Policy: Universal Face Covering (Masking) and Eye Protection for COVID-19

Please Note:
This printed copy is not a controlled document and is only to be used as a reference. Refer to the most up to date version on Pulse Policies at: https://Pulse.utah.edu

Change Notes: (This describes notable changes in this latest version.)
2/9/2021: Updated eye protection requirement.

Purpose:

  • To outline the requirements for when mask and eye protection must be worn for University of Utah Health employees, staff, students, and providers.
  • To outline the expectations for when masks should be worn by patients and visitors.
  • To describe how to obtain masks and eye protection

Definitions:

  • Eye Protection: ​Goggles, face shields, safety glasses, or prescription eye wear with protective side shields. Note: Prescription eye wear is insufficient protection. 
  • Procedural Mask: UU Health approved healthcare grade masks that offers a minimum of ANSI 2 protection. 
  • Facial Covering: a well-secured paper or cloth mask that covers the nose, mouth, and stoma (if applicable). Facial coverings that are NOT approved include the following: those with exhalation vents, bandanas, neck gaiters, and mesh based mas​ks (i.e. tulle masks) are not permitted. 

Description:

A. Procedural masks must be worn over the nose and mouth for employees, staff, students, and providers while in clinical and patient facing areas
    1. If an individual needs to remove their mask within the same room of others, as for a meal break, they must position themselves at least > 6 feet from others and limit the time they remain unmasked.​
    2. Note: facial covering may be worn when entering and exiting the building while heading to or from their work area. Facial covering must remain in place until procedural mask has been donned. ​
​​B. Eye protection must be worn for employees, staff, students, and providers while providing patient care.
    1. Note: eye protection is encouraged when either in the same room with, or within 6 feet of, other persons especially if those persons may not consistently be masked​
C. Facial coverings must be worn over the nose, mouth, and stoma (if applicable​) for:
    1. Employees, staff, students, and providers not in clinical or patient facing areas (unless already wearing a procedural mask)​ either in the same room with, or within 6 feet of, another person 
      • ​If an individual needs to remove their mask within the same room of others, as for a meal break, they must position themselves at > 6 feet from others and limit the time they remain unmasked.
    2. Outpatients over the age of 2 years (unless unable to tolerate for medical reasons) 
      • When entering, and while in, an ambulatory facility​
        1. ​Patients without their own approved facial covering will be provided a facial covering/mask​
    3. ​​Inpatients over the age of 2 years (unless unable to tolerate for medical reasons)​
      • ​​When entering the healthcare facility
        1. Patients without their own approved facial covering will be provided a facial covering/mask​
      • ​​When others are in their rooms (i.e., caregiver, visitor) or within 6 feet of them
        1. Patients shall be instructed to don facial covering/mask when a caregiver enters their room.​
        2. If needed, caregivers should assist the patient to don their facial covering/mask, unless the patient is unable to wear a facial covering/mask (i.e., receiving an aerosolized treatment).​
      • When leaving their room for any reason.
        1. ​If patient has a trach, a mask must be worn over the patients’ mouth as well as their stoma if not connected to closed circuit when outside of their room.​
    4. ​​​​​​Visitors
      • ​When entering, and while in, a healthcare facility​
        1. visitors without their own approved facial covering will be provided a facial covering/mask​
        2. visitors with respiratory complaints or who refuse to wear an approved facial covering should be denied entry
​​D. Extended Use of Personal Protective Equipment (PPE)
    1. Procedural Masks:
      • Surgical areas:
        1. Extended use of procedural masks is not approved for surgical services. Staff and providers should continue to follow the AORN recommendation of one mask per patient per caregiver. 
      • ​​​COVID-19 Accepting Units: 
        1. Extended use of procedural masks is approved. Replace mask when:
          • ​Mask is doffed for break or lunch
          • Mask is doffed in order to don a N95 respiratory, PAPR, or CAPR
          • Mask becomes wet and/or soiled
      • Other clinical areas:  
        1. ​Most staff will be issued one procedural mask per day. Masks should be replaced when mask becomes wet and/or soiled.
​​​E. Disciplinary Action: 
    1. University of Utah Health employees, staff, students, and providers who are not compliant with these requirements may be subject to removal from the work schedule, and/or discipline up to and including suspension of clinical privileges and/or termination.
    2. Disciplinary action for non-compliance will be determined by the governing body appropriate to the Health Care Worker’s position and job title.

Document Meta

Owner:Alessia Banning

Liaison:Jeanmarie Mayer

Approval Body:
Hospital Infection Control Committee
Infection Control Director
Hospital Human Resource

Organizational Area: Clinical:Infection Prevention and Control

Current Approval Date:Tue Feb 09 2021

Current Revision Date:Tue Feb 09 2021

Origin Date:Thu May 28 2020


Please Note:

​​This printed copy is not a controlled document and is only to be used as a reference. Refer to the most up to date version on Pulse Policies at: https://Pulse.utah.edu


COVID-19 Scheduling

Available OnlineDownload
New Policy – Course & Event Allocation and Scheduling GuidelinesPDF Icon PDF
Universal Face Covering and Eye ProtectionPDF Icon PDF
Request for a room. Scheduling FormPDF Icon PDF
New Room Capacity – Classroom UpdatePDF Icon PDF