Experts Share Best Practices for PPE and Barrier Protection

ICT asked experts to share their best practices relating to personal protective equipment (PPE) and/or barrier protection against infectious agents for operating room personnel.

Vangie Dennis, RN, BSN, CNOR, CMLSO: As one of the largest sports medicine centers in the state of Georgia, focusing on personal protection equipment (PPE) as an infection prevention and control measure enhances safety for our patients as well as our staff. Selection and usage of the correct surgical glove is one intervention that makes a difference. Surgical gloves serve two purposes: protect patients from infection and cross contamination during surgery and provide the first line of defense to protect healthcare workers from exposure to blood and blood borne pathogens. With some research on manufacturers quality testing of surgical gloves, we determined there were key factors important to us for glove selection. One focus was surgical glove-failure rates. High glove-failure rates can lead to risk of infection to patients and sharp exposures to the staff. When glove failures occur, the result is practitioners changing gloves at the table, (adding additional time to the surgery), contamination exposure and an increase in the overall cost of surgical procedure.

With an understanding of the stress placed on surgical gloves during orthopedic procedures, our surgeons consistently wear two surgical gloves to minimize the risk of needlestick injury, sometimes related to the instrumentation. Studies have quantified that needlestick exposure dramatically decreases when double gloving occurs. Additionally, our research found that double gloving with a colored indication system allowed us to recognize glove failures in a more timely and efficient manner.

We then reviewed the practice of not only double gloving with a colored indication system but also doing so with a surgical glove with a lower glove failure rate. Surgical gloves with a lower rate of failure can help us lower risks, offer better protection to patients and staff, and use fewer gloves that could potentially reduce costs.

Today, with pathogen transmission, such as hepatitis -- on the rise, product selection will play an even greater role in assisting the healthcare practitioner with infection prevention. For my staff, understanding that double gloving with a colored indication system, as well as choosing surgical gloves with confirmed lower failure rates, has brought us one step closer to maintaining an environment of safety in the operating rooms for our patients, surgeons and surgical staff alike.

Vangie Dennis, RN, BSN, CNOR, CMLSO, is clinical manager of surgical services at Gwinnett Medical Center in Duluth, Ga.

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Kathleen Stoessel, RN, BSN, MS: Operating room personnel rely on personal protective equipment (PPE) to protect themselves and their patients against infectious agents. Surgical gowns and masks are essential PPE that must provide an effective barrier against the transfer of microorganisms, particulates, and fluids. When evaluating the barrier properties of these PPE, best practice should include obtaining data from the manufacturer to verify the protective qualities of the barrier fabric.

The effectiveness of barrier fabrics can be measured using standard test methods published by ASTM International. One test method, the Liquid Barrier Test (ASTM F1671), assesses the capability of a material to prevent passage of liquid-borne microorganisms. The standard is a pass/fail screening test designed using a challenge organism similar in size and shape to hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV). Materials that pass this test are considered to be highly protective against liquid and microbial penetration.

A second test method, the Bacterial Filtration Efficiency (BFE) test (ASTM F2101), evaluates the capability of a material to prevent passage of aerosolized bacteria using Staphylocccus aureus as a test organism. The BFE is calculated as a percentage of bacteria that do not pass through the tested material. A higher percent BFE indicates greater protection; materials with a BFE of 98 percent or higher are considered moderate to high barrier class, and materials with a BFE of 95 percent to 98 percent are considered low barrier class. The BFE test was designed specifically as a standard for medical face mask materials but does not evaluate materials for regulatory approval as respirators. Although not required, this test may be performed on barrier fabrics in other PPE.

Obtaining information on whether these two tests were performed and, if so, with what results, will enable the end user to better differentiate the barrier effectiveness of surgical gown and mask materials.

Kathleen Stoessel, RN, BSN, MS, is senior manager for clinical education for Kimberly-Clark Health Care.

References

1. Association for periOperative Registered Nurses (AORN). Recommended Practices for Selection and Use of Surgical Gowns and Drapes. In: Conner R, ed. 2010 Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2010:127-132.

2. Association for the Advancement of Medical Instrumentation. Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities. ANSI/AAMI PB70:2003. Arlington, Va.: AAMI; 2003:v. - 22.

3. Association for the Advancement of Medical Instrumentation. Selection and use of protective apparel and surgical drapes in healthcare facilities. AAMI TIR11:2005. Arlington, VA: AAMI; 2005:v. - 38.

4. ASTM International. Standard Specification for Performance of Materials Used in Medical Face Masks. Designation: F2100 - 07. West Conshohocken, Pa.: ASTM International; 2007.

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Julie Gorog, RN, BSN, CNOR: Operating room personnel are faced with the risk of exposure to bloodborne pathogens and drug resistant bacteria on a daily basis. In order to reduce incidence of exposure and provide a safe work environment, the Occupational Safety and Health Administration (OSHA) has established key standards on the use of personal protective equipment in the healthcare environment. OSHA states that "personal protective equipment (PPE) is appropriate only if does not permit blood or other potentially infectious materials to pass through under normal conditions of use and for the duration of the time which is will be used."

In order to assist operating room personnel in complying with OSHA standards, the Association for Advancement of Medical Instrumentation (AAMI) established a classification system based on liquid barrier performance. In the standard, AAMI PB70:2003 Liquid Barrier Performance and Classification of Protective Apparel and Drapes, surgical gowns and drapes level of barrier protection are rated based on a series of industry standard tests that are required by all surgical apparel manufacturers. For surgical drapes and gowns, the range of AAMI rating starts with Level 1 which provides the least protection defined as the ability to resist liquid penetration on one test. The levels increase based on defined ratings in barrier performance. The highest rating is AAMI level 4, which contains products that have the ability to resist liquid and viral penetration.

It is important for operating room personnel to be educated on the AAMI levels, so that they can choose the appropriate level of PPE. AORN provides guidelines for selection of surgical drapes and gowns within their Perioperative Standards and Recommended Practices manual. Per their recommendations, OR personnel should obtain data from manufacturing that material used in surgical drapes and gowns should be verified by manufacturers as protective barriers against transfer of microorganisms, particulates and fluids to minimize strikethrough and the potential for personnel contamination. In addition, the selection of surgical gown should be in accordance with OSHA guidelines for PPE use.

In reviewing OSHAs standards and AORN recommendation, surgical PPE should be selected based on barrier protection levels for anticipated exposure to blood, body fluids, and OPIM. Surgical personnel should consider type of procedure, amount of fluid exposure, length of procedure, and role in surgical procedure when selecting PPE. For example, it may not be necessary for staff to wear an impervious AAMI level 4 gown, on a laparoscopic procedure with small amount of fluid exposure. In contrast, a surgical gown rated at an AAMI level 3 may not provided adequate protection during colectomy procedures where length of procedure and fluid exposure exceeds the barrier protection levels.

In summary, OR personnel need to be educated on AAMI levels of surgical drapes and gowns so that they may choose the appropriate product for the level of exposure. Manufacturers are required to label products with AAMI levels and should be easily identified.

Julie Gorog, RN, BSN, CNOR, is a clinical consultant with Cardinal Health.

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Lori Jensen, RN: Gloves are the most common barrier used by healthcare personnel to prevent the transmission of potentially pathogenic microorganisms. There are so many choices available today for the healthcare worker to use as far as barrier protection. Each of them having unique advantages, but the most important thing to do is to choose the right glove for the right task and follow the guidelines in accordance to industry standards, that will keep each employee safe from infections and harmful substances that they could encounter in an OR setting.

Surgical glove selection is established according to clinical requirements of risk exposure, anticipated physical stress on the hand, the actual procedure and equipment used, as well as surgeon personal preferences. It is imperative to have the realization that one glove is not perfect for all applications.

Barrier is the number one criteria one should look for in a medical glove. Natural rubber latex remains the gold standard for quality, barrier protection, fit, comfort and economy in medical gloves. However, with some individuals being allergic to natural rubber latex, many facilities are taking precautions to avoid or reduce exposure to natural rubber latex by selecting surgical and examination gloves made of synthetic materials.

Alternatives for latex include the following;

- Neoprene: Was one of the first glove alternatives for latex surgical and exam gloves. It offers good comfort but as with most synthetic materials, is more expensive than latex.

- Polyisoprene: Is the new alternative to latex. It has an excellent fit and feel that is very close to latex. Currently available only as a surgical style glove

- Nitrile: Has become more popular in recent years because it offers excellent tear and chemical resistance, although generally costs more than other exam glove materials. Available as an examination-style glove -- sterile and non-sterile.

- Vinyl: While an economical alternative to latex, is associated with reduced barrier protection due to its susceptibility to tears, breakage and pinholes. Available only as an examination-style glove. The CDC does not recommend this glove for bloodborne pathogen areas.(1)

The Food and Drug Administration (FDA) regulates all surgical and exam gloves and they must meet acceptable quality levels for physical specifications, defect and pinhole rates, elasticity, elongation, protein and powder levels, allergenicity or biocompatibility. The ASTM (American Society for Testing and Materials) sets the standards, and the FDA and OSHA enforce them. FDA requires that all gloves must provide adequate barrier protection against pathogens such as HIV and HBV, and comply with the OSHA Bloodborne Pathogen Standard. Manufacturers must also produce gloves that meet the customers needs for durability, flexibility, tactile sensitivity and resiliency.

Research has demonstrated that surgical gloves cannot always endure the rigors of lengthy and strenuous surgeries. Surgical gloves impart a protective barrier between healthcare workers hands and the infectious blood and body fluid, but surgical personnel do not consistently change their gloves frequently enough during lengthy procedures. When there is a breach, or barrier failure to a surgical glove, there is a subsequent potential for the transfer of pathogens to both the patient and the surgical team. AORN states that, "Healthcare workers should wear two pairs of gloves during invasive procedures."(1) In addition, it has been shown that wearing gloves of two different colors significantly increases the awareness of perforation. (2) Gloves should be changed immediately if they have been compromised. Gloves should also be changed frequently in long procedures.

Other factors to remember pertaining to gloves in the OR:

- Wearing gloves should never be considered a substitute for washing your hands; wash your hands prior to donning and after removing your gloves.

- You should always wear an appropriate sized glove and keep your fingernails short and well groomed and free from artificial nails.

- Make sure that you use soaps and hand lotions that are compatible with your gloving products to ensure optimal barrier protection

- Store your gloves in an appropriate location, between 50 degrees and 72 degrees F (10 degrees to 22 degrees C). Extreme temperatures adversely affect gloves. Shield gloves from ozone and ultraviolet (UV) or fluorescent lighting.3

Glove selection is crucial. The two principal considerations should be barrier protection and allergen content. Picking the right glove for the right task and following best practice for gloving can prevent transmission of potentially-pathogenic microorganisms and keep you safe in your work environment.

Lori Jensen, RN, is a clinical consultant with Ansell Healthcare.

References:

1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Ifnectious Agents in Healthcare Settings, June 2007. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

2. AORN. Recommended practices for prevention of transmissible infections in the perioperative practice setting. Standards, Recommended Practices and Guidelines. Association of peri-Operative Registered Nurses. 2010, pg 279.

3. 21. Nicoali P, Aldam CH, Allen PW. Increased awareness of glove perforation in major joint replacement. J Bone Joint Surg. 1997; 79-B:371-373.

4. Ansell Perry Inc. Proper Storage of Latex Gloves to Prevent Ozone Damage. May 1995.