class I or Class II flammability tests.

  1. Recommended Use.
  2. Reuse. Surgical masks should be removed and discarded daily, or if soiled, damaged, or hard to breathe through. Healthcare workers should take care not to touch their surgical mask and if they touch or adjust the mask, they must immediately perform hand hygiene. Healthcare worker should leave patient areas if they need to remove the mask.

Halyard masks (approved by EVMS Medical Group on 4/22/2020). Halyard masks are made out of two layers of medical-grade fabric (Halyard H600). The material is thought to be superior to the common surgical mask in its ability to block aerosols and droplets, including water, bacteria and other particles.  EVMS does not provide fit testing for this type of mask.

  1. Recommended Use: By clinical personnel to be used at all times while in the facility.  It can be used in place of a procedure mask (approved by EVMS Medical Group 04/06/2020), but is not a replacement for an N95. 
  2. Reuse:  Mask may be reused after proper autoclave procedure.  Your name should be written on one of the mask straps for an easy identification.
  3. Autoclave Procedure:  Follow regular autoclave procedure for mask disinfection.

Loose-Fitting Non-Medical Masks.

Loose-fitting non-medical masks do not prevent leakage around the edge of the mask and do not provide fluid resistance as outlined below.  Loose-fitting non-medical masks are not PPE.*

CUPRON masks (approved by EVMS Medical Group 4/22/2020). CUPRON masks use CUPRON material in which copper is physically and permanently embedded in the fibers and its antimicrobial and antiviral activity lasts for the life of the linens. CUPRON masks are not PPE and are not intended for particulate filtration, for use in a surgical setting, or where significant exposure to liquid, bodily or other hazardous fluids may be expected, nor should it be used in a clinical setting where the infection risk level through inhalation exposure is high, in the presence of a high intensity heat source or flammable gas, or in high-risk aerosol-generating procedures.

  1. Recommended Use: By non-clinical staff at all times when in the facility. It does not replace a procedure mask.
  2. Reuse: Mask has to be changed daily. Same masks could be reused after proper washing.
  3. CUPRON mask washing instructions:
    • Masks can be laundered at home using hot water and regular home detergent, or by your commercial laundry service provider in open pocket washer/extractors. Do not launder in commercial tunnel washers.
    • Wash prior to first use and daily thereafter, or between users, whichever comes first.
    • Do not use any fabric softeners when washing or drying (e.g. dryer sheets).
    • Do not use chlorine bleach as it may degrade the elastic bands over time.
    • Dry on medium heat only.

General Cloth masks (approved by EVMS Medical Group on 4/23/2020).  Cloth masks (cloth face coverings) may be sold by non-medical manufacturers (e.g. Amazon, clothing designers, etc.) or fashioned from household items or made at home from common materials at low cost and can be used as an additional public health measure. Cloth masks do not provide barrier protection against splashes, sprays, and larger respiratory droplets reaching your nose and mouth.  Cloth masks are not PPE and do not replace medical face masks, surgical masks or FFR/N95s. 

  1. Recommended Use:  CDC is advising the use of simple cloth face coverings to slow the spread of the virus and prevent people who unknowingly have the virus from transmitting it to others. Cloth masks along with other measures such as social distancing are an administrative control and are to be used in work and public settings and common spaces.  Cloth masks are not to be used in the clinical setting.  In addition, cloth masks should not be used by anyone who has difficulty breathing.
  2. Reuse: Mask may be reused after washing. 
  3. Washing instructions: Launder your mask daily. Use the warmest appropriate water setting and dry items completely.

Face shields and protective eye wear policy (approved by EVMS Medical Group 4/23/2020).

Face Shields

  1. Types: There are several types of face shields available: commercial types and made by the EVMS students (a hard plastic and a soft plastic face shield).
  2. Materials: Materials that form the EVMS face shields include the following:
    • Hard plastic shield:
      • PETG clear plastic 0.04 inch thickness
      • Extreme hold, heavy duty 3M Duct tape
      • Super / spray glue
      • 2-inch elastic band
      • Industrial staples
    • Soft plastic shield:
      • Industrial staples
      • Impact – ProClick Pre-punched binding covers
      • Super / spray glue
      • 1-inch elastic band
      • Industrial staples

  3. Recommended Use:  By clinical personnel while providing care.
  4. Reuse:  Face shields are intended for multiple uses by the same user. These face shields are not intended for use in the presence of high intensity heat sources or flammable gas. The face shield does not confer protection from bacterial or viral infections without the additional use of a certified N95 – N99 respirator face mask.
  5. Cleaning Instructions:  We recommend that the face shield be wiped down with alcohol-based solution (70% or greater) or with Clorox or Lysol wipes immediately after use. Use protective gloves when removing face shields and during cleaning.

Protective eye wear

  1. Type: Safety glasses or goggles. Note that corrective lenses (glasses) are not considered to be protective eye wear. 
  2. Recommended use: By clinical personnel while providing care.
  3. Reuse:  The eye wear is intended for multiple uses by the same user.
  4. Cleaning:  Can be cleaned using alcohol wipes or washed with soap and water.

* Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cannot easily be controlled through the use of other workplace hazard controls such as engineering controls and administrative controls.   PPE must meet certain standards and are used in addition to other workplace hazard controls such as engineering controls and administrative controls.

Procedure: How to Put On (Don) Daily PPE in the Outpatient Setting (universal recommendation) (approved by EVMS Medical Group 4/29/2020)

*Please follow donning and doffing procedure for PPE when seeing COVID positive or COVID suspected patients.

How to Put On (Don) PPE Gear

  1. Identify and gather the proper PPE to don (face mask/N 95 respirator and eye wear if applicable).
  2. Perform hand hygiene using hand sanitizer.
  3. Put on N95 filtering face piece respirator or facemask as follows:
    • Respirator:
      1. Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.
      2. If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand.
      3. The respirator should be extended under chin. Both your mouth and nose should be protected.

    • Facemask:
      1. Facemask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.
      2. If the facemask has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand.
      3. The facemask should be extended under chin. Both your mouth and nose should be protected.

  4. Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.
  5. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown.
  6. Healthcare personnel may now enter patient room.

How to Take Off (Doff) PPE Gear

More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing.

  1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
  2. Healthcare personnel may now exit patient room.
  3. Perform hand hygiene.
  4. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
  5. Remove and place respirator in a brown bag (or facemask if used instead of respirator). Face masks and respirator are recommended for a daily use. See N95 reuse policy and face mask policy for details. Do not touch the front of the respirator or facemask.*
    • Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
    • Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
  6. Do not wear respirator/facemask under your chin or store in a pocket between patients.*
  7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.*