Personal Protective Equipment: Getting Compliance or Resistance
By Karen A. Huggins, MN, RN, CNOR
During the past decade, the healthcare industry has provided many technical innovations, safety device equipment and supplies, and research related to healthcare risks and personnel protective equipment (PPE). The question now is "Are we achieving compliance or encountering resistance in the use of PPE?." Collectively, there may not be a right or wrong answer in the determination of which particular piece of PPE should be used; however, there are factors in the work environment that influence compliance.
The purpose of this article is to describe some attributes of PPE and to discuss some of the root causes that must be considered when an accident occurs. Do these become a pattern of non-compliance or is it resistance? If a task has been completed for many years without an incident, will it alter the result if changed?
The more appropriate issues of concern need to be that we are given access to supplies and equipment that meet the needs of healthcare workers and patients in providing safety. Training of healthcare employees must include information on blood-borne pathogens and standard precautions. Staff must gain an understanding of the risks involved in exposure, to not only themselves, but to the patient. Accidents and exposures continue to occur and need to be reported and investigated.
Among healthcare workers, one of the most universal perceptions regarding exposures is that the risk of injury is part of the nature of the business. Knowing the root cause of an exposure may help to verify whether the incident occurred due to a lack of knowledge or from non-compliance. Resistance implies a holding back as in resisting change. The individual knew PPE was available but under the circumstances held back and chose an excuse, avoiding protection. This is as if to say that "just this time, it will not happen to me, or I will be careful." Vaccines for hepatitis are available and there are some individuals who have refused to be vaccinated. Resistance is also shown by failing to report an injury and or to refuse treatment following the injury. "The failure of nurses to report needlestick injuries has been estimated in studies to range from 30% to 60%. Marcus and coworkers report that needlestick exposure to HBV carries a 6% to 30% risk of infection whereas HIV needlestick contact carries less than a 1% chance of seroconversion."1
Regrettably, knowing the incidence of blood exposure and injury does not allow us to know the exact risk of contracting a blood-borne infection. By implication, however, any maneuver that reduces exposure to blood and injury will also reduce the risk of contracting a blood-borne infection2
Risks for exposure in the healthcare setting are unlimited as to where one may occur. The literature reviewed was centered on the surgical arena and infection control research. The content may be applicable to any patient care setting. The risk of acquiring bloodborne pathogens in the surgical setting is not limited to OR personnel. There are several reports in the literature documenting health care worker-to-patient transmission of HIV, HBV, and HCV during invasive procedures.3
In the surgical setting, the occurrence of an exposure is noted as being higher among surgeons and first assistants initially, followed by OR personnel.
Several factors were found to significantly alter the risk of blood contamination or injury in surgery.
- surgical specialty,
- role of each person,
- duration of procedure,
- amount of blood loss,
- number of needles used, and
- volume of irrigation fluid used.4
Surgical specialties such as orthopedics, cardiovascular, and plastic reconstruction are noted to be among the higher risks for injury. Injuries caused by vascular access needles fall into the Centers for Disease Control and Prevention's (CDC) high risk category for bloodborne pathogen transmission. The higher risk is linked to a larger blood inoculum associated with injuries from blood filled hollow-bore needles. Anesthesia personnel sustain most of these potentially high-risk injuries.5
In the last three areas, a logical relationship exists between blood loss, needles, and irrigation fluid. The higher the quantity of the substance, the greater the risk of exposure. Gowns, are an example of PPE that clearly reflect this correlation. Liquid penetration through a gown is dependent upon several things: duration of the exposure, the pressure that is applied to the liquid, the surface tension of the liquid, the fabric contact angle, and fabric stresses (such as stretching or abrasions).6
Examples of root causes associated with the exposures to blood-borne pathogens can be categorized by the event of occurrences without providing specific details. Root causes may be identified by events that occur in a particular setting or as identified by national benchmarks such as those done by CDC. The events become the stories that many healthcare workers experienced as an exposure or injury.
No PPE being worn or used when an incident occurred or not having the most effective protection available for the task at hand. This could impact the event over a period of time and make the safety device being used inadequate. For instance not wearing eye protection during any number of procedures where there is exposure to bodily fluids; examples include activities like obtaining specimens or suctioning. In surgery, a scrub person not wearing eye protection during a laparoscopic procedure because there is not an open wound. The potential for risk is still there with the port holes where the amount of irrigation used may create the potential experience of a splash injury.
The need for more consistent use of protective eyewear also has been stressed. One study concluded: "Twice the number of blood contacts to the face were recorded than to the hands, which ranked second in frequency in a study of six hospitals during a 15 month period. Consistent with the body location was the finding that blood contact with the mucosa of the eyes was the most common type of exposure, accounting for 45.3% of incidents.7
There are several root causes associated with sharps' incidents reported by healthcare workers. The type of sharp is not the key issue in relating an injury; use and disposal relationships are the root causes. Do the sharps used have a safety device or not? If it does, is the sharp device being used appropriately?
Has the user received training on the handling of the safety device? These questions should be answered when investigating the root cause.
In surgery, suture needles account for numerous types of injuries that occur during a procedure, such as:
- during activity of suturing
- passing suture material
- loading suture onto a needle holder
- unloading a needle
- suture needles disposal.
Inappropriate disposal of sharps is also a root cause category to be assessed and evaluated. Not paying attention to where needles are placed following use accounts for a variety of stories. How often has someone heard of needles remaining in a bed or stretcher following use leading to an inadvertent exposure?
In surgery, flat needle magnets are often used and pose a greater risk for injury when being disposed. The magnet can fold in on itself and the sharps penetrate the pad.
Sharps' container buckets have designated fill lines and overfilling frequently is an observable practice. Sharps' containers should be closed and replaced when they are full as determined by the manufacturer's marker.
Recapping needles has been identified as a continual source of worker exposure, and many of these injuries are considered preventable through use of safer devices, procedures, and work practices.8
Gaining Compliance or Incurring Resistance
The comfort of PPE greatly affects staff willingness to be compliant. "If a product is not comfortable, it is more difficult to get staff compliance in using it. Convenience and ease of use also affect compliance and need to be considered in evaluating PPE9."
Accessibility to PPE and safety devices to many nurses may mastermind resistance. Unless the equipment and/or supplies are readily available to use, the delay may cause poor decision making and will not facilitate best practice. If additional steps or time is required to obtain a safety device, the mindset easily becomes "this time, I will be careful."
Cost considerations of PPE should be weighed against patient safety, personnel safety, user preferences, and the cost of OSHA fines if employees fail to adhere to PPE use. In looking at the cost of PPE, it is important to remember that the CDC recommends a performance-oriented standard.10 The task and degree of exposure should determine characteristics for PPE.
In choosing protective eyewear, comfort, clear vision, accessibility, individual preference, protection, and use with prescription glasses are all critical to compliance with universal precautions. In addition to personal eyewear, there can be standard face shields, side shields and safety glasses or goggles accessible for general use.11
Seeking Better Outcomes
In healthcare , prevention and reduction of injury incidents are the keys to successful outcomes. Manufacturer's are being forced to invent and produce products that are not only used safely, but are safe for workers and patients. Healthcare provider's, are investigating the processes and quality available to improve outcomes. Changing practices does not always come easily.
The practice of double gloving has been promoted actively as a method for reducing blood exposures to hands, especially among surgeons; the use of puncture resistant gloves has been proposed as a method for reducing percutaneous injuries to hands. The potential benefits of using puncture or laceration resistant gloves or finger guards to prevent percutaneous injuries to the hands should be assessed. The acceptance of this approach in the surgical setting remains low because of the loss of tactile sensation and less than total puncture resistance of most available barrier materials12.
Blunt suture needles have been designed to provide protection when suturing specific tissue types like muscle and fascia13 This does not indicate that a blunt needle is appropriate for all muscle or fascia or that it will be used by all surgeons. Although this may be a good practice, there is resistance to use by surgeons. If they have been in practice for an extended time and the risk for injury has been small, the reluctance to switch will occur.
Masks need to be assessed for the fit on the face, comfort, filtration, the type of procedure to be done, and the risk of exposure. There are many on the market and from experience, the one most often worn is based on habit. Exceptions to this may be when caring for patients with TB exposures or on laser cases; these require modifications. Unconventional wearing of a face shield upside down will not always a prevent splash exposure from penetrating to the face.
Gowns need to be evaluated and used according to which offers the best strike-through protection. A variety of different gowns geared toward the anticipated exposure possibility would be the ideal. The cost and inventory stock is not practical. Hospitals must decide the types of gowns they will provide the best practice for everyone. The use of shoe covers has changed to be a protective device, used when the risk for exposure is potential. Higher boot protective shoe cover wear is available for healthcare workers that are exposed to bodily fluids and irrigation such as orthopedic and urological procedures.
Better outcomes for healthcare workers includes investigating the supplies being used within a facility and identifying the safety devices available. The issues of PPE are interdependent between infection control, employee health, education and the unit level. Involvement in providing for the best practices in PPE, should include participation of multidisciplinary team members to identify the various root causes and the options for preventing or reducing incidents. Consensus of an action plan would be the next step, followed by measuring the success.
Seeking better outcomes is done also by encouraging staff to develop a sense of curiosity about the issues surrounding PPE. Begin by investigating online the information available on PPE, needlestick injuries, exposures and other related topics. Manufacturing companies provide information on line. OSHA's revision of the Bloodborne Pathogen Compliance Directive is available on line as well as the NIOSH manual for evaluating sharps disposal containers.
Concerns for safety of the patient and employees should remain a priority in any situation. Human nature dictates that accidents happen. The lessons learned in retrospective analysis usually determine whether the event could have been prevented. Maintaining awareness during any procedure is essential. Identifying personnel protective equipment will promote a best practice in any work area. Determining root causes for injuries and using a continuous improvement model to reduce incidents will continue to be researched.
Karen A. Huggins, MN, RN, CNOR, is a clinical specialist in the operating room of Presbyterian Hospital of Dallas, Texas.