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Expert Q&A: Proper PPE in Healthcare


January 12, 2017

Hospital infection control experts give you tips on how to improve compliance and staff awareness

Editor’s note: This Q&A was taken from the October 2016 webinar, PPE in Healthcare: How to Improve Culture, Consistency, and Compliance. The speakers are Marjorie Quint-Bouzid, MPA, RN, NEA-BC, who currently serves as vice president of nursing at Parkland Hospital and Health System in Dallas and Kevin Bussiere, RN-CIC, infection prevention occupational health manager at Fort Washington (Maryland) Medical Center. To listen to the full program on demand, check out the HCPro Marketplace at http://hcmarketplace.com/ppe-in-healthcare-improve-culture-consistency-compliance.

Q: How do you know that your PPE staff training program is successful?

Marjorie Quint-Bouzid: At the end of your training program, your employees should know what PPE is necessary based on the potential exposure that they're going to have in your specific work environment. So not to be able to tell you generally, oh, PPE means gown and gloves and mask. They need to be able to tie it back to what are the potential infectious risks in your organization and then what are the ways that we protect ourselves and our patients and what PPE do we select.

A key thing that we always tend to forget is a training program should involve how to check if the PPE is damaged or not working properly. Prior to the Ebola outbreak, I would never recall ever hearing anyone talk about PPE not working or reminding us to make sure it works. So I recall vividly putting on an N-95 respirator mask and never doing a fit test or never doing a quick check to make sure it’s fit properly because I was fit tested and they said, ‘Oh, this is the size mask that you wear.’ But I never took that final step until I was informed by another organization with a very good stellar PPE training program that it is a part. It’s the final step in making sure that you've donned properly, to do that test with the respirator. So don’t forget that piece as well.

Q: Should visiting children be required to wear PPE?
MQB: PPE for children rarely fits well. So why do we allow children to come in and visit? Well, they should be allowed to see, if it’s important, if it’s life threatening, if their family member is going to die and pass, or even if they just need some contact but should they be at the door and just wave and say hi? Do they really need to be in the room for an hour and a half? We need to really look at that. How many of us have designed gowns and masks for children? How about gowns and masks for the large healthcare worker or the very short healthcare worker?  We've seen those being just as badly worn as the children’s PPE.

Q: What are some reasons for noncompliance?
MQB: I personally don’t believe people go to work daily to be noncompliant. Noncompliance sometimes is just embedded in some of our structural processes. And it’s interesting. Nothing in our industry happens void of something else. It’s generally in tandem with noncompliance of other measures. Arguably rampant noncompliance in any organization is coupled in that organization with low employee engagement scores, low patient satisfaction scores, and overall, poor compliance with hand hygiene. Their approach to noncompliance must be rooted in a renewed focus on worker safety being fundamental to patient safety.

The reason why culture sometimes can be difficult, as I said before, it’s just difficult to remove and it requires a significant amount of up-front investment in resources and costs. It’s like turning the Titanic. It’s possible but requires a lot of work.

A study by OSHA was designed that actually showed that 70% of the 1,000 that responded found that PPE was too uncomfortable or too hot. So that's really the equipment, the design of the PPE that's contributing to why people tend to be noncompliant. As Kevin alluded to earlier, one size does not fit all. During the Ebola crisis, we actually realized that several of our frontline emergency department healthcare workers were well over 6 feet, not just 6. One was 6’ 5” and over 300 pounds. Nothing we had in stock at the time fit. So we had, as an organization, this person would have wanted to become complaint with PPE selection but really the organization did not have the appropriate tools for that person to be successful.

Some other organizational factors are forcing functions. We look at trying to fit, at least I refer to it as forcing a square peg into a round hole. Our PPE availability of the equipment and supply, actually sometimes we put too many of the wrong type of PPE on a cart. The employee has to go through and try to select. So one of the things that we did in our Ebola was to create an Ebola cart and make sure only the things that were appropriate to be selected were on that versus given an extended choice.

Can you recall some examples of healthcare workers who have not worn proper PPE and put others in danger?
Kevin Bussiere: In Tilton, New Hampshire, the director of nurses became ill with terminal cancer. She was a patient in her own hospital. The MD didn't think she needed isolation, and so canceled the nurse’s order for airborne and wasn't challenged. Everyone who worked there came to see her and after she died, everyone started converting on their annual TB screens. An outbreak investigation when they did everyone in the hospital showed 64% of the hospital had converted to exposed TB and everybody in the hospital was on prophylactics. That was a fun place to work, let me tell you.

In Virginia Beach, a respiratory therapist refused to come in for his annual TB screening and just kept postponing it and they didn't take him off the schedule. There was no policy saying take him off the schedule. They didn't have any bite in their policy or the program. He continued for a year and a half not being screened for TB. He finally came in and was screened. He was positive for TB and it led to 6,000 exposed patients between the hospital and another part-time job that he had over that long of a period of time. So the health department was not very happy.

Last but not least was in Chesapeake where the nurse was sick but she was one of these troopers that always showed up to work on time, good, bad, or indifferent. Even though she seemed to have this chronic problem, nobody challenged her and she ended up having TB and exposed 4,000 patients and healthcare workers over a two- to three-year period. So airborne doesn’t always seem to be the most disastrous or worrisome of the isolations, but it can certainly have a bigger impact over time.

Q: How do I correct leaders and doctors if I see them not using the correct PPE?
KB: For me, it’s easy, I walk up and I [simply say]: “I don't understand why you're not wearing the PPE correctly.” Let them fill in the blank. It’s, “Well, I’m just going to ... ” and I just stand there and look at them, you know? “Well, it’s not really needed” or then why do we have them on isolation if it’s not really needed. And the simple asking of a question without judgment because that's the part where they want to become defensive, simply ask, “I don't understand why you're not wearing the gown? Is that okay?” And they're like, “Well, no, it’s not but I really ... ” “Well, then maybe you should be wearing the gown.”

MQB: I agree with my colleague. Part of doing those crucial confrontations, I guess, is to really have a skill of putting a person at ease, not making them defensive. And it’s kind of hard to argue with a question. So I like the tactic of making it a question, understanding and saying, you know, please help me understand why you're not doing the behavior that you know is the right thing to do. And it allows for dialogue as well.

Q: Why is PPE important?
MQB: Simply, PPE is a defense against bloodborne pathogens. We used to call it universal protection. It’s now standard precautions. PPE is used as a barrier to prevent bloodborne pathogens from infecting you. It also enhances effective hand hygiene use. Alcohol rubs and soap and water can decontaminate your hands, but gloves help in preventing the initial contamination. It’s a barrier against transmission-based pathogens. Once we know how it’s transmitted: contact, droplet, airborne, etc., a mask, gown, gloves, shields and goggles, etc., prevent transmission from the different vectors and have a pretty consistent approach.

And lastly it’s a stopgap measure against emerging pathogens. Each emerging pathogen or a new superbug has its own vector or combinations of vectors. Reinventing and redesigning the use of PPE can prevent emerging pathogens. Now we could go on forever and ever and a day on the Ebola outbreak that just came out and the many, many failings that occurred, but in all honesty, the SARS came out and everyone had appropriate PPE and yet the number of healthcare workers that had gotten infected was just staggering. When we did MERS-CoV, H1N1, all the rest of them, the pathogens just found new ways to get through. So using PPE as their stopgap measure in preventing PPE contamination, with these bugs.

Q: How do I respond when the nurses tell me to hurry up and turn over a room because someone in the ED is waiting for the bed? I have to follow proper procedures for an isolation room and I’ve always been told to hurry up.

MQB: That's a good question and generally an RN telling an environmental service worker to hurry up and so then the environmental service worker is thinking, what do I do? So along the same line as, you know, I would put it back to a question. I have to do the turnover procedure requiring me to do step A, B, C, and D. Help me understand what is it you're asking me to not do and how will I harm the patient that you're going to hurry up and put in a bed.

So again, that maybe, it’s an easier said than done interaction. My advice to the environmental service worker or the organizations that are listening is to empower your workers to be able to elevate. They don’t have to stand there and argue with the nurse or the doctor. It’s to say, ‘Excuse me for a second.’ Go and get their supervisor, get their charge nurse and have that person elicit their help and have them advocate for them. But in no way, an absolute never, should they violate what they know to be the right thing to do just to get someone to stop pushing them.

KB: I agree and I see this all the time with bed flow and the need for organizational flow of patients. They need that bed. They need that bed occupied but not looking at the overall basic foundation is to keep the patient safe. And putting the patient in a contaminated room is never safe. A lot of environmental services departments have timed out exactly how long it takes to do the room at a minimum. You know, to get the minimum of this room being compliant, it’s going to take me 35 to 40 minutes. And we don’t educate the people that are in charge of assigning the beds the requirements for this. Mind you, we definitely want that ESD person there at the beginning of when we need it. They don’t need to be on a break or whatever but when they get to the room, they need to spend the time to do the room correctly.

Q: What are some components of a good PPE training program?

MQB: It really boils down to, again, training and education. And that also subscribes to the fact that there are things that an organization can do to improve PPE compliance.

We subscribe to two types of training programs that are needed. Generally, most organizations will do a good job about the onboarding, that's the initial new employee orientation. And many hospitals I know will do an annual update. What Kevin and I would recommend is that you may consider based on what's the current reality in your organization is instead of just doing an annual update, doing updates as needed. As we shared with the Ebola saga, many organizations including my own, have to do weekly updates and we did them. We scaled them down. We did a big training for everyone and then customized it for the ED staff, the receiving staff, the staff who would have to hold patients. And as we learned new information it impacted the staff that needed to know the new information. So there is no hard fast rule about how much training is required. But adamant that we should have one in the initial orientation prior to your worker interacting with patients and then on an annual, and that's minimum standard.

We recommend training all caregivers in your usual isolation categories. We're using transmission-based PPE. So the training should involve how to use them and then what are the limitations. Because you don’t want someone to believe that, ‘Oh, if I just put gloves and mask on, then I’m okay and that I cannot potentially either contaminate myself or cross-contaminate,’ because that's not true. So we train our frontline staff on emergent pathogens as well. That should be included in your training program.

Some of the tools for training on PPE that you should consider in your training program, are simplifying PPE selection. As I said, don’t give your employees a cart full of stuff and have them try to figure out, ‘Well, what do I need for this particular transmission base?’ So to the extent possible, create basic PPE, a process. What is considered basic PPE? Then maybe have a cart for your more advanced PPE or respiratory isolation, respiratory precaution PPE. Make sure in your training, you give them very easy to read information and the rural health organizations have some tools that are available to you. Very easy to read selection algorithms. And then take it a step further. Have those laminated and available for them at the point of where they're providing patient care. So they're never having to second guess or try to remember, ‘What am I supposed to do? What goes with what?’ 

And for those of you who are fortunate enough to have a very robust infection prevention program, make sure they have that number ready and available. Who to call. Make it okay for them to call 24/7, as hospitals are 24/7 organization[s]. So staff at 2 a.m. should have a number to call just to double-check. And it should be okay for them to call. They shouldn't have to get permission.

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