A Retrospect: PPE Use Then and Now

By Amber Hogan Mitchell, DrPH, MPH, CPH

The Evolution of PPE and Healthcare Then
In the days of home births, hot water and clean towels - gloves for use during patient exams began during the 1760s when physicians used obstetric gloves made from sheep intestines for vaginal exams in Germany. It wasn’t until the 1840s when Charles Goodyear patented his “vulcanized” rubber that surgical gloves became flexible enough to wear and in some iteration were used en mass by nurses at Johns Hopkins Hospital in the 1890s after surgeon Dr. William Halstead published his paper, “The Treatment of Wounds.”

Surgical masks were originally constructed from cotton gauze and worn by surgery staff in the early 1900s to prevent contamination of open surgical wounds. The first respirators were developed about the same time, but were used for protecting miners from dusts and gases, soldiers from chemical warfare, and firefighters from smoke. The evolution of further coverage to include the eyes in the form of a face shield was likely born from this.

The use of goggles for eye protection likely began in Persia in the 15th century from polished tortoise shells used for sea diving for pearls. It’s not clear when goggles were seen in healthcare settings, but as blood sprays occurring during traumas and surgical procedures became a commonplace event, the need to protect the eyes from these body fluid sprays became important.  For this reason, isolation gowns were likely born out of the common use of aprons and smocks in surgery and nursing, as a way to protect the wearer rather than the patient.

It is important to highlight the origin of PPE use in healthcare so that we can reflect on why it is worn and how it was born based on a critical need.  It is worn to protect both healthcare worker -- as a means of occupational safety and health -- and the patient -- as a means of infection prevention.  In combination, whatever the reason, there isn’t one without the other. PPE keeps both healthcare worker and patient safe from each other when exposures can be anticipated or expected.
Almost all of the time, what PPE to select and use is obvious – risk of high-velocity blood splatters, use of eye, nose, mouth, and body protection – risk of infectious disease like TB, use of respirator – risk of the unknown (aka standard precautions), use of gloves.  What is not clear is when we don’t know what type of exposure to expect, what to prepare for, what to have to hand, what to encourage people to wear.  What do we encourage healthcare workers to wear when those exposures are not typically anticipated or expected?

The State of Healthcare Now
Today, in light of the current national economic environment and immediate reform of the healthcare system, along with new demands placed on it, it is vital to keep workers in healthcare -- specifically those providing direct patient and acute care -- healthy and working in order to ensure the vitality of those seeking care. Our health systems are monumentally different than they were hundreds of years ago and as such, the risks are different and more unexpected. Patients with known infectious disease or infection are diagnosed sooner, live longer and are in and out of healthcare facilities, which means that exposure paradigms shift.
Occupational mucous membrane exposures (including face, nose, and mouth) to BBF from patients infected with bloodborne viruses (e.g., HIV, HBV, HCV) are especially high risk, creating essentially an infusion of infected fluid from patients through the membranes of healthcare workers. The population of acute-care co-infections is on the rise. Community-associated MRSA (CA-MRSA) infection is six-fold higher among HIV-positive patients (996/100,000) and significantly increasing since 2000 (Popovich 2010). Of the 37 million patient discharges per year (both living and deceased) in the United States, at least 185,000 are HIV-positive and 46 per 1,000 are colonized or infected with methicillin-resistant Staphylococcus aureus (MRSA) (NCHS 2007, Jarvis 2007).  HIV is only one bloodborne pathogen and MRSA is only one multi-drug resistant organism. There are many others with the potential to cause human disease, including bloodborne pathogens such as hepatitis B and C, syphilis, and viruses such as influenza, smallpox, West Nile virus, and others; and bacteria such as streptococcus, clostridium difficile, and others.

Because of the potential fluid to membrane infusion of microbe-rich body fluid, splashes and splatters may create a higher disease burden of significance than contaminated sharps injuries or needlesticks. Prevention of occupational injuries and illnesses among healthcare workers ensures the best work efficiencies (e.g., reducing days away from work, increasing job ability and task completion, ensuring a viable healthcare staff-to-patient ratio, etc.) through the continuity of public and private care. To do this, PPE plays a headlining role.

PPE Use Now
We know that PPE prevents exposures described above, but compliance with its use and availability are marginal.  A longstanding problem in disease prevention and infection control, specifically for occupational exposures, has been poor adherence to universal / standard precautions and poor compliance with usage of PPE not just in the United States, but throughout the world. Jagger et al. illustrate that, out of 367 blood and body fluid (BBF) exposures reported through EPINet, 74 percent of cases were not wearing protective equipment such as goggles, face shields, or eyeglasses with side shields (1998). Additionally, almost half of the splash and splatter incidents in an obstetrics setting the worker was not wearing any personal protective devices. There do not seem to be differences in developing countries like Kenya where obstetrics and gynecology represent the hospital departments / areas with the highest numbers of blood and body fluid exposures and where access to preventive or protective measures are inadequate. 

In a recent retrospective study of high risk BBF exposures – mucotaneous splash and splatter incidents (MSSIs) – captured in more than 60 hospitals in a 13 year timeframe (1995-2007), it became overwhelmingly clear that PPE use or compliance with PPE use is lower than compliance with hand hygiene (Mitchell 2013).  Data was pulled from the Exposure Prevention Information Network (EPINet™*) which was developed by Janine Jagger, MPH, PhD, and colleagues in 1991 to provide standardized methods for recording and tracking percutaneous injuries and blood and body fluid contacts (International Healthcare Worker Safety Center Website, 2010). The EPINet™ system consists of a Needlestick and Sharp Object Injury Report and a Blood and Body Fluid (BBF) Exposure Report.

From EPINet data recorded on the BBF Exposure Report, total counts of mucotaneous splash and splatter incidents (MSSIs) were calculated by type: frequency of incidents to eyes, nose, and/or mouth where any PPE was worn as well as distribution across high and low risk hospital department.  Sixty-six percent of MSSI incidents with use of PPE occurred in high risk hospital areas.  Eye incidents (79 percent) made up the majority of exposure type across all study hospitals. There were 152 incidents where the eyes, nose, and mouth were all identified for the incident of which 63 percent (96) were in high-risk hospital areas.
 
The majority of PPE use occurred in high-risk hospital areas (75 percent), despite MSSIs occurring in low risk hospital settings.  The most frequently worn type of PPE in high risk hospital areas was a mask (42 percent), most likely because surgery or surgical settings are classified as high risk. 

Because proper use of PPE is important in preventing exposures, the appropriateness of PPE use was analyzed. While eyeglasses are not considered PPE, they do serve as a physical barrier for some eye exposures. As such, eyeglasses were indicated for use during eye exposures/incidents more frequently in high risk hospital areas (65 percent) rather than low risk (22 percent). Face shields were worn more frequently in high risk hospital areas (range, 64 percent to 81 percent) for all exposure types as they serve as PPE for all exposure types. There were 152 incidents simultaneously involving the eyes, nose, and mouth. These types of exposures are extremely high risk and of these, only three were wearing face shields. 

Overall, it is more likely that any type of PPE was worn in high-risk hospital areas than in low risk hospital areas across all three MSSI types. This research disputes statements from the Centers for Disease Control and Prevention (CDC), that risk of blood exposure is “very small.” This research illustrates that not only are BBF exposures occurring frequently, but that high-risk occupational incidents like MSSIs are occurring because PPE is not being worn.

This research allows healthcare workers, the facilities they work in, and PPE manufacturers/distributors, as well as medical device companies an opportunity to translate this research into practical action. It quantifies risk and establishes the need for additional interventions and surveillance programs for assessing incidents. There are newly available and emerging technologies or engineering controls that decrease occupational exposure incidents, therefore decreasing bioburden that can transmit infectious microorganisms. 

Though far gone are the days of impromptu gauze masks and aprons – the days of acceptable PPE compliance (whether due to lack of access or wear) are still here. Quantitative research has long identified that though our PPE technologies are better and safer, they are still not being worn.  As federal agencies like OSHA move forward in this infectious disease space, it is the hope that their future Infectious disease standards will make a meaningful difference in reducing occupational exposure to microorganisms that cause infection and illness.

Amber Hogan Mitchell, DrPH, MPH, CPH, leads regulatory affairs, scientific, and educational initiatives for Vestagen Technical Textiles, Inc. She specializes in regulatory and policy issues related to safe, quality healthcare. She was the OSHA National Bloodborne Pathogens Coordinator and has several Secretary of Labor Excellence awards. She holds a bachelor’s degree in psychology from Binghamton University and a master’s degree in public health from the George Washington University. She is a doctor of public health in occupational and environmental health sciences received from the University of Texas School of Public Health. The work she has done on personal protective equipment was the research affiliated with her doctoral dissertation.

References
Jagger J, Powers RD, Day JS, Detmer DE, Blackwell B, Pearson RD. Epidemiology and prevention of blood and body fluid exposures among emergency department staff. J Emerg Med 1994; 12(6):753-765.

Jagger J, Gomaa AE, Phillips EK. Safety of surgical personnel: a global concern. Lancet 2008; 372(9644):1149.

Jarvis WJ, Schlosser J, Chinn RY, Tweeten S, Jackson M.  National Prevalence of Methicillin-resistant Staphylococcus aureus in inpatients at U.S. health care facilities, 2006.  Am J Inf Cont.  35(10):631-637.

Mitchell A et al.  Occupational Exposure to Blood & Body Fluids in U.S. Hospitals: Implications of National Policy.  Doctoral Dissertation, University of Texas School of Public Health. 2013.

Popovich KJ, Weinstein RA, Aroutcheva A, Rice T, Bala H.  Community-Associated Methicillin-Resistant Staphylococcus aureus and HIV: Intersecting Epidemics.  Clin Inf Dis 2010; 50:979-987.