By Gary Evans, Senior Staff Writer
As research spurred by the Ebola crisis continues to reveal that healthcare workers frequently contaminate themselves doffing personal protective equipment (PPE), there’s increasing interest in scaling back contact precautions and treating more patients with standard measures and rigorous hand hygiene.
A recently published study1 estimated that on any given day up to 25% of all hospitalized patients are on contact precautions, which typically means placing patients with Clostridium difficile or multidrug-resistant organisms (MDROs) in a private room and having caregivers don gloves and gowns to treat them. Some early adopters of a more “horizontal” strategy are no longer isolating patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) if they are an endemic presence in a non-outbreak setting. Instead, they may use standard precautions, ensure a high level of high hygiene compliance, and emphasize other measures like chlorhexidine bathing and cleaning and disinfection of environmental surfaces and fomites.
A survey conducted as part of the study found more than 90% of responding epidemiologists and infection preventionists currently use contact precautions for MRSA and VRE, but 62% expressed interest in possibly changing the practice. Contact precautions make “theoretical sense,” but an exhaustive review of more than 90 studies yielded no “high-quality data” that “these practices have a measurable effect on reducing infection rates” of MRSA and VRE, says lead author Daniel Morgan, MD, MS, an associate professor of epidemiology and public health at the University of Maryland School of Medicine in Baltimore.
The study concluded that there are insufficient data to support or reject contact precautions for MRSA and VRE, thus local circumstances should guide the decision of epidemiologists and infection preventionists. For example, hospitals treating patients with high acuity — “the sickest of the sick” — may find that contact precautions for MRSA and VRE provide a small benefit, Morgan notes.
However, even that margin of benefit may be undermined unless healthcare workers are compliant and competent in PPE use. There is accumulating evidence in the wake of Ebola that healthcare workers frequently use PPE improperly and contaminate themselves when removing the gear. For example, a recently published simulation study2 found that more than half of healthcare workers contaminated themselves while removing their gloves.
That certainly highlights training needs but also suggests some unknown level of transmission may be occurring to subsequent patients after healthcare workers use PPE for contact precautions. There are also the negative aspects of being in contact precautions, as previous research indicates isolated patients may suffer from depression and anxiety and receive reduced care in the form of fewer visits from healthcare workers. The latter is likely due to healthcare workers’ perception that the donning and doffing of gloves and gowns is too labor-intensive and time-consuming, Morgan notes. In light of these various factors, there is renewed interest in scaling back contact precautions. Epidemiologists and infection preventionists that adopted such strategies before Ebola have generally reported stable or declining infection rates.
“We are using less contact precautions then we were before for the simple reason that we think that they need to be used in a more judicious fashion,” says Gonzalo Bearman, MD, MPH, FACP, FSHEA, hospital epidemiologist at Virginia Commonwealth University (VCU) in Richmond. “They need to be used for the right reasons, at the right time on the right [patients]. By making it less common we can drive up the compliance with appropriate use of contact precautions.”
VCU dropped contact precautions for MRSA and VRE in 2013, though they did not make the move until they determined hand hygiene compliance rates exceeded 85% for four years. Now patients with MRSA or VRE are only placed in contact precautions if they have wound drainage not contained within a dressing or uncontained respiratory secretions.3
“We use contact precautions for Clostridium difficile and multidrug-resistant pathogens, which are fortunately uncommon,” Bearman says. “[Infection rates] are not only stable — they have continued to go down.”
STANDARIZED TRAINING NEEDED
In a commentary4 accompanying the aforementioned simulation study on PPE contamination, Bearman and co-author Michelle Doll, MD, emphasize that a standardized PPE training protocol is long overdue and suggest use of standard precautions in some cases instead of contact precautions. The simulation study showed that an intervention and training program that gave one group of workers immediate visual feedback on their level of contamination after removing PPE reduced exposures significantly.
“What we argue in our commentary is that if this [frequent contamination related to PPE removal] is the key — if that is the case — then we really have to come up with ways to properly train and evaluate the donning and doffing of PPE,” Bearman says.
The problem is ramping PPE training up to a large scale population of healthcare workers, particularly if you are going to use immediate visual feedback with fluorescent lotion as described in the simulation study.
“At VCU we have about 7,000 healthcare workers,” he says. “You try to do training, retraining on a one-by-one basis for 7,000 people — it is virtually impossible. So the real question is, can we do simulations or training [with] virtual assessments using computer programs, videos, and interactive components to really teach the methodology for putting on and taking off personal protective equipment.”
In any case, it appears that Ebola brought to light a long-standing problem with PPE use in U.S. hospitals.
“I think the issue of using PPE incorrectly has probably been going on for a long time, but what proportion it contributes to hospital infections is not known,” Bearman says. “We have no idea — it would be very hard to measure.”
IS THE TEACHABLE MOMENT FADING?
Barring admission of another U.S. case, the intense, teachable moment Ebola brought to PPE use may fade back to a baseline complacency as the outbreak in West Africa burns out. The outbreak is almost over in a conventional sense, though recent reports that the virus could survive in semen for nine months may lead to sporadic cases if the viral RNA discovered in the study is capable of sexual transmission.5 As of Nov. 1, 2015, the World Health Organization reported a total 28,571 Ebola cases with 11,299 deaths. A total of 881 healthcare workers have been infected and 513 of them died — a mortality rate of 58%. Contributing factors in the healthcare infections were a shortage of PPE and improper use of the equipment when it was available, the WHO said.
In the absence of the Ebola threat, new PPE training initiatives in the U.S. may lack a sense of urgency and face subsequent compliance problems. One barrier to PPE training programs “is the current healthcare worker attitude toward PPE for routine pathogens,” says Doll, an infectious disease physician at VCU. “While PPE training for Ebola was well accepted as vitally important for healthcare workers, the more routine PPE use is generally not regarded as a complicated procedure that necessitates specific training. This is likely due to a perceived low risk. In fact, compliance with PPE at all can be problematic in hospitals.”
Indeed, some research suggests that healthcare personnel wear PPE less than half the time when it is indicated and overall compliance is lower than that of historically difficult hand hygiene.6 These concerns and conclusions echo those made in another recent PPE study7 by Nasia Safdar, MD, PhD, 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,” she noted. “It just never reached anyone’s radar until Ebola.”
A major factor in this trend appears to be the fundamental issue of PPE training — or lack thereof. An unpublished study recently presented in San Diego at the IDWeek conference found that many hospital workers were inadequately trained in the use of PPE and some reported no training at all.8 How did we get to such a juncture?
IS AN OSHA MANDATE COMING?
Before the current CDC transmission-based precautions were issued, there was the pioneering development of Body Substance Isolation (BSI).9 The basic concept was to regard all blood, body fluids, and substances as potentially infective and use PPE accordingly.
“I’ve always been a staunch believer in the original BSI published in 1990 by Pat Lynch and her team out of Seattle,” says Patti Grant, RN, BSN, MS, CIC, director of infection prevention/quality at Methodist Hospital for Surgery (MHFS) in Addison, TX. “It is logical and uncomplicated. Being a new IP at the time, it was empowering to teach a ‘process’ and not ‘diagnosis/identification of an organism.’”
The BSI concept was subsequently absorbed and superseded by a series of CDC patient isolation guidelines which are currently standard precautions augmented as warranted by contact, droplet, and airborne transmission measures. Some suggest a sense of isolation fatigue has set in with workers as so many patients are placed under contact precautions.
“[Contact precautions] remains a difficult concept for me to teach in general orientation because I feel there is an underlying ‘mixed message’ that for these people you must gown/glove to enter the patient room,” Grant says. “Over the years I’ve learned to compromise. At MHFS we use contact isolation only for MDROs or Clostridium difficile if it is cultured from the current admission. The beauty is we also isolate for uncontrolled body substances, regardless of what is isolated. Common sense cannot be regulated.”
Therein lies the rub, for just as the post-Ebola discussions in the infection control community are rethinking the use of PPE and patient isolation, the Occupational Safety and Health Administration(OSHA) has been slowly moving toward an infectious disease standard that could codify current CDC voluntary recommendations into a regulatory mandate.
That would likely stir the ire of many IPs, much as it did when OSHA proposed a TB standard in the 1990s. However, the truth is that it is hard to imagine a better time for OSHA to argue for an infectious disease rule to protect healthcare workers from occupational infections. The agency can cite the two nurses infected by Ebola last year as well as a succession of potentially pandemic pathogens that emerged in the last dozen years, including Severe Acute Respiratory Syndrome (SARS), H1N1 pandemic influenza A, Middle East Respiratory Syndrome (MERS), and Ebola. In addition, multidrug-resistant bacteria are increasing and a virulent strain of Clostridium difficile has reached epidemic levels. OSHA has a lot more ammunition than the agency did in its failed bid for a separate TB standard, which was being proposed when the disease was at record low levels in the U.S.
OSHA has been considering regulating worker protection against infectious diseases in healthcare settings for several years. Thus the timing with Ebola was coincidental late last year when OSHA released details of a possible rule that would make infection control measures mandatory and add new requirements for hazard identification, exposure control, and documentation. (See Hospital Infection Control, Dec. 2014.)
No rule has been issued for comment, but the 38-page “regulatory framework” document released last year calls for “procedures to provide, make readily accessible, and ensure that each employee uses PPE (such as, but not limited to, gloves, gowns, laboratory coats, face shields, facemasks, and respirators) in accordance with recognized and generally accepted good infection control practices.” Training on PPE would be required for new workers and annually thereafter for all workers who may be exposed to occupational infections.
The preliminary OSHA document specifies that MRSA and VRE patients are to be placed in contact precautions, but the agency concedes that “infection control practices normally rely upon a multi-layered and overlapping strategy of employing engineering, work practice, administrative controls, and PPE. Therefore, OSHA would permit [modifications to requirements] in accordance with recognized and generally accepted good infection control practices.”
OSHA included “enhancements to current infectious disease protocols in healthcare and other high-risk environments” as a regulatory priority for 2015 and the agency is projected by some insiders to issue proposed rulemaking on the infectious disease standard in 2016.
While small hospitals and business groups and other stakeholders said the standard would be redundant with existing requirements, the American Public Health Association (APHA) emphasized that the Ebola outbreak in Dallas underscored the “urgent need” for an OSHA infectious disease standard. “Had this been a widespread outbreak involving a pathogen easily transmitted between humans, the loss of life and the economic and social impacts would have been unimaginable,” the APHA said.10
Other occupational health leaders and advocates have joined the chorus, saying “it is time for unanimous congressional support for promulgation of OSHA’s long-awaited Infectious Disease Rule. … The rule narrows safety gaps by expanding the work that has already been done related to bloodborne pathogens such as HIV and hepatitis B and C.”6
Despite such political momentum, there is still some question of if and when OSHA will proceed with an issue that is sure to be controversial.
“When I look at what the rest of the global population sometimes must manage with scarce resources and be creative with ‘work-arounds,’ I shudder to think of the wasted use of PPE that would result from a mandate of ‘requisite PPE’ under any circumstance in the U.S.,” Grant says. “A mandate could never keep up with the science.”
- Morgan DJ, Murthy R, Munoz-Price, LS. Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015;(10):1163-1172.
- Tomas ME, Kundrapu S, Thota P, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med Published online Oct.12, 2015.doi:10.1001/jamainternmed.2015.4535.
- Edmond MB, Bearman G, Stevens M. Impact of Deescalating Contact Precautions on MRSA Infection Rates in an Academic Medical Center. IDWeek. Abstract 639. Philadelphia, Oct. 8-12, 2014.
- Doll M, Bearman GM. The Increasing Visibility of the Threat of Health Care Worker Self-contamination. Invited Commentary. JAMA Intern Med. Published online Oct. 12, 2015. doi:10.1001/jamainternmed.2015.5457.
- Deen GF, Knust B, Broutet, et al. Ebola RNA Persistence in Semen of Ebola Virus Disease Survivors — Preliminary Report. New Engl J Med October 14, 2015 DOI: 10.1056/NEJMoa1511410.
- Nash D, Jagger J, Mitchell AH. Guest Commentary: Protecting our healthcare workers now. Modern Healthcare Nov. 21, 2014. http://bit.ly/1GIpdHU.
- Zellmer C, Hoof SV, Safdar N. Variation in health care worker removal of personal protective equipment. Am J Infect Control 2015;43(7):750-751.
- John A, Tomas M, Cadum J, et al. Are Healthcare Personnel Trained in correct Use of Personal Protective Equipment? IDWeek. Session 53. San Diego, CA. Oct. 7-11 2015.
- Lynch P, Cummings MJ, Roberts PL. Implementing and evaluating a system of generic infection precautions: Body substance isolation. Am J Infect Control 1990;18(1):1–12.
- APHA. Preventing Occupational and Community Transmission of Ebola and Globally Emerging Infectious Disease Threats Policy Number: LB-14-01 Nov 18 2014: http://bit.ly/1P7SWwx.