PPE Used Incorrectly Half the Time

The improper use of personal protective equipment among healthcare workers is "pretty pervasive in all institutions," says a researcher.

Nine months after a Texas nurse contracted Ebola from a patient and a National Nurses United survey found that 85% of RNs reported they had not been adequately trained to protect themselves from infection, researchers find that training for healthcare workers using personal protective equipment remains lacking.

Less than half of healthcare workers observed at a large Midwestern health system correctly removed their personal protective equipment (PPE), putting themselves at risk for infection, according to a study published in the American Journal of Infection Control.

"As a result of the recent Ebola virus outbreak, the critical issue of proper PPE removal has come front and center," says Nasia Safdar, MD, PhD, associate professor of infectious diseases at the University of Wisconsin School of Medicine and Public Health and associate chief of staff for research at the William S. Middleton VA Hospital, Madison, WI.

"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," she says.

Although the study included only healthcare workers at the University of Wisconsin, Madison, it is likely that employees of other US healthcare facilities are also improperly removing their PPE. Safdar says she believes the practice is "pretty pervasive in all institutions."

The University of Chicago Medical Center's director of infection control agrees with Safdar, "People are contaminating themselves probably 50% of the time," says Sylvia Garcia-Houchins, RN, CIC.

"These breaches of PPE removal protocol may be due to a lack of awareness of the proper procedure, time constraints, or lack of realization of the importance of proper PPE removal," Safdar says.

Much of the problem stems from nurses, physicians, and other healthcare workers not being properly trained and then tested during their professional education, Garcia-Houchins says. "People modify the process for whatever works for them. Nobody is telling them this is the way it should be done." Orientation for new employees at the University of Chicago now includes training and testing for the proper donning and removal of PPE, adds Garcia-Houchins. "We are doing something about it."

Methodology
The University of Wisconsin study was done by direct observation of healthcare workers using the Centers for Disease Control and Prevention's guidelines for PPE removal for contact isolation.

CDC recommendations state that state the healthcare workers should remove contaminated gloves first followed by gentle removal of the gown from the back of the neck while in the isolation patient's room.

The observers noted if healthcare workers took the following actions:

1. Removed gowns first
2. Removed gloves first
3. Removed gowns in a manner that was not gentle
4. Removed gloves in a manner that was not gentle
5. Properly disposed of PPE in the patient room
6. Disposed of PPE in the hallway
7. Removed PPE in the correct order
8. Removed PPE in the correct order
9. Wore PPE in hall
10.  Removed PPE in the correct order but did so with flourish
11.  Removed PPE in the correct order and did so without flourish
12.  Removed PPE in the correct order and disposed of it in the patient room

The scoring was done by calculating what percentage of healthcare workers performed the 12 actions above.

"We found that the majority of HCWs did not remove PPE in the correct order. Further, many of those who did remove the PPE in the correct order failed to properly dispose of their contaminated PPE in the isolated patient's room. Deviations from protocol were common," the authors wrote.

The poor compliance reveals that further education and collaboration with hospital and healthcare leaders to improve compliance is needed, Safdar said.

In response, the University of Wisconsin, Madison, has started reeducating its healthcare workers about how to properly remove PPE and its importance. It is using teaching methods already in place at the hospital, including grand rounds discussions, infection control liaisons for each unit, and interactive education programs. The frequency of the training was increased and all staff members are required to attend.

With the introduction of Ebola patients in the US, the University of Chicago began retraining staff on proper use of PPE, Garcia-Houchins says. "We practiced using powder and other substances to simulate the virus to show how correct removal of PPE protects against self-contamination."

The ED staff went through three sets of training and had to prove they were competent in PPE removal, she said.

Before the arrival of Ebola patients in the U.S. last year, the chance of contamination through PPE removal for contact isolation was considered slim. Healthcare workers could not see the direct consequences of incorrectly removing gloves and gowns, Nafdar says.

The consequences became clear last fall when a Texas nurse contracted the disease while caring for the first patient to be diagnosed and treated for Ebola in the US, even though she was wearing the CDC recommended PPE.