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Influenza in the ICU: Underuse of Personal Protective Equipment by Health Care Workers
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this study of physicians, nurses, and respiratory therapists in the ICUs of 2 teaching hospitals, nearly 40% reported poor adherence to influenza personal protective equipment use, and more than half reported that their colleagues often failed to use such protection when caring for patients with influenza.
Source: Daugherty EL, et al. The use of personal protective equipment for control of influenza among critical care clinicians: A survey study. Crit Care Med 2009;37:1210-1216.
Along with yearly vaccination, the U.S. Centers for Disease Control and Prevention (CDC) recommend the use of personal protective equipment (PPE) by health care workers (HCWs) to prevent influenza infection in the ICU. Daugherty and colleagues at The Johns Hopkins Hospital performed this study to characterize the knowledge, attitudes, and behavior of ICU HCWs with respect to these recommendations. During influenza season in early 2007, they surveyed internal medicine residents, pulmonary-critical care fellows and faculty, nurses, and respiratory therapists (RTs) working in the medical and cardiac ICUs in 2 Baltimore teaching hospitals.
Surveys were distributed to 292 clinicians at the 2 study hospitals, and 256 (88%) were completed by housestaff (82), faculty and fellows (39), nurses (91), and RTs (44). Overall, 85% of respondents reported knowing when their patients were on droplet (respiratory) precautions, although nurses and RTs were less likely to report knowing this than doctors. Overall, 62% reported high adherence (> 80%) to the protection measures. However, only 63% of respondents correctly identified the equipment that would provide adequate protection, with failure to indicate that a gown and gloves were needed in 27% and 11% of HCWs, respectively. Eleven percent of respondents indicated that they did not wear a mask when patients were on respiratory isolation; 53% reported that their co-workers "often forget to use recommended PPE when taking care of influenza patients."
Although 80% of respondents believed that adhering to the precautions prevented the acquisition of influenza infection, about half of them considered their use inconvenient, and 21% of them said that using the recommended precautions interfered with patient care. HCWs who considered adherence to be inconvenient were less likely to report a high rate of personal adherence (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.22-0.82). In all work categories, 56% indicated that they would be reprimanded by their supervisor if they did not use the precautions when caring for a patient with influenza, and those so indicating were more likely to report high adherence (OR, 2.40; 95% CI, 1.25-4.62).
The authors noted that the use of self-report via a questionnaire likely resulted in over-estimation of PPE use among the HCWs in the study. They concluded that levels of such use were suboptimal, indicating that HCWs may be at substantial risk for both acquisition and transmission of influenza and other respiratory viruses during a pandemic. Further, they concluded that both increased knowledge and modification of organizational factors would likely be required to improve respiratory virus infection control in the ICU.
Even if the case fatality rate of the current influenza A H1N1 (swine flu) pandemic proves to be low, it is likely that many patients infected with this and other respiratory viruses will be cared for in the ICU, whether for virus-related or other reasons. Thus, secondary transmission of respiratory viruses in the ICU is of major concern for public health reasons and also for the health of both HCWs and other patients in the unit. The CDC recommends the use of barrier precautions — droplet (surgical mask) and standard (gown and gloves for potential contact with infectious secretions) — in the care of patients with influenza. While the optimal form of PPE in some instances remains to be established with certainty, whatever the equipment employed, it must be used to be effective. This study, carried out 2 years ago, indicates that both knowledge of and adherence to current recommendations for the prevention of nosocomial spread of influenza and other respiratory viruses are not as good as they should be.
The study included ICU HCWs in several job categories and at 2 different large general hospitals. Although there were some differences between the institutions and among physicians, nurses, and RTs on some included items, the deficits in knowledge and reported practice and in the attitudes revealed were common to both hospitals and all categories of HCWs. Importantly, both the belief that adherence to respiratory precautions was inconvenient and the assumption that non-adherence would bring reprimand by one's supervisor were significant factors in the likelihood that the individual HCW would adhere to the guidelines — making such adherence less and more likely, respectively. These findings point to areas in which efforts to improve PPE use, and hence to decrease the risk of nosocomial influenza transmission, might profitably be targeted.