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Improper removal of personal protective equipment contaminates healthcare workers

Almost 40 percent of workers made errors in removing personal protective equipment -- PPE -- including gowns and gloves.

Jeff Lagasse, Associate Editor

More than one-third of healthcare workers were contaminated with multi-drug resistant organisms, or MDRO, after caring for patients colonized or infected with the bacteria, according to a study in Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

The study found that 39 percent of workers made errors in removing personal protective equipment -- PPE -- including gowns and gloves, increasing the incidence of contamination.

The results suggest a need to reevaluate strategies for removing PPE, as well as the frequency with which staff are trained on those methods. A simple education-based intervention may help reduce contamination with MDRO, the authors said.

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Researchers at Rush University Medical Center monitored 125 healthcare workers in four adult intensive care units who were caring for patients colonized or infected with a MDRO, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.

Researchers took more than 6,000 samples from workers' hands, gloves, PPE and other equipment, such as stethoscopes and mobile phones, taking cultures before and after patient interaction.

Trained observers also monitored the technique each worker used to put on and remove their PPE and tracked errors based on guidelines established by the Centers for Disease Control and Prevention. The CDC suggests two removal methods for PPE: a gloves-first strategy, and an approach that removes gown and gloves together.

The observers also tracked a third method of removing the gown first. A significant majority of the healthcare workers had received training on appropriate methods for putting on and removing PPE within the past five years.

After patient contact, 36 percent of healthcare workers were contaminated with a MDRO. Contamination of healthcare workers' PPE was more common in settings of higher patient and environmental contamination. After removing their PPE, 10.4 percent were contaminated on their hands, clothes or equipment.


Healthcare workers who made multiple errors when removing their PPE were more likely to be contaminated after a patient encounter, but the rate of making errors depended on the PPE removal method, with 72 percent of workers who used a glove-first removal making multiple errors.

Examples of errors included touching the inside of the gown or glove with a gloved hand, touching the outside of the gown or glove with bare hands, and not unfastening the gown at the neck.

Given the high rate of hand contamination of those who used the gloves-first strategy, the authors recommend further research and possible reconsideration of this technique, as well as research to examine the impact of improved education for putting on and taking off PPE.

They also note several limitations to their work, including the influence of observers on healthcare workers' practices and the potential that not all contamination was detected.


Protective equipment isn't the only facet of healthcare subject to potential infection or contamination.

Each day, one out of 25 patients in the U.S. contracts a hospital-acquired infection resulting in billions of wasted dollars and an eye-popping 90,000 deaths annually. A 2018 report published by The Leapfrog Group shows that the percentage of hospitals achieving zero infections has declined dramatically since 2015, indicating many patients are still at risk.

Delivering quality care has become even more essential for hospitals and health systems since Medicare started issuing penalties for high rates of hospital-acquired conditions -- things such as falls, ulcers and infections that could well have been avoided. Recent statistics underscore this importance: In 2017, Medicare penalized 751 hospitals and health systems for that very reason with a 1 percent reduction in reimbursement rates for 2018.

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