By Frances T. Koch, RN, MSN, CNOR
Extra use of towels to reinforce the back table drape.
Since 1991 when OSHA published the final rule on occupational exposure to bloodborne pathogens, healthcare institutions have been responsible for providing barrier protection for healthcare workers (HCWs).1 Numerous products are available that provide protection from bloodborne exposure. There remain concerns regarding the way staff select the appropriate device for the anticipated exposure, and whether they use the product correctly. The cost of providing healthcare continues to rise and the level of reimbursement continues to decrease; therefore, it is imperative that HCWs know how to select the appropriate product and use it properly.
Gloves are probably the most frequently used and abused personal protective equipment (PPE) in healthcare. There is often the tendency to don gloves and to keep them on for extended periods of time, especially by less knowledgeable staff. Obviously, there are reasons why this is unacceptable. First and foremost, if the employee does not understand the way that organisms are spread to inanimate objects, they do not understand the risk that they are subjecting themselves and their fellow workers to when they continue to wear contaminated gloves. There must be a program to educate staff to the method of bacteria transmission. This is not an easy task as many housekeepers, orderlies, and nursing assistants may use English as a second language. The education must have teaching tools that illustrate how bacteria from contaminated gloves can be deposited on a clean surface and spread to an innocent person who later touches that surface. This information must be factual. The idea is to instill information and understanding for appropriate decision making--not fear. The Emergency Care Research Institute has an education program, Bloodborne Pathogens Training Program, available for use.2
When HCWs clearly understand how bacteria are transferred, they know when it is appropriate to don gloves and when they must be removed and discarded.
Not only should gloves be worn appropriately to limit the spread of microorganisms, the use of gloves should be limited to reduce the risk of developing a latex allergy. The increased use of gloves in the 1980s, due to the heightened awareness of the need for personal protection, led to an increased exposure to latex in the healthcare environment. In the 1990s, we began to identify the increase in latex allergies in HCWs. In several instances, HCWs have been forced to leave the healthcare environment and identify alternative practice environments. Latex allergy is currently a major concern for healthcare institutions for both patients and staff. Cost constraints and product acceptability may preclude conversion to non-latex gloves, but the use of low-protein, powder-free examination gloves can be mandated for use where unsterile, latex gloves are needed for personal protection. In areas that do not require latex gloves, the use of alternative products such as vinyl should be encouraged.3 All employees must be taught to limit their exposure to latex whenever that is acceptable.4
Double gloving is another area of concern. Studies have shown a reduction in needlesticks result when surgeons double glove; however, some surgeons seem reluctant to implement this practice and scrub personnel, who research has shown do not have a need to double glove, may initiate the practice believing it to be appropriate for them.5 The number of needlesticks by surgeons should be identified and double gloving recommended when there is a concern. Double gloving by scrub personnel should be discouraged as it may be an unnecessary expense.
Over-draping of the Mayo stand with a huck towel.
Gowns are the more critical product as they provide barrier protection for patients from surgical site infections (SSIs) and personal protection for the healthcare worker. There are numerous gowns on the market that provide varying levels of barrier protection. Acceptable levels of protection can be found in both single-use and multiple- use products. Cost constraints dictate that a gown providing the appropriate level of protection be selected for the anticipated level of exposure. There is no need to wear a gown with the highest barrier protection when assisting with a procedure that has minimal or no exposure to blood and body fluids, such as a cataract extraction or myringotomy.
In 1994, the Association for the Advancement of Medical Instrumentation (AAMI) published a Technical Information Report (TIR), The Selection of Surgical Gowns and Drapes in Healthcare Facilities, that provides guidance to the user in the selection of gowns and drapes. Subsequent to the publication of that document, the American Society for Testing and Materials (ASTM) adapted ASTM F1670 as a Standard Test Method for Resistance of Protective Clothing Material to Synthetic Blood and ASTM F1671 as a Standard Test Method for Resistance of Protective Clothing Materials to Penetration by Bloodborne Pathogens Using Viral Penetration as a Test System for Viral Penetration. Both are pass-fail tests and discern strikethrough when two pounds of pressure is exerted on fabric. ASTM F1671 is only necessary for use with gowns to determine whether the fabric allows viral penetration and thus prevents HCW exposure to viruses such as hepatitis (HBV) and AIDS (HIV). Although these tests are accepted national test methods, they have not been universally accepted by all experts; due to the pass-fail aspects, the fact that the product being tested, such as a gown must be destroyed to perform the test, the testing equipment is very expensive and thus not practical for use in the healthcare setting and only uses two pounds of pressure when previous studies have shown that as much as 50 pounds of pressure may be exerted during complex orthopedic procedures where pressing, leaning and external force is applied. Nonetheless, these are currently the only two standardized tests approved for measuring barrier properties in the US.
With that understanding, the healthcare worker in need of making a decision on appropriate barrier protection for a surgical procedure involving an intermediate or minimal level of exposure is totally at the mercy of the vendor. At this time, there is no consensus regarding appropriate test methods for determining other levels of barrier protection. Two tests that are frequently mentioned by vendors are AATCC127 the hydrostatic head test and AATCC42 the impact penetration test. Both tests are routinely used in laboratories to indicate levels of barrier protection. There is a lack of consensus regarding the significance of the tests as well as whether there is a correlation between the two tests. The hydrostatic head test is somewhat subjective in that it requires the tester to identify strikethrough when it occurs and to end the test promptly. The impact penetration is less subjective in that the volume of strikethrough is quantified by weight. Results of both tests are routinely quoted by vendors.
Currently AAMI has convened the Protective Barriers Committee to work on the development of a standards document that identifies multiple levels of barrier protection and to establish a consensus on the appropriate tests for lesser levels of protection.
A patient care assistant rests a gloved hand on an IV pole--is the glove clean, or is the pole now contaminated?
While drapes have not been shown to have a conclusive impact on SSIs, there is little question regarding the need for draping of patients for surgical procedures. Besides their use for the establishment of the sterile field, patient drapes maintain personal dignity for the patient and hopefully, assist somewhat in the conservation of body temperature. Draping techniques should be closely examined. In years past when cotton drapes were used, surgeons became accustomed to layering drapes to prevent strikethrough. This practice is no longer required for barrier products whether single-use or multiple-use products. OR managers should review current practices in each procedure to determine whether draping practices are excessive. There are substantial cost savings to be made by draping appropriately. Surgeons need to have a clear understanding of the implications of these excesses and the cost of continuing these practices. In today's practice environment, physician profiling affects the surgeons as well as adding additional, unnecessary expense to the OR budget. OR staff also must understand the reason for the change and support the effort; otherwise, product creep will occur and soon the surgeon may return to his old habit.
Drapes serve an important function in providing a sterile field for the back table and Mayo stand. OR managers must insist that the quality of these products provide adequate protection. The tendency by some vendors to go to a lesser quality of plastic should not be accepted.
Some complex orthopedic procedures require 30-40 instrument sets that are varying weights and various tray configurations. It is critical that the drapes for these tables provide an adequate barrier and resist tearing during lengthy, complex procedures.
Operating room expense budgets should not have to assume the cost of additional drapes, i.e., sheets or towels, to provide adequate protection. In fact the cost of the use of huck towels, while not a barrier, should be identified by OR managers. It is important to know how many towel packs are used in the OR in a month and what that total cost is. OR staff frequently do not attach a cost to huck towels and open towel packs in a cavalier fashion. While this is a very difficult practice to change, at the very least staff should be told of the cost of this practice.
While we may not have all of the information that we would like to have to make the best decisions, we must develop mechanisms within our institutions to:
- Ensure that employees know how to use personal protective products appropriately.
- Verify that employees consistently use the products appropriately.
It is the responsibility of the leadership within an organization including the infection control department and the quality assurance area to verify that all employees have a clear understanding of standard precautions, what they mean to that person as an individual, what PPE is available, and how that equipment is to be used for the protection of themselves and the protection of others in the environment.
Education offerings must be developed that clearly communicate this information at a level that is appropriate for the audience. There must be return demonstrations to reassure the educator that the individual has a clear understanding of the information.
Each individual in the healthcare setting must be mindful of their responsibility to monitor the performance of others.
Fran Koch's is the Director of the Operating Rooms and Sterile Processing and Distribution at Presbyterian Hospital in Dallas, Tex.
Prior to joining Presbyterian Hospital of Dallas, Fran was the Associate Administrator of Operative Services at Henry Ford Hospital in Detroit, Mich.
1. Occupational Safety and Health
Administration, Occupational Exposure to Bloodborne Pathogens: Final Rule 29 CFR Part
1910.1030. Federal Register, Dec. 1991, 56, 235: 64175-64182.
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