The 'Suboptimal' State of Proper PPE Removal and What's Being Done to Fix It

By Kelly Teal
 
With the Ebola crisis in the rearview mirror but lurking, cases of C. difficile on the rise, and other known and emerging viruses creeping across the globe, health leaders are focusing greater attention on protecting the people on the front lines of care. The proper removal of personal protective equipment (PPE) – think masks, gloves and gowns – ranks among the most critical of those topics and it’s one infection preventionists should address with physicians, nurses and other healthcare personnel sooner rather than later. The need is pressing. Recall that Ebola infected more than 500 health workers in West Africa in 2014. Meanwhile, other professionals have contracted C. diff and MERS. Experts have not been able to irrefutably link those occurrences to improper PPE removal; however, they have enough experience to posit with authority that poor technique has played a role in at least some of the diagnoses. The reason is simple: Too few healthcare workers take off their PPE in such a way that does not pollute their clothing or skin. To wit, a recent study published by JAMA Internal Medicine showed that 46 percent of doffing simulations engendered some level of contamination.

That’s a frightening figure for the medical profession and specialists including Curtis J. Donskey, MD, staff physician at the Louis Stokes Cleveland VA Medical Center and professor of medicine at Case Western Reserve University, aim to reduce it. (They’re the ones who discovered that 46 percent failure rate) Achieving that goal will take concerted effort all around. Schools and facilities need to ramp up, and apply, their PPE removal training and procedure, and companies need to design better equipment.

Any improvement, though, starts with training and Donskey has dubbed the industry’s standing in this area as “suboptimal.” Citing a 2016 article in the American Journal of Infection Control, he noted that 14 percent of physicians report no previous instruction in PPE removal; a follow-up survey underscored a lack of formal training programs around the world. If teaching was provided, it was through computer-based modules, he says, a somewhat faulty method because it doesn’t seem to translate into enough accurate usage. Thus, the healthcare sector needs to validate and standardize training methods to fix improper PPE removal. That appears to be on the horizon. Spurred by current events, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), along with other government agencies, as well as academics, medical centers and business all are tackling the matter of PPE removal.

"The recent Ebola outbreak has resulted in heightened awareness that this is a problem with potentially serious consequences,” Donskey says. So have the increased numbers of health are staff getting C. diff and MERS from patients. Imprecise PPE removal appears to be a key culprit, despite the absence of “direct evidence that transmission occurred due to this,” Donskey adds. “However,” he says, “there are plenty of examples where transmission occurred and failure to use PPE or failure to use it correctly was probably a major contributor.”

Indeed, think about the 2014 MERS outbreak in Saudi Arabia. Of the 65 diagnosed occurrences, healthcare workers contracted the majority – 70 percent. The remainder – 22 percent and 7 percent – manifested in patients and hospital visitors, respectively. So why the soaring rate among professionals? “They were not wearing PPE because they didn’t suspect MERS,” says Donskey. "Similarly, we have examples where personnel who were taking antibiotics acquired C. difficile infection (CDI). They may have not been aware that a patient had CDI because they weren’t diagnosed yet (gloves should be worn when caring for any patient with diarrhea) or they didn’t wear PPE correctly (for example, personnel often are not aware that just touching a surface in a CDI room can result in pick-up of spores) or they contaminated themselves during PPE removal.”

In other words, getting a contagious disease can happen all too easily, even when doctors, nurses and their staff wear PPE. To mitigate complications, experts including Donskey are pushing for new training strategies. One simple, potential one they tested relied on fluorescent lotion during simulation exercises. The substance showed where a bug lived on a gown or glove, for example, and helped medical workers see where and how to employ more proficient skill. Hands-on application such as this “is likely to be more effective than education alone,” Donskey says.

Another tactic surrounds the integration of PPE training into medical school. There’s little, and Donskey and his colleagues continue to assess standing practices and to push for enhancements. Trouble is, the inability, so far, to “directly link” contamination during PPE removal to transmission of infection remains a barrier to the acceptance and implementation of training programs, Donskey says. “One of the things that will be needed moving forward is evaluation of whether interventions focused on use of PPE can reduce infection rates,” he said. “It is likely that these interventions would have to focus both on improving compliance with use of PPE and using PPE correctly. In the short term, the increasing appreciation for the risk of contamination during PPE removal should stimulate research to develop effective training methods that can be applied in interventions.”

Yet there’s a troubling reality: “No studies have demonstrated that PPE training reduces the risk for pathogen acquisition or transmission,” Dons-key says. Some institutions or professionals may feel tempted to view the lack of such proof as rationale to ignore training.  That would be a big and arguably unnecessary gamble. 

For one thing, observe how much training in proper removal can affect outcomes. As an example, Donskey and his colleagues recently evaluated face-mask donning and/or doffing simulation sequences. Almost all of them – 97 percent – featured incorrect sequences. The most common infraction happened when taking off the face mask before the gloves and gown. But once participants learned the right order, “facial contamination was reduced to zero,” Donskey says.
“Educational interventions can significantly reduce the risk for contamination,” he emphasizes.

So can simple changes to traditional approaches. To that point, Donskey and his colleagues have been exploring the idea of disinfecting PPE be-fore it is even removed. In light of those 500-plus health care workers contracting Ebola, this might seem an obvious requirement. It is not. CDC guidelines still do not suggest disinfecting gloves before removing PPE. Adding this step “might be beneficial” and is being studied, Donskey says.

Both bleach and ethanol show promise as sterilizing agents. In one quasi-experimental intervention, Donskey and his colleagues found that clean-ing gloves with bleach wipes before removing them led to a “significant reduction” – i.e., no detected contamination during 30 episodes of patient care – in spore acquisition, compared to just training. Even so, healtcare personnel complained about inadvertent spills staining their clothes and about the odor of bleach. In response to that feedback, Donskey and his colleagues did a follow-up that looked at a sporicidal ethanol disinfectant instead of bleach. They found the ethanol rapidly decontaminated C. diff spores on gloves, “without damaging clothing or causing respiratory irrita-tion.” An ensuing analysis by Donskey and six of his colleagues showed that spraying and/or wiping gowns, not just gloves, with an ethanol formulation also quickly disinfected PPE worn around Ebola patients, in particular. The subsequent abstract provided by Donskey, “Evaluation of a Spray Disinfectant for Decontamination of PPE Prior to Removal,” notes that ethanol’s efficacy increased with longer exposure time. Still, the bleach was best overall, giving researchers some hurdles to leap. 

Nonetheless, all of this information could help healthcare professionals to lower their chances of contracting an infectious disease when removing their PPE. They must, though, do their part by treating the matter with the gravity and attention it deserves – a poor attitude can contribute to contamination risk, Donskey says. “Personnel who are busy or who don’t perceive contamination as an important issue during routine care may not comply with PPE use or may not be willing to participate in training to improve PPE technique,” he said. 

If or when those issues crop up, infection preventionists will want to have safeguards in place to help shift healthcare professionals’ perceptions. Donskey has input here, too. “One of our strategies has been to incorporate education on ‘scary infections you can catch in the hospital’ into our training sessions,” he said. Following suit could help translate into lower PPE-removal contamination rates.

So could advances in PPE design. This field remains nascent and worth monitoring. A seamless PPE suit, perhaps similar to the one Donskey and his colleagues created, could offer an important solution. That’s because the weakest links in PPE suits seem to be the glove-gown interface, where skin is easily exposed, and gown size because the one-size-fits-all approach means material rips or tears during removal, most often for people who are smaller or larger. To test those spots, Donskey and crew made a polyethylene prototype that featured permanent contact bond adhesive on the outer sleeve of the gown and the wrist attached to the inner cuff of nitrile gloves. This continuous coverage of the wrist and hand “prevents expo-sure of skin and requires that gloves be peeled off as the gown is removed,” Donskey, et al. wrote in a 2016 letter to the editor of the journal Infection Control & Hospital Epidemiology. This can, they noted, “reduce self-contamination of the hands and wrists.” As such, they are calling on the industry to develop a seamless PPE suit. 

But changes – in training, in thinking, design – will take a while. Such delays put the onus on infection preventionists to take matters into their own hands in the interim. Certainly, given the ever-present threat of the next new disease, there is no time like now. Therefore, consider this: While the simulation study in JAMA Internal Medicine demonstrated the terrifying potential for contamination when PPE is removed improperly, it also offered hope. After Donskey and colleagues showed personnel how to correctly take off their PPE, contamination figures dropped from 46 percent to 18.9 percent, and stayed at that level after one and three months. Such improvements speak for themselves and direct the way toward change. As Donskey says, “the increasing appreciation for the risk of contamination during PPE removal should stimulate research to develop effective training methods that can be applied in interventions.”

Kelly Teal is a freelance writer.