Guidelines for PPE Usage During Periods of Shortage
These guidelines apply for use of personal protective equipment during periods of extreme shortage and/or during
large, prolonged outbreak events. Guidelines are presented for facilities that can and cannot cohort patients.
Definitions
Aerosol-generating procedure- a procedure that stimulates coughing and promotes the generation of aerosols.
Common procedures include: nebulizing procedures, CPT, open airway suctioning, intubation, nebulizer, etc.
PPE- Personal Protective Equipment
HCW- Healthcare Worker
N95 Respirator - disposable N95 filtering facepiece respirators - commonly called “N95 respirators” or “N95 Masks”
EVS – Environmental Services
Reuse of PPE- refers to a process wherein a PPE item assigned to a specific patient is donned and doffed multiple
times by the same healthcare provider without being discarded during a designated timeframe.
Extended use of PPE- refers to the practice of wearing the same surgical mask or N95 respirator for repeated close
contact encounters with several different patients, without removing the respirator between patient encounters.
Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis,
whose care requires use of a respirator, are cohorted.1
PAPR – Powered air purifying respirator
COHORTED UNIT – a unit with patients in one hallway or area with physical proximity that can be closed off from
other areas (ie “hot zone”). A cohorted unit only houses patients with a specific diagnosis that is either suspected or
confirmed.
NON-COHORTED UNIT – a unit with patients located in various areas across the unit and not adjacent to one
another. Patients with multiple diagnoses are housed on a non-cohorted unit.
Reuse and Extended Use Measures for Conservation of Personal Protective Equipment
The following guidelines detail PPE conservation strategies in units where patients are not cohorted together by
symptoms/diagnosis, and a separate set of guidelines where patients are cohorted by symptoms/diagnosis. While
procedures may differ depending on whether a unit is cohorted, the following points apply to both cohorted and noncohorted units:
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Utilize a negative pressure room if available (prioritized for patients needing aerosol-generating procedures).
o If negative pressure room is unavailable, use a private room with the door closed.
It is very important for the healthcare worker (HCW) to stop, check and confirm their need for PPE prior to
entering the patient’s room.
Staff should bundle care prevent excessive entry to patient rooms (I.e. drawing labs, performing vitals and
delivering meal tray all at the same time).
In times where N95 respirators are critically low, they will only be used by HCWs who are performing aerosolgenerating procedures.
▪ All other HCWs will utilize surgical masks and eye protection when performing patient care.
▪ N95 respirators that are beyond their shelf-life can be used in times where N95 stock are critically low
• N95 must be visually inspected prior to use to ensure mask can maintain a seal and to ensure straps mask
or straps are not damaged.
• It is preferred that N95’s that are beyond their shelf-life NOT be used during surgery or aerosol
generating procedures

 NON-COHORTED Unit Reuse Instructions
The following procedure represents a strategy for conserving N95 respirators* during times of shortage on NONcohorted units. The healthcare worker will use one N95 respirator per patient for the duration of their shift or until
the respirator is no longer fit for use.
*During critical shortage, the following procedure will be used for the conservation:
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Surgical masks – each HCW will wear one surgical mask per shift, unless the mask becomes soiled. If leaving the
unit, use the paper bag methodology below. Fold the mask inward before placing in the bag.
N95 – this mask type should be reserved only for Aerosol Generating procedures
Gown Extended Use – One gown per patient per HCW – don gown for patient care, when care is complete
follow below:
o Blue/plastic gown - Wipe the chest, torso and sleeves of the gown with disinfectant before leaving the
room. Exit room. Hang gown directly outside of room for re-use.
o Cloth/Yellow gown ▪ Wipeable Apron Available - Cover gown with plastic apron before patient care. Complete patient
care. Remove plastic apron before exiting room and discard in the trash in the room. Exit the
room. Hang yellow gown for reuse.
▪ Wipeable Apron not Available – Remove gown when exiting room and hang directly outside of
the room.

Procedure for Reuse of N95 Respirators on Non-Cohorted Unit
1. At beginning of shift, HCW places name on a paper bag for each patient in which they will store their N95
respirator when not in use
2. Prior to first patient care of the day, HCW will don gown, gloves, N95 respirator and eye protection as part of
their usual PPE-donning procedure
3. Upon leaving patient room, HCW will appropriately remove gloves and gown and perform hand hygiene. To
remove N95:
i. HCW will don a new pair of gloves
ii. HCW will remove eye protection and clean with disinfectant wipe
iii. HCW will remove N95 respirator in the manner described below:
1. To remove the N95 respirator, grasp bottom neck strap followed by the top neck strap
and remove without touching the inside of the respirator as much as possible.
Note: If inadvertent contact is made with the inside of the respirator, perform hand hygiene
and discard mask.
iv. Instead of discarding N95, HCW will place respirator in designated bag until needed again
4. When HCW needs to reuse N95 respirator, they will utilize the following procedure before re-entering the
patient’s room:
i. HCW will perform hand hygiene and don gown and gloves
ii. HCW will don N95 respirator while avoiding contact with inside of mask.
iii. HCW will remove gloves and perform hand hygiene
iv. HCW will don a new pair of gloves and put on eye protection
5. Upon exiting room for the second time, HCW will follow step 3
6. At end of shift, HCW will dispose of N95 respirator and bag after last patient encounter
When to discard N95 respirator:
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Discard N95 respirator if it becomes moist or wet.

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Discard N95 respirator following use during aerosol generating procedures.
Discard N95 respirator contaminated with blood, respiratory or nasal secretions, or other bodily fluids from
patients.
Discard any N95 respirator that is obviously damaged or becomes hard to breathe through.
Environmental Cleaning Recommendations

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Cleaning should be performed in a manner to minimize room entry
o Bedside nurse to perform cleaning of high touch surfaces at least every shift and as needed
o Bedside nurse to pull trash as needed and dispose appropriately
o EVS to perform bi-weekly room cleaning (if applicable)
o EVS to perform Terminal Clean after every discharge
▪ Appropriate PPE should be worn during terminal clean

 CO-HORTED Unit Reuse Instructions
The following procedure represents a strategy for conserving N95 respirators** and disposable gowns during times of
shortage on cohorted*** units.
In facilities where large volumes of patients are expected, cohorting of patients is preferred to optimize conservation of
PPE and minimize the risk to HCWs during the doffing procedure.
Considerations when Practicing Extended Use
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Units practicing the following option should designate separate areas in which to don and doff PPE.
o Included in this are clean break rooms where staff can eat, hydrate, and use the restroom.
o If possible, designate specific and separate entrances and exits for HCWs
o Ancillary staff accessing this unit should be evaluated and access should be granted for medically
essential procedures.
HCW will continuously use one N95 respirator (or PAPR^), gown and eye protection until their designated
breaktime or until the respirator becomes visibly soiled
This is to be done only on units where patients with the same illnesses are housed (e.g. acute respiratory units)
o If applicable and if space allows, it is recommended to cohort based off disease status (I.e. suspected
cases are cohorted separately from confirmed cases)

Procedure for Extended Use on a Cohorted Unit:
1. Prior to first patient care of the day, HCW will don gown, gloves, N95 respirator and eye protection (or PAPR) as
part of their usual PPE-donning procedure
2. Upon leaving patient room:
i. HCW will remove gloves
ii. HCW will perform Hand hygiene
iii. HCW will don a new pair of gloves
iv. HCW will use disinfecting wipe to clean the torso, chest, and arms of their plastic gown (i.e. blue
gown) or plastic apron
v. HCW will dispose of wipe
vi. HCW will remove gloves
vii. HCW will perform hand hygiene
viii. HCW will don a new pair of gloves
3. When HCW reaches their designated break time, the HCW will remove all PPE and discard in typical fashion.
4. Once designated break is completed, HCW will don new, unused PPE.
Note: Avoid touching the outside of the mask while in use.
When to discard N95 respirator:
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Discard N95 respirator if it becomes moist or wet.
Discard N95 respirator following use during aerosol generating procedures.
Discard N95 respirator contaminated with blood, respiratory or nasal secretions, or other bodily fluids from
patients.
Discard any N95 respirator that is obviously damaged or becomes hard to breathe through.

 **Should the need arise, the following procedure may be used for the conservation of surgical masks and N95
respirators on a cohorted unit.
***Emergency Departments receiving a high volume of patients with respiratory illness symptoms may consider
cohorting based on symptoms and using the following guidelines.
^A note on PAPRs:
If N95 respirators become unavailable while working on a cohorted unit, it is acceptable to use PAPRs. HCW will
designate an appropriate place to store their PAPR during breaktimes and will ONLY use the PAPR designated to them.
HCW will disinfect PAPR during breaktime and at end of shift.

 Use of Gowns and Aprons on Cohorted and Non-Cohorted Units
Gown Types
Plastic Gowns (e.g. blue gowns): may be wiped down with hospital approved disinfectant
Fabric Gowns (e.g. yellow gowns, fabric surgical, sterilizable gowns): may NOT be wiped down with hospital
approved disinfectant. Fabric gowns should be reserved for situations when wipeable gowns are not available. If a
disposable (cafeteria) apron is available, that may be worn over the fabric gown to promote extended reuse of the
fabric gown.

A Note on Non-Clinical Staff
The following examples are potential measures that could be taken in order to decrease the number of people entering
a patient’s room and conserve PPE more effectively:
1. Have nursing staff wipe any high-touch surfaces (e.g. overbed table, bed/siderails, furniture, phone, remote,
room door handles, light switches, etc.) instead of having EVS do it multiple times a day
2. Have EVS worker only clean patient’s room twice a week or when needed during a patient’s admission
3. Have EVS worker replace the sharps containers during biweekly clean so that other HCWs do not have to enter
the room
References
1. Centers for Disease Control and Prevention. Pandemic Planning. Recommended Guidance for Extended Use and
Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings.
https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
2. Centers for Disease Control and Prevention. Strategies for Optimizing the Supply of N95 Respirators:
Contingency Capacity Strategies. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respiratorsstrategy/contingency-capacity-strategies.html