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Fewer than one in six healthcare workers followed the correct recommendations for removal of personal protective equipment (PPE) after patient care, likely contaminating themselves and increasing the risk of transmission to others, researchers report.1
Observations of workers for the study took place October 13-31, 2014. With Ebola still very much in the news at that time, the findings are somewhat surprising, but likely would be similar at many other hospitals.
“Very few facilities report this kind of data, but I think it is highly likely that we are just one of many [hospitals],” says Nasia Safdar, MD, PhD, co-author of the paper and infectious disease epidemiologist at William S. Middleton Veterans Hospital in Madison, WI. “There’s no national benchmark for [PPE] compliance and there’s no requirement to routinely collect this sort of information. We assume that things were happening because there is a policy, but really people were not able to comply because they had competing priorities [or other reasons]. It just never reached anyone’s radar until Ebola happened. I think this is a good time if we want to change practice using Ebola and MERS as the reason. We tell them about MERS and Ebola, but also about C. diff and MRSA and the things that we [frequently] see in this country. And who knows what could be coming tomorrow?”
What came yesterday was severe acute respiratory syndrome (SARS), which hit Toronto healthcare workers hard in 2003 with respiratory infections that were sometimes fatal. Donning and doffing of protective gear was an issue during the outbreak, which involved a coronavirus similar to today’s MERS.
Though Safdar’s was a relatively small study involving 30 healthcare workers, the findings echo similar PPE issues in Ebola care and training. For example, in Centers for Disease Control and Prevention training, donning and carefully doffing the protective gear was emphasized in a routine and ritual observed by a partner, says Rupa Narra, MD, a CDC Epidemic Intelligence Service officer and one of the Ebola trainers.
“Doffing seemed to be a common theme in breaches or problems,” Narra says. “The responders felt like they needed the most practice in doffing, and we agreed. That is the most critical part of the process. It is just small things like making sure not to touch the inside of the suit with a dirty glove and making sure they are washing their hands with chlorine during every step of what is about a 15-step process.”
As occupational health and infectious disease colleagues try to translate the lessons of Ebola to day-to-day practice, proper removal of PPE has been a recurrent theme. Of particular concern, Safdar and colleagues found that workers had a very difficult time following the correct doffing process when using contact precautions that require much less PPE — and have no respiratory component — than pathogens like Ebola and MERS.
In the study by Safdar and colleagues at the University of Wisconsin, a trained observer watched healthcare workers entering and exiting rooms where patients were under designated isolation precautions on various units of the hospital. For removing PPE, the CDC recommends that gloves should be removed first, followed by the “gentle” removal of the gown from the back while still in the patient’s isolation room. Of the 30 workers observed removing the gear, 17 removed the gown out of order; 16 wore their PPE out into the hallway; and 15 removed their gown in a manner that was not gentle, which could cause pathogens from the gown to transfer to their clothes.
Overall, 43% of HCWs (13 of 30) removed their PPE in the correct order. However, only 17% removed their PPE in the correct order and properly disposed it in the patient room. Only 13% of the workers (4 of 30) removed their PPE in the correct order and did so gently as recommended. Twenty-three percent (7 of 30) failed to remove their gloves gently. Another 40% incorrectly removed their PPE in the hallway, outside of the designated isolation area in the patient room. Fifty-seven percent (17 of 30) incorrectly removed their gown before removing their gloves. Half (15 of 30) incorrectly removed their gown with a lot of movement, including wriggling their arms out and pulling the whole gown over their head with or without untying it as instructed. On the positive side, 60% (18 of 30) of workers properly disposed of their PPE in the patient room. In the end, only four healthcare workers followed all CDC recommendations for the removal of personal protective equipment (PPE) in the correct order and manner after patient care.
“We found that many HCWs did not tie the back of their gown, leading to the gown falling over the patient and increasing the risk of contamination,” the authors report. “Additionally, many HCWs removed their PPE — both gowns and gloves — by rolling the equipment against their previously uncontaminated work clothes or bare hands before disposal. These breaches of PPE removal protocol may be due to a lack of awareness of the proper protocol, time constraints, or lack of realization of the importance of proper PPE removal.”
The next step is feeding the results back to workers, which has been shown to be an effective way to improve compliance with the hand hygiene, Safdar says.
“We are now consistently over 95% [compliance] with hand hygiene,” she says. “I think that ought to be possible to do with PPE too, but we are just at the beginning with this,” she says. “We do frequent audits to see if any change is happening [and to assess] barrier compliance.”