By Phenelle Segal, RN, CIC
As personal protective equipment (PPE) continues to play an integral role in prevention of transmission of infection in the healthcare setting, we discover by looking back at the history of protection of healthcare workers (HCWs) and prevention of spread of infection, that the concept is several centuries old.
PPE was thought to have originated during the war years as a means to prevent contamination from chemical warfare. The use of respirators allowed soldiers to protect themselves from toxic chemicals and Leonardo da Vinci was thought to be the original inventor of the respirator during the 16th century. Since Da Vinci’s invention, respiratory protection technology has been standardized, is much more reliable and requirements for safe devices clearly spelled out by the National Institute for Occupational Health and Safety (NIOSH) and the Occupational Safety and Health Agency (OSHA). The N95 respirator mask, which is mandated for use in healthcare settings that are equipped to treat patients with pulmonary tuberculosis or other respiratory illnesses transmissible via the airborne route is an example of NIOSH’s involvement with PPE. HWCs who are identified as “at risk” for airborne transmission of organisms and required to wear these masks, are mandated to undergo a “fit test” for maximum benefit as face shape influences effectiveness of use.1
The more commonly used PPE items include cover gowns and gloves which originated when the Centers for Disease Control and Prevention (CDC) published a manual known as “Isolation Techniques for Use in Hospitals” in 1970 with a revision in 1975. It was developed for use in small community hospitals as well as large teaching hospitals and included category systems for isolation. By the mid 1970s approximately 93 percent of hospitals were using these guidelines which included the use of limited PPE. By the early 1980s new pathogens were emerging including resistant bacteria and healthcare professionals were seeking assistance particularly for special care units that appeared to have an issue with these emerging pathogens. In 1983, the CDC Guideline for Isolation Precautions in Hospitals was published which replaced the isolation manual from 1975 and included significant changes to practice. The use of PPE was intensified after the human immunodeficiency virus (HIV) was identified and in 1985 Universal Precautions (UP) was introduced as a new strategy to prevent transmission of infection from needlestick injuries and possible contamination of skin. Traditional use of gloves and gowns expanded to include face masks and eye shields to prevent mucous membrane exposure. Devices for resuscitation as they pertained to artificial ventilation were addressed too. In 1989, OSHA proposed a rule on occupational exposure to bloodborne pathogens that raised concerns in the infection prevention arena and after a series of hearings it was modified in 1991 when a final rule was published.2 Healthcare workers were on heightened alert for exposure to blood and body fluids and manufacturer’s worked round the clock to develop disposable impervious gowns, latex and vinyl gloves, procedure masks for use outside the operating room and eyeshields to protect mucus membranes. At times, especially in the mid- to late- 1980s, items were periodically in short supply or unavailable.
PPE in the 21st Century
CDC issued a major isolation guideline in 2007, which remains in use and PPE is addressed in detail including technique for donning and doffing PPE with helpful illustrations.3 After the release of the guideline and the exponential rise in incidence of multidrug resistant organisms includ-ing Clostridium difficile infection (CDI), facilities were under pressure to educate and monitor HCWs providing hands-on care. PPE to be used universally when contamination of hands, clothing and mucous membranes were anticipated. Ongoing education, direct observation and monitoring, written documentation of compliance and type of action for non-compliance are key components of an infection prevention program. In addition, input from HCWs as to the barriers for PPE is critical as the wearing of PPE can be uncomfortable and certain staff members have allergies to products. Input includes but is not limited to consideration of various gown fabrics to ensure impermeability and ease of wear. Gloves of various materials to accommodate the needs of HCWs were introduced such as powder free, nitrile and latex free gloves and require ongoing evaluation. Eye shields became available in the form of reusable goggles (cleaning according to manufacturer’s instructions for use) and disposable faceshields with or without attached masks. Various types of procedure masks were also introduced.
PPE Across the Continuum of Care
PPE has evolved and adopted across the continuum including specialty hospitals such as mental health facilities and surgical specialty hospitals, long-term care facilities and outpatient settings. Use of PPE in the long-term care setting was scant until the healthcare landscape shifted from lengthy acute care stays to admitting patients with high acuity needs to nursing homes, rehabilitation facilities and sub-acute facilities. For at least the past two decades long-term care facilities have had no option but to introduce and maintain contact precautions which at a minimum, necessitates the use of gowns and gloves when rendering care to residents colonized or infected with multi-drug resistant organisms. Categories of isolation with corresponding PPE remain a vital component of infection prevention and facilities adapt them to their individual settings. Ambulatory surgery centers (ASCs) have been closely scrutinized since 2009 with respect to overall infection prevention practices including management of MDROs and outpatient settings such as clinics (freestanding and hospital based) were included in the CDC’s effort to manage transmission of infection across the continuum of care.4-5
Special Circumstances: PPE and Ebola Virus Disease
In October 2014, the first case of Ebola Virus Disease (EVD) was identified in a patient who traveled to West Africa, entered the U.S. after exposure and died at a hospital in Dallas. Through miscommunication upon his first visit to the emergency department (ED), this patient was not identified as a possible Ebola victim and therefore PPE use was at a minimum.6 He returned to the hospital and died in the intensive care unit. As a result of exposure, two nurses were infected and cared for at hospitals designated to treat Ebola patients. It is unclear how the exposures occurred as in particular, one nurse was wearing full PPE during the care of the index patient. This incident emphasizes that correct use of PPE at all times is imperative.7 The CDC and the World Health Organization (WHO) upon recognizing the potential for additional cases from West Africa to the U.S., ramped up efforts to include full coverage of healthcare worker’s bodies including mucous membranes as contact with infected bodily fluids is highly contagious. Ebola can infect blood, sweat, feces, emesis, semen and saliva. The WHO released guidelines on Oct. 31, 2014 that included use of PPE “that protects the mucosae – mouth, nose and eyes – from contaminated droplets and fluids. Given that hands are known to transmit pathogens to other parts of the body, as well as to other individuals, hand hygiene and gloves are essential, both to protect the health worker and to prevent transmission to others. Face cover, protective foot wear, gowns or coveralls, and head cover were also considered essential to prevent transmission to healthcare workers.” The WHO had to take into account that selecting PPE included a balance between protection for healthcare workers and providing the best possible care while donning full body covering that was subject to difficulty in movement and heat-related issues.8 CDC provided initial guidance in a special document which highlighted the following: “All PPE must be used in the context of a comprehensive infection control program that follows CDC recommendations and applicable Occupational Safety and Health Act of 1970 (OSHA) requirements, including the Bloodborne Pathogens (29 CFR 1910.1030), PPE (29 CFR 1910.132), and Respiratory Protection (20 CFR 1910.134) standards, and other requirements under OSHA (e.g., the General Duty Clause, section 5(a)(1); and prohibitions against dis-crimination or retaliation against workers, section 11(c)).”9 In addition, ongoing updates for use of PPE and the 2007 guidelines include an Appendix A with the most recent guidance.3
PPE in the Surgery Setting: Recent Controversy
PPE use in the surgery setting for the purpose of prevention of transmission of infection, particularly in the pre-op or holding and post anesthesia care unit or PACU has played a role in the facility’s infection prevention program and during the course of the past couple of years, accreditation agencies (The Joint Commission, AAAHC, DNV) as well as CMS have been particularly focused on surgical attire including the correct use of PPE. Hospitals and ASCs are expected to follow “nationally recognized guidelines and standards”4
Recent controversy has arisen after a statement was released by the American College of Surgeons (ACS) on Aug. 4, 2016 titled “Statement on Operating Room Attire.” The statement includes the following language: “The guidelines for appropriate attire are based on principles of professionalism, common sense, decorum, and the available evidence.” This guidance includes several statements that pertain to wearing of scrubs and head coverings.10 The Association of periOperative Registered Nurses (AORN) responded on Aug. 16, 2016 as the guidelines were quickly referred to by surgery staff as confusing and controversial. The controversy amongst other items in the statement, pertains to covering hair and the scalp as this is an ongoing issue in many surgical suites. It has taken a huge effort on the part of infection prevention personnel and managers of operating room suites to enforce AORN standards, particularly as it relates to surgical attire and PPE. The following opening statement was of particular concern to AORN: “The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence.” As AORN points out in its response, “Regulatory agencies, accrediting bodies, and patients expect healthcare organizations to follow guidelines that are evidence based rather than conclusions based on professionalism, common sense or decorum. All cur-rent evidence for safe surgical attire is presented along with recommended evidence-based practices in AORN’s Guideline for Surgical Attire. The AORN guideline development process meets the rigorous requirements of, and are accepted by, the AHRQ National Guidelines Clearing-house.”11-12
In conclusion, PPE has evolved over the centuries as healthcare needs have increased and become more challenging. It is important for facilities, regardless of the setting, to utilize PPE effectively and include the following in the infection prevention plan for maximum benefit:
• Follow nationally recognized guidelines and standards for prevention of transmission of organisms from healthcare worker to patient, patient to healthcare worker and patient to patient.
• Ensure that the facility has selected evidence-based guidance from national known associations and agencies.
• Provide healthcare workers with the necessary guidance, education, tools and supplies to enhance the use of PPE.
• Listen to healthcare workers concerns as they relate to choice and/or use of PPE.
• Monitor compliance and develop a plan of action for non-compliant healthcare providers.
• Document compliance and action taken to show that the facility is serious about the use of PPE.
Phenelle Segal, RN, CIC, is president of Infection Control Consulting Services.
1. PPE from the beginning. Health and Safety Middle East. March 11, 2013. Available online at: http://www.hsmemagazine.com/article.php?article_id=786
2. CDC isolation manual obtained from archives. Available online at: http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp
3. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. CDC and HICPAC. Available online at: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
4. Ambulatory Surgery Center (ASC) Surveyor Worksheet. Centers for Medicare and Medicaid Services (CMS). Updated July 2015. Available online at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf
5. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. Centers for Disease Control (CDC). Updated November 2015. Available online at: http://www.cdc.gov/hai/pdfs/guidelines/Ambulatory-Care+Checklist_508_11_2015.pdf
6. Dallas Hospital Diagnoses First Patient With Ebola. USA Today. October 1, 2014. Available online at: http://www.usatoday.com/story/news/nation/2014/09/30/dallas-ebola-patient/16496665/
7. American Nurse with Protective Gear Gets Ebola – How Could This Happen. CNN. October 14, 2014. Available online at: http://www.cnn.com/2014/10/13/health/ebola-nurse-how-could-this-happen/index.html
8. WHO Updates Personal Protective Equipment Guidelines for Ebola Response. WHO News Release. October 31, 2014. Available online at: http://www.who.int/mediacentre/news/releases/2014/ebola-ppe-guidelines/en/
9. Guidance on PPE To Be Used By Healthcare Workers During Management of Patients with Confirmed Ebola. CDC guidance. Updated August 2015. Available online at: http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html
10. Statement on Operating Room Attire. American College of Surgeons. Aug. 4, 2016. Available online at: https://www.facs.org/about-acs/statements/87-surgical-attire/
11. Association of periOperative Registered Nurses. AORN Responds to ACS Statement on Surgical Attire. August 16, 2016. Available online at: https://www.aorn.org/about-aorn/aorn-newsroom/periop-insider-newsletter/2016/2016-articles/aorn-responds-to-acs-statement
12. National Guidance Clearinhouse Fact Sheet. Agency for Healthcare Research and Quality. Updated August 2012. Available online at: http://www.ahrq.gov/research/findings/factsheets/errors-safety/ngc/national-guideline-clearinghouse.html