Review of personal protection equipment used in ...

CLINICAL FOCUS

Review of personal protection equipment used in practice Jon Hinkiriyjohn Gammon^ Jayne Cutter Jon Hinkiii is a Tutor.Joliii Gammon is Depuly Head of School of Health Sciences andjayne at Swansea University, Wales

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he idenrification of infected patients through clinical assessment, or readily available laboratory tests is not always possible. This difficulty is compounded by differing incubation periods for various microorganisms during which time individuals may he infectious. Since it is impossible to identify all those who may have an infection, every patient should be regarded as a potential risk. Therefore, healthcare workers should routinely use appropriate barrier methods Co prevent contamination by blood and body fluids, Sound infection control practices known as standard precautions (SP) which regard all patients as potentially infectious, in both community and hospital settings, are imperative.

Standard precautions Standard precautions are a development of universal precautions (UP), an American ideology originally intended as a consistent approach to the prevention of transmission of blood-borne diseases (Centres for Disease Control and Prevention (CDC), 1987). However, nationally and internationally, confijsion existed over the application and interpretation of UP leading to poor compliance (Ronk and Girard, 1994; Williams et al, 1994; Leliopoulou et al,

ABSTRACT Standard precautions offer a consistent approach to infection control that does not rely on knowiedge or suspicion of infection, and contributes to staff and patient safety by reducing the risk of exposure to potentially infectious material. One of the cornerstones of standard precautions is the appropriate use of personal protective equipment (PPE) whenever contact with hlood or body fluids is anticipated. However, evidence suggests that compliance with standard precautions including correct use of PPE is inadequate. Demographic and epidemiological changes in the UK, and the drive to provide more complex patient care outside acute hospitals may lead to increased infection risks for both patients and community heaithcare workers. This review examines the importance and use of PPE by community nurses and discusses the implications for practice of poor compliance with standard precautions. Recommendations for practice will be made aimed at improving compliance with this important element of standard precautions.

KEYWORDS Community nurses - Standard precautions ' Compliance

Cutter is a lecturer. AU are based Email: [email protected]

1999). Consequently, new guidelines were suggested to provide a logistically feasible strategy for preventing tlie many infections occurring in heaithcare settings through diverse modes of transmission. These precautions needed to be epidemiologically sound, recognize the importance of all body fluids, secretions and excretions in the transmission ot pathogens, contain adequate precautions for infections transmitted by the airborne, droplet and contact routes of transmission and be as simple as possible. On the basis of these considerations, guidelines were developed for Standard Precautions and TransmissionBased Precautions hy Garner et al (1996) on behalt of the CDC, These precautions have recently been updated by Siegel et al (2007) who acknowledge that guidance and research specifically on the prevention of transmission of infection in home care settings is limited and may, out of necessity, require adaptation of hospital-based guidelines. Standard precautions are an effective means of controlling the spread of infection and providing protection to healthcare staff and patients (Cullen et al, 2006) and apply to blood, all body fluids, secretions and excretions except svyeat, regardless of whether they contain visible blood.The main components of SP include: • • • • • •

Hand decontamination Use of personal protective equipment Safe use and disposal of sharps Decontamination of equipment and the environment Patient placement Linen and waste management (Garner et al, 1996). The adoption of UP and SP in the UK is supported by the Department of Health (DH, 1998), National Institute of Clinical Excellence (NICE, 2003), the All Wales Health Protection Nurse (Infection and Communicable Disease) Forum (2007) and in the epic (phase 2a) and epic2 guidelines (I'cllowe et al, 2003; Pratt et al, 2007). Compliance with precautions is equally important in hospital and community care settings. Demographic changes and the drive to provide more complex care outside hospitals means that infection control must be uppermost in the minds of all healthcare practitioners working in the community (Hanrahan and Rcutter, 1997; Wanless 2002; NICE, 2003; Bennett and Manseil, 20U4; Welsh Assembly Government (WAG), 2005). A previous review has described one component of SP in the community i.e. sharps handling and management

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(Cutter and Gammon, 2007) which identified that complijiicf among community nurses is variable (Hanrahan and Reutter, 1997; Bennett and Mansell, 2004; Haiduven and Ferrol, 2004).A variety of reasons have been identified including insufficient knowledge and training (Ward, 21K)0; Bennett and Mansell, 2004; Haiduven and Ferrol. 2004), lack of suitable equipment, concerns about efficacy of equipment and loss of dexterity, length of service (Bennett and Manseli, 2004) and the unpredictable nature of the home environment and it's occupants (Hanrahan and Reutter. 1997; Ward. 2000; Bennett and Mansell. 2004). This review will concentrate on reviewing the evidence relating to another element of SP i,e. personal protective equipment (PPE) in the community.

Aim The purpose of this literature review is to consider key themes from research relating to knowledge of and compliance with SP, specifically PPE among conmiunity health care practitioners. Drawing on international studies, the review discusses practitioner compliance and strategies used to improve the application of personal protective equipment. The review evaluates practice implications for the community setting.

Methodology A literature search of studies listed in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database was conducted from 1995-2007. Using the terms 'universal precautions', 'standard precautions', 'compliance', 'intervention studies', 'personal protective equipment', 'protective clothing' and 'knowledge'. To ensure completeness of the review additional words included: 'gloves', 'masks', 'respiratory protective equipment', 'plastic aprons','gowns','eye protection','visors','goggles' and "face protection'. Research studies were included in the review if they: • Related to the efficacy of personal protective equipment in a clinical setting • Identified knowledge and compliance relating to appropriate selection and use of PPE • Analysed interventions aimed at improving knowledge and compliance to PPE use. Also included were relevant guidelines, policy, audit and government reports that had direct reference to personal protective equipment. Snidies were excluded from the review if they were not written in English, undertaken on SP with no reference to PPE and had no nursing involvement. The review identified a lack of research specifically within the community setting relating to PPE, so studies undertaken in hospital settings, where the results can be extrapolated to the community were included. In total thirty-three research articles were included, one audit report, and two national guidelines.

Personal protective equipment Personal protective equipment is used to minimize poten-

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tial exposure to infec-

.jj^j^ review

tive agents and mate-

rials thereby providing protection to both healthcare worker and

patient (Clark et al 2002) The key compo^ nents of PPE are

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conceiitrate

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Oil reviewipg the evidefice relating to another element r^***

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of SP i,e, personalptotective equipment (PPE) in ^^^ COmmUnitv'

• Gloves ' • Gowns • Aprons • Masks • Goggles • Visors • Caps • Theatre footwear (Clark at al, 2002). This review will focus on the use of gloves, aprons/gowns, masks and eye protection. Pratt et a! (2007) emphasized that a personal risk assessment taking account of health and safety legislation and the associated risk with a specific care intervention should guide the selection and use of PPE. This is underpinned by key legislation that aims to provide clear guidance and direction (Health and Safety Executive (HSE), 1992; Control of Substances Hazardous to Health (COSHH). 1999). This legislation highlights the responsibility of employers to ensure appropriate PPE is available, that it is fit for purpose, and that training is provided in its selection and use. Specific guidance on the selection and use ot PPE in the community was pubhshed by the National Institute of Clinical Excellence (NICE. 2003) and was reinforced by the publication of the epic (phase 2a) guidelines (Pellowe et al, 2003).

Efficacy of PPE The efKcacy of the individual components of PPE in minimizing exposure to potential contamination through contact with microorganisms has been demonstrated. Srinvasan et al (2002) identified that using gowns in conjunction with gloves decreased the acquisition rates ofVancomycin resistant enterococci (VRE). Grant et al (2006) attributed a small reduction in Methicillm resistant Staphylococcus aureus (MRSA) transmission due to increased gown use. However, failure to use PPE has led to an increased risk of infection. Seto et al (2003) found that all infected staff during a severe acute respiratory syndrome (SARS) outbreak had omitted either correct PPE use or had not complied with hand hygiene guidance while Ganimage et al (2005) identified that failure to implement training and poor availability ot respiratory protective equipment was the key factor in nosoconiial transmission of SARS.

Glove integrity However, use of PPE alone is insufficient. For example. Tenorio et al (2001) demonstrated that the integrity of gloves could be compromized and found that VRE

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Personal protective equipment is of paramount importance to community practitioners

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BIOV-O could remain on healthcare workers hands after gloves have been removed. This reinforces the importance of performing hand decontamination when gloves and indeed when any element of PPE is removed (Boyce and Pittet, 2002). With the evidence showing the effectiveness of PPE, combined with national guidelines and knowledge of transmission of microorganisms, it would be expected chat comphance with PPE among healthcare workers would be high. Unfortunately the literature does not corroborate this. The literature identified that knowledge of and compliance with PPE is often sub-optimal.

Compliance with PPE None of the studies reviewed reported comphance with all available protective clothing during each potential exposure to infectious material. Knight and Bosworth (1998)

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reported that 73% of nurses stated that they used infection control precautions on all occasions while Evanoff et al (1999) observed full compliance with PPE on 66% of occasions and Sadoh et al (2(K)6) found that less than two thirds of respondents always used PPE. Ganczak and Szych's (2007) study demonstrated that only 5% of surgical nurses wore all components of PPE when in contact with potentially infective material. The PPE worn most readily in both hospital and community is gloves (39-96%), while compliance with eye protection was poorest at 2-78%; mask use varied between 5% and 6H% and use of aprons or gowns ranged from 3-94% (Knight and Bodsworth, 1998; EvanofF et al, 1999; Beltrami et al, 2000; Madan et al, 2002; Bennett and Mansell, 2004; Kermode et al, 2005; Kuzu et al, 2005; Golan et al, 2006; Sacar et al, 2006; Ward, 2006; Manian and Ponzillo, 2007).

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CLINICAL FOCUS A number of these studies used self-reporting as the chosen method of data collection (Kiiight and Bodsworth, 1998; Bennett and Mansell, 2004; Ward, 2006). Consequently, the accuracy of many of these results must be viewed with caution. [Reported compliance may be higher than observed compliance because the true answer does not portray respondents as they would want to be viewed (Polit and Beck. 2004). Madan et al (2002) compared selfreported usage rates against observed rates. Observation of actual PPE usage showed significantly lower rates than reported rates, except for glove use. The reliability of observation itself must also be questioned as the presence of an observer may influence the results, a phenomenon known as the 'Hawthorne effect' (Roethlesberger and Dickson, 1939).

Inappropriate use of PPE This review has established that PPE is an important component of SP and can help to reduce the risk of infection. However, it must be worn appropriately. Inappropriate use of PPE can actually increase the risk of infection. Girou et al (2004) identified the danger of glove overuse where healthcare workers wore gloves as a substitute for hand-hygiene. Hand-hygiene was not undertaken on 64% of appropriate occasions due to improper glove use. Flores and Pevahn (2006) found similar results. Compliance with glove use was 92% but glove overuse was 42%, This had an adverse effect on band-hygiene rates. This may be a particular problem among community healthcare workers where access to suitable hand-washing facilities may be difficult (Gould et al. 2000; Ward. 2000; CarroU, 2001).

Factors influencing non-compliance with PPE So that appropriate strategies can be employed to improve compliance with PPE and reduce the risk of infection, it is important to understand why compliance is poor.The following reasons for non-compliance with appropriate PPE use were identified in the review.

Workload and staffing levels Ward's (2006) audit analysing infection control practice in primary care identified two predominant factors that had an adverse effect on PPE use: time constraints and workload stress. Gershon et al (1999) identified that workload stress influenced compliance. While Madan et al (2002) and Sax et al (2005) found that lack of time was the primary reason for non-compUance.

Availability Not only has availability of PPE been identified as a factor influencing compliance (Sax et al, 2005), it can influence die risk of acquiring an infection. Lau et al (2004) identified that a shortage of PPE was likely to be associated with a higher risk of SARS acquisition. Not surprisingly, PPE was more likely to be used if it was available. However, unavailability of PPE has been identified by 7-50% of

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respondents in various studies (Cutter and Jordan, 2004; Ferguson et al, 2004; Ganzack and Szych. 2007). GreenMcKenzie et al (2001) identified that gloves were nearly always available compared to other components of PPE. This may explain the higher rates of compliance with glove use compared to other elements of PPE.

Perceived risk to healthcare worker The perception of risk associated with caring for certain patient groups influenced the decision making process of some healthcare workers (Evanoff et al, 1999; Cutter and Jordan, 2004). This category included fear of contracting a blood-borne virus and whether the patient is known to have a blood-borne viral infection (Preston et al, 2002; Ferguson et al, 2004; Ganzack and Szych, 2007).This contradicts the principles of standard and transmission-based precautions.

Knowledge Lack oi knowledge has been shown to influence compliance with PPE (Kermode et al, 2005; Sax et al, 2005). Knight and Bodsworth (1998) found a discrepancy in knowledge among nurses who claimed to use infection control precautions at all times, yet only used gloves to handle blood and body fluid on 50% of occasions. Bennett and Mansetl (2004) identified that only 26% of community nurses felt their knowledge of SP to be adequate. Only 65% of respondents had received training on UP and only 20% had received update training. Similarly, Ward (2006) identified insufficient knowledge among primary care staff related to a lack of training and no or inappropriate policies. Ganzack and Szych (2007) found greater comphance with PPE in nurses who had attended infection control training.

Loss of dexterity Decreased dexterity due to PPE was a theme that emerged throughout the review. Madan et al (2002) reported that one third of respondents found PPE too cumbersome. Other authors support this, reporting that glove use interfered with nurses' ability to provide care (Cutter and Jordan, 2004; Ferguson et al, 2004; Bennett and Mansell, 2004; Ward, 2006). Osborne (2003) found that even the perception that PPE interfered with duties contributed to poor compliance.

Improving compliance Cutter and Gammon (2007). in their review of SP and sharps management in the community, identified initiatives that have been used to improve practice with SP generally and these can also be apphed specifically to PPE. Education has been identified as a useful strategy in improving compliance with elements of SP including use of eye paitection and double gloving (Kim et al, 2001) and compliance with UP in general (Wang et al,2003). The use of a targeted information fiyer was introduced by Robert et al (2006) to improve compliance with isolation precautions. Use of gowns increased from 82% to 100%

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CLINICAL FOCUS after the intervention. No other aspect of PPE compliance was measured. Hovrever, it is possible that the effect of such interventions may be short-lived. For example, a peer feedback programme by Moongtui et al (2000) found no longterm improvement in compliance with handwashing and glove use. Raskind et al (2007) identified that the largest improvement in compliance occurred one-month post intervention compared to three months and advocated the use of periodic educational interventions to maintain the improvement in compliance. Appropriate equipment should be available at all times to prevent the situations described by Green-McKenzie et al (2001) and Blake (1999). Pratt et al (2007) noted that in relation to interventions that aim to improve compliance with hand hygiene, single interventions have a short-term effect; remmders have a longer modest effect; regular feedback on compliance can be effective but multi-faceted interventions are often the most effective in improving compliance. There is no reason to suppose that similar interventions wouldn't be successful in improving compliance with PPE in the community. Pratt et al (2007) identified that future research should be directed at identifying behavioural approaches to improve healthcare workers adherence to infection control practices. Changing behaviour is a complex challenge shaped by numerous variables including beliefs, attitudes, perceived health threat and communication (Kretzer and Larson. 1998). Community healthcare workers will need to incorporate these variables into targeted interventions to improve compliance.

Implications for practice In order to promote the appropriate use of PPE, employers must provide suitable facilities and support for example, ensuring sufficient supplies of PPE. However, some activities that may have an impact on compliance may be particularly challenging in community settings for example. waste disposal, hand hygiene and education. Once PPE is removed it must be disposed of responsibly to minimize the risk of exposure to blood and body fluids in waste handlers. Recent guidance (DH, 2006) has identified that transport of waste by community nurses should be undertaken only if waste is held within secure, rigid packaging. The alternative is to arrange collection by a suitable agent. While awaiting collection, any waste stored in patients' homes remains the responsibility of the community nurse which given the unpredictable nature of some patients and their enviromnent (Hanrahan and Reutter, 1997; Ward, 2000; Bennett and Mansell, 2004) may be problematic. It has been identified that thorough hand hygiene must be observed following removal of PPE. yet facilities in patients' homes may inhibit this (Gould et al, 2000; Ward, 2000; Carroll. 2001). Alcohol hand-rub is an effective skin sanitizer, however, it must be recognized that alcohol will not clean dirty hands. Improving hand hygiene in primary care will be the latest focus of the National Patient Safety Agency (NPSA) 'Cleanyourhands' campaign which is due

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to be extended outside acute hospitals in 2008 (NPSA, 2007). Providing education for groups of staff spread over wide geographical areas with no common base may be difficult and could be supported by use of e-learning packages.

Conclusions The review has identified the role of PPE in infection control but has also identified shortfalls in compliance. Much of the work has been undertaken in hospitals and limited guidance is available specifically for community settings (Seigel et al, 2007).Therefore, it is paramount that research and guidance is developed that considers the unique nature of community care. It is apparent that education and training for community staff is required and it is imperative that infection control education is integrated in a structured and effective manner into the continuing protcssional development of healthcare practitioners in order to promote safety for both healthcare worker and patient. BJCN All W.i!c< Health I'nnection Niirst- (liitettion and Communie.ible I)ir hmd hygiene in heiiJtb care settinp. hfeiT G'nfm/ Htup Epidi-rniol 23(12): suppleincnt CarrollA (2f)Ul) Hand-washinp for heaith-carc workers m domestic c.-ire facilities. Br j Community X'lirs 6{5): 2 1 7 - 2 3 Centres for Disease Control and Prevention (l')87) Rewmmt-ndiiiiiiiis fir prireiiiiorio AR, Badri SM. Sahgal NB et a\ (2001) Effectiveness of gloves in the workers in rural north India. Am J tnfect Controt 33(1): 27-33 prevention of hand c.irriage of vancomycin resistant enterococcus species by Kim LE. jeffe DU. Evanoff BA, Mutha S. Freeman B and Fraser VJ (20III) healthcare workers afi^er patient care. Clin Infect Dts. 32; 826-9 Improved compliance with universal precautions in the operating rooni following jn educational inter^'ention, Infect Control Hosp EpiilemhI. 22(8): UK Health Departments (1998) Guidance for Clinical Health Care Workers: Protection against Infection with Blood-borne Viruses. Recommendations 522-4 of the Expert Advisory Group on AIDS and the Advisory- Group on Knight VM ajid Boiiswortli NJ (1998) Perceptions of practice of universal Hepatitis. Department of Health. London blood and body tluid precautions by registered nurses at ii major Sydney Wang H. Fennie K, He G. Burgesi J and Williams AB (2{K]3) A training teaching hospital.^^t/y Nurs. 27: 746-32 programme for the prevention of occupational exposure to bloodborne Kretzer EK and Larson EL (1998) Behavioural interventions to improve infecpathogens: impact on knowledge, behaviour and incidence of neodlestick tion control practices. AmJ Infect Canin'i 26: 245-253 injuries among student nurses in Changsha. People's Republic of China. J Kii7u N. Oi;er F. Aydemir S, Yalrin AN. Zencir M (2OI>5) Compliance with Adv Nurs.Ai: 187-94 hand hygiene and glove use in a university affiliated hospital. Infect Conlrot Wanless D (2{)02) Securing Our Future Health: Taking a Long-li'rm I'lcii', HM Hosp fpiJi'/iiK./, 26(3): 312-15 Treasury. London Lau JT, Fung KS.WongTW et al {2004), SARS transmission among hospital Ward D (21100) Delivering effective infection control in the comniuiiit>' setworkers in Hong Kong, Hinerg tufcct Dii 10(2): 28()-(i ting. Journal of Community Nursitig On line: www.jcn.co.uk/journal. Leliopoulou C, Waterman H. Chakrabarty S (1999) Nurses' failure to appreasp?MontbNum^lO&YearNum-200f>&Type^backissue&ArticlelD=283. ciate the risks of infection due to needle stick accidents: a hospital based Accessed July 10th 2007. survey. J Hosp Infect. 42: 53-9 Ward D (2006) Compliance with infection control precautions in primary Madan AK. Raafat A. Hunt JP. Rent:; D. Wihle MJ and Film LM (2002) Barrier care. Primary Health Care 16(10): 35-39 precautions in trauma: is knowledge enough? _/ Trauma. 52(3): 54C)-3 Welsh Assembly Government (2(KI5) Designed for Life: A Wir/J CIMS Health Manian FA and Ponzillo JJ (2007) Compliance with routine u«e of gowns by Service for Wales. Cardiff: Welsh Assembly Government healthcare workers and n on-health care worker visitors on entry into the rooms of patients under contact precautions, tnfecl Ctintrol Hosp Epidemiol. Williams CO. Campbell S, Henry K, Collier P (1994) Variables influencing compliance with universal precautions in the emergency department. AmJ 28(3): 337-40 Infect Control. 22{i): 138-4H Moongtui W. Gauthier DK and Turner JG (2IKI()) Using peer feedback to improve handwashing and glove usage among Thai healthcare workers. .4i>\ J tnfeci Control. 28: 365-9 National Patient Safety Agency (2007) National Patient Safety Agency takes cleanyoiirhandsbeyondhospitals. vyww. npsa.cyh.uk/iiisplay?collteiltld-63'.J5. Accessed October 2nd 20(17. NICE (2003) Infection Cantrfl. Preveiilion cif heiilthcare atsodaicd infection in pri* Standard precautions have been demonstrated as effective in reducing mary and camiminity carr. www.nice.org.uk , Accessed July 10th 2007. Osborne S (2(MI3) Influences on compliance with standard precautions among the risk of infection to health care workers. operating room nurses, AmJ Infect Control. 31(7): 415-23 • PPE is an essential component of standard precautions. I'ellowe DM. I'ratt RJ. Harper P et al {2003} Infection control: PrnvnUon cf • Current available evidence suggests that compliance with PPE among healthcare associated infection in primary and community care, www.epic.tvu. community nurses is less than optimum. ac/epicphase/2a.html. Accessed July Uith 2(107. I'olit DF. Beck CT {2(HH) Nursing Research. Principles and Mfthods (7th edition) • Appropriate strategies must be employed to improve compliance to Lippincott. Williams andWilkins. Philadelphia reduce risks associated with increasingly complex health care in the Pratt RJ, Pellowe CM. Wilson JA et al {2007) Epic 2: National Evidence Based community. Guidelines for the Prevention of Healthcare Associated Infection in NHS Hoipiuls. www.epic.tvu.ac.uk/epic/iiotice.htnil. Accessed lulv 10th 2007. •Research specifically designed to address compliance with PPE among Preston DB. Forti EM and Kassab CD (2002) Profiles of rural nunes' use of community practitioners is urgently needed. personal protective equipment: a cluster analysis._/ Assoc Nurses .4IDS Cart: 13{6); 34-^5 k.iskiiid CH.Worley S.VinskiJ and GoldfarbJ (2007) Hand hygiene compli-

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