Do the healthcare workers in your facility properly put on and remove personal protective equipment (PPE)? Tomas et al1 conducted a multicenter point-prevalence study to determine the frequency and sites of contamination on the skin and clothing of personnel when donning and doffing PPE.
Participants (physicians, nurses, and allied healthcare) put on contact isolation gowns and nitrile gloves then rubbed fluorescent lotion over their gloved hands for 15 seconds then the front of their gowns to simulate contamination.
These gloves were exchanged for clean gloves and the participants were asked to remove gloves and gown in their usual manner. Each simulation was observed by a trained research assistant and a black light used to assess contamination of hair, clothing (shirt sleeves, chest, and back), and skin (hands, forearms, neck, and face).
Out of 435 simulations involving 234 soiled glove simulations and 201 soiled gown simulations, almost half (46.0%) resulted in healthcare worker self-contamination of skin or clothing - most commonly involving the hands during glove removal and the neck during gown removal. In addition, 39.5% of the participants observed were using improper technique when compared with the CDC procedure for donning and doffing. As you may expect, those who did not use proper technique had a 70% probability of self-contamination, while those who did use proper technique had a 30.0% chance.
What are the implications of these results? In an accompanying commentary to the original article, Doll and Bearman2 point out that higher levels of microbial contamination of hospital surfaces lead to higher rates of healthcare worker contamination with multi-resistant bacteria. Now we have more evidence that bioburden on hands and PPE contributes to the risk of contamination from healthcare worker to patient.
A portion of the study participants decreased self-contamination after a training session that included a 10 minute instructional video with defined practice using simulated contamination with the fluorescent lotion. By using a real-time assessment with “immediate visual feedback,” the self-contamination rates decreased from 60.0% to 18.9% and was sustained at 1 and 3 month intervals.
There are limitations to the study: the intervention was conducted in only one facility, the intervention outcome was based on simulations with the fluorescent lotion and not hand contamination with pathogens, and contamination frequency was high compared to other studies. However, in the age of C. difficile, multi-drug resistant organisms, Ebola, and other pathogens, what can we do to make sure our HCWs and patients are protected?
Should there be annual training on proper donning and doffing technique? Do HCWs suffer from contact isolation fatigue - are too many people in isolation?
Do you train your frontline staff on proper PPE removal by utilizing return demonstration?
- Tomas ME, Kundrapu S, Thota, P, Sunkesula VCK, Cadnum J, Mana TSC, Jencson A, O’Donnell M, Zabarsky TF, Hecker MT, Ray AJ, Wilson BM, Donskey CJ.Contamination of Healthcare Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904-1910. Abstract accessed from the internet: http://archinte.jamanetwork.com/article.aspx?articleID=2457400
- Doll M, Beaman GM. The Increasing Visibility of the Threat of Health Care Worker Self-contamination. JAMA Intern Med. 2015;175(12): 1911-1912.