Tips for PPE Usage, Compliance

Infection Control Today invited manufacturers to share their perspectives on the importance of staff being able to use personal protective equipment (PPE) properly, and describe important aspects of PPE use that facilitate healthcare worker compliance.

Wear the Right PPE for the Right Application
Historically, surgical masks were designed to minimize the risk of contamination and spread of microorganisms expelled from the nose and mouth of healthcare professionals (HCPs) in the operating room (OR). Combination surgical masks/ respirators have been introduced to help reduce HCPs' exposures to certain airborne contaminants, including viruses and bacteria. Surgical respirators combine the features and performance specifications of both devices into one product.

Respirators, Surgical and Procedure Masks: A Comparison
Respirators are designed to help reduce the wearers respiratory exposure to airborne contaminants (particles, gases and/or vapors). Particulate respirators help reduce exposure to particles that are small enough to be inhaled less than 100µm in size. This includes certain airborne biological particles, e.g., Bacillus anthracis, Mycobacterium tuberculosis, the virus that causes SARS, and Pandemic Novel Swine Origin Influenza A (H1N1) virus, etc.  Workers wearing respirators that are designed to fit tightly to the face, such as N95 respirators, must undergo a fit test prior to using the respirator to ensure an adequate seal. Surgical masks do not have adequate filtering or fitting attributes to provide respiratory protection for the wearer.

Surgical and procedure masks are intended to help capture large droplets expelled from the wearer, such as those generated from a cough or a sneeze, as well as help protect HCP from exposure to blood or other potentially infectious material from the patient and the environment.

Infection Control and Personal Protection Equipment (PPE)
PPE can be a key component of infection control programs and can help in reducing the HCPs exposure to infectious agents and the likelihood of the HCP becoming the disease vector from one patient to the next.

There is a wide range of hospital and healthcare settings where PPE is intended for various applications.

Selecting Appropriate PPE
How a disease is transmitted indicates what types of prevention controls may be utilized by HCP. When caring for a patient with active TB, or performing aerosol generating procedures on patients with an airborne transmissible disease, always choose an N95 (NIOSH-certified) respirator or higher level of protection.
If there is the potential for exposures to spray or splatter of blood, a fluid resistant mask or respirators should be selected.

AORN indicates a mask that is securely tied at the back of the head and behind the neck decreases the risk of HCP transmitting microorganisms to patients or to the sterile field.

HCPs should consider wearing respiratory protection (e.g. N95 respirator) during procedures that generate surgical smoke, to help reduce exposures to inhalation of laser and electrocautery generated aerosols, when local exhaust ventilation is inadequate.

Appropriate selection and use of surgical masks and respirators is critical to implementing proper precautions in the OR and throughout the healthcare facility and to help protect both HCP and patients.

-- Shawn Matalas, 3M Infection Prevention technical service, and Brigette Master, 3M Infection Prevention marketing

10 Steps to Exam Gloving
So many times people say to me, How much is there to a glove. You put the right one on, you put the left one on. I would like to say it is that simple, but to ensure the best barrier experience, there are several steps that you must follow. When doing these steps you will always ensure that the gloves that you are wearing will be protective. Always wear gloves when touching blood, other bodily fluids, secretions, excretions, or contaminated items.

Step 1: Ensure your gloves are stored in an appropriate storage location, between 50 degrees to 72 degrees F (10 degrees to 22d egrees C). Extreme temperatures adversely affect gloves.  Shield gloves from ozone and ultraviolet (UV), or florescent lighting.  This will help to prevent deterioration of the glove film and maintain the gloves barrier properties.

Step 2: Confirm youre not allergic to the glove film you are about to wear. If allergic to natural rubber latex (NRL), you should not wear a glove made of NRL. Consider selecting a synthetic glove option such as nitrile.

Step 3: Ensure you have the right gloves for the right task. While hospitals sometimes want gloves with a synthetic origin to avoid concerns about the risk of NRL allergy, vinyl gloves have several features that limit their performance in terms of protection and safety. Therefore, vinyl gloves should not be used in all situations due to the potential risk they can present for patients and healthcare workers.

Step 4: Remove all of the jewelry on your hands, including your watch. Not only can they cause your glove to rip, they can harbor unwanted microorganisms. Also make sure that your fingernails are clean and short, kept no longer than ¼ inch in length. 

Step 5: Wash your hands prior to donning to avoid transfer of microorganisms to other patients or environments. Wearing gloves is never a substitute for washing your hands. 

Step 6: Make sure to use soaps, sanitizers and hand lotions that are compatible with your glove products to ensure optimal barrier protection, and that they do not negatively affect the gloves composition.  Mineral oil and petrolatum, common emollients in skin-care formulations, have been shown to contribute to latex glove deterioration, according to the Occupational Safety and Health Administration. Water-based products are preferred. To moisture your skin and maintain healthy skin you can also select a glove product that has moisturizing properties within the glove.

Step 7: Check your glove for good barrier properties to ensure that it is flexible, free from holes, breaches and cracks, and should be strong enough to prevent breakage during normal use.

Step 8: Change gloves between tasks and procedures, or after contact with material that may contain a high concentration of microorganisms.

Step 9: Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Dispose of your gloves in an appropriate receptacle after use and never snap flick or toss your gloves.

Step 10: Wash your hands again to avoid transfer of microorganisms to other patients or environments.

Following these steps and recommended practices can prevent transmission of potentially pathogenic microorganisms and keep you and your patient safe.

-- Lori Jensen, clinical consultant, Advocate Lutheran General Hospital and Lutheran General Childrens Hospital

Education of HCWs About Proper PPE Use is Vital
Kristin Turner, a lab technician, was infected with HIV and hepatitis C when a blood analyzer machine malfunctioned and the personal protective equipment (PPE) she wore did not provide the appropriate level of protection from the fluids to which she was exposed.(1) The role of PPE was also highlighted in the rapid spread of the Severe Acute Respiratory Syndrome (SARS) in 2003. As reported by the Centers for Disease Control and Prevention (CDC), the greatest risk of SARS transmission was to those who were not properly trained in the use of protective infection control procedures and did not consistently use appropriate PPE.(2)

Personal Protective Equipment is worn to protect the wearer, patients, and others from the spread of infectious agents in the healthcare setting. Unfortunately, compliance with the appropriate selection and use of PPE is a continued area of concern. Each year, OSHA reports the top-ten citations issued to employers in the healthcare industry. In 2012, under the OSHA Bloodborne Pathogens standard, properly wearing PPE was cited as an ongoing challenge for healthcare workers.(3)

Extensive guidance on PPE use is available and should be communicated on a regular basis in healthcare settings. One resource, the CDCs Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings can be found on the CDC website. This program reviews Standard Precautions and addresses the attitude with which healthcare professionals should consider PPE: during care for any patient, one should assume that an infectious agent could be present in the patients blood or body fluids, including all secretions and excretions except tears and sweat. Therefore appropriate precautions, including use of PPE, must be taken.

Standard Precautions dictate:
- Gloves should be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and non-intact skin.
- A gown should be used during procedures and patient care activities when contact of clothing and/or exposed skin with blood, body fluids, secretions, or excretions is anticipated.
- A mask and goggles or a face shield should be used during patient care activities that are likely to generate splashes and sprays of blood, body fluids, secretions, or excretions.

Proper PPE removal also plays a critical role in helping to prevent the spread of pathogens. The Hepatitis B virus can remain viable on environmental surfaces for seven days while studies show that gram-positive bacteria, particularly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), have the ability to survive on various items such as clothing, towels, scrubs, drapes and splash aprons for at least one day and some have survived more than 90 days. Individuals wearing PPE should remove their gloves first, as they are considered to be the most contaminated, followed by their face shield or goggles and then their gown. Their mask or respirator should be removed last, immediately followed by hand hygiene.

It is imperative that healthcare personnel are appropriately educated on PPE use so that they can protect themselves and ultimately help to prevent the spread of infectious pathogens.

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

References:
1. Perry J and Jagger J. Occupational Co-Infection with HIV and HCV in Clinical Lab Via Blood Splash. Advances in Exposure Prevention 7. 2005.
2. Siegel JD, Rhinehart E, et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings." Am J Infect Control. 35(10 Suppl 2): S65-164. 2007.
3. Casey  T. Top 10 OSHA Citations in the Healthcare Industry. LexisNexis Martindale-Hubbell. February 2012. 

Proper Use of Personal Protective Equipment
The importance of staff being able to use personal protective equipment properly is vital to the safety of both the person wearing the PPE as well as the patient. Hand protection, for example, is an intricate part of the PPE repertoire.
When used correctly, disposable gloves can protect against dangerous elements clinicians come into contact with everyday such as bloodborne pathogens, bodily fluids, harsh chemicals and more. The proper donning and doffing technique of gloves is critical to ensure full protection.

When donning a glove, one should make sure their hands are completely dry and remove all jewelry that could possibly puncture or compromise the fit of the glove. It is also important to accurately identify what size glove best fits keeping in mind that sizing can vary depending on who makes the product and where it comes from. One brands medium may fit like another brands small. So its imperative to try on different sizes to see how they fit. A glove that is too tight can cause hand fatigue or increase the risk of tearing. A glove that is too large may hinder tactile sensitivity or allow fluids to enter from around a loose cuff.

Once the appropriate size been identified, open the glove at the cuff with one hand and extend the opposite hand in until your thumb is in place (thumb webbing should touch the cuff of the glove). Once your hand is properly aligned in the glove, slide your fingers down into the openings suitable for each finger. Then, roll the cuff down your wrist until the glove is secure.

To safely doff the glove, pull the glove from the cuff upwards on the hand inside out to trap potential contaminants inside the used glove. Place the used glove into the palm of the opposite hand (which remains gloved). Repeat this action on the opposite hand, trapping the first glove inside the second. Discard the gloves and wash your hands.

It is important to replace gloves frequently to eliminate possible contamination or spreading of germs, especially when changing tasks. Examination gloves should not be worn for more than 15 to 30 minutes at a time to avoid potential punctures or material breakdown (varies depending on the task in which the hand protection is being used or material it is made of).

-- Katie Brunelle, marketing specialist, acute care, Sempermed

Building Blocks of a Solid Respiratory Protection Program
Proper implementation of an organization-wide respiratory protection program can be a huge undertaking that requires coordination and cooperation between infection control, occupational health and industrial hygiene professionals. Conscientious healthcare administrators know that an effective respiratory protection program it is about more than just regulatory compliance. The program also provides reassurance that respiratory protection is actually being delivered to the healthcare worker, and that the worker is confident in the use and effectiveness of their respirator. The component of the respiratory protection program that offers this reassurance is the respirator fit test.

The primary reason most people conduct a fit test is to assess whether a specific type, model and size of respirator adequately fits a specific individual. But an even more important reason for fit testing is to ensure that an individual knows how to properly don (put on) and wear the respirator. A properly sized respirator will provide little protection if it is not worn correctly.

A good respiratory protection program also includes respirator-specific training for individuals who must wear a respirator. Some organizations hold day-long classes, while others may offer more condensed training, where employees are taught the why and wherefore of respirator usage, and are given a chance to work with the respirators. Respirator training includes instruction on how to adjust the respirator straps, the bendable nose band, and how to perform the mandatory user seal checks. The annual fit-test is done to make sure that training knowledge is retained and properly put to use.

Think of the fit-test as a final exam. The employee receives training, and then a fit-test is performed to verify that the person actually learned what was taught. Without a fit-test, there is absolutely no way to know that the person is capable of achieving the protection level expected from the respirator. Annual respirator training and the subsequent fit-test are inseparable.

Another critical element of a good fit testing program that is too frequently overlooked is training the people who conduct the fit test. The expertise of the test conductor can make the difference between a mediocre program and a great one. To provide a proficient fit test, the people conducting the test must be well aware of the issues and ramifications involved. They need to know why the test is necessary and why it's important. They need to know what to do, and just as importantly, what not to do. A fully trained test conductor will greatly improve the efficiency and quality of the fit testing operations. One simple way to dramatically improve a fit testing program is to have any person who conducts a fit tests attend a one to three day seminar on the subject. These courses will offer the test conductor confidence in the process, and ensure your workers are truly receiving the highest level of protection. 

-- Johnathan Morton, TSI applications specialist

PAPRs vs. N95s: PAPRs Enhance Compliance
Healthcare workers are often confronted with the difficult task of working safely in hazardous environments so compliance is an essential part of the occupational health professionals mandate. All staff should be trained accordingly when it comes to the importance of personal protective equipment, but the prime responsibility for health and safety in the workplace rests with management.

Powered Air Purifying Respirators (PAPRS) and N95 masks are an important part of respiratory protection programs where compliance is necessary. Like other PPE, the selection of a respirator type must consider the nature of the exposure and risk involved. Policies can be in place, but following them remains the biggest challenge.

Without compliance, the risks of infection significantly increase and an incident will occur; it is only a matter of time. 

N95 mask-style respirators are the historical minimum protection standard for respiratory infection prevention in hospitals; however, for a higher level of respiratory protection, powered air-purifying respirators or PAPRs are becoming increasingly more popular.

For example, N95s, compliance is confounded by high percentages of healthcare workers not passing fit-testing. Because the N95 is a tight-fitting negative pressure respirator, it is only effective when its properly fitted with a tight seal (no gaps around the edges), so fit-testing is required. When healthcare workers are not fit-tested or trained properly, they cannot tell with any accuracy whether they have achieved an effective or adequate facial seal.

According to Tom Anderson, cardio-pulmonary lab supervisor at Sunnyside Community Hospital in Washington, N95s are good, but once you put it on (even if you go through your own initial check) there is no way of telling if something has moved a little. Is it now leaking 15 percent instead of 5 percent because you scratch your nose or eyebrow?

Employees often don them incorrectly or re-use them, which is inappropriate. This leads to poor compliance and safety burdens. Tom says PAPRs are safer, in his opinion, and easier to use.

Many who are unfamiliar with PAPRs perceive they are too costly or difficult to use. In practice, PAPRs can be more comfortable, better for patient communication, easy to use and more cost effective to implement. PAPRs enhance compliance, which leads to better infection control.

Anesia Carter, employee health nurse at Citrus Memorial Hospital, says the occupational safety advantages of PAPRs are going to be ten-fold. She has many employees who get splashes into their mouth, nose and eyes and the PAPR is another way to help limit these types of exposures. She describes the PAPR as being more comfortable, it doesnt fog-up and is much easier to breathe in. N95s are hot and uncomfortable and you get a wonderful little pattern around your face from the mask digging into your skin, so nobody likes to wear them.

In comparison, a PAPR utilizes a battery-powered fan to draw in ambient air through the HE filter, sending a continuous flow of clean air into the facepiece. This creates a cooling effect so employees can work comfortably and safely for several hours. Comfort leads to compliance, which leads to better infection control.

Implementing a PAPR-based program for your facility can increase occupational safety and compliance. It is time for hospitals to end the frustration of fit-testing failures and consider PAPRs as the mainstay of respiratory protection.

-- Corey Wick, Global Marketing Manager, MAXAIR Systems

Clinical  Evidence Points to a Need for Vigilance in Infection Control
It is widely accepted in the healthcare industry that eye protection is a barrier capable of both preventing eye injury and of limiting transmission of infectious material via eye mucous membranes. Healthcare-acquired infection (HAI) risks from touching conjunctiva can include viruses and bacteria causing conjunctivitis (e.g., adenovirus, herpes simplex, Staphylococcus aureus) and viruses causing systemic infections, including bloodborne viruses (e.g., hepatitis B and C viruses, human immunodeficiency virus), herpes viruses, and rhinoviruses.
The U.S. Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), the American National Standards Institute (ANSI), and the Centers for Disease Control and Prevention (CDC) all recommend appropriate eye protection as part of Personal Protective Equipment (PPE) guidelines to reduce the risk of infectious disease transmission through conjunctiva and, therefore, reduce the overall HAI risk.

Virtually all research available supports protective eyewear use in emergency, operating, and especially cardiac and other invasive surgical settings, including for endoscopic procedures. Best-practice protocols in place at acute-care facilities include targeted protective eyewear recommendations. Most protocols specify not only that eyewear be used, but that it be removed in an aseptic manner in order to minimize the possibility of blood and body fluid contact with the mucous membrane and conjunctiva of the eye.

One of the most vulnerable acute-care environments is the hospital operating room (OR), where highly invasive procedures and equipment raise the likelihood of fluid transmission and infection risk. Infectious material sprays and splashes, including of blood and of other bodily fluids, can occur throughout the course of an OR caseload and workday. Clinical evidence also shows that surgical team members can be sprayed or splashed by infectious material without an apparent spray or splash eventin other words, without the affected individuals knowledge.

Consequently, ongoing vigilance around OR-associated infection-control protocol development, education, and adherence, is vital. Infection-control protocols generally dictate that, following removal, contaminated protective eyewear is disposed of immediately after use or is promptly decontaminated in accordance with guidelines. Protective eyewear that is not properly disposed of and/or decontaminated may continue the risk of infection to surgical patient and healthcare worker populations via cross-contamination and inter-case contamination.

However, the success rate of many in-place protocols depends heavily on a few factors as givens: first, that staff adhere to protocol decontamination guidelines; second, that spray events are known; and third, that eyewear can effectively be aseptically disposed of or decontaminated. Again, clinical evidence shows that sprays can occur without individual knowledge and that some eyewear can retain microbial growth even after disinfection.

Close examination of infection control protocols and, specifically, regarding protective eyewear use and disinfection practices particularly by OR and infection-control staff is essential to maximizing infection control efforts and minimizing HAI risk. In the case of PPE in acute-care, protocol implementation practices and ongoing protocol evaluations are as important as already-defined best-practices. Vigilance is key and clinical evidence must be heeded.

-- Katie Umentum, senior product manager, acute care, TIDI Products, LLC

Effective and Safe Use of Todays Medical Gloves
 The proper selection and use of medical gloves is critical in providing healthcare professionals and their patients protection against viral transmission and other harmful infectious substances. Using gloves with inferior barrier capability could expose both users and their patients to serious health risks. With the availability of many types of gloves in the market place, one should therefore be mindful that gloves made from different materials have different barrier properties and qualities.

It is well-acknowledged that natural rubber latex gloves are the gold standard in barrier protection, having superior qualities in barrier integrity (which includes their unique ability to reseal when very tiny needle punctures are encountered), durability, comfort, fit, tactile sensitivity, good puncture and high tear resistance. Non-latex (synthetic) gloves like nitrile, polychloroprene, polyurethane and polyisoprene, on the other hand, may have some properties comparable to latex gloves, but they are often more costly, particularly the polyisoprene gloves. However, nitrile gloves have become more price-competitive in recent years.

As for the inexpensive polyvinyl or PVC medical gloves, they have the least barrier capability as demonstrated by numerous studies. High glove failure rates during use have been reported. For this reason, they are not suitable for medical procedures that come in contact with blood and body fluids which may contain infectious micro-organisms. As a matter of fact, surgical gloves which demand a high degree of barrier capability are not made from polyvinyl chloride (PVC).

With the increasing awareness of Green Health, environmental impact by the production and disposal of the millions of gloves consumed annually is a matter of concern. It is noteworthy that while natural rubber latex gloves are environmental friendly, being derived from a renewable and sustainable resource, and are biodegradable, non-latex gloves are made from petrol chemicals, which are often toxic or carcinogenic. They are not biodegradable. Their incineration is known to release harmful substances like dioxin, hydrogen chloride, and even cyanides. Disposing them through landfill would result in their perpetual presence in the ground, leaching out their harmful chemicals into the ground water, thereby contaminating the soil and subsequently the food chain.

While natural rubber latex gloves remain the choice for barrier protection, individuals allergic to latex proteins are advised to opt for synthetic gloves with no proteins, but with adequate barrier capability. Latex gloves with high protein and powder content were the cause of the allergy. But today, low-protein and powder-free latex gloves are available. The use of such gloves has been shown by many hospital studies to drastically reduce sensitization and allergic reactions in work places. More importantly, they demonstrated that healthcare professionals wearing these gloves can work alongside their latex allergic coworkers with no heightened allergy concerns. To ensure the latex gloves are of quality and low protein content, appropriate manufacturing processing measures are necessary, as in the case for the SMG certified gloves. SMG is a quality certification program for low-protein latex examination gloves which ensures high barrier compliance and very low protein level.

-- Esah Yip, D.Sc., Malaysian Rubber Export Promotion Council

Improving Personal Protection Program Compliance
 We suggest the following steps to improve personal protection program compliance:

1. Identify the hazards that cant be alleviated by other means and for which personal protective equipment (PPE) is the only available option
2. Identify those individuals potentially exposed to the hazards
3. Select the appropriate PPE that will provide the necessary level of protection using expert recommendations and guidelines from respected sources like the CDC and OSHA
4. Train the users on the proper use of the selected PPE. Fit-testing is always required and the OSHA Respiratory Regulation 29CFR1910.134 should be followed, which includes annual fit testing and a respirator medical evaluation completed and approved prior to the start of the fit testing process.
5. The user should be given choices of various models and or sizes, so that the individual has the opportunity to achieve a comfortable and proper fit especially when N95s or other forms of higher level facial protection are deemed necessary. 

We believe more than two sizes of N95s are needed to successfully fit all the face shapes in our population, and PPE products should be as easy to don and convenient to transport to the work area as possible. By giving employee options and letting them choose what works best for them it helps reduce non-compliance with respiratory program guidelines. Comfort and convenience drive compliance.

Once the respiratory program has been documented and all the participants in the program trained it is necessary to routinely monitor proper use and provide feedback. The feedback should reinforce good behaviors and bring unacceptable behaviors up to the necessary respiratory protection program standards.

-- Greg Taylor, vice president, business development - healthcare, Moldex-Metric, Inc.

-- Compiled by Jessica Barreras