個人防護裝備使用建議 衛生署疾病管制局2009/12/03初訂

說 明 本建議係參考世界衛生組織與美、加、澳等國家之個人防護裝備(PPE)使用指引等內容訂定，提供PPE的選取與使用之原則及注意事項供各醫療(事)機構參考。 建議內容所提之PPE穿脫順序係屬建議性質，各機構可參考本使用建議所提之相關原則與注意事項，自行依隔離單位特性、暴露風險及穿戴裝備不同，酌予修訂穿脫順序，以降低脫除過程中自我污染的可能性。 醫療(事)機構工作人員平時即應加強工作風險評估之觀念，依工作內容性質與病原體之傳染途徑等因素選取合適的PPE並正確使用。因此本建議之目的係為介紹個人防護裝備使用之基本概念，並非針對特定疾病訂定，也未考量防疫物資缺乏時可能有像N95口罩等原屬拋棄式之防護裝備需要重複使用的特殊狀況。

大 綱 PPE選取 PPE使用 PPE介紹 基本原則 防護措施 穿戴順序 注意事項 手套 – 保護雙手 隔離衣 –保護皮膚和/或服裝 大 綱 PPE選取 基本原則 防護措施 PPE使用 穿戴順序 注意事項 PPE介紹 手套 – 保護雙手 隔離衣 –保護皮膚和/或服裝 眼、口、鼻防護 外科口罩/高效過濾口罩：保護口、鼻以免受到飛沫/飛沫微粒的污染 高效過濾口罩(Respirators)：保護呼吸道，使其不被經空氣傳染的病原體感染 護目鏡：保護眼睛以免受到噴濺 面罩：保護臉、口、鼻、眼以免受到噴濺

基本原則 依循傳播途徑防護措施指引工作時，必須注意： 正確使用個人防護裝備，保護自身安全 確保不會造成環境汙染或其他人感染 儘量降低因防護措施可能對病人產生的不良影響 (例如：焦慮、沮喪和其他情緒低落的情形，感覺到被污辱，減少與臨床員工的接觸，增加可預防之不良事件的發生…)

『各項PPE應於進入病室前，確實穿戴正確無誤後再進入』

穿PPE的順序 以下提供的為穿戴個人防護裝備建議順序，這個順序的主要目在於降低穿脫個人防護裝備時的自我污染可能性，但各個機構可依隔離單位特性不同及所需穿戴裝備不同之所需，酌予修訂 步驟 (資料來源:因應H5N1流感醫療事機構感染控制指引) 1.使用乾洗手液或水及肥皂執行洗手 2.戴上拋棄式的外科口罩或高效過濾口罩 3.使用高效過濾口罩者，執行密合度檢查 (fit check) 4.穿上隔離衣 5.戴上髮帽(執行引發飛沫微粒(aerosol)產生的治療措施時可使用) 6.戴上面罩或護目鏡 7.戴上手套(確定手套有覆蓋於隔離衣袖子上) 8.進入病室並關門

如何穿隔離衣 選擇適當的隔離衣型式和大小，隔離病房醫療用途的隔離衣，最好是防水且長度足以覆蓋至小腿 隔離衣開口在背後 注意頸部和手腕位置要綁緊 To don a gown, first select the appropriate type for the task and the right size for you. The opening of the gown should be in the back; secure the gown at the neck and waist. If the gown is too small to fully cover your torso, use two gowns. Put on the first gown with the opening in front and the second gown over the first with the opening in the back.

如何佩戴口罩 佩戴的口罩應合乎臉型，口罩太大或太小或根本不符合臉部外型，口罩面體與臉部之間產生縫隙，空氣中的危害物便會在未經濾材過濾的情況下進入口罩面體以內，造成危害 佩戴口罩時 先將口罩覆蓋口、鼻、下巴 以綁帶或鬆緊帶將口罩固定 輕壓鼻樑片，使口罩與臉頰和鼻貼合 調整口罩，確認已經貼合臉部並 完全覆蓋口鼻和下巴 (若佩戴高效過濾口罩，此時應執行密合度檢查) 參考疾病管制局全球資訊網 (標題有超連結設定，連結至「個人防護裝備組裝與穿戴影片教學」網頁) 首頁 > 防疫專區 > 院內感染 > 感控教室 >個人防護裝備組裝與穿戴影片教學 >II 防護裝備穿脫介紹 > 1. 口罩穿戴(rmvb檔案)

密合度檢查 每次配戴N95或P2高效過濾口罩時都應該執行密合度檢查(Fit Check) 執行密合度檢查時 吸氣，此時可感覺到口罩有微微的塌陷 吐氣，重點需注意觀察口罩邊緣是否有漏氣情形 注意觀察口罩邊緣是否有漏氣情形

如何佩戴眼部或面部防護裝備 使用護目鏡時，以護目鏡耳架或彈性帶固定於頭部 使用面罩時，將頭帶固定於額頭部位 調整使佩戴舒適，護目鏡應該密合臉部但不會過緊 If eye protection is needed, either goggles or a face shield should be worn. Position either device over the face and/or eyes and secure to head using the attached ear pieces or head band. Adjust to fit comfortably. Goggles should feel snug but not tight.

如何戴手套 手套是個人防護裝備中最後一個穿戴的品項 選取適當的大小與材質 戴上手套 如果穿著隔離衣，要將手套拉上使其完全覆蓋袖口 The last item of PPE to be donned is a pair of gloves. Be sure to select the type of glove needed for the task in the size that best fits you. Insert each hand into the appropriate glove and adjust as needed for comfort and dexterity. If you are wearing an isolation gown, tuck the gown cuffs securely under each glove. This provides a continuous barrier protection for your skin.

注意事項 可能的話，應有觀察者或鏡子可以觀察個人防護裝備穿脫情形 接觸病人前，通常是在進入隔離病室/區域前，穿戴好個人防護裝備 若穿隔離衣或穿戴全套裝備時，應避免在同一地點穿著及脫除個人防護裝備(即：避免清潔區與污染區交叉或重疊) 平時最好預先做好密合度測試(fit test) ，以選取適合個人配戴之N95口罩，並於每次使用時進行密合度檢查(fit check)，以達到N95口罩對呼吸道的預期保護效果 如何正確使用個人防護裝備? 進入污染區後注意 不要用戴手套的手碰觸臉部 避免用戴手套的手調整或碰觸身上穿戴的其他防護裝備 手套破損就要脫除，並在換戴上新的乾淨手套前必須執行手部衛生 避免不必要的物品或環境接觸

脫PPE的順序 以下提供的為脫除個人防護裝備建議順序，正確地脫除個人防護裝備可預防由已受污染的個人防護裝備及手部造成的自我污染，但各個機構可依隔離單位特性不同及所需穿戴裝備不同之所需，酌予修訂 步驟 (資料來源:因應H5N1流感醫療事機構感染控制指引) 1.離開隔離病室/區域 2.脫除手套並丟棄於垃圾桶內 3.移除隔離衣並丟棄於垃圾桶內（若戴雙層手套，在脫除隔離衣時或脫下隔 離衣後脫除第二層手套） 4.使用乾洗手液(較佳)或水及肥皂執行手部衛生 5.脫除護目鏡並丟棄於垃圾桶內。若是可重複使用的，放置於指定容器內送 後續消毒 6.若戴有髮帽，脫除髮帽並丟棄於垃圾桶內 7.當手移除外科手術口罩或高效過濾口罩時，避免接觸到口罩表面(或許受 到污染)並丟棄於垃圾桶內 8.使用乾洗手液(較佳)或水及肥皂執行手部衛生

如何脫除手套 (1) 此時雙手皆戴有手套，先以一手抓起另一手手套接近腕部的外側 將手套以內側朝外的方式脫除 脫下來的手套先以仍戴有手套的手拎著 Using one gloved hand, grasp the outside of the opposite glove near the wrist. Pull and peel the glove away from the hand. The glove should now be turned inside-out, with the contaminated side now on the inside. Hold the removed glove in the opposite gloved hand.

如何脫除手套(2) 已脫除手套的手，將手指穿入另一手的手套腕口內側 以內側朝外的方式脫除手套，並在脫除過程中，將拎在手上手套一併套入其中 將脫下來的手套丟入醫療廢棄物垃圾桶中 Slide one or two fingers of the ungloved hand under the wrist of the remaining glove. Peel glove off from the inside, creating a bag for both gloves. Discard in waste container.

脫除護目鏡或面罩 以未戴手套的手抓住耳架或頭帶(即：護目鏡或面罩的清潔面) 將護目鏡或面罩移離開臉部 將回收使用的護目鏡或面罩置入預備容器中，送後續處理；單次使用者則丟入醫療廢棄物垃圾桶中 Using ungloved hands, grasp the “clean” ear or head pieces and lift away from face. If goggle or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the waste receptacle.

脫除隔離衣 解開頸部與腰部綁帶打結位置 將隔離衣自頸部與肩膀位置緩緩脫除 內側面朝外，將汙染的外側面捲包在內 將脫下的隔離衣捲疊起來，丟入醫療廢棄物垃圾桶中 Unfasten the gown ties with the ungloved hands. Slip hands underneath the gown at the neck and shoulder, peel away from the shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull the hand into the sleeve, grasping the gown from inside. Reach across and push the sleeve off the opposite arm. Fold the gown towards the inside and fold or roll into a bundle. (Only the “clean” part of the gown should be visible.) Discard into waste or linen container, as appropriate.

脫除口罩 脫除高效過濾口罩 依序先解開下側，然後是上側的口罩綁帶；或移開固定於頭部或耳朵的鬆緊帶 脫除口罩 脫除高效過濾口罩 依序先解開下側，然後是上側的口罩綁帶；或移開固定於頭部或耳朵的鬆緊帶 不碰觸口罩外側污染面；以抓住綁帶或鬆緊帶方式，將脫下的口罩丟入醫療廢棄物垃圾桶 先移除固定於下側的鬆緊帶 再移除固定於上側的鬆緊帶 不碰觸口罩外側污染面；以抓住綁帶或鬆緊帶方式，將脫下的高效過濾口罩丟入醫療廢棄物垃圾桶 The front of the mask is considered contaminated and should not be touched. Remove by handling only the ties or elastic bands starting with the bottom then top tie or band. Lift the mask or respirator away from the face and discard it into the designated waste receptacle. The bottom elastic should be lifted over the head first. Then remove the top elastic. This should be done slowly to prevent the respirator from “snapping” off the face.

注意事項 避免在脫除個人防護裝備過程中污染自身是使用個人防護裝備最需要注意的事項 脫除個人防護裝備時，避免接觸污染面，降低污染自身的風險 污染面：個人防護裝備上，比較有機會接觸到可能有病原體存在之病人身體、分泌物或污染環境的區域通常是個人防護裝備的外側正面 清潔面：個人防護裝備上，比較不可能接觸到病原體的區域通常是個人防護裝備的內側、外側背面、或頭部/背部的防護裝備打結位置 脫除個人防護裝備的地點應備有手部衛生設備及感染性廢棄物垃圾桶 脫除個人防護裝備過程中若疑似或確定污染到手部，隨時執行手部衛生 脫除個人防護裝備後立即執行手部衛生

注意事項 如果配戴高效過濾口罩，應在離開隔離病室(前室)並關上房門後立即脫除，並執行手部衛生 脫除個人防護裝備的地點，可視穿戴裝備的規格不同及病人隔離的狀況不同而有所差異，但須注意確保隔離病室/區域外的環境及其他人不會受到汙染或感染。例如， 只戴手套，則於離開病室前在病人房內即可脫除 若有穿隔離衣或穿戴全套裝備時，則建議在前室脫除個人防護裝備；如果沒有前室可以在病室內側之門口通道處脫除

手套 目的 – 照護病人、環境清消、其他 手套材質 – vinyl, latex, nitrile, 其他 對含有乳膠材質的手套會產生過敏反應者，可以尼龍(nylon)、塑膠(plastic)或橡膠等材質的手套取代。 含有乳膠(latex)或乙烯醇(vinyl)材質的手套應使用於做病患檢查或一般性操作時 橡膠(heavy rubber)材質的手套用於清潔器械和環境表面清消工作 手扒雞手套(food-handlers’ gloves)只適用於接觸未污染的物品 在執行侵入性醫療處置或需採無菌操作之工作時，例如手術、配置病人的營養輸液或準備化療藥品等，需要使用無菌的手套。除此之外，一般使用的手套都不需無菌。 一般性操作以配戴單層手套為原則。 限單次使用的手套，不可重複使用。 Most patient care activities require the use of a single pair of nonsterile gloves made of either latex, nitrile, or vinyl. However, because of allergy concerns, some facilities have eliminated or limited latex products, including gloves, and now use gloves made of nitrile or other material. Vinyl gloves are also frequently available and work well if there is limited patient contact. However, some gloves do not provide a snug fit on the hand, especially around the wrist, and therefore should not be used if extensive contact is likely. Gloves should fit the user’s hands comfortably – they should not be too loose or too tight. They also should not tear or damage easily. Gloves are sometimes worn for several hours and need to stand up to the task. Who uses the other glove options? Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive patient procedures. During some surgical procedures, two pair of gloves may be worn. Environmental services personnel often wear reusable heavy duty gloves made of latex or nitrile to work with caustic disinfectants when cleaning environmental surfaces. However, they sometimes use patient care gloves too.

使用手套的注意事項 使用手套的時機 換手套的時機 當預期可能接觸到血液或其他可能的感染物質、黏膜組織、不完整的皮膚或可能受污染的完整皮膚時(如病人大小便失禁)，應穿戴手套。 換手套的時機 手套若有破損或明顯髒汙情形，即使仍在照護同一位病人，仍需更換手套 每要變換照護對象時，都應更換手套 絕勿清洗或重複使用拋棄式手套 脫除的手套應丟入醫療廢棄物垃圾桶 Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces. Therefore, the way YOU use gloves can influence the risk of disease transmission in your healthcare setting. These are the most important do’s and don'ts of glove use. Work from clean to dirty. This is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for “touch contamination” - protect yourself, others and environmental surfaces. How many times have you seen someone adjust their glasses, rub their nose or touch their face with gloves that have been in contact with a patient? This is one example of “touch contamination” that can potentially expose oneself to infectious agents. Think about environmental surfaces too and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door and cabinet knobs can become contaminated if touched by soiled gloves. Change gloves as needed. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.

使用手套的注意事項 工作順序由清潔部位到污染部位 減少碰觸污染的機會 – 保護自己、他人、和環境 不要用戴手套的手碰觸臉部或調整身上穿戴的其他防護裝備 除非照護病人工作之所需，否則應避免用戴手套的手接觸物品或環境 Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces. Therefore, the way YOU use gloves can influence the risk of disease transmission in your healthcare setting. These are the most important do’s and don'ts of glove use. Work from clean to dirty. This is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for “touch contamination” - protect yourself, others and environmental surfaces. How many times have you seen someone adjust their glasses, rub their nose or touch their face with gloves that have been in contact with a patient? This is one example of “touch contamination” that can potentially expose oneself to infectious agents. Think about environmental surfaces too and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door and cabinet knobs can become contaminated if touched by soiled gloves. Change gloves as needed. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.

隔離衣或圍裙 (Gowns or Aprons) 使用目的－通常用來保護工作人員的皮膚和工作服，避免受到血液、體液等感染物質的污染。同時避免照護傳染病病人時，受到病人或是存在環境中的感染物質的污染。 材質－將影響其是否可以洗滌或是否具備防水性 天然或人工合成材質 可重複使用或拋棄式 防水性 乾淨或無菌－通常是在執行侵入性醫療處置時，例如在插置中心導管，才會需要使用無菌的隔離衣 There are three factors that influence the selection of a gown or apron as PPE. First is the purpose of use. Isolation gowns are generally the preferred PPE for clothing but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist. Second are the material properties of the gown. Isolation gowns are made either of cotton or a spun synthetic material that dictate whether they can be laundered and reused or must be disposed. Cotton and spun synthetic isolation gowns vary in their degree of fluid resistance, another factor that must be considered in the selection of this garb. If fluid penetration is likely, a fluid resistant gown should be used. The last factor concerns patient risks and whether a clean, rather than sterile gown, can be used. Clean gowns are generally used for isolation. Sterile gowns are only necessary for performing invasive procedures, such as inserting a central line. In this case, a sterile gown would serve purposes of patient and healthcare worker protection.

眼、口、鼻防護 用於眼、口、鼻防護的個人護裝備，可評估執行工作性質之風險，依所需組合使用 外科口罩/高效過濾口罩 護目鏡 面罩 目的：保護口、鼻以免受到飛沫/飛沫微粒的污染 應完全覆蓋口鼻部位，並具防水功能 護目鏡 目的：保護眼睛以免受到噴濺 應與眼部周圍緊密貼合 個人使用的眼鏡不適宜當成護目鏡的替代品 護目鏡若能具備防起霧功能當有助於視線清晰度 面罩 目的：保護臉、口、鼻、眼以免受到噴濺 遮蔽範圍應自前額延伸至下巴下方，並環繞臉部周圍 A combination of PPE types is available to protect all or parts of the face from contact with potentially infectious material. The selection of facial PPE is determined by the isolation precautions required for the patient and/or the nature of the patient contact. This will be discussed later. Masks should fully cover the nose and mouth and prevent fluid penetration. Masks should fit snuggly over the nose and mouth. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable. Goggles provide barrier protection for the eyes; personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. Goggles with antifog features will help maintain clarity of vision. When skin protection, in addition to mouth, nose, and eye protection, is needed or desired, for example, when irrigating a wound or suctioning copious secretions, a face shield can be used as a substitute to wearing a mask or goggles. The face shield should cover the forehead, extend below the chin, and wrap around the side of the face.

呼吸道防護 目的 – 保護使用者，避免吸入帶有感染性物質(如: Mycobacterium tuberculosis)的飛沫微粒 用於呼吸道防護的個人防護裝備 高效能口罩 (Particulate respirators) 全面具或半面具特殊呼吸防護具 (Half- or full-face elastomeric respirators) 動力式空氣濾淨呼吸防護裝備 (Powered air purifying respirators, PAPR) 有關P100口罩之組裝、清潔消毒、使用注意事項，以及PAPR的介紹， 可參考疾病管制局全球資訊網 (「個人防護裝備組裝與穿戴影片教學」網頁http://www.cdc.gov.tw/ct.asp?xItem=13446&ctNode=1888&mp=1) 首頁 > 防疫專區 > 院內感染 > 感控教室 >個人防護裝備組裝與穿戴影片教學 >II 防護裝備穿脫介紹 > 4. P100口罩組裝步驟 及 6. 動力過濾式呼吸防護具(PAPR)(rmvb檔案)

呼吸防護計畫 (Respiratory Protection Program)的要件 評估使用者是否有不適合使用高效能口罩的健康因素(Medical Evaluation) 為每位使用者進行口罩密合度測試 (Fit testing) 教育如何正確佩戴高效能口罩 (Training) 每次使用皆應確實執行口罩密合度檢查 (Fit checking before use) 有關口罩密合度測試教學影片 可先參閱澳洲衛生部門網站資料(Department of aging and health, Australian Government) Government information, plans & assistance | Safe Use of Personal Protective Equipment (PPE) | Chapter 4 - Selection and Fit testing of P2 or N95 respirator masks 網址: http://www.flupandemic.gov.au/internet/panflu/publishing.nsf/Content/safeuse-dvd-1 影片說明可參閱 Government information, plans & assistance | Transcript of the "Safe Use of Personal Protective Equipment“| 4. Selection and Fit testing of P2 or N95 respirator Masks 網址: http://www.flupandemic.gov.au/internet/panflu/publishing.nsf/Content/safeuse-transcript-1

現階段連身型防護衣 使用時機建議

連身型防護衣(coveralls)和隔離衣(isolation gown)之材質與規格區別 標準 隔離衣(isolation gown) 連身型防護衣(coveralls) CNS14798 T5019 拋棄式醫用防護衣 性能要求 P1等級 (約等同AAMI* Level 1) 淨水壓≧20 cmH2O 衝擊穿透≦4.5 g P2等級 (約等同AAMI Level 2) 淨水壓≧50 cmH2O 衝擊穿透≦1.0 g 次微米粒子過濾效率≧20% 及其他抗拉強力、破裂強度、縫合強力、撕裂強力、透濕度等項目 市售材質規格比較 目前較為常見的拋棄式隔離衣材料有PP、PP+PE、SMS、ACT等，罩袍式，若不具防潑濺功能，因視需要搭配使用防水圍裙。 目前常見的拋棄式防護衣材質有Microporous film、Microporous film+PP、PP+PE等，包覆全身，防潑濺和防次微米粒子穿透之效果較佳，但透濕性及透氣性較隔離衣差，不耐久穿亦不易穿脫。 * AAMI（Association for the Advancement of Medical Instrumentation）

現階段連身型防護衣使用時機建議 照護生物安全等級第四級之病毒性出血熱、天花、SARS或肺鼠疫病例 執行不明原因死亡或疑似因高傳染性疾病致死之屍體解剖時 視疫情與疾病嚴重度之所需另行訂定