By Kelly M. Pyrek
The best-designed and engineered items of personal protective equipment (PPE) will fail healthcare workers and their patients if the PPE is donned or doffed incorrectly and contamination is spread.
Knowing that seeing is believing, researchers at the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital secured the consent of healthcare personnel to videotape how they gowned and gloved, and other related clinical practices. Kang, et al. (2017) discovered that healthcare personnel contaminated themselves in almost 80 percent of the PPE simulations
Various styles of each PPE item were randomly combined by taking one sample among each different PPE available from each category in order: disposable gown, surgical mask, N95 respirator, gloves, cap, full-body gown, hood, face shield, eye protection, and shoe cover. In addition, a powered air purifying respirator (PAPR) was used as part of some randomly assigned full-body PPE sets. Simulation practices were videotaped and examined using fluorescent powder with ultraviolet lighting. After donning an assigned PPE set, each participant was asked to demonstrate their usual patient care (physical assessment which was intensive enough to contaminate the surface of PPE; touching-involved practices varied by occupation and were chosen by participants) at bedside to a SimMan that was covered with fluorescent powder. After doffing the PPE set, contamination with fluorescent powder was examined using an ultraviolet light in the darkened simulation room. Any contaminated areas were photographed using a tablet computer and/or a high-resolution camera. All contamination with fluorescent powder was thoroughly cleaned using soap and water before the healthcare personnel left the simulation room.
Among 130 total sessions from 65 participants, contamination occurred in 79.2 percent of simulations during the doffing process with various PPE items: simple set (92.3 percent) and full-body set (66.2 percent). Among 11 follow-up evaluation participants, contaminations still occurred in 82 percent after receiving individual feedback, but the overall contamination level was reduced. Using the contamination information gained during the simulation analysis, 66 percent of potential contamination was estimated for the clinical observation. Concerns and barriers in PPE use from HCP survey responses were as follows: time-consuming, cumbersomeness, and PPE effectiveness. As Kang, et al. (2017) explain, "Although participants believed in the effectiveness of PPE use in minimizing exposure to infectious pathogens, they also reported that PPE use during their practice was cumbersome. Participants showed relatively high confidence in their PPE use in general and with a simple PPE set. However, they were less confident in the use of full-body protection PPE sets, as in Ebola preparedness. Barriers or concerns in PPE use expressed by the simulation participants were time consumption (e.g., slowed down team rounding), cumbersomeness (e.g., tough to move with a PAPR), lack of training (e.g., not sure in what order to don or doff PPE), worry about PPE effectiveness (e.g., thin yellow disposable gown), PPE issues (e.g., throwing PPE away), and others. Suggestions from participating HCP for better PPE use were more training (e.g., yearly continuing education, orientation training), the need to develop better PPE (e.g., something more efficient), and the hope to resolve unexamined issues (e.g., trash container, stethoscope)."
The researchers report that contamination locations with fluorescent powder were observed where participants can contact during the doffing process. The most contaminated areas for both simple and full-body sets were hands and fingers followed by arm-wrist and face. Even among the eight participants who used randomly assigned full-body PPE set with a hazmat suit and a PAPR, 50 percent of healthcare workers contaminated their shirt neckline, forearm, chin, cheek, and palm at the minor level during the doffing process. The researchers report that the main reasons for doffing contamination observed were removing several PPE items at once; doffing gloves first and then touching other PPE with bare hands; pushing PPE into a trash can; and unconscious cross-touch, such as touching the outer surfaces of a gown when rolling it up to reduce its volume for discard. They found no significant difference between contamination levels when comparing participant demographics such as profession, sex, age, years of experience, education exposure, beliefs in PPE effectiveness, perceptions of cumbersomeness, and confidence in using PPE.
Most significantly, the researchers report that even immediately after participants received individual feedback about the type, amount, and cause of their contaminations and tried to avoid the same mistakes, 91 percent of healthcare personnel still had contamination(s) during follow-up evaluation simulations. As the researchers emphasize, "These evaluation simulation contaminations occurred as the HCP were using the same PPE sets as the previous assigned sets. Although contamination levels during the follow-up simulations were reduced from obvious to minor in most cases, HCP contaminated themselves in other ways as they were trying to avoid the previous mistakes."
The researchers suggest that because simulation participants largely believed PPE could minimize exposure to infectious pathogens and most participants showed a willingness to use PPE correctly, more training, evidence and support could fill the gap between desired performance and actual practice. As they point out, "Evidence shows that traditional learning methods (e.g., watching educational videos, learning PPE guidelines) are inferior to immersive learning methods, including active learner involvement using simulations that include feedback on performance."
Another recent study compared healthcare worker donning and doffing efficacy using contact precaution (CP) PPE and Ebola virus disease (EVD) PPE. In their prospective pilot study conducted in a tertiary-care hospital, Kwon, et al. (2017) included 36 healthcare workers (18 using each set of PPE) who donned their PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to healthcare personnel who then doffed their PPE. After doffing, healthcare workers were scanned for fluorescence and swabbed for MS2. The donning and doffing processes were videotaped, and protocol deviations were recorded. Overall, 27 percent of EVD PPE healthcare workers and 50 percent of CP PPE healthcare workers made =1 protocol deviation while donning, and 100 percent of EVD PPE healthcare workers and 67 percent of CP PPE healthcare workers made =1 protocol deviation while doffing. The average number of doffing protocol deviations among EVD PPE healthcare workers was four, versus one among CP PPE healthcare workers. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on eight EVD PPE healthcare workers (44 percent) and five CP PPE healthcare workers (28 percent), most commonly on hands. MS2 was recovered from two EVD PPE healthcare workers (11 percent) and three CP PPE healthcare workers (17 percent).
Through a mixed methods approach, Herlihey, et al. (2016) sought to identify issues during donning and doffing of PPE for infectious diseases and to inform PPE procurement criteria and design. Usability testing assessed the appropriateness, potential for errors, and ease of use of various combinations of PPE. A qualitative constructivist approach was used to analyze participant feedback. The study was conducted in four academic health sciences centers (with 82 participants who were representative of the potential users of PPE within healthcare institutions. According to the researchers, "None of the tested combinations provided a complete solution for PPE. Environmental factors, such as anteroom layout, and the design of protocols and instructional material were also found to impact safety. The study identified the need to design PPE as a complete system, rather than mixing and matching components." They add, "Healthcare institutions are encouraged to use human factors methods to identify risk and failure points with the usage of their selected PPE, and to modify on the basis of iterative evaluations with representative end users. Manufacturers of PPE should consider usability when designing the next generation of PPE."
Education and Training Around PPE Donning and Doffing
Education and training around proper use of PPE is essential, as we have seen the knowledge and practice gaps that exist, particularly when it comes to donning and doffing. As Doll, et al. acknowledge, "Healthcare workers routinely self-contaminate even when using personal protective equipment." These researchers observed PPE donning/ doffing practices on inpatient units and administered surveys to assess the need for a personal protective equipment training program. As the researchers emphasized, "In contrast to low perceived risk, observed doffing behaviors demonstrate significant personal protective equipment technique deficits."
A visual demonstration of the contamination involved in patient care and the need for properly donned and doffed protective gear was undertaken by researchers in the UK. As Poller, et al. (2018) acknowledge, "Healthcare workers caring for patients with high consequence infectious diseases (HCID) require protection from pathogen exposure, for example by wearing PPE. Protection is acquired through the inherent safety of the PPE components, but also their safe and correct use, supported by adequate training and user familiarity. However, the evidence base for HCID PPE ensembles and any associated training is lacking, with subsequent variation between healthcare providers."
In their study, these researchers developed an evidence-based assessment and training tool for evaluating PPE ensembles and doffing protocols, in the assessment of patients with suspected HCIDs. Their system, dubbed VIOLET (Visualizing Infection with Optimized Light for Education and Training) is comprised of a healthcare mannequin adapted to deliver simulated bodily fluids containing UV-fluorescent tracers. On demand and remotely operated, the mannequin projectile vomits (blue), coughs (red), has diarrhea (yellow) and is covered in sweat (orange). Wearing PPE, healthcare staff participate in an HCID risk assessment and examination of the 'patient,' thereby becoming exposed to these bodily fluids. Contamination of PPE is visualized and body mapped under UV light before and after removal. Observational findings and participant feedback, around its use as a training exercise, is also recorded.
Poller, et al. (2018) report that they found significant contamination from different exposure events during PPE doffing practices. Observational data and participant feedback demonstrated its strengths and success as a training technique. Conclusion: Simulation exercises using VIOLET provide evidence-based assessment of PPE ensembles, and are a valuable resource for training of healthcare staff in wearing and safe doffing of PPE.
As the researchers emphasize, "Removal of PPE is a complex procedure, with studies showing that there are high rates of doffing errors even with basic PPE, and that self-perceived proficiency correlates poorly with correct use. However, contamination is more likely to occur when incorrect technique is noted. Ensuring safe practices for high-risk, high-potential exposure scenarios, to minimize risks of contamination therefore requires the user to be well trained and with proven competence, as well as using safe PPE components. Immersive simulation, where the user engages in an exercise recreated from the real-world, can be used to address the human, system and technical elements of PPE. Integral to healthcare education, simulation training ensures familiarity prior to patient care, providing a safe environment for ‘deliberate practice’ of procedural skills, communication and teamwork, and management of medical emergencies. An example of simulation that has expanded greatly in recent years is the use of ultraviolet (UV) fluorescence markers, well established as a means of assessing compliance with hand hygiene, but also for assessing contamination of the environment and equipment. Their value in assessing PPE and user competence, especially for HCID pathogens, is increasingly recognized, with visualization of cross-contamination providing strong and instant feedback to users. However, these studies have low numbers of participants. The lack of clear evidence for PPE components and training methods required for their correct use and doffing was concluded in a Cochrane review, which called for higher-powered studies to address both issues."
Doll M, Feldman M, Hartigan S, et al. Acceptability and Necessity of Training for Optimal Personal Protective Equipment Use. Infect Control Hosp Epidemiol 2017;38:226–229
Herlihey TA, Gelmi S, Flewwelling CJ, Hall TNT, et al. Personal Protective Equipment for Infectious Disease Preparedness: A Human Factors Evaluation. Infect Control Hosp Epidemiol 2016;37:1022–1028.
Kang J, O'Donnell JM, Colaianne B, Bircher N, Ren D and Smith KJ. Use of personal protective equipment among health care personnel: Results of clinical observations and simulations. Vol. 45, No. 1, Pages 17-23. Jan. 1, 2017.
Kwon JH, Burnham CA-D, et al. Assessment of Healthcare Worker Protocol Deviations and Self-Contamination During Personal Protective Equipment Donning and Doffing. Infect Control Hosp Epidemiol. Vol. 38, No. 9. Pp. 1077-1083. September 2017.
Poller B, Hall S, Bailey C, Gregory S, Clark R, Roberts P, Tunbridge A, PoranV, Crook B, Evans C, ‘VIOLET’ – a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment, Journal of Hospital Infection (2018), doi: 10.1016/j.jhin.2018.01.021