Health care workers face infectious disease risks every day, but the Ebola outbreak put those hazards into a harsh, new perspective: You have protective gear, and if you don’t wear it properly, you could die.
Public health officials hope to capitalize on the awareness that was raised in the Ebola outbreak to promote better practices during routine health care encounters. That effort is bolstered by an infusion of $576 million in federal funds for preparedness, with money for state and local health departments to conduct infection control assessments at hospitals, target gaps and improve health care worker training.
Hospitals also now have new guidance to help them select personal protective equipment. While employee health professionals are aware of the differences between face masks, N95 respirators and powered air-purifying respirators, with Ebola they suddenly had to determine if their protective apparel was protective enough.
Full protection meant no exposed skin, no penetration of microbes, no gaps in the seams. “Protective clothing in health care has been underappreciated,” says Maryann D’Alessandro, PhD, director of the National Personal Protective Technology Laboratory (NPPTL) of the National Institute for Occupational Safety and Health (NIOSH). “Since the Ebola response hit, we have been getting many questions.”
Having the right protective apparel and donning and doffing procedures will help hospitals in the ongoing efforts to combat hospital-acquired infections, says Anthony Harris, MD, MPH, president of the Society of Healthcare Epidemiology of America (SHEA) and associate hospital epidemiologist at the University of Maryland Medical Center in Baltimore. “The advantage of Ebola preparedness is that it allows us to prepare for other potential outbreak situations,” he says.
Training and protections for health care workers are receiving a burst of attention after a long period of cutbacks as hospitals and health departments faced financial constraints.
“Most hospitals have seen very limited to flat change in resources for infection control and hospital epidemiology in the last decade despite a dramatic increase in the issues that need to be dealt with on a day-to-day basis,” says Harris.
Employee health professionals also felt the strain of developing Ebola preparedness plans, training health care workers on PPE, and monitoring returning travelers, tasks they carried out in addition to their ongoing responsibilities, notes Dee Tyler, RN, COHN-S, FAAOHN, executive president of the Association of Occupational Health Professionals in Healthcare (AOHP).
Many hospitals rely on help from local health departments for training and gear that would be needed in a public health emergency. But the per capita preparedness funding for local health departments fell from $2.07 in 2010 to $1.15 in 2013, according to the National Association of County and City Health Officials (NACCHO).
Preparedness funds support regional health care coalitions and local partnerships, where community hospitals can access training and share PPE, says Katie Schemm, senior program analyst for public health preparedness at the NACCHO in Washington, DC. “In order to successfully respond to a disease like Ebola, you want to have these relationships in place,” she says.
Ebola also prompted hospitals to purchase more protective PPE and re-train employees. Those expenses were especially high for hospitals that treated Ebola patients or agreed to serve as a designated Ebola Treatment Center.
“We are hopeful that an appropriate amount [of federal funding] will go to those hospitals which volunteered and invested significant amounts to become Ebola-ready and to those which actually cared for Ebola patients,” Roslyne Schulman, director of policy for the American Hospital Association in Washington, DC, told HEH by email.
The National Institute of Environmental Health Sciences, a part of the National Institutes of Health, also received $10 million for safety training of hospital employees, first responders and other health care workers.
‘Fluid-resistant’ isn’t ‘impermeable’
The Ebola outbreak also has highlighted the more esoteric distinctions in personal protective equipment, particularly for gowns, coveralls and aprons.
The U.S. Occupational Safety and Health Administration (OSHA) published a PPE matrix, identifying which items of PPE should be worn for different tasks and hazards. It distinguished between “fluid-resistant” and “impermeable” apparel and gave specific parameters for fabric and seams, based on voluntary standards. (www.osha.gov/Publications/OSHA3761.pdf)
NIOSH followed up with detailed guidance — more information than many hospitals may have ever included in their decisions to purchase isolation and surgical gowns. Some considerations: Barrier properties, fabric strength, seam configuration, ease of donning and doffing, comfort, range of sizes, and integration with other PPE.
“The gown has to work with the gloves, the knee covers. The best way to identify those issues is to practice and train in the gear that you’re going to ask people to use,” says Ronald Shaffer, PhD, branch chief for technology research at NPPTL. “That’s one thing the Ebola epidemic has caused people to think about.”
Health care workers may believe that any fluid-resistant garment would protect them from blood and body fluids, NIOSH said. But microorganisms can penetrate material even without liquid being visible, the guidance states. (www.cdc.gov/niosh/npptl/topics/ProtectiveClothing/default.html)
According to NIOSH, fluid-resistant means the fabric resists liquid penetration, but the liquid may still penetrate if under pressure. Impermeable means the fabric prevents liquid or microorganisms from penetrating.
More importantly, gowns have been tested using methods of the American Society of Testing and Materials (ASTM) for blood penetration (ASTM F1670) and viral penetration (ASTM F1671). In its Ebola guidance, Cal-OSHA required hospitals to use apparel that met those standards.
The NPPTL began developing guidance on protective apparel after the emergence of H1N1 pandemic influenza in 2009. Often, health care purchasers don’t understand the descriptive terminology and protective qualities of different products, says Shaffer.
“Once a hazard is identified, we want to make sure there is protective clothing that will provide the protection they’re looking for,” he says. “We want to help employers ask the right questions when they talk to representatives of manufacturers of the products.”
Those questions should stem from a risk assessment, including the tasks, hazards, and duration that the garment will be worn, Shaffer says.
The ANSI/ASTM PB70 standard classifies garments for their barrier protectiveness, grouping them in levels one through four. Only level four garments are tested for blood and viral penetration; levels one through three are tested for different degrees of water resistance.
There are no standards for surgical scrubs. And while new antimicrobial fabrics have been developed, their role in protecting against infection is still being evaluated.
