A few years ago, as Ebola hit the U.S., personal protective equipment (PPE) was on many hospitalists' minds. The index case-patient was a man who traveled from West Africa to Dallas and died in a hospital there on Oct. 8, 2014. Two nurses who had cared for him tested positive for the virus but later recovered.
At the New York University (NYU) School of Medicine, clinicians were particularly focused on preventing transmission during the outbreak, said hospitalist Leora Horwitz, MD, MHS, FACP, partly because a physician infected with Ebola while volunteering in Guinea was hospitalized at Bellevue Hospital in Manhattan on Oct. 23, 2014. (The physician subsequently recovered.)
The outbreak was an eye-opening moment regarding the difficulty of properly using PPE and avoiding costly mistakes, said Dr. Horwitz, who is an associate professor in the departments of medicine and population health. “Health care professionals obviously did a much better job after the initial suboptimal performance in Texas,” she said, noting that NYU staff needed step-by-step training and supervision.
The need for such training may be more widespread, according to a study conducted at the University of Wisconsin Hospital in Madison. Researchers observed as health care workers removed their PPE between Oct. 13 and Oct. 31, 2014. Thirteen of 30 (43%) workers removed their PPE in the correct order, and just five (17%) removed it in the proper order and also correctly disposed of it in the patient room, according to results published in July 2015 by the American Journal of Infection Control.
Even though Ebola increased awareness of careful PPE use, old habits proved hard to break. “When we went back and looked to see if people had changed their behavior—were they taking PPE off more carefully?—it turned out that that still wasn't the case,” said senior author Nasia Safdar, MD, PhD, health care epidemiologist and professor of infectious diseases at the University of Wisconsin School of Medicine and Public Health in Madison and associate chief of staff for research at the affiliated William S. Middleton Memorial Veterans Hospital.
PPE is designed to 1) prevent health care workers from transmitting a pathogen from one patient who is in contact precautions to another who might be vulnerable, and 2) prevent health care workers from getting sick with the same pathogen, she explained. One factor may be more important than the other, depending upon what type of pathogen is present, said Dr. Safdar.
“It's an important distinction because why people take precautions in wearing PPE or not wearing PPE really depends on what they feel the perceived risk is,” she said. Unlike with Ebola, transmission from patient to health care worker is unusual for Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and other resistant bacteria, Dr. Safdar said.
Therefore, a more likely scenario in routine care is that a clinician with contaminated hands goes on to the next patient and transmits the organism. “It's very easy to get that contamination in our current way of wearing and taking off PPE because there's hardly ever any formal instruction given to us during training,” said Dr. Safdar.
A persistent problem
Some hospitals do have some form of PPE training, often led by the infection prevention team, but there are challenges to offering it, said Sarah L. Krein, PhD, RN, a research professor of internal medicine at the University of Michigan in Ann Arbor. Many staff members, from environmental services workers to clinicians, have to be trained, so turnover across the board can make it difficult to keep everyone up to date, she noted.
Therefore, some hospitals may train on the job rather than hold standardized group training sessions, but “If someone's training you but doing things improperly, they may pass along some of those practices,” Dr. Krein said.
Even when hospitals do provide training, recent research from Dr. Krein's group indicates that proper PPE use is still elusive. In 325 direct observations of real-world PPE practices at two hospitals between March 1 and Nov. 30, 2016, they found 283 failures, according to results published in the August 2018 JAMA Internal Medicine.
The researchers categorized errors as violations (n=102), mistakes (n=144), and slips (n=37) to understand which may be modifiable. Violations included intentional rule-breaking, such as a clinician forgoing PPE and entering a room with the intent of talking to a patient in contact precautions without touching anything in the room.
“We saw that happen quite frequently. One of the problems with that is . . . often, once you're in the room, the patient needs something or you're brushing up against things in the environment,” said Dr. Krein, also a research career scientist at the VA Ann Arbor Healthcare System.
Mistakes occurred when staff were trying to follow protocol but something went awry, such as when they improperly removed PPE or took their badges out from beneath their gowns to log into the computer. And slips, which are “probably the most difficult” to address, comprised unconscious behaviors, such as wiping one's face with a gowned arm or pushing one's glasses up with a gloved hand, Dr. Krein said. The instinct to answer a ringing device was also considered a slip.
One factor that could have contributed to the PPE violations is the debate over when contact precautions are necessary. Some hospitals have made the decision not to use contact precautions for more endemic organisms, such as MRSA, especially if it's just a patient colonization, Dr. Krein noted. “But we're concerned about multidrug-resistant organisms and the emergence of new pathogens, so I don't think these precautions are going to go away anytime soon,” she said. “It's just that what they're being used for may change a little bit.”
Do's and don'ts
For all the situations in which PPE is used, experts offered hospitalists the following do's and don'ts for keeping themselves and their patients safe:
Do be more mindful of your behaviors when caring for patients with contact precautions. Slowing down a little bit and making sure to follow PPE protocols properly is preferable to rushing through the process, “which I think happens a lot, unfortunately,” said Dr. Krein. One way to get clinicians to be more aware of their behaviors may be videotaping them, she suggested. “It's being used in some other areas, especially in infection prevention. I think if people see themselves, for example, touching their face, maybe they'd be a little more aware the next time around,” Dr. Krein said.
Do make sure to tie the gown behind you so it doesn't fall off when you're in the patient's room, Dr. Safdar said. Otherwise, “Not a lot of thought has to go into [putting on the gear] except that you want to make sure you are covered in the areas that you think you will get contaminated,” she said.
Do properly remove PPE without touching any potentially contaminated areas, Dr. Safdar said. Even though this advice may seem obvious, the removal step is where contamination happens. “Since there isn't gross contamination, it's nothing that you can see. That's why you often don't realize that you actually haven't correctly taken off your PPE,” she said. Take the gown off very carefully, rolling it up and away so it does not come in contact with clothing, Dr. Safdar said. “The same thing with a mask: You reach for the sides of the mask, not the front, because the front is where the contamination is,” she said. Same with the gloves: Roll them inside out. “These are things that once you get into the habit, they're not hard to do,” Dr. Safdar said.
Don't make hard-and-fast hospital policies requiring PPE if they're not necessary, said Dr. Horwitz. Hospital policymakers should review rules around PPE to make sure they make sense to clinicians, she recommended. “If people don't believe in the necessity of your policies, then they will violate deliberately,” Dr. Horwitz said. “That's an insidious culture to have at an institution because then they're violating other rules, especially when there's no consequence.”
Don't touch your badge, pager, phone, or other uncontaminated items when wearing PPE in the patient's room. If there is a chance of clean surfaces becoming contaminated, Dr. Safdar recommended frequently using alcohol gel to decontaminate hands. If you've got to answer that page, the ideal solution is taking off PPE, leaving the room to answer, and coming back into the room after putting on the protective gear again, which “can get very annoying quite quickly.” A more practical option is to take the contaminated gloves off, answer the page, and perform hand hygiene before putting on a fresh pair of gloves, Dr. Safdar said.
Do work with colleagues from infection prevention, human factors, and/or engineering to come up with some better strategies to address the logistical issues surrounding proper PPE use, Dr. Krein recommended. “It's a little hard—your hospital is already designed and you can't really change the room—but there are environmental factors that I think could be looked at,” she said. For example, rooms often don't have many places to put down items while staff are taking off their PPE. Another common setup challenge is having the sink in the back of the room. “With certain organisms, you have to wash your hands with soap and water rather than using alcohol hand gels,” Dr. Krein said. “But as you can imagine, you take everything off and then you have to walk to the back of the room to wash your hands.” And although most hospitals have signage outside patients' doors that explain exactly what PPE to put on, they may have no signage at all inside the room that explains how to take it off, she added. “That could be a simple strategy to help with some of these issues.”
Do consider asking for training on proper PPE use, which should include troubleshooting common problems identified in studies, Dr. Horwitz said. “When you do training, focus it around evidence like this that shows what it is that people are messing up and help people work through challenges,” she said.
Don't forget that the CDC's standard precautions apply to all patients. Depending on the exposure that's anticipated, such as a patient with diarrhea, clinicians should use appropriate PPE and hand hygiene whether or not contact precautions are in place, Dr. Safdar said.