Personal Protective Equipment

Excuses abound for not wearing proper personal protective equipment (PPE), but none are acceptable to Atlantas Victoria Nahum, who lost her 27-year-old son to a hospital-acquired infection (HAI) in 2006.

Nahum has since been inspired to start the Safe Care Campaign, a national organization that seeks to spur clinical and ideological change nation-wide in regards to infection prevention through education and partnerships between healthcare facilities and other organizations.

Within one year Nahum, her son, and another relative were afflicted with HAIs in three different hospitals in three different states. As a consequence, when Nahum hears about healthcare workers (HCWs) who fail to don appropriate PPE, she becomes livid and cannot understand why there is such lack of compliance.

Firemen dont enter burning buildings unprepared to do the work they came to do, Nahum says. They adequately suit up and go in. Clinical users should care about barrier properties, safety, consistency, and comfort of PPE. Safety issues, especially those related to adequate protection of professional staff and patients, are always important.

Protection from coagulase-negative Staphylococcus aureus, methicillin-resistant S. aureus and other resistant organisms and bloodborne pathogens is necessary for safe practices, she continues. Exposure to blood has for years been recognized as a risk for infection, so dependable barriers are needed. There is no excuse that justifies sloppy care in a healthcare environment not time restraints, not budget- cuts, not ignorance no, nothing. The consequences of not wearing PPE can be traumatic and endless.

Our son became a ventilator-dependent quadriplegic from an HAI involving the cerebro-spinal fluid around his brain, Nahum says. He did not have this condition when he was admitted for his original injuries many weeks prior. At the end of his life, he said goodbye to me with his eyes because thats all he could move not an arm or a leg or a single finger. No one who has witnessed this kind of catastrophe could ever just choose not to care, could they?

The ramifications of wearing inappropriate PPE are huge for the health of a facility at large, but most acutely affect the HCW whos wearing it.

PPE, of course, acts as a barrier between infectious materials (such as blood and respiratory secretions) and the skin, mouth, nose and eyes.¹ According to the Food and Drug Administration (FDA), PPE reduces the chance that HCWs will infect or contaminate others and reduces the chance of transmitting infections from one person to another.

Trends

Overall rules involving PPE stay the same unless an outbreak dictates otherwise, says Susanne Pear, PhD, RN, CIC, associate director for infection control practices for Kimberly- Clark Health Care.

There have not been recent, major changes in what PPE should be donned, but the SARS outbreaks where many patients and HCWs became infected and died after being exposed to this lethal virus within the healthcare setting provided us with many new lessons, Pear says. This out-break showed us the importance of implementing reliable strategies for identifying infected patients so HCWs will know when to use appropriate, required PPE. We also learned that proper removal of PPE and avoidance of self-contamination is as important as what PPE we wear.

Indeed, treatment of soiled scrubs is receiving increased attention of late, says Milt Hinsch, technical services director for Mölnlycke Health Care.

Recent AORN recommended practices and AAMI (Association for the Advancement of Medical Instrumentation) directives have pointed to the practice of individual HCWs taking hospital scrubs and garments into and out of the hospital for laundering, for example as a questionable practice, Hinsch says.

Some administrators are even considering disposable scrubs, and others are preventing employees from wearing scrubs out of the facility. Another PPE trend, according to Hinsch, is the emergence of N95 respiration masks that would be used by healthcare workers if the avian influenza broke out.

N95 respirators and masks have become more readily available and more important, Hinsch says. N95 respirators and masks are best used in case of influenza, because they are designed for protection of the HCW from the virus rather than for protection of the patient from the HCW's bacteria- loaded saliva droplets.

In the glove market a shift continues toward powder-free surgical gloves, Hinsh notes.

Powder-free surgical gloves continue to erode the powdered surgical glove market, thank goodness, and the powder-free gloves comprise more than half the surgical glove market (perhaps as much as 60 percent), he says. There is tremendous confusion about hospitals claiming that they are, or are going to be powder free or latex free. Many people in the hospitals think that powder free and latex free are one in the same, and they are not.

Another theme that HCWs are sure to hear more about involves the treatment of pyrogens (a bacterial toxin that raises human temperature) and endotoxins.

Few people are familiar with the dangers of pyrogens and endotoxins, so Mölnlycke is developing a campaign to educate customers about the effects these bugs have on surgical gloves. When Hinsch tells HCWs that they should be concerned about these threats, they often ask why.

People asked the same thing about surgical glove powder 20 years ago, Hinsch says. They said we have been using powdered gloves for years and never had any problems, so why should we use a powder-free glove? Today, hundreds of millions of powder-free gloves are used in hospitals, eliminating the potentially harmful effects of glove powder everything from adhesions to asthma, Hinsch says. "Today, people ask what are pyrogens and endotoxins, and why should I be concerned? The reasons are many, and education is paramount.

Hinsch points out that all surgical implants from hips to stents to intraocular lenses should be non-pyrogenic, as should fluids, pharmaceutical drugs and all intravenous devices such as tubes, connectors and needles.

If pyrogens and endotoxins are not important, then why does the FDA dedicate so many regulations to them? Hinsch asks. The reason is that they are very important. They can cause everything from fevers to death and everything in between.

So, how does one handle drugs, surgical implants and IV components with powdered or non-powdered gloves contaminated with pyrogens and endotoxins and not contaminate the surgical implants, wounds, sutures, IV devices, and drugs that are required to be non-pyrogenic before use? Hinsch continues.

It is a problem.

Tips

Purchasing the proper PPE is no easy task, says Carolyn Twomey, RN, vice president of clinical and technical affairs at Mölnlycke Health Care.

For example, it makes a significant clinical difference in what direction the pleats of your face mask are turned and where the fluid barrier is in the layers of your mask, Twomey says. As in dealing with more sophisticated medical devices, it pays clinically and financially to be a smart consumer.

Twomey suggests that organizations enforce stronger PPE regulations and that facilities bundle strategies and approaches.

While I believe there is good awareness regarding exam gloves, we are finding those healthcare systems having the greatest successes against MDROs are using cover gowns and face masks in their bundled approach to reducing transmission and HAIs, she says.

More tips Twomey recommends are to:

• use cover gowns, masks and gloves 

• wash hands using an antimicrobial agent with continued killing action 

• carefully manage potentially contaminated equipment and environmental surfaces 

• preemptively isolate high-risk patients 

• chart patients who have egregious infections and chart the personnel who care for them 

• screen asymptomatic patients and personnel disinfect contaminated surfaces 

• educate personnel 

• destroy and discard supplies in a contaminated environment using biohazard strategies after a patient is transferred or discharged 

If a glove tears, the HCW should remove it carefully, wash their hands thoroughly with soap and water or alcohol-based hand rub, and put on new gloves, FDA guidelines proclaim. In the case of a mask or gown ripping, the HCW should follow the same protocol.

If the same items tear often or if other consistent flaws become apparent, the HCW should contact the manufacturer. One should never try to wash disposable gloves, masks or gowns, as the act may destroy their protective qualities, and these items should be thrown away carefully after each patient visit or if the items become otherwise soiled.¹ According to the FDA researchers, the only type of PPE that can be washed is a surgical gown that is labeled as washable for multiple use. There is no way to disinfect disposable PPE.

Inconsistency in the Ranks

Most HCWs know that PPE is important but they dont necessarily know which pieces are appropriate for which circumstances, Hinsch believes.

Double gloving, fluid-resistant fabrics, puncture indication gloves, N95 masks or respirators, etc., are just a few examples of products designed for increased protection (but) most healthcare workers might be hard pressed to explain when and why each should be worn, Hinsch says.

Every worker has different sets of challenges in their job, and the reasons for non-compliance are therefore conditional, according to Pear.

In most ICU and medical, surgical, unit-based care (which requires) standard or contact precautions, HCWs know when to use PPE, including hand hygiene, during a particular episode of care, she says. It isnt usually a knowledge gap, but rather an adherence gap. The excuses for nonadherence, when an episode occurs, may vary, but the primary reasons are either the HCW feels that she or he doesnt have enough time to use the PPE or the PPE isnt conveniently available.

Unfortunately, the average HCW does not take the issue of PPE seriously enough, says Bob Marrs, BA, CRCST, CHL, director of sterile processing at St. David's Medical Center in Austin, Texas.

I do think there are facilities that take this issue very seriously (but) I also know that there are numerous facilities that do not, Marrs says.

AAMI standards and recommended practices suggest that personnel working in the decontamination area should wear general-purpose utility gloves, liquid-resistant covering with sleeves (for example, a backless gown, jumpsuit, or surgical gown), Marrs says.

If there is a risk of any splash or aerosols, PPE should include a high-filtration-efficiency face mask and eye protection. I have visited institutions where the staff in the decontamination area only wore gloves. How scary is that? Marrs asks.

Facility leaders need to constantly preach the importance of correct PPE, Marrs believes.

We should remind our staff that not only are we keeping them safe, we are also looking out for the wellbeing of their co-workers and more importantly their loved ones, he says. In our facility, we take this issue so seriously that the incorrect donning of correct PPE 100 percent of the time is immediate disciplinary action up to and including termination.

What Needs to Happen

Pear agrees that healthcare administrators should create a pervasive culture of safety.

A culture where it is unacceptable not to perform hand hygiene or not to wear PPE when indicated, where HCWs wouldnt dream of approaching a patient without first performing hand disinfection, she says. In such an environment, adequate infection prevention staffing, healthcare worker staffing and environmental cleaning staffing, ongoing education and performance feedback and readily available PPE supplies would be the norm rather than the exception.

If staff members are expected to don appropriate PPE, that PPE needs to be abundant.

For fighting infection, best PPE means appropriate for the exposure risk and I would say that this critical, Pear says. If blood or body fluids is a potential exposure, then the PPE needs to be fluid resistant. If an infectious respiratory aerosol is a potential, then respirators rather than surgical grade masks need to be readily available and the HCW should already be fitted and trained on respirator use. Also, it cant be stressed enough the importance of having the PPE reliably and conveniently available.

There is no shortage of such supplies, Marrs maintains.

I believe that the market provides fair amount of products that offer the protection that we are looking for, he says. (However) I also believe that there is room for growth in this industry.

Back to School

Proper PPE education is an absolute must, according to Pear.

There does seem to be a lack of understanding among HCWs about how easily their hands, scrubs, equipment, etc. become contaminated with potentially pathogenic organisms, which subsequently contaminate and colonize their patients, she says. It is the rare healthcare facility that fully tracks patient colonization and most importantly, feeds that information back to the HCWs so that they get a true, ongoing report card on the adequacy of their infection prevention activities.

Effective PPE education campaigns are certainly available, according to Hinsch.

Mölnlycke Health Care has hand hygiene programs already and is developing new programs for the proper use of PPE (including) caps, masks and gloves, he says.

Six clinical nurse consultants provide this program to healthcare personnel free of charge.

A myriad of organizations can also provide vital resources, says Nahum. To find out more about Safe Care Campaign and other resources, visit Nahums Web site at www.safecarecampaign.org. 

Facility leaders need not reinvent the wheel. Instead, they should rely at least in part on the wealth of resources available. The Centers for Disease Control (CDC) and Prevention, for example, provides the following PPE education template intended for nurses, doctors, technicians, housekeepers and maintenance workers.

It can be tweaked for use in any facility and only requires a trainer, a projector, screen, flip chart and pens. Presenters can solicit the CDC for corresponding slides that provide a PPE overview and terminology explanation. Presenters will find it helpful to bring in actual PPE for demonstration purposes to show adequate examples as well as inadequate examples (such as torn or outdated items).

The goal of the session is for participants to be able to identify the correct use of PPE, understand how PPE helps prevent even the most refractory illnesses, become more acquainted with general safety issues and learn how to properly don and remove apparel.

The CDC tutorial consists of an approximately half-hour lecture, 15 minutes of question and answer, a 15-minute apparel demonstration (of how to properly don), and however much practice time is necessary for participants to reenact donning and disposal techniques. Planners recommend starting with a five-minute ice breaker wherein audience members answer questions such as:

• what is the biggest roadblock to properly using PPE 

• do you feel protected when wearing PPE 

• what type of PPE do you use most often 

• what are the biggest mistakes that you think HCWs make in regards to PPE?

The workshop planners suggest that the group be divided into teams of three or four people, each of whom critique each others PPE donning and removal.

Another training exercise is to share hypothetical patient scenarios, then ask the groups to discuss which PPE would be appropriate for that situation.

While some of this information may be too basic for HCWs who are knowledgeable about PPE and who use it appropriately 100 percent of the time, it is far better to risk patronizing this group than to forsake less knowledgeable staff members from information that could save a patients life, or their own.

References 

1. www.fda.gov/cdrh/ppe/fluoutbreaks.html 

2. www.cdc.gov/ncidod/dhqp/ppe_train.html

Theres No  Linen in the Laundry:
A Clarification of Terms

By Nathan L. Belkin, PhD 

Wheres the Linen?

It's a question commonly asked of the laundry. Actually, although it is quite possible that the inquirer may be questioning the whereabouts of sheets and pillow cases, they can actually be inquiring about one of a number of patient care items. Yet, strangely enough and for whatever reason, in the mind of the user, if the item comes from the laundry, it is "linen."

Just What is Linen?

The truth of the matter is that as fabric, linen is made from the fiber and yarn of flax plants. The botanical name of flax is derived from the Latin Linum usitatissimum and originally referred to linen. As a textile material, linen has been used for a millennia. As evidence of its durability to the elements, linen fabrics dating back to as early as 4500 B.C. have been uncovered in Egyptian archaeological sites. The hot, dry climate of Egypt has preserved samples of both coarse and fine linen materials used during that period. Linen fabrics thought to be as much as 7,000 years old have been excavated from the dried-out lake mud of prehistoric villages in Switzerland. Until about 500 A.D., linen was the choice of the wealthy because it produced fabrics that were lighter, more absorbent and comfortable than those made of either cotton or wool.

Flax was probably the first fiber to be used to make textiles in the Western Hemisphere. When Tutankhameen's tomb was opened in 1922, linen curtains, placed in the tomb about 1250 B.C. were still intact.

Linen in Today's Textile World

In 2006, the United States grew approximately 700,000-plus acres of flax which represented about one-third of the North American crop. Of world fiber production today, linen's share is estimated to be about 2 percent. Nevertheless, linen does have a place in the textile world. A good portion of its production is used in apparel items and accessories (i.e., dresses, skirts, blouses, suits, coats, shirts, ties, handbags, purses, hats and handkerchiefs). Linen is also found in altar cloths, religious vestments, artists' canvas and sutures for delicate operations. Linen has been found to be ideal for wallpaper and wall coverings because of their irregular texture that adds interest, hides nail holes or wall damage and muffles noise. The fabric is also used in upholstery and window treatments because of its durability, interesting and soil-hiding textures and versatility in fabrication and design.

Processing Healthcare Textiles

The community has three options that can be utilized for the processing (laundering) of their textiles.

First is the commercial sector that can provide that service. Known as the Textile Rental Association of America (TRSA), each of the items is provided on a rental basis. For those facilities that want to buy their items, they are charged only for the processing cost. Whatever plan a hospital may choose, the commercial sector is the largest provider of the services to the healthcare market today.

This group recently spearheaded the formation of the Healthcare Laundry Accreditation Council (HLAC). As a non-profit organization, its mission is to publish high standards for processing textiles for hospitals, nursing homes and other healthcare facilities. The Council can provide an inspection and accreditation process that recognizes those laundries that meet those high quality standards. To date, 11 laundries have received accreditation and another 30 are in the process of preparing for the inspection that will qualify them.

The second option is one in which the services are provided by what is known as a co-op plant. As the name implies, the plant is owned by a number of institutions in the area. The managers of these operations have their own association known as the International Association for Hospital Textile Management (IAHTM). This group also participated in the formation of the HLAC.

The original and oldest of the three options is for the hospital to own its own processing (laundry) plant. The managers of these type of facilities also have a professional organization known as the National Association of Institutional Linen Managers (NAILM). Their sister group, known as the American Laundry and Linen College (ALLC) also has a three-part educational program that it offers their members and others. Those that complete the three courses are recognized as being a Registered Laundry and Linen Director (RLLD).

The question as to why NAILM continues to use the term 'linen' in their name as well as that of their ALLC and RLLD programs can only answered by them. It should also be noted that there are vendors who similarly continue to promote their products for use in processing 'linen.'

Summary

The purpose of this epistle is not to answer the question, but rather is one for those who continue to use the term 'linen' in the healthcare market when they well know that the items are actually made of one of the myriad of the 21st century's generation of reusable textiles and should be called what ever they are. Even if used on beds, if not made of fibers and yarns from flax plants, they're not linen!

Nathan L. Belkin, PhD, is founder and past president of the American Reusable Textile Association. The author wishes to acknowledge the assistance of Karen Leonas, PhD, professor of textile science in the Department of Textiles, Merchandising and Interiors at the College of Family and Consumer Sciences at the University of Georgia in Athens, Ga., in the preparation of this article.

Resources 

1. AmeriFlax, Mandan, N.D. Flax Council of Canada, Winnipeg, Manitoba, Canada.

2. Collier, B. J., and Tortora, P. G., Understanding Textiles, Sixth Edition, Prentice Hall, Upper Saddle River, N.J.

3. Hatch, K. L., Textile Science, West Publishing Company.

4. Kadolph, S. J., and Langford, A. L., Textiles, Ninth Edition, Prentice Hall, Upper Saddle River, NJ Smith, B.F. and Block, I., Textiles in Perspective, Prentice-Hall, Inc., Englewood Cliffs, NJ.

5. Trotman, E. R., Dyeing and Chemical Technology of Textile Fibres, Fifth Edition, Charles Griffin & Company, Ltd., London, and High Wycombe, UK.