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By Karen A. Huggins, MN, RN, CNOR
Duringthe past decade, the healthcare industry has provided many technicalinnovations, safety device equipment and supplies, and research related tohealthcare 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 ofwhich particular piece of PPE should be used; however, there are factors in thework environment that influence compliance.
The purpose of this article is to describe some attributes of PPE and todiscuss 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 hasbeen completed for many years without an incident, will it alter the result ifchanged?
The more appropriate issues of concern need to be that we are given access tosupplies and equipment that meet the needs of healthcare workers and patients inproviding safety. Training of healthcare employees must include information onblood-borne pathogens and standard precautions. Staff must gain an understandingof the risks involved in exposure, to not only themselves, but to the patient.Accidents and exposures continue to occur and need to be reported andinvestigated.
Among healthcare workers, one of the most universal perceptions regardingexposures 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 incidentoccurred due to a lack of knowledge or from non-compliance. Resistance implies aholding back as in resisting change. The individual knew PPE was available butunder the circumstances held back and chose an excuse, avoiding protection. Thisis as if to say that "just this time, it will not happen to me, or I willbe careful." Vaccines for hepatitis are available and there are someindividuals who have refused to be vaccinated. Resistance is also shown byfailing to report an injury and or to refuse treatment following the injury."The failure of nurses to report needlestick injuries has been estimated instudies to range from 30% to 60%. Marcus and coworkers report that needlestickexposure to HBV carries a 6% to 30% risk of infection whereas HIV needlestickcontact carries less than a 1% chance of seroconversion."1
Regrettably, knowing the incidence of blood exposure and injury does notallow us to know the exact risk of contracting a blood-borne infection. Byimplication, however, any maneuver that reduces exposure to blood and injurywill also reduce the risk of contracting a blood-borne infection2
Risks for exposure in the healthcare setting are unlimited as to where onemay occur. The literature reviewed was centered on the surgical arena andinfection control research. The content may be applicable to any patient caresetting. The risk of acquiring bloodborne pathogens in the surgical setting isnot limited to OR personnel. There are several reports in the literaturedocumenting health care worker-to-patient transmission of HIV, HBV, and HCVduring invasive procedures.3
In the surgical setting, the occurrence of an exposure is noted as beinghigher among surgeons and first assistants initially, followed by OR personnel.
Several factors were found to significantly alter the risk of bloodcontamination or injury in surgery.
Surgical specialties such as orthopedics, cardiovascular, and plasticreconstruction are noted to be among the higher risks for injury. Injuriescaused by vascular access needles fall into the Centers for Disease Control andPrevention's (CDC) high risk category for bloodborne pathogen transmission. Thehigher risk is linked to a larger blood inoculum associated with injuries fromblood filled hollow-bore needles. Anesthesia personnel sustain most of thesepotentially 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, thegreater the risk of exposure. Gowns, are an example of PPE that clearly reflectthis correlation. Liquid penetration through a gown is dependent upon severalthings: 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-bornepathogens can be categorized by the event of occurrences without providingspecific details. Root causes may be identified by events that occur in aparticular setting or as identified by national benchmarks such as those done byCDC. The events become the stories that many healthcare workers experienced asan exposure or injury.
No PPE being worn or used when an incident occurred or not having the mosteffective protection available for the task at hand. This could impact the eventover a period of time and make the safety device being used inadequate. Forinstance not wearing eye protection during any number of procedures where thereis exposure to bodily fluids; examples include activities like obtainingspecimens or suctioning. In surgery, a scrub person not wearing eye protectionduring a laparoscopic procedure because there is not an open wound. Thepotential for risk is still there with the port holes where the amount ofirrigation used may create the potential experience of a splash injury.
The need for more consistent use of protective eyewear also has beenstressed. One study concluded: "Twice the number of blood contacts to theface were recorded than to the hands, which ranked second in frequency in astudy of six hospitals during a 15 month period. Consistent with the bodylocation was the finding that blood contact with the mucosa of the eyes was themost common type of exposure, accounting for 45.3% of incidents.7
There are several root causes associated with sharps' incidents reported byhealthcare workers. The type of sharp is not the key issue in relating aninjury; use and disposal relationships are the root causes. Do the sharps usedhave a safety device or not? If it does, is the sharp device being usedappropriately?
Has the user received training on the handling of the safety device? Thesequestions should be answered when investigating the root cause.
In surgery, suture needles account for numerous types of injuries that occurduring a procedure, such as:
Inappropriate disposal of sharps is also a root cause category to be assessedand evaluated. Not paying attention to where needles are placed following useaccounts for a variety of stories. How often has someone heard of needlesremaining in a bed or stretcher following use leading to an inadvertentexposure?
In surgery, flat needle magnets are often used and pose a greater risk forinjury when being disposed. The magnet can fold in on itself and the sharpspenetrate the pad.
Sharps' container buckets have designated fill lines and overfillingfrequently is an observable practice. Sharps' containers should be closed andreplaced when they are full as determined by the manufacturer's marker.
Recapping needles has been identified as a continual source of workerexposure, and many of these injuries are considered preventable through use ofsafer 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 staffcompliance in using it. Convenience and ease of use also affect compliance andneed to be considered in evaluating PPE9."
Accessibility to PPE and safety devices to many nurses may mastermindresistance. 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 mindseteasily 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 failto adhere to PPE use. In looking at the cost of PPE, it is important to rememberthat the CDC recommends a performance-oriented standard.10 The taskand 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 allcritical to compliance with universal precautions. In addition to personaleyewear, there can be standard face shields, side shields and safety glasses orgoggles accessible for general use.11
Seeking Better Outcomes
In healthcare , prevention and reduction of injury incidents are the keys tosuccessful outcomes. Manufacturer's are being forced to invent and produceproducts that are not only used safely, but are safe for workers and patients.Healthcare provider's, are investigating the processes and quality available toimprove outcomes. Changing practices does not always come easily.
The practice of double gloving has been promoted actively as a method forreducing blood exposures to hands, especially among surgeons; the use ofpuncture resistant gloves has been proposed as a method for reducingpercutaneous injuries to hands. The potential benefits of using puncture orlaceration resistant gloves or finger guards to prevent percutaneous injuries tothe hands should be assessed. The acceptance of this approach in the surgicalsetting remains low because of the loss of tactile sensation and less than totalpuncture resistance of most available barrier materials12.
Blunt suture needles have been designed to provide protection when suturingspecific tissue types like muscle and fascia13 This does not indicatethat a blunt needle is appropriate for all muscle or fascia or that it will beused by all surgeons. Although this may be a good practice, there is resistanceto use by surgeons. If they have been in practice for an extended time and therisk for injury has been small, the reluctance to switch will occur.
Masks need to be assessed for the fit on the face, comfort, filtration, thetype of procedure to be done, and the risk of exposure. There are many on themarket 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 lasercases; these require modifications. Unconventional wearing of a face shieldupside down will not always a prevent splash exposure from penetrating to theface.
Gowns need to be evaluated and used according to which offers the beststrike-through protection. A variety of different gowns geared toward theanticipated exposure possibility would be the ideal. The cost and inventorystock is not practical. Hospitals must decide the types of gowns they willprovide the best practice for everyone. The use of shoe covers has changed to bea protective device, used when the risk for exposure is potential. Higher bootprotective shoe cover wear is available for healthcare workers that are exposedto bodily fluids and irrigation such as orthopedic and urological procedures.
Better outcomes for healthcare workers includes investigating the suppliesbeing used within a facility and identifying the safety devices available. Theissues of PPE are interdependent between infection control, employee health,education and the unit level. Involvement in providing for the best practices inPPE, should include participation of multidisciplinary team members to identifythe various root causes and the options for preventing or reducing incidents.Consensus of an action plan would be the next step, followed by measuring thesuccess.
Seeking better outcomes is done also by encouraging staff to develop a senseof curiosity about the issues surrounding PPE. Begin by investigating online theinformation available on PPE, needlestick injuries, exposures and other relatedtopics. Manufacturing companies provide information on line. OSHA's revision ofthe Bloodborne Pathogen Compliance Directive is available on line as well as theNIOSH manual for evaluating sharps disposal containers.
Concerns for safety of the patient and employees should remain a priority inany situation. Human nature dictates that accidents happen. The lessons learnedin retrospective analysis usually determine whether the event could have beenprevented. Maintaining awareness during any procedure is essential. Identifyingpersonnel protective equipment will promote a best practice in any work area.Determining root causes for injuries and using a continuous improvement model toreduce incidents will continue to be researched.
Karen A. Huggins, MN, RN, CNOR, is a clinical specialist in the operatingroom of Presbyterian Hospital of Dallas, Texas.