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Buabungkhung P, Srisamranrungruang P, Bhucharoen J, Singhasuvich K, Pratumvinit B, Kost GJ, Tientadakul P. Modified glove removal technique to prevent hand contamination in routine phlebotomy. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2024:1-8. [PMID: 38976229 DOI: 10.1080/15459624.2024.2371899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
The World Health Organization and the Centers for Disease Control and Prevention (CDC) have established guidelines recommending the performance of hand hygiene routines for healthcare workers following glove removal. However, the completion of frequent hygiene routines can cause allergic and adverse skin reactions. This double-blind, randomized study aimed to address this concern by developing and evaluating a modified glove removal technique that minimizes contamination risk during routine phlebotomy procedures. Furthermore, this study used fluorescent detection to compare the frequency of contamination associated with the CDC-recommended technique and the modified technique using fluorescent detection. One hundred healthcare personnel were enrolled and divided into two groups: one group followed the CDC technique, while the other group implemented the modified technique. Participants received instructional videos and practiced under supervision. They subsequently performed blood collection using a simulation arm covered with fluorescent cream as a contamination marker. After removing gloves, hand contamination was assessed under a black light. The median time required for glove removal in the modified group was four seconds longer than that in the group that followed the CDC technique (p < 0.001). Contamination was observed in 2% (1/50) of subjects using the CDC-recommended technique, while no contamination was detected with the modified technique (p ≥ 0.05). Both the group that followed the CDC technique and the group that used modified glove removal techniques demonstrated the potential to prevent contamination during phlebotomy, thereby reducing the need for hand hygiene and the occurrence of contamination and adverse skin reactions. These findings prompt further exploration into whether proper glove removal can reduce the frequency of completing a hand hygiene routine after each glove removal, specifically within the context of phlebotomy. However, it is essential to note that hand hygiene following glove removal is still recommended to prevent contamination. Further research is warranted to validate these findings.
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Affiliation(s)
- Pongsatorn Buabungkhung
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Piyada Srisamranrungruang
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Jiraporn Bhucharoen
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Katesophon Singhasuvich
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Busadee Pratumvinit
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Gerald J Kost
- Point-of-Care Testing Center for Teaching and Research, School of Medicine, University of California, Davis, California
| | - Panutsaya Tientadakul
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Noi, Bangkok, Thailand
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Chasco EE, Pereira da Silva J, Dukes K, Baloh J, Ward M, Salehi HP, Reisinger HS, Pennathur PR, Herwaldt L. Unfamiliar personal protective equipment: The role of routine practice and other factors affecting healthcare personnel doffing strategies. Infect Control Hosp Epidemiol 2023; 44:1979-1986. [PMID: 37042615 PMCID: PMC10755157 DOI: 10.1017/ice.2023.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Healthcare personnel (HCP) may encounter unfamiliar personal protective equipment (PPE) during clinical duties, yet we know little about their doffing strategies in such situations. OBJECTIVE To better understand how HCP navigate encounters with unfamiliar PPE and the factors that influence their doffing strategies. SETTING The study was conducted at 2 Midwestern academic hospitals. PARTICIPANTS The study included 70 HCP: 24 physicians and resident physicians, 31 nurses, 5 medical or nursing students, and 10 other staff. Among them, 20 had special isolation unit training. METHODS Participants completed 1 of 4 doffing simulation scenarios involving 3 mask designs, 2 gown designs, 2 glove designs, and a full PPE ensemble. Doffing simulations were video-recorded and reviewed with participants during think-aloud interviews. Interviews were audio-recorded and analyzed using thematic analysis. RESULTS Participants identified familiarity with PPE items and designs as an important factor in doffing. When encountering unfamiliar PPE, participants cited aspects of their routine practices such as designs typically used, donning and doffing frequency, and design cues, and their training as impacting their doffing strategies. Furthermore, they identified nonintuitive design and lack of training as barriers to doffing unfamiliar PPE appropriately. CONCLUSION PPE designs may not be interchangeable, and their use may not be intuitive. HCP drew on routine practices, experiences with familiar PPE, and training to adapt doffing strategies for unfamiliar PPE. In doing so, HCP sometimes deviated from best practices meant to prevent self-contamination. Hospital policies and procedures should include ongoing and/or just-in-time training to ensure HCP are equipped to doff different PPE designs encountered during clinical care.
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Affiliation(s)
- Emily E. Chasco
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jaqueline Pereira da Silva
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
| | - Kimberly Dukes
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Jure Baloh
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Melissa Ward
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Hugh P. Salehi
- Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
- Department of Engineering Education, The Ohio State University, Columbus, Ohio
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Priyadarshini R. Pennathur
- Department of Industrial, Manufacturing and Systems Engineering, University of Texas at El Paso, El Paso, Texas
| | - Loreen Herwaldt
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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Obuhoro O, Jones RM. Assessing Patterns of Body Contamination after Personal Protective Equipment Removal among Healthcare Workers: A Scoping Review. Am J Infect Control 2022:S0196-6553(22)00674-5. [PMID: 36116680 DOI: 10.1016/j.ajic.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is now widely recognized that healthcare personnel (HCP) are at risk of contamination with pathogens during personal protective equipment (PPE) doffing. Studies of this phenonemona, have utilized a variety of PPE ensembles, doffing methods and experimental methods. METHODS A scoping review was performed, consistent with PRISMA guidance. The PubMed and sciVerse Scopus databases were searched using an a priori search strategy. Data were extracted for analysis using the matrix method, and then a narrative analysis performed. Articles were classified based on PPE ensemble. RESULTS Only 19 of 151 articles were included in the final anlaysis. All included studies reported some post-doffing contamination, and this contamination was most frequently observed on the hands, wrist, face and neck. Reviewed studies used a variety of tracer contaminants, PPE ensembles, doffing protocols, tracer assessment locations and methods, making it difficult to identify patterns across studies. DISCUSSION&CONCLUISONS Additional research is needed to improve study methodology related to the selection and placement of tracers to ensure sensitive detection of post-doffing contamination, compare how specific doffing procedures or pieces of PPE influence post-doffing contamination, and to understand what post-doffing contamination means for patient and HCP infection risk.
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Affiliation(s)
- Olosengbuan Obuhoro
- Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Rachael M Jones
- Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT; Department of Environmental Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA.
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Baloh J, Reisinger HS, Dukes K, da Silva JP, Salehi HP, Ward M, Chasco EE, Pennathur PR, Herwaldt L. Healthcare Workers' Strategies for Doffing Personal Protective Equipment. Clin Infect Dis 2020; 69:S192-S198. [PMID: 31517970 PMCID: PMC6743502 DOI: 10.1093/cid/ciz613] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Personal protective equipment (PPE) helps protect healthcare workers (HCWs) from pathogens and prevents cross-contamination. PPE effectiveness is often undermined by inappropriate doffing methods. Our knowledge of how HCWs approach doffing PPE in practice is limited. In this qualitative study, we examine HCWs’ perspectives about doffing PPE. Methods Thirty participants at a Midwestern academic hospital were recruited and assigned to 1 of 3 doffing simulation scenarios: 3 mask designs (n = 10), 2 gown designs (n = 10), or 2 glove designs (n = 10). Participants were instructed to doff PPE as they would in routine practice. Their performances were video-recorded and reviewed with participants. Semistructured interviews about their doffing approaches were conducted and audio-recorded, then transcribed and thematically analyzed. Results Three overarching themes were identified in interviews: doffing strategies, cognitive processes, and barriers and facilitators. Doffing strategies included doffing safely (minimizing self-contamination) and doffing expediently (eg, ripping PPE off). Cognitive processes during doffing largely pertained to tracking contaminated PPE surfaces, examining PPE design cues (eg, straps), or improvising based on prior experience from training or similar PPE designs. Doffing barriers and facilitators typically related to PPE design, such as PPE fit (or lack of it) and fastener type. Some participants also described personal barriers (eg, glasses, long hair); however, some PPE designs helped mitigate these barriers. Conclusions Efforts to improve HCWs’ doffing performance need to address HCWs’ preferences for both safety and expediency when using PPE, which has implications for PPE design, training approaches, and hospital policies and procedures.
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Affiliation(s)
- Jure Baloh
- Department of Internal Medicine, University of Iowa, Iowa City.,Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa, Iowa City.,Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City
| | - Kimberly Dukes
- Institute for Clinical and Translational Science, University of Iowa, Iowa City
| | | | - Hugh P Salehi
- Department of Industrial and Systems Engineering, University of Iowa, Iowa City.,Department of Engineering Management, Systems and Technology, University of Dayton, Ohio
| | - Melissa Ward
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Emily E Chasco
- Department of Internal Medicine, University of Iowa, Iowa City.,Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City
| | - Priyadarshini R Pennathur
- Department of Internal Medicine, University of Iowa, Iowa City.,Department of Industrial and Systems Engineering, University of Iowa, Iowa City
| | - Loreen Herwaldt
- Department of Internal Medicine, University of Iowa, Iowa City.,Department of Epidemiology, University of Iowa, Iowa City
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 5:CD011621. [PMID: 32412096 PMCID: PMC8785899 DOI: 10.1002/14651858.cd011621.pub5] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
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Affiliation(s)
- Jos H Verbeek
- Cochrane Work Review Group, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Blair Rajamaki
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Bronagh Blackwood
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland
| | | | - F Selcen Kilinc Balci
- National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Pittsburgh, PA, USA
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6
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 4:CD011621. [PMID: 32293717 PMCID: PMC7158881 DOI: 10.1002/14651858.cd011621.pub4] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
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Affiliation(s)
- Jos H Verbeek
- Academic Medical Center, University of Amsterdam, Cochrane Work Review Group, Amsterdam, Netherlands, 1105AZ
| | - Blair Rajamaki
- University of Eastern Finland, School of Pharmacy, Kuopio, Finland
| | - Sharea Ijaz
- University of Bristol, Population Health Sciences, Bristol Medical School, Bristol, UK, BS1 2NT
| | | | | | - Bronagh Blackwood
- Queen's University Belfast, Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Building, 97 Lisburn Road, Belfast, Northern Ireland, UK, BT9 7LB
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland, FI-70032
| | - Jani H Ruotsalainen
- Finnish Medicines Agency, Assessment of Pharmacotherapies, Microkatu 1, Kuopio, Finland, FI-70210
| | - F Selcen Kilinc Balci
- Centers for Disease Control and Prevention (CDC), National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), 626 Cochrans Mill Road, Pittsburgh, PA, USA, 15236
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7
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A crossover trial comparing contamination of healthcare personnel during removal of a standard gown versus a modified gown with increased skin coverage at the hands and wrists. Infect Control Hosp Epidemiol 2019; 40:1278-1280. [PMID: 31436146 DOI: 10.1017/ice.2019.211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In a crossover trial, a gown designed to increase skin coverage at the hands and wrists significantly reduced contamination of personnel during personal protective equipment (PPE) removal, and education on donning and doffing technique further reduced contamination. Simple modifications of PPE and education can reduce contamination during PPE removal.
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8
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Alhmidi H, Gonzalez-Orta M, Cadnum JL, Mana TSC, Jencson AL, Wilson BM, Donskey CJ. Contamination of health care personnel during removal of contaminated gloves. Am J Infect Control 2019; 47:850-852. [PMID: 30638677 DOI: 10.1016/j.ajic.2018.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 11/29/2022]
Abstract
In simulations of contaminated glove removal, 37% of health care personnel using their typical doffing technique contaminated their skin with a fluorescent solution. The frequency of contamination was significantly lower when the technique recommended by the Centers for Disease Control and Prevention was used versus not used (8 of 34, 24% vs 29 of 66, 44%). In simulations in which only the palm of the glove was contaminated, a modified doffing technique, to minimize the risk for contact with contaminated surfaces, reduced contamination of personnel.
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Affiliation(s)
- Heba Alhmidi
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Melany Gonzalez-Orta
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Thriveen S C Mana
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Annette L Jencson
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH.
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Verbeek JH, Rajamaki B, Ijaz S, Tikka C, Ruotsalainen JH, Edmond MB, Sauni R, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2019; 7:CD011621. [PMID: 31259389 PMCID: PMC6601138 DOI: 10.1002/14651858.cd011621.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed. OBJECTIVES To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE. SELECTION CRITERIA We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results. MAIN RESULTS We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants. AUTHORS' CONCLUSIONS We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.
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Affiliation(s)
- Jos H Verbeek
- University of Eastern FinlandCochrane Work Review GroupKuopioFinland70201
| | - Blair Rajamaki
- University of Eastern FinlandInstitute of Public Health and Clinical Nutrition, Occupational Health UnitKuopioFinland
| | - Sharea Ijaz
- University of BristolPopulation Health Sciences, Bristol Medical SchoolBristolUKBS1 2NT
| | - Christina Tikka
- Finnish Institute of Occupational HealthCochrane Work Review GroupTYÖTERVEYSLAITOSFinlandFI‐70032
| | - Jani H Ruotsalainen
- Coronel Institute of Occupational HealthCochrane Work Review GroupAcademic Medical Center, University of AmsterdamPO Box 22700AmsterdamNetherlands1100 DE
| | - Michael B Edmond
- University of Iowa Hospitals and ClinicsC512 GH, 200 Hawkins DriveIowa CityIAUSA52241
| | - Riitta Sauni
- Finnish Institute of Occupational HealthP.O.Box 486TampereFinlandFI‐33101
| | - F Selcen Kilinc Balci
- Centers for Disease Control and Prevention (CDC)National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH)626 Cochrans Mill RoadPittsburghPAUSA15236
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Resende KKM, Neves LF, de Rezende Costa Nagib L, Martins LJO, Costa CRR. Educator and Student Hand Hygiene Adherence in Dental Schools: A Systematic Review and Meta-Analysis. J Dent Educ 2019; 83:575-584. [PMID: 30804172 DOI: 10.21815/jde.019.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/17/2018] [Indexed: 01/22/2023]
Abstract
Health professionals and their patients are subject to cross-contamination and potential exposure to harmful infectious diseases. A common form of cross-contamination is through dental procedures without proper instrument care and lack of hand hygiene. The aim of this systematic review was to evaluate the published research on the adherence of educators and students in academic dental institutions to hand hygiene procedures. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and included articles collected in the Cochrane, LILACS, PubMed, Science Direct, Scopus, and Web of Science databases. The initial search identified 1,196 articles. Ultimately, three studies were included for qualitative synthesis and two for the meta-analysis. The three articles had similar characteristics of observational hand hygiene research involving educators and dental students. In all three, hand hygiene among dental students did not reach 50% of the total number of opportunities, which is a troubling result. Although the hand hygiene rate of educators was higher than that of dental students, these findings point to a need to further promote hand hygiene to future professionals to avoid cross-contamination between health professionals and patients.
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Affiliation(s)
- Kemelly Karolliny Moreira Resende
- Kemelly Karolliny Moreira Resende is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Layla Ferreira Neves is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Leonardo de Rezende Costa Nagib is a postgraduate student, Universidade Federal de Uberlandia, Uberlandia, Brazil; Lázara Joyce Oliveira Martins is Professor, Universidade de Rio Verde, Rio Verde, Brazil; and Cláudio Rodrigues Rezende Costa is Professor, Universidade de Rio Verde, Faculty of Dentistry, Rio Verde, Brazil
| | - Layla Ferreira Neves
- Kemelly Karolliny Moreira Resende is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Layla Ferreira Neves is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Leonardo de Rezende Costa Nagib is a postgraduate student, Universidade Federal de Uberlandia, Uberlandia, Brazil; Lázara Joyce Oliveira Martins is Professor, Universidade de Rio Verde, Rio Verde, Brazil; and Cláudio Rodrigues Rezende Costa is Professor, Universidade de Rio Verde, Faculty of Dentistry, Rio Verde, Brazil
| | - Leonardo de Rezende Costa Nagib
- Kemelly Karolliny Moreira Resende is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Layla Ferreira Neves is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Leonardo de Rezende Costa Nagib is a postgraduate student, Universidade Federal de Uberlandia, Uberlandia, Brazil; Lázara Joyce Oliveira Martins is Professor, Universidade de Rio Verde, Rio Verde, Brazil; and Cláudio Rodrigues Rezende Costa is Professor, Universidade de Rio Verde, Faculty of Dentistry, Rio Verde, Brazil
| | - Lázara Joyce Oliveira Martins
- Kemelly Karolliny Moreira Resende is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Layla Ferreira Neves is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Leonardo de Rezende Costa Nagib is a postgraduate student, Universidade Federal de Uberlandia, Uberlandia, Brazil; Lázara Joyce Oliveira Martins is Professor, Universidade de Rio Verde, Rio Verde, Brazil; and Cláudio Rodrigues Rezende Costa is Professor, Universidade de Rio Verde, Faculty of Dentistry, Rio Verde, Brazil
| | - Cláudio Rodrigues Rezende Costa
- Kemelly Karolliny Moreira Resende is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Layla Ferreira Neves is a graduate student, Universidade de Rio Verde, Rio Verde, Brazil; Leonardo de Rezende Costa Nagib is a postgraduate student, Universidade Federal de Uberlandia, Uberlandia, Brazil; Lázara Joyce Oliveira Martins is Professor, Universidade de Rio Verde, Rio Verde, Brazil; and Cláudio Rodrigues Rezende Costa is Professor, Universidade de Rio Verde, Faculty of Dentistry, Rio Verde, Brazil.
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