Research spurred by the Ebola crisis continues to reveal that healthcare workers are poorly trained in the use of personal protective equipment (PPE), frequently contaminating themselves with pathogens that can endanger their personal health and subsequent patient contacts.
On the positive side, an intervention and training program that gave workers immediate visual feedback on their level of contamination after removing PPE reduced exposures significantly.
In general, however, it appears Ebola brought to light a longstanding problem in U.S. hospitals. In West Africa, the outbreak is almost over in a conventional sense, though recent reports that the Ebola 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.1 As of Oct. 25, 2015, the World Health Organization reported a total of 28,575 Ebola cases with 11,313 deaths. As of Aug. 31, WHO reported a 50% mortality rate in healthcare workers, as 240 doctors, nurses, aides, and support staff have acquired Ebola and 120 of them died. A contributing factor was a shortage of PPE and improper use of the equipment when it was available, the WHO noted.
Yet barring another introduction in a U.S. hospital, the teachable moment — the intense focus on healthcare worker safety — may fade out here with the epidemic in Africa. Still, a return to PPE complacency is hardly acceptable since research now shows worker contamination is a chronic problem. For example, researchers recently reported that more than half of healthcare workers contaminated themselves while removing their gloves in a simulation study.2 Clearly, an emphasis on standardized training and competent PPE use is needed, but healthcare workers may feel little sense of urgency on the issue in the absence of a life-threatening infection.
One barrier to PPE training programs “is the current healthcare worker attitude toward PPE for routine pathogens,” says Michelle Doll, MD, co-author of an editorial3 on the simulation study and an infectious disease physician at Virginia Commonwealth University in Richmond. “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, 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.4
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.5
“Among the physicians, 16% denied ever receiving any sort of training,” said lead researcher Curtis Donskey, MD, an infectious disease physician at Louis Stokes Cleveland VA Medical Center. “They were working with gloves and gowns and had never been told how to properly use them. Another thing that we assessed was how effective was the training? A lot of the training that nurses and others get is suboptimal. It primarily involves a demonstration but does not necessarily go beyond that to have them demonstrate that they are proficient in removing PPE quickly and following the recommendations.”
The researchers say these findings could be generally extrapolated to indicate a similar lack of training in other hospitals.
“We focused on personnel in our facility but we have also discussed this with infection control and other people around the country and they describe similar deficiencies in training on PPE,” Donskey says.
If contamination is occurring as frequently as it now appears, healthcare workers must redouble their hand hygiene practices after PPE use to protect themselves and their patients. While transient colonization of pathogens on workers’ hands has been long known to spread infections between patients, employee health professionals should remind workers that they are also at risk. Ebola drove home the threat of occupational infections, but improper use of PPE also leaves healthcare workers exposed to common pathogens they may encounter frequently. (See related story in this issue.)
“Healthcare personnel want to protect themselves against Ebola, but they have acquired Clostridium difficile, norovirus and [multidrug resistant bacteria],” Donskey says. “They don’t want to acquire an infection or carry those things home on their clothing, and they also don’t want to spread infections in the hospital.”
Training deficiencies
In the IDWeek study, the VA Medical Center personnel were surveyed to assess the type and frequency of PPE training they received and their confidence in avoiding contamination.
“We were looking at physicians, nurses, and ancillary staff, most of whom are regularly going in and out of isolation rooms,” Donskey says.
Those three healthcare worker groups were equally represented in the survey participants, comprising about one-third each of the 222 respondents. Overall, 25% of personnel reported that they had received no PPE training in their current position, and 9% reported never receiving such training during their career. Only 1% of nurses had received no PPE training, as opposed to the aforementioned 16% of physicians. Of the physicians that reported prior training, only 13% said they received “formal training” that requires the trainee to demonstrate correct technique.
“These [physicians] were staff members at our hospital — residents or fellows,” he says. “They weren’t people who would have been trained somewhere outside our facility, but we were asking about training in our facility and outside as well.”
Of overall respondents that had been trained, 46% received formal training, 42% reported informal on-the-job instruction, and 41% completed computer-based instruction. Of 222 personnel, 80 (36%) did not feel confident that they could avoid contamination with their PPE technique.
“We implemented an intervention that was in part inspired by the Ebola crisis, which led us to think that we really need to do more to train personnel in the use of PPE,” he tells Hospital Employee Health. “We are incorporating a lot of our training tools that we developed into our [routine] training. We would like to make this something done on an ongoing basis that includes [all] physicians and allied health personnel.”
The new training initiative is based on an intervention Donskey and colleagues developed during a study that quantified the frequency of contamination of workers removing PPE, using surrogate markers to show where pathogens would be found on the skin. In that recently published study,2 contamination of the skin and clothing of healthcare workers happened frequently during the removal of gloves or gowns as shown by fluorescent lotion under black light.
“Part of the problem is that if we asked healthcare personnel about this I suspect most would be unaware of the significant risk of contamination during PPE removal,” he says. “These deficiencies in our PPE practices create a potential recipe for disaster when we ask personnel with limited training in use of PPE to provide care for patients with Ebola and other highly transmissible pathogens.”
Study participants included a convenience sample of healthcare personnel from four northeast Ohio hospitals who conducted simulations of contaminated PPE removal using the fluorescent lotion. An intervention was conducted in one medical center, where healthcare workers received education and practice in removal of the contaminated PPE. Importantly, they received immediate visual feedback showing the fluorescent lotion contamination of their skin and clothing.
“The sessions included a 10-minute educational video and 20 minutes of demonstrations with practice in PPE donning and doffing using the fluorescent lotion to identify sites of contamination,” Donskey says.
The PPE donning and doffing technique was considered correct if the following four criteria were met:
- correct donning order, with gown first followed by gloves;
- gloves extended to cover the wrist of the isolation gown;
- gown doffed by pulling away from the neck, shoulders, and body
- gloves removed by peeling off the gloves at the same time as the gown or using a glove-in-glove technique wherein gloves are removed one at a time, making sure that bare skin does not touch the contaminated outside surface of the glove.
Contamination in 46% of PPE use
Overall, of the 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46%), with a similar frequency of contamination among the four hospitals (range, 43%-50%). Contamination occurred more frequently during removal of contaminated gloves (53%) than gowns (38%) and when lapses in technique were observed (70%) than not (30%).
In the intervention group, skin and clothing contamination during glove and gown removal fell from 60% to 19%. This reduction fell further to 12% at one-month and three-month checkpoints after the initial training. These findings suggest that simulations using fluorescent lotions can improve techniques for standard glove and gown removal and for training in removal of full-body coverage PPE used in the care of patients infected with pathogens such as Ebola virus, the authors concluded.
In the overall study, a sobering detail is that even when no lapses in technique were observed, contamination occurred in approximately one-third of the simulations. Even the highly successful intervention could get no lower than a 12% contamination rate. Additional measures used for Ebola — disinfecting gloves during the removal process or having a partner observe doffing technique — would be difficult to implement in day-to-day patient care. A study in press by the same group of researchers found that glove disinfection with bleach wipes after care of C. diff patients reduced the spore levels on worker hands, but gowns were still frequently a source of contamination.6
There may be a need for a PPE redesign to create products that are easy to remove while minimizing the risk for self-contamination. For example, Donskey and colleagues found that only one size of cover gown was available at each hospital in the contamination study, leaving small, large, and tall personnel in ill-fitting gowns.
In the accompanying editorial to the study, Doll and her co-author emphasize that a standardized PPE training protocol is long overdue and suggest use of standard precautions in some cases instead of patient isolation for so many pathogens. The immediate feedback method used in the Donskey study should be part of any standard training, but questions remain about sustaining the gain. Healthcare worker “fatigue” with contact precautions has been widely evidenced, and thus any training program may face subsequent compliance problems.
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. (See HEH, September 2015.)
“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.”
Editor’s note: The CDC last updated its guidelines for PPE use for Ebola on August 27, 2015. The updated guidance is for both confirmed Ebola patients and clinically stable persons under investigation. It includes a frequently asked questions section and is available at http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/index.html.
REFERENCES
- 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.
- 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.
- 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.
- Nash D, Jagger J, Mitchell AH. Guest Commentary: Protecting our healthcare workers now. Modern Healthcare Nov. 21, 2014. http://bit.ly/1GIpdHU.
- John A, Tomas M, Cadum J, et al. Are Healthcare Personnel Trained in correct Use of Personal Protective Equipment? IDWeek. Session 53: HAI: Occupational Health. San Diego, CA. Oct. 7-11 2015.
- Tomas ME, Sunkesula VCK, Kundrapu S, et al. An intervention to reduce healthcare personnel hand contamination during care of patients with Clostridium difficile infection. Am J Infect Control 2015; in press.
- 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.
Research spurred by the Ebola crisis continues to reveal that healthcare workers are poorly trained in the use of personal protective equipment, frequently contaminating themselves with pathogens that can endanger their personal health and subsequent patient contacts.
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