New Revised Requirements for Emergency Medical Protective Clothing
A new 2008 edition of NFPA 1999 became effective last month — and it has been heavily revised to address changes requested by end users and the industry. Many of the changes to the Standard on Protective Clothing for Emergency Medical Operations were aimed at addressing requirements for clothing categories where there were no certified products being made available to the end user. It was found that in clothing items that were being used, the earlier criteria in the 2003 edition simply did not define products consistent with end user expectations.
Research by NIOSH, which supported the revision effort, focused on the introduction of sensible, field-based criteria to encourage industry participation. Key changes in the new edition include:
- Establishment of separate performance categories to distinguish single and multiple use garments (formerly the same strength requirements were used for both disposable and reusable garments)
- Reconciliation of confusing criteria for cleaning gloves and footwear covers
- The creation of three separate types of acceptable face protection devices and related performance criteria
- Establishment of a new category of head protection defining helmets for emergency medical operations
- The introduction of a new category of footwear for medical care facilities.
NFPA 1999 is designed to offer a "menu" approach. The standard recognized that different response organizations have different preferences and different needs for protective clothing, depending on the hazards at the scene. Generally, all responders may wear examination gloves but the use of eye and face protection, garments, and other clothing will depend on the likelihood of exposure and the hazard environment. The revised standard offers several choices of protective clothing to accommodate the hazard/risk assessment of the end user organization.
In addition, the 2008 edition of NFPA 1999 has been expanded to address both first responders at emergency medical operations as well as first receivers at medical care facilities. The range of clothing covered in the standard now includes:
1. Both single and multiple-use protective garments that may either be full body items such as coveralls and jackets or partial body items such as aprons or sleeve protectors
2. Single-use examination gloves, cleaning/utility gloves or multiple-use work gloves
3. Single-use medical masks, single-use eye and face protection devices, or multiple-use eye and face protection devices
4. Multiple-use emergency medical protective footwear, medical care facility footwear, or single-use footwear covers
5. Protective helmets
The 2008 edition of NFPA 1999 also establishes [C]BRN criteria for a complete protective ensemble. These criteria set requirements for a combination of reusable garments, gloves, footwear and other clothing items combined with an appropriate respirator for protecting first responders against biological particulate and aerosol hazards (e.g., anthrax).
Originally, NFPA 1999 was developed in response to the Occupational Safety and Health Administration's Regulation on Bloodborne Pathogens. The standard was established to define "appropriate protection" for first responders, such as firefighters and emergency medical personnel who were affected by the OSHA regulations. The principal feature of the standard is the specification of biopenetration resistance for each of the clothing components worn during emergency medical services. The chosen material and product tests define the performance of these items as barriers to blood and body fluids, which may contain bloodborne pathogens, such as Hepatitis Virus and HIV.
The most significant change in the 2008 edition of NFPA 1999 for garments is the establishment of separate criteria for single-use items. Through 2007, all of the certified garments were reusable, yet a significant number of disposable garments are used). Part of the problem was that the same physical strength criteria were being used for both single-use and multiple-use garments . Now, appropriate criteria for each have been established. Furthermore, total heat loss (breathability) is now only applied to full body garments (coats, jackets, pants and coveralls). In addition, there are new design requirements to address partial body clothing items such as smocks, aprons or sleeve protectors. These items must be constructed such that the area of the body covered by the garment affords complete barrier protection. For example, a garment with barrier panels built into the front of the garment, but with non-barrier materials in the back, would be considered unacceptable per the 2008 revision of NFPA 1999.
As with all products in the standard, garments are subject to a full product liquid integrity test and materials are tested for viral penetration resistance. Additional criteria are applied for evaluating the strength and durability of the garment materials. NFPA 1999 is unique in that all tests are performed on specimens that have been taken from garments, instead of pieces of fabric. For multiple-use garments, the tests are conducted both in the as received condition and after they've been laundered 25 times. Also new in the 2008 revision are criteria for trim and flammability. If visibility materials are present, garments have to meet the national high visibility safety apparel standard — ANSI 107. A flammability requirement has been added, but this is not the flame-resistance requirement used in other NFPA standards. Instead, the new test is intended to prevent the use of materials that would easily ignite and rapidly burn.
Three different types of gloves are specified by the standard including a single-use examination glove, a single-use but heavier cleaning glove and a multiple-use work glove. The workhorse product is the examination glove, which is like any other medical glove. But NFPA 1999 establishes robust criteria for glove performance that go beyond normal healthcare industry standards. These include a whole glove viral penetration test, minimum dexterity, and the only glove industry standard for protein levels in the glove material. Cleaning/utility gloves, as the name implies, are intended for situations where a more physically protective glove is needed. These are heavier and must meet certain physical requirements for puncture, cut and abrasion resistance in addition to maintaining integrity after contact with normal cleaning solvents (e.g., bleach and hydrogen peroxide), but trade off some dexterity as compared with examination gloves. The category of work gloves is really intended for a situation where there are severe physical hazards present, such as vehicle victim extrication and rescue events. These gloves are also expected to be reusable, so they are subject to a wide range of tests that demonstrate physical hazard resistance and durability.
NFPA 1999 now defines three types of footwear. Standard barrier footwear for emergency medical operations are set with criteria to demonstrate that the footwear keeps liquids out while providing physical protection to the wearer’s feet during emergency operations where there is potential for blood or body fluid content. A new category of footwear has been added to the 2008 edition that has all the requirements of emergency medical footwear but permits a shorter height and does not require toe impact/compression or sole puncture requirements.
This footwear is positioned for use in medical care facilities where a risk assessment does not show significant physical hazards to exist. The standard also addresses single-use footwear covers, which are intended to be worn over standard footwear but provide barrier protection to the wearer’s feet. Ordinary footwear would provide the physical protection to the foot. Consequently, the footwear cover is tested for its overall integrity and viral penetration resistance, as well as for cut, puncture, and abrasion resistance for base material and abrasion, puncture and slip resistance for the wear surface (portion of the footwear cover that contacts the ground when walking).
Face Protection Devices
This category has gone through extensive changes in the 2008 edition to accommodate the wide range of end user protection practices. Face protection devices are now divided into three categories: single-use medical facemasks, single-use eye and face protection devices, and multiple-use eye and face protection devices. Separate design and performance criteria have been established for each category. Medical face masks, which are surgical masks with and without plastic visors, have to meet an ASTM standard that defines blood strikethrough, filtration and other performance areas. The masks must further demonstrate liquid integrity in different areas other than those specified in the ASTM standard and must meet certain design criteria for ease of use. It must be recognized that facemasks are not respirators and are not held to the same rigorous viral penetration requirements as other items in NFPA 1999. Therefore, medical masks are only intended for the lowest liquid exposure risks. Single-use eye and face protection devices include items such as disposable visors, faceshields and hoods. These items must meet both biopenetration and overall integrity requirements in addition to certain physical requirements. Most of these devices will not provide primary eye protection and will have limitations in the amount of liquid protection provided. Occupational eye protection device requirements in ANSI Z87.1 are used as the basis for most of the requirements for multiple-use eye and face protection devices, which include safety glasses, goggles, faceshields and combination devices. Additional criteria have been added to include a simulated spray test for integrity of joints. However, only certain types of goggles will provide primary eye protection. In many cases, a combination of devices will be needed to provide full eye and face protection.
The requirements for EMS helmets are similar to those required in general industry for hardhats as established in ANSI Z89.1, but some additional criteria have been included to address performance of the suspension system and chin strap. These helmets are intended to be lightweight and offer protection at the scene of an accident. These helmets may also provide protection to responders inside vehicles during victim transport.
Following implementation of the new NFPA 1999 standard, it is expected that a greater variety of certified products will be made available to end users, affording choices that are consistent with the hazards present and with specific protection practices adopted by the responding organization.