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By John Roark
Gowns, gloves and masks cannot protectyou if they do not properly fit. Protect yourself and your patient bysuiting up smart. The bottom line with all personal protective equipment (PPE)is that it must be user-friendly, says Geri Braddock, RN, BSN, PHN, CIC,infection control practitioner at Santa Monica-UCLA Medical Center in SantaMonica, Calif. PPE has to be comfortable, easy to put on, and not excessivelyhot. If people arent comfortable in it, theyre just not going to wear it,she says. If its tricky to put on and use, theyre either going tobypass it completely hospital workers are very clever with finding waysaround things or figure out a way to get around using it correctly.
There are two components to gowns, says Keith Kaye, MD, MPH, assistant professor in medicine, an infectious disease attending physician, and associate hospital epidemiologist for Duke University Medical Center in Durham, N.C. First is protecting yourself. In universal precautions, if you anticipate a splash of bloody fluid or even fecal or urinary incontinence, youwear a gown to protect your gear and your person from things like HIV andhepatitis C. The other side of things is protection of patients, and trying notto contaminate yourself with something like Clostridium difficile sporesor Vancomycin-resistant Enterococci (VRE).
One of the most important factors in surgical gowns isadequate coverage. Clinicians need to select gowns large enough to provide amplecoverage and tie in the back, minimizing the risk of contamination. A gown that fits properly is not so tight that it binds orrestricts movement, and not so large that it causes a hazard during a procedure. Gowns should be securely fastened at the neck and waist, andextend to the knees. Sleeves should cover the arms completely, preventing skinexposure between the end of the sleeve and the cuff of the clinicians gloves.If the sleeve is too short, flexing the elbow pulls the cuff of the sleevebeyond the cuff of the glove.
We like to look at the surgical gown as the suit and tie ofthe clinician, says Frank Czajka, senior product manager for the Proximadivision of Medline. We give more room so that that suit fits better. Our focus is on room through the chest and sleeve areas, notskimping on cuts to make sure that the proper fit is assured and the clinicianis not worrying about whether their gown fits well, but whether their patientis doing well.
Start by choosing the right size, says Donna Armellino, RN,MPA, CIC, infection control coordinator for North Shore University Hospital inManhasset, NY. Most institutions make available various sizes of gloves. Mostpeople who work in an area and utilize gloves frequently do know and do selectthe appropriate size glove. If your hands are small and you take a medium, youdont get the dexterity that you need. If you take a small and youre reallya large, its going to easily tear. Its common sense.
There should be no excess material at the fingertips andthe gloves should not be too tight across the palm, offers Donna Gaidamak,media relations manager for Cardinal Health. This can lead to hand fatigue, skinirritation and damage. The most common mistakes as it relates to gloveselection are different for surgical and exam gloves. With surgical gloves, some people will select a glove that istoo small, especially when changing suppliers. Glove sizes vary frommanufacturer to manufacturer. With exam gloves, individuals may grab anyavailable glove and end up with one that is too tight or too loose. A looseglove is more likely to get caught in pinch points with scissors and the barrierprotection will be compromised.
Gloves that are too small will easily tear; gloves that are too large minimize tactile sensitivity and canbe hazardous. People have to have a glove that fits fairly close to theirhands, or they just cant do their work, says Braddock. If you do not have a good fit, the gloves especially the non-latex, which are not as flexible will literally comeoff your hands as youre making a patient bed or doing some procedures. People will get frustrated and just take them off, becausetheyre in the way of doing their care.
Gloves should be changed not only between patients, butbetween procedures on the same patient, continues Braddock. A very commonmistake that people make is not changing gloves between a dirty and a less-dirtyprocedure on the same patient, she says. Lets say you just took the patient off of thebedpan or did some such contaminated procedure, and then proceeded to give thepatient a drink of water with the same gloves on. There are nurses will do woundcare on a dirty wound, and then proceed to do another procedure on that patientwith the same gloves. Thats something that a lot of healthcare providers dontthink about washing your hands, putting another pair of gloves for that samepatient. They actually smear contamination from one end of the patient to theother.
Wava Truscott, PhD, director of scientific affairs andclinical education at Kimberly-Clark Health Care, agrees that compliance on thisissue is lacking. Gloves do carry those organisms with them, and they attachto things. The organisms love to fi nd a place to hide and cuddle. Theyre onthat glove until they find another place to transfer.
Sometimes clinicians dont think of it as a dirty area,because the word, dirty implies something you can see, continuesTruscott. Although you may know it may be an infective area, you maynot see organisms, and youre not even thinking as you reach up and grabsomething else. It also takes more time. Technically, clinicians should even bewashing their hands between same-patient procedures. Theres also expense.Suddenly thinking about having to go through three pair of gloves to work withone patient seems wasteful to them when they dont see physical dirtiness onthe glove.
Use the right mask for the right job, says Truscott.Unfortunately many clinicians dont understand which mask is the correctchoice because the information is not communicated well, she says. Masks thattie at the crown of the head and the nape of the neck are surgical masks; maskswith loops to go behind the ears are procedural masks. Molded cone-shaped masks present another option. Whichevermask is used, proper fit is paramount to minimize pathogenic exposure to bothclinician and patient.
A properly fitting surgical or procedure maskwill fit snugly about the face, without noticeable gaps at the sides of thenose, on the cheeks, ears or chin.
Often clinicians will tend to wear a larger mask, thinkingits more comfortable, Truscott says. Theyve got more of a breathingarea. But the problem is it doesnt fit around the edges. Mostmanufacturers construct the masks so that the top ties go toward the tip of thecrown of the head, and the bottom ties go lower. By cris-crossing the ties youcan get quite a crease at the cheeks, thus letting organisms in and out. Generally, your procedural mask will not fit quite as tightlyat the sides of the cheeks.
Clinicians hypersensitive to infectious disease may don twomasks, says Truscott, which is not the best course of protective action. Itsmuch worse. What happens is you really decrease the amount of airflow that canpossibly get through that much material. So it goes out the sides and over thetop, on the sides of the nose. So they bypass it its actually worseprotection.
Most surgical masks have a wire or molding that conforms tothe face, originally developed to fit under glasses to prevent fogging. Itsprobably not that egregious if theres a gap between the bridge of the noseand the cheeks, says Braddock. This mask is not meant to filter the air,its really meant to be a barrier. If theres a splatter, youre not goingto hit the mucous membranes of your nose or mouth. It would have to be a heck ofa splatter or stream to get under that gap and hit your lips. It should be areasonable fit, but it doesnt have to be an absolute fit.
Eye protection goes hand in hand with proper mask fit. Eyeshields and protective goggles shield the mucous membranes of the eyes, but this PPE is often overlooked, says Braddock. Goggles are generally heavy and big,and people dont like them, she says. They will fall off most people,because they dont fit to your face properly. Either they pinch you and theyhurt, or they will fall off as you are leaning over the patient. And theyreuseless. Its hard to get people to buy in to wearing goggles before they dohigh-risk, splashy procedures this is just not something that we are goodat. We wear gloves pretty good these days, but well put a mask on and stilllet our eyes be in harms way. During procedures such as intubating,suctioning or dealing with patients who are on ventilators, in my opinion youshould always have eye protection. Those tubing connections can pop off andsplatter your face.
People who are doing wound irrigation should be careful of a backsplash of that fluid into their faces. We arent as a society doing agood job of protecting our eyes, and I think thats partly due to infectioncontrol people needing to spend time teaching about it, and getting goggles thatpeople will accept.
Kaye agrees. The mucous membranes in the eyes are veryvascular, and you can absorb all sorts of things even aerosolized through theair, he says. With the SARS epidemic, healthcare workers were infectedthrough their eyes they wore everything but goggles. Eyewear isunderestimated particularly for things like GI insertions where people just dontanticipate having a spurt of blood. Eye care is very important for healthcareworker protection, particularly in the age of emerging infection and SARS.
The N95 respirator, worn as a preventive means againsttuberculosis, SARS and other respiratory pathogens, should fit snugly over theface, without gaps. Elastic loops should be separated for the most effective fit.
Truscott brings up a concern about the N95s construction.During the SARS epidemic, clinicians were using masks with staples in thebody of the filter media, about a half-inch in from the edge. That means thatwherever the edges of that staple punctured that filter, organisms could comethrough. You could hold a flashlight up to it and see it. The reason they cando that is that the National Institute for Occupational Safety and Health(NIOSH) tests right at the very apex of the cone. All of their testing is of thematerial, not the structure. They are either unaware of it, or it is set up soit just doesnt test it.
Always hotly debated is the requirement for annual fittesting of N95 respirators. The Occupational Safety and Health Administration (OSHA)regulations mandate annual fit-testing of N95 respirators for employees. InAugust 2004, the American Association of Occupational Health Nurses, Inc.(AAOHN), conducted a Respirator Fit-Testing Compliance Survey of 2,196occupational and environmental nurses and infection control professionals inhospital settings. The object of the survey was to better understand the issues,challenges and trends related to respirator fit-testing.
Among the survey findings: 69 percent of respondents reporteda high level of difficulty complying with the new OSHA requirement. Of these, amajority (75 percent) work in non-government not-for-profit hospitals, areresponsible for fit-testing between 500 and 5,000 individuals (61 percent), andhave an employee health staff of three or smaller (69 percent).
Additional anecdotal findings of the survey revealed severalrecurring themes among participants asked to describe why compliance with OSHAcreated challenges. Among those reasons listed:
The Association for Professionals in Infection Control andEpidemiology (APIC) and other healthcare associations believe that the OSHA fit-test mandate, which went into effect July 1, 2004, is scientificallyunjustified, and that workers are already adequately protected by guidelinesissued by the Centers for Disease Control and Prevention (CDC), according toan APIC statement issued July 1, 2004.
Furthermore, the release stated, The scientific orepidemiologic rationale for this new mandate has not been met. This extremelyburdensome task will take nurses and other staff away from their patient careduties to undergo a series of needless exercises.
ICPs are polarized on the issue. Based on what has occurredwith the number of TB cases over time, we see the constant decline in new cases.That should be enough to keep things as is, says Armellino, who adds that theN95 is far from conducive to wear. If youve ever worn one, theyrerestrictive. Theyre very uncomfortable. No matter which model you wear,its hard to breathe in these things, she says. OHSA should wear themand come take care of patients. You cant stay in the room for any extendedperiod of time its a shame.
Braddock sees annual fit-testing as a nuisance. I thinkthe whole nine yards of fit-testing is an enormous burden on our resources, andIm sure Im not alone, she says. I personally think its thesilliest thing Ive ever heard of for this particular mask.
Ive said for years that we would be better served if wewould do an annual competency on putting them on, taking them off, and fit-checking the masks. If I can see that people are putting them on properly andfit-checking them properly, in my mind that is the most important thing, that Iknow that theyve got a good seal. You can see it. I think that would onlytake a few minutes. That is reasonable to do, and that really is where we shouldbe going if were really concerned about keeping people safe.