Saturday, July 18, 2015

APIC: Most HCWs Are Removing PPEs Improperly


Full PPE – Credit Emory University


# 10,236


Performing the intricate ballet of properly donning and doffing PPEs (Personal Protective Equipment) requires a skill born of proper training and constant practice. Concerns over deficits in PPE protocols were highlighted last fall after multiple Ebola cases were treated at hospitals in the United States, leading to the creation of several online `refresher courses’


CDC Ebola Guidance: Web Based PPE Training

Video: The Emory Ebola PPE Doffing Protocol

The Ebola PPE Demonstration Video


Complicating matters, there are a number of acceptable combinations of PPEs that may be used when dealing with infectious patients, and so there is no one-size-fits-all training video.


In the Ebola PPE Demonstration video above, I counted 10 points during the PPE doffing routine (N95 version) where the HCW must stop and sanitize their hands.  Miss just one, and you increase your risk of exposure during this difficult process.  Given the complexities, this isn’t something you can watch or practice once, and commit to memory.


It takes practice.


This week the American Journal of Infection Control  published a report on observed PPE doffing behavior by HCWs last October as they entered and exited patient rooms with specified isolation precautions.  Fewer than 20% of (4 of 30) HCWs followed the CDC’s PPE doffing recommendations to the letter.


First the link to the study (full PDF available for downloading), then some excerpts from an APIC press release.


Variation in health care worker removal of personal protective equipment

Caroline Zellmer, Sarah Van Hoof, BSN, RN, Nasia Safdar, MD, PhD

William S. Middleton Veterans Hospital and Section of Infectious Diseases, Department of Medicine, University of Wisconsin, Madison, WI 



|  In the current era of emerging pathogens such as Ebola virus, removal of personal protective equipment (PPE) is crucial to reduce contamination of health care workers. However, current removal practices are not well described. We undertook a systematic evaluation of health care worker removal of PPE for contact isolation to examine variation in removal procedures. Findings indicate that under usual conditions, only about half of health care workers correctly remove their PPE, and very few remove their PPE in the correct order and dispose of it in the proper location.


This press release from APIC:


Healthcare workers are not removing protective garments correctly: report


Washington, DC, July 16, 2015 – Fewer than one in six (4/30) healthcare workers (HCW) followed all CDC recommendations for the removal of personal protective equipment (PPE) after patient care, according to a brief report published in the July issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).

In this study undertaken by researchers from the University of Wisconsin, a trained observer watched healthcare personnel entering and exiting patient rooms specified as following isolation precautions on various units of the hospital. Isolation precautions are used to help stop the spread of germs from one person to another and may require use of gowns, gloves, and face protection. Observations took place October 13-31, 2014.

The Centers for Disease Control and Prevention (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 thirty HCWs observed removing PPE, seventeen removed the gown out of order, sixteen wore their PPE out into the hallway, and fifteen removed their gown in a manner that was not gentle, which could cause pathogens from the gown to transfer to their clothes.

“As a result of the current Ebola outbreak, the critical issue of proper PPE removal has come front and center,” the authors state. “Healthcare facilities should use this opportunity of heightened interest to undertake practice improvement focused on PPE removal protocol, including technique, for all healthcare-associated conditions that require the donning and doffing of PPE.”

(Continue . . .)


When a hospital has a known Ebola, Lassa Fever, MERS, or other `exotic’ infection to deal with, the checklists come out, trained monitors supervise the PPE donning and doffing procedures, and infection control training becomes paramount. 


But during day-to-day operations, particularly away from `high risk’  settings, procedures, attitudes and awareness often become lax.


Many HCWs - particularly those who do not work in ICU or isolation units - may only get one brief training session a year on PPEs (often during their annual fit-testing for N95s).  In some facilities, in-service instruction may consist of little more than an array of infection control posters on the wall.


Two years ago in nCoV: PPE Adherence & Infection Control we looked at a number of studies that examined some of the barriers to PPE compliance. PPEs can be hot, uncomfortable, and a considerable bother to don and doff - and without a clear and present biological threat - compliance can degrade over time.


Over the past 16 months  we’ve seen two Ebola cases (Dallas & New York), two MERS cases (Indiana & Florida), and two Lassa fever cases (New Jersey & Minnesota) show up unannounced in hospitals around the country.  Exotic infectious diseases can literally walk in off the street just about anyplace and at anytime. 


But it doesn’t require some rare imported pathogen to make proper infection control a must; TB,  meningitis, mumps, rubella, pneumonic plague, and a long list of other locally available pathogens will do just fine.


The time to improve (and maintain) HCW PPE skills is now, as awareness is heightened due to the recent debacle with MERS in Korea and the deaths of over 500 Health Care workers due to Ebola in West Africa.  A little over two weeks ago we saw the HHS Launches National Ebola Training & Education Center, designed to help prepare other medical facilities to deal with Ebola, and other emerging infectious disease threats.

But three national training centers can only do so much, so a real commitment on PPE and infection control training will have to come from within every hospital, clinic, long-term care facility, and doctor’s office.


Expensive?  Yes, and inconvenient, too.


But I suspect if you ask the infection control departments of several very large Korean hospitals that were recently shut down after MERS ran rampant through them, they’d agree it is worth it.

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