Self-Contamination High Among Healthcare Workers: Study Published

Laurie Barclay, MD

October 12, 2015

Healthcare workers (HCWs) often contaminate their skin and clothing when removing contaminated gloves or gowns, according to a report and editorial published online October 12 in JAMA Internal Medicine. Educational tools including practice with immediate visual feedback on skin and clothing may help remedy this situation.

"Personal protective equipment (PPE) reduces, but does not eliminate, the risk of skin and clothing contamination with pathogens among health care personnel," write Myreen E. Tomas, MD, from the Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Ohio, and colleagues. "Even when gloves and gowns are worn, 2% to 5% of personnel caring for patients colonized with multidrug-resistant bacteria acquire the pathogens on their hands after glove removal. In addition, 24% of personnel caring for patients with Clostridium difficile infection...had spore contamination on their hands after glove removal."

Results from the study were presented May 15 at the Society for Healthcare Epidemiology of America (SHEA) Spring 2015 Conference.

The goals of this point-prevalence and intervention study were to examine the frequency and sites of skin and clothing contamination of HCW during PPE removal and to assess the effect of an intervention on contamination frequency.

From October 28, 2014, through March 31, 2015, a convenience sample of HCW from four Northeast Ohio hospitals performed simulations of contaminated PPE removal, using fluorescent lotion.

In addition, a cohort of HCW from seven study units at one medical center took part in an intervention consisting of viewing a 10-minute instructional video and practice in removing contaminated PPE, with immediate visual feedback based on fluorescent lotion contamination of skin and clothing.

Skin or Clothing Contaminated in Nearly Half of PPE Removals

Contamination of skin or clothing with fluorescent lotion occurred in nearly half (200/435; 46.0%) of glove and gown removal simulations (range, 42.5% - 50.3%). Contamination was more frequent during removal of gloves rather than gowns (52.9% vs 37.8%; P = .002) "and when incorrect vs correct technique was observed for contaminated glove and gown removal (70.3% vs 30.0%, P < .001)," the authors write.

The researchers found no significant difference in the overall percentage of contamination when fluorescent lotion (58.0%) was used compared with bacteriophage MS2 (52.0%; P = .45). MS2 is a nonpathogenic, nonenveloped virus often used to study the spread of pathogens. The researchers studied it as a secondary outcome.

Training Intervention Reduced Skin and Clothing Contamination

Skin and clothing contamination during PPE removal were lower after the training intervention (18.9% vs 60.0% before the intervention; P < .001); this reduction was sustained after 1 and 3 months with no additional training (12.0% at both points; P < .001 compared with before the intervention).

"Our findings suggest that contamination of health care personnel with pathogens occurs frequently when contaminated PPE is removed, and simple interventions have the potential to markedly reduce the risk of contamination," the study authors write.

The fluorescent lotion method for training HCW provides immediate visual feedback on sites and routes of contamination, and the lotions are inexpensive, easy to use, and safe.

Even after the intervention, however, up to 18.9% of PPE removals resulted in skin and clothing contamination. Additional strategies to reduce contamination might include disinfection of PPE before removal, monitoring of removal by a trained coach, and/or redesign of PPE to provide products that are easy to remove while minimizing the risk for self-contamination.

"These findings highlight the urgent need for additional studies to determine effective strategies to minimize the risk of contamination during PPE removal, to improve PPE design, and to identify optimal methods for training of personnel in PPE use," the authors conclude.

Study limitations include performing the intervention in only one facility with a quasi-experimental design and relatively short follow-up.

In an invited commentary, Michelle Doll, MD, and Gonzalo M. Bearman, MD, MPH, from Virginia Commonwealth University in Richmond, note that these findings have clear implications for HCW safety and for spread of hospital-acquired infections.

"A standardized training procedure for [HCWs] on the recommended techniques for donning and/or doffing gowns and gloves is long overdue," they write. "The training should include educational context, proficiency monitoring, and feedback."

However, they note that even the Centers for Disease Control and Prevention's recommended procedures have been found by some to be insufficient. To optimize adherence with glove and gown precautions in the instances when it will be most important, the editorialists suggest considering prioritization of patients for contact precautions, based on the presence of highly transmissible, nonendemic organisms causing significant morbidity and mortality.

"It is now up to individual hospitals to ensure effective use of PPE through selective and judicious use of contact precautions and mastering of PPE donning and doffing techniques," the editorialists conclude. "Optimizing the removal of PPE via targeted training with adherence assessments and feedback and an ongoing emphasis on rigorous hand hygiene are critical steps toward empowering [HCWs] to practice consistent infection prevention, not only for special pathogen protection but also for routine care interactions."

The Department of Veterans Affairs; the Cleveland Veterans Affairs Geriatric Research, Education and Clinical Center; and a grant from STERIS supported this study. One coauthor reported financial disclosures involving Merck, Cubist, Clorox, EcoLab, GOJO, STERIS, and 3M. The other authors and commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online October 12, 2015. Article full text, Editorial full text

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