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Disposable products can facilitate and enhance infection prevention and control efforts in the healthcare setting and reduce the opportunity for cross-contamination.
“Intelligent and informed use of disposable personal protective equipment (PPE) is a critical component of any facility’s efforts to prevent and control infection,” says Caroline Gullion, product manager of surgical apparel at Cardinal Health.
Disposable products can also help remove reservoirs of pathogenic organisms, namely healthcare workers (HCW)'s medical apparel during patient-care activities.
“The purpose of disposable barrier products is to prevent the transfer of microorganisms from a non-sterile field to a sterile field,” says Caroline Ginn, RN, BSN, senior consultant in infection prevention for Cardinal Health. “The qualities of disposable products provide excellent barrier performance. For example, linting in the surgical setting has been documented to increase the incidence of surgical site infections by providing a mode for transporting bacteria. With the advent of non-woven materials, the lint has virtually been decreased to little or no lint present.”
One important aspect of disposable products such as gowns is barrier protection levels.
“Protective apparel must meet minimum performance standards for strength, barrier protection and fluid resistance to ensure the safety of HCWs and patients,” says Judson Boothe, marketing director of medical supplies for Kimberly-Clark Health Care.
Gullion says that these performance properties — minimum strength, barrier protection and fluid resistance — are especially important in the operating room. “For surgical gowns, the Association for the Advancement of Medical Instrumentation (AAMI) has developed a recommended standard for liquid barrier performance to help protect HCWs during surgery and other procedures in which exposure to blood, body fluids and other potentially infectious material (OPIM) might occur,” she says. “The critical zones of a surgical gown include those areas where direct contact with blood, body fluids and OPIM are most likely to occur.
In order to select the most appropriate and effective personal protective equipment, HCWs must be able to assess a product’s protective capabilities, including its barrier requirements and AAMI classification. When selecting a surgical gown, it is also important to consider the type of surgical procedure it will be used for, how long the procedure will last, and the clinician’s level of exposure to fluid during the procedure.
“It’s estimated that clinicians in 30 percent of all surgical procedures should wear an AAMI Level 4, fully impervious surgical gown,” Gullion says. “Those involved in the remaining 70 percent of procedures should wear an AAMI Level 3 surgical gown. HCWs exposed to even minimal amounts of fluid during surgical procedures should avoid AAMI Level 1 or 2 gowns, because they won’t likely offer the necessary level of protection.”
Boothe explains that the AAMI guidelines, a widely accepted system of classification for protective apparel and drapes, are based on liquid barrier performance in four tests:
• The Spray Impact Test - simulates resistance to “arterial spurting,” often seen when an artery or blood vessel is damaged during blood draws, I.V. changes, or injections. When checking the AAMI guidelines, the higher the number, the lower the fluid resistance.
• The Hydrostatic Pressure Test - measures liquid penetration like that of a healthcare worker’s arm or torso leaning or resting against contaminated fluids on a gown during procedures involving irrigation fluids, tissue fluids, or other liquids. The higher number means better resistance.
• ASTM F1670 - used for testing drapes, measures resistance of materials used in protective clothing to penetration by synthetic blood at 2psi under ambient pressure.
• ASTM F1671 - used for testing gowns, measures resistance in protective clothing to bloodborne pathogens by viral penetration at 2psi and ambient pressure.
“For gowns, drapes and other protective apparel, AAMI minimum performance levels ranging from 1 (least protective) to 4 (most protective) have been determined,” Boothe says. “These levels apply to the product’s critical zone; in gowns, the critical zone is the entire gown, including seams, but excluding cuffs, hems and bindings.”
It is important for HCWs to be familiar with AAMI PB70: Standard and Reusable Apparel. Boothe notes that it is possible for re-usable, multiple-use products to receive AAMI classification, however they must meet a few additional criteria. “If purchasing reusable apparel, the manufacturer must provide the processing instructions, which the facility must follow. Facilities using reusable apparel need to know the number of times the article can be processed while still maintaining its performance properties. Facilities should have a verifiable tracking system in place, such as manual check off, bar code or radio frequency (RF) chip to track the number of times the product has been processed. This will allow the facility to know when a product must be removed from use, in accordance with the manufacturer’s instructions. Also, each product must be routinely inspected for maintenance of barrier quality. If barrier performance cannot be verified, the product must then be downgraded to ‘nonprotective.’”
Boothe continues, “Another important point to remember is that gowns protect patients and staff. However, they can also be a mode of pathogen transmission if not used, removed and discarded appropriately. Regardless of whether disposable or re-usable gowns are purchased, they should only be used once, then discarded or reprocessed. This is extremely important as organisms such as MRSA can survive as long as several months on virtually any surface with patient or healthcare worker contact, such as stethoscopes, pagers, pens, blood pressure cuffs, otoscopes, bed rails, bed tables, doorknobs, patient charts, etc., proper use of personal protective equipment (PPE) is crucial in preventing the contact transfer of infection—to patients, visitors and to fellow HCWs.”
There are pros and cons to using disposable and reusable infection control products. The decision-making process often becomes more difficult for healthcare facilities that are trying to reduce both disposal costs and high labor costs related to reprocessing. And when it comes to evaluating the safety and infection control abilities of disposable and reusable products, particularly surgical textiles, there is little consensus on which is better, other than the importance of balancing cost considerations relating to infection prevention issues and the environment.
Pick your study – there is well-document information supporting both types of products. The American National Standards Institute and AAMI published a study showing that when laundered properly, reusable garments and drapes are 70 percent more effective in providing barrier protection. However, a European study concluded that the microbial-penetration resistance of single-use drapes and gowns is superior to that of reusable drapes and gowns, highlighting that the reusable products showed a lower liquid resistance than required in critical areas. There was one thing both studies agreed upon: appropriate processing is of major importance.
Costs and Environmental Issues
In today’s economy, hospitals are beginning to fully appreciate that purchase price is not the only cost of the product – one must also take into account associated costs in the product’s lifecycle. For example, with disposables one must consider the cost of waste removal, which for an average hospital is $44 to $68 a ton. According to the 2005 Comparative Operating Revenues and Expense Profile for the Healthcare Textile Maintenance Industry, if a 300-bed hospital chose to use disposable surgical products rather than reusables, they would incur upward of an additional $250,000 in costs to trash the disposable products – or about 35 cents per pound or $833.33 per bed per year. Disposable textiles require more onsite storage as compared with reusables that are delivered daily, and whether sent to a landfill or burned, disposable medical textiles potentially can pollute water supplies and the air. Potentially, the space currently used for storing disposable products could be converted to revenue-generating uses, such as for medical equipment, operating rooms or more patient beds. However, while disposable products generate a significant amount of waste, the cleaning and storage of reusable products has its own impact on the environmental and cost management. According to the Environmental Protection Agency (EPA)’s Energy Star program, hospitals spend $8.3 billion on energy each year and offer $2.5 billion in potential savings. While innovations in laundering have cut the amount of water, energy and chemical use by two to three times, a hospital with more than 300 beds typically uses 16 pounds of textiles per patient day, making laundry services one of the top services accounting for most of a hospital’s energy use. Reusable textile services can create economical benefits for the hospital in this area by taking over or simplifying logistic procedures and transparency of consumption and costs allow effective control.
So how do you choose? Alecia Cooper, RN, MBA, CNOR, senior vice president of clinical services for Medline Industries, suggests that clinicians establish performance criteria for product selection and then measure both products against them. For example, the considerations for for surgical textiles are:
• Strength: Will the product last throughout the entire procedure?
• Absorbency and fluid control: Does the fabric and associated fluid control features hold up during routine surgical application?
• Conformability: Is the material easily applied and will it drape according to the proper application techniques?
• Comfort and breathability: While it must perform according to standards, it must also be something that can be worn comfortably for long periods of time.
• Barrier protection: Without this, there would be no reason to wear a gown or drape a patient.