Personal protective equipment. Healthcare workers (HCWs) know they need it and they know why they need it, but stressful working conditions can sometimes interfere with making perfect choices. There’s no easy cure for that, but one way HCWs can take control is by adding to what they already know.
According to the Centers for Disease Control and Prevention (CDC), personal protective equipment (PPE) is one of four parts of the hierarchy of prevention and is “very important for protecting healthcare workers from disease transmission.” Main pieces of equipment include gloves, gowns, masks, goggles and respirators.
In general, the public is embracing PPE, and there seems to be more products available for the healthcare sector, says Milt Hinsch, technical services director for Mölnlycke Health Care.
“I see more masks, antiseptics and gloves in drugstores such as Walgreens, CVS and Eckerd (which is switching to the name Rite Aid) every day,” Hinsch says. “There are kits available for people concerned about flu (avian or otherwise, and other airborne pathogens) that contain masks, gloves and antiseptic. We are receiving more bids asking about ordering N-95 respirators and asking about abilities to supply future N-95 needs from existing or future manufacturing capacity.”
There are a few simple, but vital answers that HCWs must find as they’re assessing which type of PPE to don, according to a CDC paper titled “guidance for the selection and use of personal protective equipment in healthcare settings.”
The first assessment to make has to do with anticipated exposure. How much touching of the patient will be required, and what is the probable extent of bodily fluid splashes and sprays? Another factor is the category of isolation precautions related to the patient in question.
Next, the HCW should ask, “what is the durability and appropriateness of the PPE for the task?” This will determine, for instance, whether a gown is chosen instead of an apron, and whether the item of choice should be fluid resistant, fluid proof, or neither.¹ The next factor is often overlooked: size. The PPE must fit the user. It is the employer’s job to make certain that PPE is available in all necessary shapes for every staff member.
Administrators are responsible for ordering the proper equipment and the HCW is in charge of using the equipment properly, but because neither of these components is fool proof, patients and the friends and relatives of patients must provide a third line of defense.
The medical industry should get used to healthcare consumers taking a more active role, says Cathryn Murphy, RN, MPH, PhD, CIC, an associate professor in the faculty of health services and medicine at Bond University in Australia.
“Patients should question HCWs and base their questions on reasonable expectations and appropriate education and understanding,” Murphy says.
“Patients will increasingly have to become advocates for themselves and their loved ones. HCWs should begin to expect such new types of scrutiny and questioning as a routine part of accountability during care provision.”
Indeed, consumers should be involved, says Lori Jensen, RN, a clinical consultant for Ansell Healthcare. “I think that they should be extremely active and inquisitive as to what the healthcare workers are doing to them and their loved ones,” Jensen says.
That statement is true, according to Sandy Lonchar, BARRIER® product manager in the surgical business division of Mölnlycke Health Care, U.S.
“In all respects, patients and their relatives should take an active role in their healthcare,” Lonchar says. “Patients and their relatives have a right to ask and expect that healthcare workers are wearing proper equipment, washing their hands, etc., to protect them.”
Such interaction is necessary, says Victoria Nahum, an Atlanta woman who started Safe Care Campaign — a national organization that promotes infection prevention through partnerships with healthcare facilities and other organizations — after she lost her 27-year-old son to a hospital acquired infection (HAI) in 2006.
Within one year, Nahum, her son and another relative were afflicted with HAIs in three hospitals in three states. As a consequence, Nahum gets angry when she hears about healthcare workers (HCWs) who fail to don appropriate PPE.
“Medically educated caregivers and trained healthcare workers are taught best practices,” Nahum says. “How they are carried out is normally up to them but in instances where they should fail to practice safest care measures, then the onus has to fall upon the patient advocate, family member or friend who notices when a breach is about to occur.”
Hinsch agrees that patients, friends and family members should get involved.
“Every patient should have a temporary tattoo placed on their forehead when they check into the hospital that says, ‘Touch me only with washed hands …’ Just kidding, but patients and relatives (if the patient is incapacitated) should ask each person who comes into their room if they have washed their hands and should check to see if the healthcare worker is practicing good hygiene,” Hinsch says. “Unfortunately, most people do not know what to look for (such as) stethoscope covers, clean and short nails, clean lab coats, no ties.”
A Healthy Balance
In regard to HCWs wearing appropriate PPE, motivation should come from facility-wide programs as well as the leadership of key people who set good examples.
“Both are equally important,” Lonchar says. “First, a facility-wide program sets the standard and details to employees specifically about what needs to be done, how and why. Additionally, a facility-wide program communicates to employees that the organization places a high level of importance on wearing appropriate personal protective equipment.
“What is even more important than having the leadership of a few good people is having management set a good example through their support and actions,” Lonchar adds. “People take their cues regarding how things should be done and how they should conduct themselves based on how their managers do things.”
Individual leadership can go a long way, according to Nahum.
“I’ve been fortunate to have spent some time with several (infection control practitioners) over the last few months and continue to notice a genuine effort to not only prevent infections in general, but to assure that staffers use appropriate contact precautions,” Nahum says. “Almost always, it’s the hospitals’ individual ICPs that have done the great job in raising awareness and compliance and making this happen rather than some kind of program. And if it is a program, the ICPs are the ones who’ve put it into place. I applaud them for that discipline and the passion I see surrounding their genuine efforts.”
It is important to find out what factors motivate a HCW to use appropriate PPE, Murphy says.
“The answers to that question depend on the HCW’s infection prevention belief model, which includes things like: their perception of risk, their familiarity with available PPE, and correct usage and disposal of same and their ability to appropriately assess risk,” she says. “…Also, the feel and comfort (and availability) of PPE is important as is the cost. So in terms of leadership versus facility-wide programs, both are important to the extent to which they influence individual behaviors.”
Accountability in the healthcare industry is important, but to what degree, and how does one asses it? Should HCWs be punished for PPE infractions, or does a punitive approach only affect a symptom while ignoring the cause?
“Accountability is a big word that has unfulfilled potential within healthcare,” Nahum says. “While much good is being done and many strides are being taken, there is much confusion regarding accountability, its full definition, practice and consequences. We can always do better.”
There are obvious and serious personal consequences for healthcare workers who do not don sufficient PPE. Inflicting more negative consequences is therefore unnecessary, Lonchar says.
“I believe leading by example and providing positive reinforcement would be more effective in gaining workers’ compliance than actual punishment,” she says.
Punishment is not only unnecessary, it is ineffective, according to Murphy.
“The use of punitive responses to non-compliance are unproven in infection prevention and policy/guideline writers have to appreciate that nothing they are asking HCWs to do is either easier or less cumbersome than the HCW’s normal efforts,” Murphy says. “That means that most often to comply, a HCW has to be taking additional steps and investing additional efforts. This requirement is difficult when modern HCWs are so pressed for time and have increasing pressures placed upon them.”
Murphy therefore advocates for better education, reinforcement and root-cause analysis.
“Non-compliance and infection transmission are not related linearly,” she says. “For every episode of non-compliance it is not proven that one infection is transmitted — therefore cynics could reasonably argue that spread is unfortunate but not clearly able to be attributed solely to non-compliance.”
Safety from Beginning to End
Even when HCWs chose the right PPE and don it appropriately, danger can still exist if the items are not disposed of or laundered properly after use.
According to the Occupational Safety and Health Administration (OSHA), employers must not only provide appropriate PPE for employees, they must be responsible for cleaning, laundering and repairing the materials.
This should be done professionally, not at the homes of HCWs, Hinsch says.
“…It is my opinion that scrubs should only be washed by a qualified laundry because of the risks of household contamination by pathogens carried on the scrubs and the possibility that home wash cycles, detergents, and drying conditions might not be effective against some pathogens,” he says.
Indeed, household laundry equipment does not eliminate bacterial contamination, Lonchar says.
From choosing to donning to washing to disposing, employers and patients should ask questions and make observations, but ultimately, it is the HCW who has the most control over the situation. They also have high stakes, since improper protection endangers them.
“No one with good sense enters a burning building unprotected,” Nahum says. “We wouldn’t think to act in a cavalier manner in that kind of a potentially unsafe environment – why would we think is this any different?”
1. Guidance for the selection and use of personal protective equipment in healthcare settings. Centers for Disease Control and Prevention. www.cdc.gov/ncidod/dhqp/pdf/ppe/PPEslides6-29-04.pdf