PPEs Role in Standard and Contact Precautions

“To protect and serve” is the mission statement most often associated with police departments, and it is a mandate also followed by healthcare workers (HCWs) as they uphold patient safety by observing the myriad precautions necessary to decrease the risks of disease transmission.

STANDARD AND CONTACT PRECAUTIONS

Microorganisms are transmitted by countless routes.¹ The five main routes of transmission are contact, droplet, airborne, common vehicle, and vectorborne. Contact transmission is the more frequent mode of transmission of healthcare-acquired infections (HAIs), and it is divided into two subgroups: direct-contact transmission and indirect-contact transmission.

According to the Hospital Infection Control Practices Advisory Committee (HICPAC)’s “Guideline for isolation precautions in hospitals,” standard precautions reflect the major features of universal precautions (UP).³ UP, which were designed to reduce the risk of transmission of bloodborne pathogens and other infectious agents, applies basic precautions and steps to take when caring for patients. These precautions should be in place at all times for all patients receiving care in hospitals — regardless of their diagnosis or presumed infection status.

Standard precautions are the basic level of infection prevention and control that should be used in the care of all patients all of the time.² Standard precautions apply to:

• Blood 
• All body fluids, secretions, and excretions (except sweat) regardless of whether or not they contain visible blood 
• Non-intact skin 
• Mucous membranes 

Personal protective equipment (PPE) is a key asset to carrying out standard precautions. PPE includes: gowns, masks, eye protection, and/or a face shield for high splash areas such as the operating room (OR) or a trauma area.

Standard precautions include varying aspects of protective measures. Some examples include:³ 

Hand hygiene: following any patient contact.

Gloves: Clean, non-sterile gloves when touching or coming into contact with blood, body fluids, secretions or excretions. Gloves should be applied just before touching mucous membranes or contacting blood, body fluids, secretions, or excretions. Remove gloves promptly after use and discard before touching non-contaminated items or environmental surfaces, and before providing care to another patient. Hands should always be washed immediately after removing gloves.

Gowns: Gowns should be fluid resistant, non-sterile, and are used to protect soiling of clothing during activities that may generate splashes or sprays of blood, body fluids, secretions and excretions.

Mask, face shield, and eye protection: Protects the eyes, nose, mouth and mucous membranes from exposure to sprays or splashes of blood, body fluids, secretions and excretions, and may also protect from airborne pathogens.

Patient care equipment is another aspect that applies to standard precautions and contact precautions. It is advised that all non-disposable equipment be cleaned, disinfected or reprocessed before reuse with another patient. All single-use items should be disposed of properly.

HCWs should avoid contamination of clothing and the transfer of microorganisms to other patients, surfaces, and environments. Standard precautions are thought to be the most effective way to accomplish this and they protect against healthcare-associated infections (HAIs).⁴

Such precautions not only provide “adequate protection” for the HCW⁵, but the practice protects the patients from infectious HCWs as well. A good example of this occurred in April 2004 at the Cleveland Clinic when three neonates in the neonatal intensive care unit (NICU) were diagnosed with MRSA bloodstream infection.⁶ Six additional colonized neonates were identified, and then two new colonized neonates were identified one month later.

Through methods of deduction, researchers found that one HCW in the NICU had chronic otitis and when swabbed, methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the HCW’s ear canal and nares. Further molecular typing confirmed that the isolates from the HCW and the neonates were more than 90 percent similar. In a retrospective review of NICU isolates, the outbreak strain was found to have initially occurred in a neonate just two months after the same HCW began working in the unit.

PERSONAL PROTECTIVE EQUIPMENT

In May 2004, the Centers for Disease Control and Prevention (CDC) issued its “Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings” which addresses the proper usage of applications of PPE to be worn by healthcare workers (HCWs).

As the CDC explains in its introduction, the Occupational Safety & Health Administration (OSHA)’s bloodborne pathogen standards and other regulations require the use of PPE in healthcare settings to protect healthcare personnel from exposure to bloodborne pathogens, Mycobacterium tuberculosis, and other infectious organisms.

However, as the CDC points out, the OSHA General Duty Clause only requires PPE for any potential infectious disease exposure. The CDC, on the other hand, adds to that and issues recommendations for when PPE should be used. The recommendations cover the hierarchy of safety and health controls. The specific PPE which the CDC addresses includes gloves, which protect the hands; gowns or aprons, which protect the skin and/or clothing; masks and respirators, which protect the mouth, nose and respiratory tract; goggles, which protect the eyes; and face shields, which protect the entire face.

It is advised that when selecting PPE, a HCW should consider three key aspects:

Anticipated exposure: Such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing. PPE selection, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on.

Durability and appropriateness: This will affect, for example, whether a gown or apron is selected for PPE or if a gown is selected, whether it needs to be fluid resistant, fluid proof, or neither.

Fit: PPE must fit the individual user, and it is up to the employer to ensure that all PPE are available in sizes appropriate for the workforce that must be protected.

Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices with the Association of periOperative Registered Nurses (AORN) Center for Nursing Practice Health Policy and Research, says the use of PPE is “pretty much standardized.” She adds, “It’s really not going to change — and certainly OSHA hasn’t changed their regulations.”

Conner says that the 2007 edition of the AORN standards and recommended practices book includes an update of the recommended practices for prevention of transmissible infections. Within that is a newly written, extensive section on double-gloving. Double-gloving is now the recommended practice during all invasive procedures.

Conner acknowledges that not all HCWs will be too fond of this new recommended practice, noting that delicate procedures such as some in ophthalmology may not enable this practice, but she says double-gloving is essential nonetheless.

“Where it is most important is people doing orthopedics, trauma — situations where there is a huge risk,” she says.

Conner says the biggest challenge encircling PPE is getting people to wear PPE outside of the OR. “When they are doing cleaning procedures, for example,” she explains. “Or where there is a high risk of splash when people are in the decontamination areas. It is a real challenge for organizations to get people to wear face and eye protection. People find that uncomfortable. A lot of time in ORs, the circulator doesn’t want to wear eye protection because she feels that she is not going to be exposed to splash, that she is not close enough to the field, when in fact there is pretty good evidence that splashes occur even when people are pretty far distance from the field. Particularly in orthopedic cases when they are using drills and so forth.

“Getting people to wear PPE when they are disposing of large quantities of contaminated fluid is another (difficulty). They might wear gloves, but it is very difficult to get them to wear a gown to protect their clothing from splash.” 

She says open and thorough communication is the best medicine for curing this lack of compliance. “Education, education, and education. Keep raising people’s awareness of what they are exposing themselves to. The more people are aware of why they need to protect themselves, the more they will be conscientious of wearing the PPE. When in doubt, wear it!” 

References

1. CDC. Guideline for Isolation Precautions in Hospitals www.cdc.gov/ncidod/dhqp/gl_isolation_ptII.html  

2. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80, and Am J Infect Control 1996; 24:24-52.

3. Minnesota Department of Health. Standard Precautions. www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/pre/standard.html  

4. Kanemitsu K, Kaku M. Infection control measures in surgical wards and operating theaters. Nippon Geka Gakkai Zasshi. 2006 Sep;107(5):211-4.

5. Chandler RE, et. al. Transmission of group A Streptococcus limited to healthcare workers with exposure in the operating room. Infect Control Hosp Epidemiol. 2006 Nov;27(11):1159-63. 2006 Oct 17.

6. Bertin ML, et. al. Outbreak of methicillinresistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis. Infect Control Hosp Epidemiol. 2006 Jun;27(6):581-5. 2006 May 25.