The Role of PPE in Contact Transfer

The Role of PPE in Contact Transfer
Part one in a series.

By Wava Truscott, PhD

THINK FOR A MOMENT ABOUT THIS ROUTINE SCENARIO. A healthcare worker (HCW) enters the room of a patient who hasan antibiotic-resistant infection such as methicillin-resistant Staphylococcusaureus (MRSA) or vancomycin-resistant Enterococcus(VRE). She dons a pair of ordinary disposable gloves and proceeds to examine thepatient, listening to the heart and lungs and taking vital signs. She recordsthe results on the patients chart. She chats with the patient for a fewminutes, discards the exam gloves, washes her hands and moves on to the nextroom. There, she dons a new pair of gloves, puts her stethoscope inher ears, and begins the next examination.

Has the caregiver done anything tocompromise her patients outcomes? She did wear and properly dispose of her gloves, after all. But glove usage is not enough to prevent the spread ofinfection. Without knowing it, the HCW has just transferred millions ofharmful, antibiotic-resistant microorganisms to her second patient, just bytouching the stethoscope with her contaminated gloves and then moving on to thenext patient.

When portable equipment is carried by HCWs, such asstethoscopes, blood pressure cuffs, otoscopes, pens, and pagers,¹ microorganismscan be carried directly to another patient or transferred to furniture orequipment. Thus unwittingly, microorganisms are transferred betweenpatients. Many surfaces in the room can be affected, including bed rails, bedtables, linens, wheelchairs, thermometers, pulse oximeters, patient gowns,privacy curtains, patient charts, and doorknobs. Nurses gloves becomecontaminated 42 percent of the time after touching these contaminated surfaces.²

Despite the best efforts of healthcare facilities to maintaina clean and safe environment, contact transfer of harmful microorganisms appearsto be inevitable. Studies have shown that, in rooms of patients who werecolonized or infected, 70 percent of environmental surfaces were contaminatedwith potentially harmful microorganisms,³ and 65 percent of HCWs gowns werecontaminated with MRSA after routine morning care for patients with MRSA in a wound or patients urine.⁴

The impact of healthcare-acquired infections (HAIs) isstaggering:

• Annually, more than 2.9 million patients (5 percent to 10percent) develop HAIs⁵

• Approximately 30 percent of patients in ICUs developHAIs⁶

• Patients with HAIs spend an average of 12 additional days in the hospital⁷

• Treatment costs can range from $2,300 to $80,000 perpatient⁸

• HAIs represents an annual impact of $6.7 billion to healthcare facilities⁹

• Approximately 90,000 deaths occur annually due to HAIs¹⁰

Setting the Standards

In recognition of HAIs profound impact on patient outcomesand healthcare costs, the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) released strengthened infection control guidelines. In addition to raising awareness that infections can beacquired in any healthcare setting, including hospitals, ambulatory care, homecare, and long-term care organizations, the new guidelines also address emergingantimicrobial resistance. The Centers for Disease Control and Prevention (CDC) highlighted the importance of utilizingcontact precautions for mitigating the transmission of MRSA and VRE,underscoring the critical importance of a total protocol that includes properhandwashing, gloving, masking (for MRSA), gowning, and appropriate practices forhandling devices and laundry, and for daily surface disinfection. The Societyfor Healthcare Epidemiology of America (SHEA) issued additional guidelines toaddress the increased prevalence of MRSA including active surveillance cultures,maximum barrier isolation precautions, strict hand hygiene and antimicrobialstewardship.

The Role of PPE

While these recommendations provide strong behavioralguidelines for preventing transmission, personal protective equipment (PPE)itself can become a potential source of cross-contamination from other surfaceswithin a facility. An increasing number of studies are focusing on the role ofPPE contamination, paving the way for manufacturers to investigate methods toinhibit the growth of a broad spectrum of harmful microorganisms on the surfaceof these products. By gaining a better understanding of the modes of contacttransfer, these innovations would lead to the development of permanent solutionsthat can break the chain of cross-contamination, not just anotherpatient-centric, receptor site-specific antibiotic to which microorganisms candevelop immunity. There are a few promising glove innovations on the horizon,but finding a solution for apparel is not an easy task.

Manufacturers are looking at ways to combine barriercharacteristics with an active anti-microbial ingredient that would entrap orkill the microorganism, preventing transfer at the source, and ultimatelyreducing HAIs. One of the biggest challenges is finding specific solutions thatremain effective after being added to latex and nitrile, SMS fabrics, linen andcotton. They must not create their own version of resistant organisms orsuper-bugs. Additionally, the antimicrobial agent needs to work quickly, remaineffective when in contact with blood and other body fluids, and not irritate thewearers or patients skin.

The Time is Now

Bacteria with adaptive mechanisms such as MRSA and VRE aresurvivors; they multiply and give their adaptation to their progeny. By doingso, they alter their own genetic evolution to favor resistant strains as thepredominate population. Incredibly, bacteria can also transfer the geneticinformation to construct these defensive weapons into other bacteria and evenother bacterial species. Clearly, the problem of antibiotic resistance isntgoing away. So the objective is to lessen the need to use them by getting HAIsunder control. And like almost everything else in healthcare, it will take acomprehensive protocol of behavioral changes and product evolutions across thecare continuum to resolve the issue. And we need to step it up now.

WavaTruscott, PhD, is director of scientific affairs and clinical education forKimberly-Clark Health Care.

References

1. Muto C., Jernigan, J., Ostrowsky B., Richet H., Jarvis W.,Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission ofMultidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003,367.

2. Boyce J.M. Infect Control HospEpidemiol. 1997; 18:622-627.

3. Boyce J.M. Infect Control HospEpidemiol. 1997;18:622.

4. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W.,Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission ofMultidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003,367.

5. CDC. 1992; 41: 783-7.

6. CDC. 1992; 41: 783-7.

7. Kopp B., Nix D., and Armstrong E. AnnPharmacother.2004;9:1377-82; Carbon C.J AntimicrobialChemotherapy. 1999;44:31-36.

8. Salgado C. and Farr B. Infect Control Hosp Epidemiol.2003;24:690-698; Managing Infection Control. 2003;3:14-16.

9. CDC Guideline 1999 Surgical Site Infections.

10. Weinstein R.A. Emerging Infectious Diseases. 1998.

11. Proceedings of the Fourth Decennial InternationalConference on Nosocomial Infections And Healthcare-Associated Infections; 2000March 5-9; Atlanta, Ga.

12. Boyce J.M. Infect Control HospEpidemiol. 1997;18:622.

13. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W.,Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission ofMultidrug-Resistant Strains of Staphylococcus aureus andEnterococcus. Infect Control Hosp Epidemiol. 2003,367.

14. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W.,Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission ofMultidrug-Resistant Strains of Staphylococcus aureus andEnterococcus

15. Ibid.

16. Ibid.

17. Ibid.

18. Ibid.

19. Ibid.

20. Ibid.

21. Ibid.

22. Ibid.

Contact Transfer by the Numbers

• Thirty percent to 40 percent of resistant infectionsresult from contact transfer via the hands of HCWs¹¹

• Seventy percent of rooms had environmental contaminationwhen the patient was colonized or infected¹²

• Bed rails, wheelchairs, thermometers, pulse oximeters,doorknobs, bed tables, linen, patient gowns, charts, etc.¹³

• Sixty-four percent of environmental surfaces in burn units were contaminated¹⁴

• VRE can persist on dry environmental surfaces anywherefrom seven days to four months¹⁵

• MRSA can survive on sterile packages for more than 38 weeks¹⁶

• Forty-two percent of nurses gloves were contaminatedwith MRSA after touching environmental surfaces even if they never touched the MRSA infected patient¹⁷

• Forty percent of HCWs gowns were contaminated with VREafter care of a colonized or infected patient¹⁸

• Sixty-five percent of HCWs gowns were contaminatedwith MRSA after routine morning care for patients with MRSA in a wound or in their urine¹⁹

• Of 144 employees, none carried MRSA in the nose ifwearing a mask when caring for MRSA patients during the first eight months of a NICU breakout²⁰

• Four out of five studies reported lower rates of patientsbecoming VRE positive when HCWs used gowns and gloves as compared to gloves alone²¹

• A significantly lower rate of colonization was foundamong HCWs caring for MRSA patients when wearing gloves, a gown, and a maskinstead of just a glove and gown²²