By Frances T. Koch, RN, MSN, CNOR
Since 1991 when OSHA published the final rule on occupational exposure to bloodbornepathogens, healthcare institutions have been responsible for providing barrier protectionfor healthcare workers (HCWs).1 Numerous products are available that provideprotection from bloodborne exposure. There remain concerns regarding the way staff selectthe appropriate device for the anticipated exposure, and whether they use the productcorrectly. The cost of providing healthcare continues to rise and the level ofreimbursement continues to decrease; therefore, it is imperative that HCWs know how toselect 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 forextended periods of time, especially by less knowledgeable staff. Obviously, there arereasons why this is unacceptable. First and foremost, if the employee does not understandthe way that organisms are spread to inanimate objects, they do not understand the riskthat they are subjecting themselves and their fellow workers to when they continue to wearcontaminated gloves. There must be a program to educate staff to the method of bacteriatransmission. This is not an easy task as many housekeepers, orderlies, and nursingassistants may use English as a second language. The education must have teaching toolsthat illustrate how bacteria from contaminated gloves can be deposited on a clean surfaceand spread to an innocent person who later touches that surface. This information must befactual. The idea is to instill information and understanding for appropriate decisionmaking--not fear. The Emergency Care Research Institute has an education program, BloodbornePathogens Training Program, available for use.2
When HCWs clearly understand how bacteria are transferred, they know when it isappropriate to don gloves and when they must be removed and discarded.
Not only should gloves be worn appropriately to limit the spread of microorganisms, theuse of gloves should be limited to reduce the risk of developing a latex allergy. Theincreased use of gloves in the 1980s, due to the heightened awareness of the need forpersonal 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 severalinstances, HCWs have been forced to leave the healthcare environment and identifyalternative practice environments. Latex allergy is currently a major concern forhealthcare institutions for both patients and staff. Cost constraints and productacceptability 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 areneeded for personal protection. In areas that do not require latex gloves, the use ofalternative products such as vinyl should be encouraged.3 All employees must betaught to limit their exposure to latex whenever that is acceptable.4
Double gloving is another area of concern. Studies have shown a reduction inneedlesticks result when surgeons double glove; however, some surgeons seem reluctant toimplement this practice and scrub personnel, who research has shown do not have a need todouble glove, may initiate the practice believing it to be appropriate for them.5The number of needlesticks by surgeons should be identified and double gloving recommendedwhen there is a concern. Double gloving by scrub personnel should be discouraged as it maybe an unnecessary expense.
Gowns are the more critical product as they provide barrier protection for patientsfrom 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- useproducts. Cost constraints dictate that a gown providing the appropriate level ofprotection be selected for the anticipated level of exposure. There is no need to wear agown with the highest barrier protection when assisting with a procedure that has minimalor 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 andDrapes in Healthcare Facilities, that provides guidance to the user in the selectionof gowns and drapes. Subsequent to the publication of that document, the American Societyfor Testing and Materials (ASTM) adapted ASTM F1670 as a Standard Test Method forResistance of Protective Clothing Material to Synthetic Blood and ASTM F1671 as a StandardTest Method for Resistance of Protective Clothing Materials to Penetration by BloodbornePathogens Using Viral Penetration as a Test System for Viral Penetration. Both arepass-fail tests and discern strikethrough when two pounds of pressure is exerted onfabric. ASTM F1671 is only necessary for use with gowns to determine whether the fabricallows 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 notbeen universally accepted by all experts; due to the pass-fail aspects, the fact that theproduct being tested, such as a gown must be destroyed to perform the test, the testingequipment is very expensive and thus not practical for use in the healthcare setting andonly uses two pounds of pressure when previous studies have shown that as much as 50pounds of pressure may be exerted during complex orthopedic procedures where pressing,leaning and external force is applied. Nonetheless, these are currently the only twostandardized tests approved for measuring barrier properties in the US.
With that understanding, the healthcare worker in need of making a decision onappropriate barrier protection for a surgical procedure involving an intermediate orminimal level of exposure is totally at the mercy of the vendor. At this time, there is noconsensus regarding appropriate test methods for determining other levels of barrierprotection. Two tests that are frequently mentioned by vendors are AATCC127 thehydrostatic head test and AATCC42 the impact penetration test. Both tests are routinelyused in laboratories to indicate levels of barrier protection. There is a lack ofconsensus regarding the significance of the tests as well as whether there is acorrelation between the two tests. The hydrostatic head test is somewhat subjective inthat it requires the tester to identify strikethrough when it occurs and to end the testpromptly. The impact penetration is less subjective in that the volume of strikethrough isquantified by weight. Results of both tests are routinely quoted by vendors.
Currently AAMI has convened the Protective Barriers Committee to work on thedevelopment of a standards document that identifies multiple levels of barrier protectionand to establish a consensus on the appropriate tests for lesser levels of protection.
While drapes have not been shown to have a conclusive impact on SSIs, there is littlequestion regarding the need for draping of patients for surgical procedures. Besides theiruse for the establishment of the sterile field, patient drapes maintain personal dignityfor 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 isno longer required for barrier products whether single-use or multiple-use products. ORmanagers should review current practices in each procedure to determine whether drapingpractices are excessive. There are substantial cost savings to be made by drapingappropriately. Surgeons need to have a clear understanding of the implications of theseexcesses and the cost of continuing these practices. In today's practice environment,physician profiling affects the surgeons as well as adding additional, unnecessary expenseto the OR budget. OR staff also must understand the reason for the change and support theeffort; otherwise, product creep will occur and soon the surgeon may return to his oldhabit.
Drapes serve an important function in providing a sterile field for the back table andMayo stand. OR managers must insist that the quality of these products provide adequateprotection. The tendency by some vendors to go to a lesser quality of plastic should notbe accepted.
Some complex orthopedic procedures require 30-40 instrument sets that are varyingweights and various tray configurations. It is critical that the drapes for these tablesprovide 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 useof huck towels, while not a barrier, should be identified by OR managers. It is importantto know how many towel packs are used in the OR in a month and what that total cost is. ORstaff frequently do not attach a cost to huck towels and open towel packs in a cavalierfashion. While this is a very difficult practice to change, at the very least staff shouldbe told of the cost of this practice.
While we may not have all of the information that we would like to have to make thebest decisions, we must develop mechanisms within our institutions to:
It is the responsibility of the leadership within an organization including theinfection control department and the quality assurance area to verify that all employeeshave a clear understanding of standard precautions, what they mean to that person as anindividual, what PPE is available, and how that equipment is to be used for the protectionof themselves and the protection of others in the environment.
Education offerings must be developed that clearly communicate this information at alevel that is appropriate for the audience. There must be return demonstrations toreassure the educator that the individual has a clear understanding of the information.
Each individual in the healthcare setting must be mindful of their responsibility tomonitor the performance of others.
Fran Koch's is the Director of the Operating Rooms and Sterile Processing andDistribution at Presbyterian Hospital in Dallas, Tex.
Prior to joining Presbyterian Hospital of Dallas, Fran was the AssociateAdministrator 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.
2. Operating Room Risk Management, Bloodborne Pathogens Training Program ECRI, Infection Control 9.2 Nov. 2000: 3-33.
3. Donaldson K., Creating a Latex-Safe Environment: Converting to Power-Free Gloves Infection Control Today, Feb. 2000: 32-34.
4. Kurtz S., Make Your Facility Latex-Safe, Outpatient Surgery Magazine, June 2000. 1, 5: 29-33.
5. Quebbeman E J., et al. Double Gloving; Protecting Surgeons from Blood Contamination in the Operating Room, Archives of Surgery 127, Feb. 1992: 213-217.
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