Personal Protective Equipment (PPE)

Proper use of masks and following the universal masking policy is required for hospital and clinic personnel. Inappropriate use of masks or failure to adhere to the policy may result in disciplinary action. 

Who Should Wear What Equipment:

Staff Required to Wear Face Covering or Mask in All Denver Health Buildings

Per public health orders, all staff members – including full-time and part-time employees, contractors, students, residents and volunteers, are required to have on a mask or a face covering when entering, and while inside, all Denver Health buildings. This includes all of our clinical and non-clinical locations. A face covering is also sometimes referred to as a non-medical mask. When you show up for work, please come wearing your own face covering. Only those wearing face coverings or masks are allowed to enter. If you do not have a face covering, you may show your badge at any main building entry point or screening location to receive one. Face coverings must align with Denver Health dress code standards, which prohibit outside logos, profanity and offensive images. Clinical personnel are required to wear medical-grade PPE appropriate to their location. If you have questions about PPE or face coverings, talk to your supervisor.

Employees are allowed to remove their masks or face coverings if they are alone in a room, such as an office with the door closed, but they must wear masks or face coverings in any shared, indoor space that accommodates people outside of their households, including physically distanced cubicles.

Masks or face coverings are also required in common areas, such as hallways, elevators or breakrooms. In spaces used for eating, employees can remove masks or face coverings when they’re seated at a table to eat but must put them back on when leaving the table for any reason.

Please handle your mask properly. Here's a video with step-by-step instructions.

PPE Recommendations

Specialized respiratory isolation is:

❏ Contact precautions (gown and gloves)

❏ Airborne precautions (N95 mask)

❏ Eye protection (face shield or goggles)


❏ Single-person room with the door closed for outpatients, including outpatients and those in the Emergency Department or Urgent Care settings

❏ Airborne Infection Isolation Rooms (AIIRs) for all inpatients


Specialized Respiratory Isolation Sign (English/Spanish) 

Optimizing PPE Supplies

Donning & Doffing Educational Materials

Tip Sheet for Disinfecting Face Shield

Mask Re-Use & Extended Use Guidelines

How to Store Your N95 Mask

Supply Shortage & Preservation

Personal protective equipment (PPE) is periodically in short supply in the United States, and Denver Health continues to prepare for any future shortages. In order to preserve our supplies, we recommend the following use of PPE:

Surgical Masks and N95

All staff members who work in the hospital or a clinic should wear a mask continuously throughout their shifts. Employees shall obtain one mask at the beginning of their shift and wear it continuously throughout the day including in hallways and in break rooms. Most employees will don a surgical mask for the duration of their shift. Employees who care for patients who have frequent aerosol-generating procedures should don an N95 mask for the duration of their shift. It should only be removed for eating and drinking. Replace the mask with a new one if it becomes saturated, soiled, damaged, or contaminated with blood or body fluids OR after 8-12 hours total usage or 5 donning/doffings (whichever occurs first). Wash your hands well before and after touching your mask. These recommendations do NOT apply to sterile environments (e.g. Operating Room). Sterile procedures, including surgery, should always be performed wearing a new mask.

N95 Mask Options are Available:

Some employees have run into a situation where their normal N95 size and brand is unavailable. Our Infection Prevention and Safety teams have a few recommendations:

  1. Use a sterilized mask. Denver Health has reprocessed many N95 masks, and these are approved by the FDA for reuse. Ask your manager if a sterile reprocessed mask is right for you.

  2. Try another Denver Health-provided mask. Fortunately, many masks can fit an individual face. We recommend that you try on other N95 masks and contact COSH to perform a fit test to ensure that you have a good seal.

  3. Contact your manager. If you cannot find a mask that passes the fit test AND if a sterile reprocessed mask is unavailable, then please contact your manager. They may be able to procure a PAPR for your use during shifts or arrange for you to be located in regions that do not require N95 mask.

Demand for small 3M 1860 N95 masks is high, and they continue to be in short supply. Staff who are only fit tested to the small 3M 1860 mask should go to the Center for Occupational Safety and Health (COSH) and get fit tested to another mask so that they have an alternative if the small 1860 is not in stock. We encourage staff to try the 3M 8000 mask because it is available in plentiful supply. There is also a small 1860 alternative called the Tronex. Both of these alternatives are available from COSH. Fit testing is available Monday through Friday from 7:30 a.m. through 3:30 p.m. Fit testing is also available where you work if scheduled in advance by contacting Vicki Haseman.

Eye Shields:

Per updated CDC guidelines, Denver Health requires eye protection for staff that enter patient rooms in the course of their work. This includes both clinical and non-clinical personnel. The CDC notes that face shields are the preferred method of eye protection, as goggles or glasses may not protect the wearer from all splashes or droplets. The face shield or eye protection should be cleaned with a purple top or bleach wipe before and after each use, placed outside the room, and reused until it is damaged or contaminated with blood or body fluids.


We no longer require contact precautions for MRSA in both outpatient and inpatient settings. As always, standard precautions should be followed. Contact precautions for other multi-drug resistant organisms, including VRE, ESBL, CRE, and C. difficile, will continue unchanged. Gowns and gloves remain as single patient, single use items.

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