Despite the provision of personal protective equipment to hospital staff and clinicians, a new study published in JAMA revealed it isn't always used properly and the danger of spreading pathogens is still highly present.
With the goal of identifying the types of personal protective equipment, or PPE, failures and going on to devise strategies to mitigate risk, during a seven-month period in 2016 researchers observed healthcare personnel both outside and inside patient rooms that had signage posted pertaining to required precautions for transmission of pathogens through contact.
Observations occurred on 16 acute care medical and/or surgical units and four intensive care units at two medical centers, a university-based academic medical center and a Veterans Affairs hospital as well as the emergency department at the university-based medical center. There were 325 room observations total, with 259 happening outside the room and 66 inside the room.
More than 280 failures were observed and researchers put them into three categories: violations mistakes and slips. First, violations were defined as "intentional deviations from recommended practices, procedures or standards" and a common scenario described included a staff member or clinician entering a room without any PPE including gloves, or improper use of PPE which included entering a room with a gown not tied.
Researchers said violations often happened when staff entered a room to speak to patients and/or families, checking devices or dropping something off and then leaving. Though they entered the room without PPE and no intention to touch a patient, these encounters often resulted in contact with the patient and/or the patient environment.
However, there were also violations where direct patient contact was the intention.
The following example was described: "Physician sanitizes hands using the dispenser then enters the room without donning gloves or gown, touches patient's stomach over the (patient) gown. Physician rests arm on the bedside, pulls records out of white coat pocket, reviews, then places back in the pocket exits the room and sanitizes hands."
Errors were defined as the failure of planned actions to achieve the desired goal. Mistakes, which are errors of intent, were often observed when personnel were dealing with a challenge and used a course of action that led to a failure with probable self-contamination. These scenarios often were related to the removal of PPE i.e. removing eye protection and a mask with gloves still on.
Slips were errors that occurred due to "highly automatic behaviors" that resulted in likely self-contamination.
Some of the most frequently observed slips involved personnel touching their face with contaminated gloves or external parts of a gown and subconsciously or automatically using their personal devices. One such scenario was described as "Nutritionist is standing and leaning on the overbed table with gloved hands. During the conversation, nutritionist uses a gloved hand to push hair behind ear, then places hand back on the table, then uses a gloved hand to push eyeglasses higher up on the face."
Some of the situations observed involved personnel rushing to see to a patient's needs or an emergency, and in those situations attending to an emergent issue supersedes scrutinizing behavior for potential transmission of pathogens, researchers said.
However many of the scenarios were deemed to be relatively deliberate or suggested a lack of knowledge or calculated determination by the staff member about potential risk versus the effort and time needed for proper PPE use.
"As such, reducing mistakes requires not only tackling possible knowledge gaps but developing guidance and strategies for dealing with specific environmental and logistical challenges," the study said.
In the case of slips especially, preventing "reflexive actions" like wiping sweat from one's brow or adjusting hair or glasses requires a very high level of awareness and "cognitive input." In these cases, a hospital might consider using full face protection and banning devices from patient rooms so that there is no reflex to reach a gloved hand into one's pocket to check it.
Increasing reliance on technology might make that challenging though, researchers said.
In the end, the proper use of PPE requires skills, training and increasing knowledge of protocols and risks. While time-consuming, hospital and physician leaders would do well to allot the necessary time and resources to such efforts for the sake of thwarting the spread of increasingly difficult to treat and drug-resistant pathogens like Clostridium difficile and methicillin-resistant Staphylococcus aureus, commonly known as staph.
Not only are vulnerable patients further jeopardized by such infections, which are acquired in the hospital often while being treated for unrelated conditions, but the proliferation of such hospital-acquired infections can mean poor safety scores, public rankings and government penalties.