The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals

Factors Influencing Self-reported Facial Protective Equipment adherence among Home Care Nurses and Personal Support Workers - A multi-site cross-sectional study

BACKGROUND

Facial Protective Equipment (FPE) use increased during the SARS-CoV-2 pandemic. This study explored factors influencing home care personal support workers' (PSWs) and nurses' self-reported adherence to FPE.

METHODS

A cross-sectional, electronic, survey was distributed to PSWs and nurses (1108 complete responses) at three home care agencies in Ontario, Canada, in May-June 2022. Descriptive, bivariate, and multivariable analysis were used to assess individual, environmental, and organizational factors influencing adherence.

RESULTS

Among participants (786 PSWs, 322 nurses), 64% reported being adherent to both respiratory and eye FPE (Respiratory: 96%, Eye: 64%). Higher adherence was associated with facility-based work; better knowledge of FPE; pre-pandemic FPE use; good availability and convenient access; strong organizational support for health and safety; and Caribbean identity. Lower adherence was found for men; nurses with 2-year diplomas; shorter length of employment; communal transportation; and experiencing negative mental health effects from workplace infectious disease exposure.

DISCUSSION

Agencies should prioritize increasing providers' knowledge of FPE, supporting mental well-being, fostering a supportive culture, and ensuring availability of FPE. The influences of gender, ethnicity, and role require further exploration.

CONCLUSION

FPE adherence may be improved by addressing modifiable factors and developing population-specific strategies.

Factors influencing nursing professionals' adherence to facial protective equipment usage: A comprehensive review

BACKGROUND

Facial protective equipment (FPE) adherence is necessary for the health and safety of nursing professionals. This review was conducted to synthesize predisposing, enabling, and reinforcing factors that influence FPE adherence, and thus inform efforts to promote adherence.

METHODS

Articles were collected using Cumulated Index to Nursing and Allied Health Literature and MEDLINE and screened for inclusion. Included articles were original studies focused on FPE adherence by nurses to prevent respiratory infection which contained occupation-specific data from at least 10 individuals and were published in English between January 2005 and February 2022.

RESULTS

Thirty articles were included, 21 of which reported adherence rates. Adherence ranged from 33% to 100% for respiratory protection and 22% to 100% for eye protection. Predisposing demographic factors influencing adherence included tenure and occupation, while modifiable predisposing factors included knowledge and perception of FPE, infection transmission, and risk. Enabling factors included geography, care settings, and FPE availability. Reinforcing factors included organizational support for health and safety, clear policies, and training.

CONCLUSIONS

The identified demographic factors suggest populations that may benefit from targeted interventions, while modifiable factors suggest opportunities to enhance education as well as operational processes and supports. Interventions that target these areas have the potential to promote adherence and thereby improve the occupational safety of nurses.

Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes

BACKGROUND

Standard precautions may prevent patient health care associated infections and provider occupational exposures but are not often used by health care workers. A positive patient safety climate might contribute to improved adherence. The aim of this study was to determine the relationships among patient safety climate, standard precaution adherence, and health care worker exposures and HAIs.

METHODS

This multi-site, cross-sectional study included survey data from nurses on patient safety climate, observational data on adherence, and existing health care worker exposure and health care associated infections data. Data were aggregated to hospital unit level for correlational and multivariable regression analyses.

RESULTS

A total of 5,285 standard precaution observations and 452 surveys were collected across 43 hospital units. Observed adherence to all categories of standard precautions was 64.4%; there were significant differences by provider role. Multivariable models identified key predictors explaining sizeable variance in methicillin-resistant Staphylococcus aureus (41%), catheter associated urinary tract infections (23%), mucotaneous exposures (43%) and needlestick and sharps injuries (38%).

DISCUSSION

This study produced findings not previously published thus advancing the state of the science in patient and occupational health safety. These include identifying modifiable features of the safety climate and key organizational characteristics associated better outcomes.

CONCLUSIONS

In this novel study we identified that a positive patient safety climate and adherence to standard precautions predict key HAI and occupational health outcomes.

Characterization of perceived biohazard exposures, personal protective equipment, and training resources among a sample of formal U.S. solid waste workers: A pilot study

In the United States, the majority of waste workers work with solid waste. In solid waste operations, collection, sorting, and disposal can lead to elevated biohazard exposures (e.g., bioaerosols, bloodborne and other pathogens, human and animal excreta). This cross-sectional pilot study aimed to characterize solid waste worker perception of biohazard exposures, as well as worker preparedness and available resources (e.g., access to personal protective equipment, level of training) to address potential biohazard exposures. Three sites were surveyed: (1) a family-owned, small-scale waste disposal facility, (2) a county-level, recycling-only facility, and (3) an industrial-sized, large-scale facility that contains a hauling and landfill division. Survey items characterized occupational biohazards, resources to mitigate and manage those biohazards, and worker perceptions of biohazard exposures. Descriptive statistics were generated. The majority of workers did not report regularly coming into contact with blood, feces, and bodily fluids (79%). As such, less than one-fifth were extremely concerned about potential illness from biological exposures (19%). Yet, most workers surveyed (71%) reported an accidental laceration/cut that would potentially expose workers to biohazards. This study highlights the need for additional research on knowledge of exposure pathways and perceptions of the severity of exposure among this occupational group.

COVID-19 Obesity: Differences in Infection Risk Perception, Obesity Stress, Depression, and Intention to Participate in Leisure Sports Based on Weight Change

This study examined the impact of COVID-19 on individuals' weight change and mental health by analyzing differences in risk perception, obesity, stress, depression, and intention to participate in leisure sports during the COVID-19 pandemic. Data were collected in the Republic of Korea between June and August 2022. This study included 374 individuals aged ≥ 20 years who regularly participated in leisure sports. A comparative analysis subdivided the participants into two groups based on weight changes during the pandemic: weight loss and maintenance (Group 1) and weight gain (Group 2). These formed the independent variable. The dependent variables were (a) infection risk perception, (b) obesity stress, (c) depression, and (d) intention to participate in sports. The results revealed statistically significant differences between the two groups in infection risk perception, obesity stress, and depression factors, but not in the intention to participate in sports. This study demonstrated the impact of COVID-19 on weight changes and mental health. These findings can guide future quarantine strategies to control new infectious diseases and policies to prevent obesity and stress.

Impact of Non-Face-to-Face Teaching with Passive Training on Personal Protective Equipment Use in Health Science Students: A Randomized Controlled Trial

BACKGROUND

In the COVID-19 era, there was a call for the transformation of higher education. Universities had to combine non-face-to-face teaching with traditional procedures. This study analyzed the effectiveness and perceived satisfaction in a cohort of health sciences students of non-face-to-face teaching with passive training versus face-to-face teaching with active training in the proper donning and doffing of personal protective equipment (PPE) in a clinical simulation scenario.

METHODS

A total of 142 participants were randomized into two groups: (a) non-face-to-face teaching with passive training; (b) face-to-face teaching with active training. The proper protocol for donning and doffing PPE was assessed. Students evaluated their skills before and after training and satisfaction with training received.

RESULTS

Significant differences were observed for the statements "I felt more confident in donning after receiving this training" (p = 0.029) and "I felt more confident in doffing after receiving this training" (p = 0.042) in the face-to-face teaching with active training group compared to the non-face-to-face teaching with passive training group, whose number of tasks violated was significantly higher (p = 0.020). Satisfaction was significantly higher in the face-to-face and active training group (p = 0.004).

CONCLUSIONS

Face-to-face teaching with active training improves effectiveness and satisfaction more than non-face-to-face teaching with passive training for acquiring skills in donning and doffing PPE properly.

Compliance to Infection Prevention and Control Practices Among Healthcare Workers During COVID-19 Pandemic in Malaysia

Healthcare workers (HCWs) are at risk of contracting coronavirus disease-2019 (COVID-19) in their workplace. Infection prevention guidelines and standard operating procedures were introduced to reduce risk of exposure and prevent transmission. Safe practices during interaction with patients with COVID-19 are crucial for infection prevention and control (IPC). This study aimed to assess HCWs' compliance to IPC and to determine its association with sociodemographic and organizational factors. A cross-sectional study was conducted between March and April 2021 at public healthcare facilities in the east coast of Peninsular Malaysia. HCWs who were involved with COVID-19-related works were invited to participate in the online survey. The questionnaire was adapted from the World Health Organization (WHO) Interim Guidance: WHO Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19. Respondents were categorized as compliant or non-compliant to IPC. A total of 600 HCWs involved in COVID-19-related works participated in the survey. Most of them (63.7%) were compliant to IPC as they responded to all items as “always, as recommended” during interaction with patients with COVID-19. The multivariate analysis showed that non-compliance was significantly associated with working in the emergency department (AOR = 3.16; 95% CI = 1.07–9.31), working as laboratory personnel (AOR = 15.13; 95% CI = 1.36–168.44), health attendant (AOR = 4.42; 95% CI = 1.74–11.24), and others (AOR = 3.63; 95% CI = 1.1–12.01), as well as work experience of more than 10 years (AOR = 4.71; 95% CI = 1.28–17.27). The odds of non-compliance among respondents without adequate new norms and personal protective equipment training were 2.02 (95% CI = 1.08–3.81) more than those with adequate training. Although most of the respondents complied to IPC protocols, compliance status differed according to department, work category, and years of service. Ensuring adequate training that will hopefully lead to behavioral change is crucial to prevent breach in IPC and thus minimize the risk of exposure to and transmission of COVID-19 in healthcare facilities.

Determinants of nurse's and personal support worker's adherence to facial protective equipment in a community setting during the COVID-19 pandemic in Ontario, Canada: A pilot study

Background

Appropriate and consistent facial protective equipment (FPE) use is critical for preventing respiratory illness transmission. Little is known about FPE adherence by home care providers. The purpose of this study is to adapt an existing facial protection questionnaire and use it to develop an initial understanding of factors influencing home care providers’ adherence to FPE during the COVID-19 pandemic.

Methods

A survey was shared with home care providers during Wave 2 of the COVID-19 pandemic in Ontario. Descriptive statistics and logistic regression by FPE adherence were conducted across individual, organizational, and environmental factors.

Results

Of the 199 respondents (140 personal support workers; 59 nurses), 71% reported that they always used FPE as required, with greater adherence to masks (89%) than eye protection (73%). The always-adherent reported greater perceived FPE efficacy, knowledge of recommended use and perceived occupational risk, lower education, and not experiencing personal barriers (including difficulty seeing, discomfort, communication challenges).

Discussion

Adherence rates were relatively high. In this context, with participants reporting high levels of organizational support, individual-level factors were the significant predictors of adherence.

Conclusions

Initiatives addressing perceived FPE efficacy, knowledge of recommended use, perception of at-work risk, and personal barriers to use may improve FPE adherence.

Online survey of university students' perception, awareness and adherence to COVID-19 prevention measures

BACKGROUND

Determining factors correlated with protective measures against COVID-19 is important to improve public health response. This study describes student opinions related to university COVID-19 preventive measures.

METHODS

In fall 2020, 643 US university students completed an online survey on perception, awareness, and adherence to COVID-19 preventive measures. Outcomes included protocol effectiveness (self or others), protocol adherence (self or others), consequences of protocol violation, knowledge of violations, and level of concern for COVID-19. Multiple linear regression models determined correlates of outcome variables. Covariates included gender, race, residence, area of study, class, and knowledge of someone with a positive COVID-19 test.

RESULTS

Overall, students agreed with protective measures (equivalent to higher scores). In adjusted linear models, females (versus males) had significantly higher scores for protocol effectiveness (self) (p < 0.001), consequences of protocol violation (p = 0.005), and concern about COVID-19 (p < 0.001). Asian/Pacific Islander (versus white) had significantly higher scores for protocol effectiveness (self) (p < 0.001), consequences of protocol violation (p = 0.008), and concern about COVID-19 (p = 0.001). Graduate students (versus freshman) had higher scores for protocol effectiveness (self) (p < 0.001), protocol adherence (self) (p = 0.004) and concern about COVID-19 (p < 0.001). In contrast, participants who had a positive COVID-19 test had significantly lower scores for protocol effectiveness (self) (p = 0.02), protocol adherence (self) (p = 0.004), and consequences of protocol violation (p = 0.008).

CONCLUSION

Overall, females, Asian/Pacific Islanders, and graduate students were more likely to agree with or adhere to COVID-19 prevention guidelines but those who tested positive for COVID-19 were less likely to do so. These results may inform future prevention efforts.

Risk Perception and Emotion Reaction of Chinese Health Care Workers Varied During COVID-19: A Repeated Cross-Sectional Research

Objectives: To examine risk perception and negative emotions during two periods of the COVID-19 and provide plausible intervention points for the psychological aid under a stressful condition. Methods: The current study adopted the repeated cross-sectional research and was participated by a cohort of Chinese HCWs who were assigned to work at the current disease resistance line. The between-group information about gender, profession, and location was collected in the demographic questionnaire. Risk perception questionnaire was adapted for COVID-19 to assess risk perception and the Chinese version of emotional self-rating scale (PANAS) was used to evaluate HCWs' negative emotions. Results: Findings revealed the risk perception and negative emotions of HCWs varied in different gender, profession, location, as well as different periods of COVID-19. Over the different periods, the predominated negative emotion expressed by HCWs varied, but negative emotion was consistently associated with risk perception and could be a significant indicator of risk perception. Conclusion: The significance of this research lies in its examination of risk perception and negative emotions of HCWs confronting the COVID-19 during two periods of the pandemic, which underscored the importance of monitoring the risk perception and negative emotions of HCWs to ensure safety and prevent the return of the pandemics.

Communication in the intensive care unit during COVID-19: early experience with the Nightingale Communication Method

Objective

To assess the utility and frequency of use of the Nightingale Communication Method, during the early operational phase of the Nightingale Hospital London (NHL) 4000-bed field hospital’s intensive care unit.

Design

Survey-based cross-sectional assessment.

Setting

The intensive care unit at the Nightingale London hospital.

Participants

Staff working in the clinical area and therefore requiring full personal protective equipment (PPE).

Intervention

Survey of all staff members sampled from a single shift at the Nightingale Hospital. This investigated perceived utility and actual use of identification methods (name and role labels on visors and gowns, coloured role identification tapes) and formal hand signals as an adjunctive communication method.

Main Outcome Measure

Self-reported frequency of use and perceived utility of each communication and personnel identification adjunct.

Results

Fifty valid responses were received (72% response rate), covering all clinical professional groups. Prominent name/role identifications and coloured role identification tapes were very frequently used and were perceived as being highly useful. Formal hand signals were infrequently used and not perceived as being beneficial, with respondents citing use of individual hand signals only in specific circumstances.

Conclusion

PPE is highly depersonalizing, and interpersonal identification aids are very useful. Despite being difficult, verbal communication is not completely prohibited, which could explain the low utility of formal hand signals. The methods developed at the Nightingale hospital have enhanced communication in the critical care, field hospital setting. There is potential for wider application to a variety of healthcare settings, in both the current situation and future pandemic scenarios.

Activities of employers and OHS services during the developing COVID-19 epidemic in Poland

BACKGROUND

The epidemic is affecting the global economy, plunging many industries. The global extent of the epidemic and government controls, restrictions and constraints have led to imbalances in world trade and have put many companies under pressure. The epidemic is a test of individual companies' ability to operate effectively in the new environment. It is up to managers to mitigate its impact on business. The aim of the article is to identify the activities of employers in Poland related to the protection of workers with the developing epidemic COVID-19.

METHODS

A survey was carried out among the employees of OHS services employed in enterprises in Poland. The research was conducted in three stages at two-week intervals. The obtained results were subjected to statistical analyses.

RESULTS

In the analysed three periods a total of 588 answers were obtained, which allowed to formulate conclusions. The research showed that in connection with the COVID-19 epidemic, about 30% of the plants updated their occupational risk assessment, about 40% updated their safety instructions, about 90% of the plants equipped their employees with additional personal protective equipment.

CONCLUSIONS

The COVID-19 outbreak in Poland resulted in taking additional actions by employers to protect workers. Systematicity (methodicality) of these activities depended mainly on the seniority of the OHS service. As a border internship indicating a different approach to an emergency situation related to the epidemic, 7 years were set.

Behavioral strategies for reducing disease transmission in the workplace

The coronavirus pandemic highlighted that workplaces may serve as a hub of disease transmission if proper precautions are not enacted. The Centers for Disease Control recommends several strategies for decreasing the spread of illnesses in the workplace, including a) promoting proper hand hygiene, b) cleaning and sanitizing the work area, c) encouraging sick employees to stay home, d) personal protective equipment, and, e) social distancing. Research suggests that instructions are often not sufficient to change work behaviors, and behavioral interventions may be needed. Thus, the present paper reviews existing research that informs the implementation of behavioral strategies to reduce the spread of disease in the workplace, and makes recommendations for organizations to protect employees, clients, and customers. Intervention components such as training, prompts, the reduction of response effort, clear workplace policies, feedback, and consequences are discussed, and practical recommendations and suggestions for future research are provided.

For Whom the Pandemic Tolls: A Person-Centric Analysis of Older Workers

We offer a worker-centric perspective on the impact of the COVID-19 pandemic for the aging workforce. We briefly describe 3 broad characteristics of pandemics-mortality salience, isolation from the workplace, and rising unemployment-in terms of their associated pathways of influence on older workers, and recommendations for future research.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

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.

Storage and Availability of Elastomeric Respirators in Health Care

Use of reusable respirators, such as elastomeric half-face respirators (EHFRs), may serve as one solution to combating the problem of N95 respirator shortages experienced during infectious disease emergencies. To clarify whether logistical issues like respirator storage and availability are barriers to implementation of healthcare respiratory protection strategies that include EHFRs, this study aimed to evaluate the availability, storage, and respirator and filter replacement practices of EHFRs used in healthcare settings under routine use. Healthcare workers using EHFRs were surveyed about their use practices. To explore whether issues related to storage and availability of EHFRs affected compliance with assigned respirator use, responses were compared between concordant users and EHFR users who were assigned to use EHFRs but currently use different respirators ("discordant users"). Most concordant EHFR users reported that their respirator was always available when needed (63.8%). Almost two-thirds of concordant but only half of discordant users reported storing their EHFRs conveniently in the patient care area (p = <0.001). Among mobile workers, discordant users had higher odds (aOR = 3.2, 95% CI [1.4,7.5]) of reporting that their respirator was not stored in the patient care area, suggesting that storage location has a significant impact on compliance with expected practice, particularly in this group. Storage and access are barriers to optimal elastomeric respirator use in healthcare. Strategies to assure ready availability and storage of respirators will permit EHFR inclusion in pandemic and routine respiratory protection programs.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

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.

A qualitative study of factors affecting personal protective equipment use among health care personnel

BACKGROUND

Health care personnel (HCP) use of personal protective equipment (PPE) reduces infectious disease transmission. However, PPE compliance remains low. The objective of this study was to better understand how HCP perceptions factor into PPE decision making as well as how organizational processes and the environment impact behavior.

METHODS

This qualitative study used observation and focus groups at 2 medical centers. Data were analyzed using thematic analysis.

RESULTS

The decision to use PPE and to follow precaution practices was influenced by risk perception as well as organizational and environmental factors. Perceived risk, related to certain organisms and work tasks, was considered by HCP when deciding to use PPE. Organizational processes, such as policies that were not applied uniformly, and environmental factors, such as clean versus contaminated space, also played a role in HCP PPE use.

DISCUSSION

Because HCP seemed focused on organisms and work tasks, education on specific organisms and helping HCP think through their workflow may be more effective in conveying the importance of PPE in reducing transmission. Additionally, isolation practices should be compared across disciplines to ensure they complement, rather than contradict, one another. Assessment of the environment may help protect HCP and patients from infectious organisms.

CONCLUSION

Preventing the spread of infectious organisms should not depend solely on PPE use, but should also be recognized as an organizational responsibility.

A Case Study Evaluating the Risk of Infection from Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) in a Hospital Setting Through Bioaerosols

Middle Eastern respiratory syndrome, an emerging viral infection with a global case fatality rate of 35.5%, caused major outbreaks first in 2012 and 2015, though new cases are continuously reported around the world. Transmission is believed to mainly occur in healthcare settings through aerosolized particles. This study uses Quantitative Microbial Risk Assessment to develop a generalizable model that can assist with interpreting reported outbreak data or predict risk of infection with or without the recommended strategies. The exposure scenario includes a single index patient emitting virus-containing aerosols into the air by coughing, leading to short- and long-range airborne exposures for other patients in the same room, nurses, healthcare workers, and family visitors. Aerosol transport modeling was coupled with Monte Carlo simulation to evaluate the risk of MERS illness for the exposed population. Results from a typical scenario show the daily mean risk of infection to be the highest for the nurses and healthcare workers (8.49 × 10^-4 and 7.91 × 10^-4 , respectively), and the lowest for family visitors and patients staying in the same room (3.12 × 10^-4 and 1.29 × 10^-4 , respectively). Sensitivity analysis indicates that more than 90% of the uncertainty in the risk characterization is due to the viral concentration in saliva. Assessment of risk interventions showed that respiratory masks were found to have a greater effect in reducing the risks for all the groups evaluated (>90% risk reduction), while increasing the air exchange was effective for the other patients in the same room only (up to 58% risk reduction).

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

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.

Clinician perceptions of respiratory infection risk; a rationale for research into mask use in routine practice

Outbreaks of emerging and re-emerging infectious diseases are global threats to society. Planning for, and responses to, such events must include healthcare and other measures based on current evidence. An important area of infection prevention and control (IPC) is the optimal use of personal protective equipment (PPE) by healthcare workers (HCWs), including masks for protection against respiratory pathogens. Appropriate mask use during routine care is a forerunner to best practice in the event of an outbreak. However, little is known about the influences on decisions and behaviours of HCWs with respect to protective mask use when providing routine care. In this paper we argue that there is a need for more research to provide a better understanding of the decision-making and risk-taking behaviours of HCWs in respect of their use of masks for infectious disease prevention. Our argument is based on the ongoing threat of emerging infectious diseases; a need to strengthen workforce capability, capacity and education; the financial costs of healthcare and outbreaks; and the importance of social responsibility and supportive legislation in planning for global security. Future research should examine HCWs' practices and constructs of risk to provide new information to inform policy and pandemic planning.

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Emerging and remerging infectious diseases continue to pose a threat to human health and global security.

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Outbreaks of respiratory infection result in human and economic costs including staff illness and wider societal disruption.

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Clinicians' use of personal protective equipment is critical to reducing the risk of transmission of infectious disease.

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Training in the use of PPE should take account of clinicians' and patients' perceptions of risk.

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Individual and societal responsibility towards infection prevention may influence clinicians' use of protective masks.

Best Practices in the Management of Central Vascular Access Devices: An Observational Study in Areas With a High Prevalence of Trained Nurses

Since 2009, the Department of Continuing Education at the Orthopedic and Trauma Center Hospital in Turin, Italy, has provided a training course for nurses in the management of central vascular access devices (CVADs). The course focuses on dressing and flushing procedures, as well as compliance with other CVAD guidelines. An observational study was conducted among nurses to determine the level of best practices in areas with a high prevalence of nurses trained in the management of CVADs. A correlation was observed between best practices and having attended the course, but other variables also influenced best practices.

Predictors of Respiratory Protective Equipment Use in the Norwegian Smelter Industry: The Role of the Theory of Planned Behavior, Safety Climate, and Work Experience in Understanding Protective Behavior

Previous research has revealed a higher prevalence of respiratory symptoms in Norwegian smelter workers compared to average population controls. Nevertheless, respiratory protective equipment (RPE) is not always used, even in situations with high exposure risk. A questionnaire was distributed to workers in the Norwegian smelting industry to investigate the relationship between psychological factors and self-reported use of RPEs. Response rate was 567/1,253. A scale measuring attitudes toward behavior (ATT), subjective norms (SN), perceived behavioral control (PBC), and behavioral intention (BI) was constructed based on the Theory of Planned Behavior (TPB). Reliability and Confirmatory Factor Analyses partially supported the theoretical structure of the TPB-based scale, the Work Experience Measurement Scale (WEMS) and the Short Scale for Safety Climate (SC). A model explaining the relationship between observed variables, latent constructs from TPB, WEMS and SC was developed by SEM-analysis. Significant influence on BI from ATT (β = 0.31 p < 0.01), SN (β = 0.36 p < 0.01), and SC (β = 0.19, p < 0.01) emerged. Among the observed variables included, relationship status (β = −0.12 p < 0.05), education level (β = 0.09, p < 0.05), previously completed respirator fit-testing (β = −0.09, p < 0.05) and average hours spent in exposed areas (β = −0.09) p < 0.05) had significant influence on behavioral intention. The model explained 48% of the variance in BI. BI and PBC significantly predicted PB, with β = 0.65 and β = −0.06, respectively. Results of this investigation can help facilitate further work and development of health & safety routines within industrial settings.

Exploring respiratory protection practices for prominent hazards in healthcare settings

The use of respiratory protection, an important component of personal protective equipment (PPE) in healthcare, is dependent on the hazard and environmental conditions in the workplace. This requires the employer and healthcare worker (HCW) to be knowledgeable about potential exposures and their respective protective measures. However, the use of respirators is inconsistent in healthcare settings, potentially putting HCWs at risk for illness or injury. To better understand respirator use, barriers, and influences, the National Institute for Occupational Safety and Health (NIOSH) Health and Safety Practices Survey of Healthcare Workers provided an opportunity to examine self-reported use of respirators and surgical masks for targeted hazards. The hazards of interest included aerosolized medications, antineoplastic drugs, chemical sterilants, high-level disinfectants, influenza-like illness (ILI), and surgical smoke. Of the 10,383 HCWs who reported respiratory protection behaviors, 1,904 (18%) reported wearing a respirator for at least one hazard. Hazard type, job duties, site characteristics, and organizational factors played a greater role in the likelihood of respirator use than individual factors. The proportion of respirator users was highest for aerosolized medications and lowest for chemical sterilants. Most respondents reported using a surgical mask for at least one of the hazards, with highest use for surgical smoke generated by electrosurgical techniques and ILI. The high proportion of respirator non-users who used surgical masks is concerning because HCWs may be using a surgical mask in situations that require a respirator, specifically for surgical smoke. Improved guidance on hazard recognition, risk evaluation, and appropriate respirator selection could potentially help HCWs better understand how to protect themselves at work.

Annual Burden of Occupationally-Acquired Influenza Infections in Hospitals and Emergency Departments in the United States

Infections among health-care personnel (HCP) occur as a result of providing care to patients with infectious diseases, but surveillance is limited to a few diseases. The objective of this study is to determine the annual number of influenza infections acquired by HCP as a result of occupational exposures to influenza patients in hospitals and emergency departments (EDs) in the United States. A risk analysis approach was taken. A compartmental model was used to estimate the influenza dose received in a single exposure, and a dose-response function applied to calculate the probability of infection. A three-step algorithm tabulated the total number of influenza infections based on: the total number of occupational exposures (tabulated in previous work), the total number of HCP with occupational exposures, and the probability of infection in an occupational exposure. Estimated influenza infections were highly dependent upon the dose-response function. Given current compliance with infection control precautions, we estimated 151,300 and 34,150 influenza infections annually with two dose-response functions (annual incidence proportions of 9.3% and 2.1%, respectively). Greater reductions in infectious were achieved by full compliance with vaccination and IC precautions than with patient isolation. The burden of occupationally-acquired influenza among HCP in hospitals and EDs in the United States is not trivial, and can be reduced through improved compliance with vaccination and preventive measures, including engineering and administrative controls.

Evaluation of reported fatality data associated with workers using respiratory protection in the United States (1990-2012)

OSHA revised the 1971 respiratory protection standard in 1998 to add guidance for selecting and maintaining respirators. Fatality reports from 1990 to 2012 were used to characterize historical trends in fatalities associated with respirators. Industry- and time-specific trends were evaluated to determine the effect of the revision to the standard on respirator-related fatalities; 174 respirator-related deaths were reported. The majority of fatalities were associated with using an airline respirator (n = 34) or the absence of using a respirator in required spaces (n = 38). Overall, 79% of fatalities were associated with asphyxia. Fatalities were associated with improper employee use or lack of employer compliance. Reductions in fatality rates over time appeared to be associated with the revisions to the respirator standard, although other variables may influence rates (eg, controls). Recommendations for employers and employees regarding maintaining safe use of respirators are provided.

Febrile illness in healthcare workers caring for Ebola virus disease patients in a high-resource setting

Ebola virus disease (EVD) patients treated in high-resource facilities are cared for by large numbers of healthcare staff. Monitoring these healthcare workers (HCWs) for any illness that may represent transmission of Ebola virus is important both for the individuals and to minimise the community risk. International policies for monitoring HCWs vary considerably and their effectiveness is unknown. Here we describe the United Kingdom (UK) experience of illness in HCWs who cared for three patients who acquired EVD in West Africa. Five of these 93 high-level isolation unit (HLIU) HCWs presented with fever within 21 days of working on the unit; one of these five presented outside of the UK. This article discusses different approaches to monitoring of HCW symptom reporting. The potential impact of these approaches on HLIU staff recruitment, including travel restrictions, is also considered. An international surveillance system enhancing collaboration between national public health authorities may assist HLIU HCW monitoring in case they travel.

Herd protection effect of N95 respirators in healthcare workers

Objective

To determine if there was herd protection conferred to unprotected healthcare workers (HCWs) by N95 respirators worn by colleagues.

Methods

Data were analysed from a prospective cluster randomized clinical trial conducted in Beijing, China between 1 December 2008 and 15 January 2009. A minimum compliance level (MCL) of N95 respirators for prevention of clinical respiratory illness (CRI) was set based on various compliance cut-offs. The CRI rates were compared between compliant (≥MCL) and non-compliant (<MCL) N95 wearers by ward, and between non-compliant wearers and control subjects who did not wear masks.

Results

Data were analysed from 949 HCWs who wore N95 respirators and 125 HCWs who did not wear masks. At 50% MCL there were no significant differences in the CRI rates between compliant and non-compliant N95 wearers by ward. In multivariate analysis, the CRI rate in non-compliant HCWs was significantly lower compared with controls (relative risk 0.26; 95% confidence interval 0.08, 0.82).

Conclusion

This study suggests herd protection from use of N95 respirators by colleagues within a hospital ward.

Relationship between patient safety climate and adherence to standard precautions

BACKGROUND

Standard precautions (SPs) are designed to limit bloodborne pathogen exposures among health care workers (HCWs) and health care-associated infections. SP adherence is globally suboptimal; however, reasons are underexplored. This study aim was to explore the relationships among safety climate factors and SP adherence by HCWs in hospitals using newly developed survey and observational tools.

METHODS

Cross-sectional data from 11 units in 5 hospitals were collected between March and September 2015. A patient safety and standard precaution survey was administered to nurses and pooled with data from observations of HCW-patient interactions using defined SP indications. Descriptive statistics of distributions, frequencies, and Pearson correlation coefficients were calculated to determine the unit-level relationships among dimensions of the patient safety climate and unit percentages of SP adherence (P < .05).

RESULTS

There were 540 HCW-patient encounters with 1,713 SP indications and 140 surveys collected. Although most nurses (94%) reported always or often adhering to SPs and generally reported positive scores on unit safety climate, observed SP adherence was 62% (unit range, 31%-80%). Only 30% of nurses rated staffing positively, and this was inversely related to observed SP adherence.

CONCLUSIONS

Adherence to the full complement of observed SP behaviors by HCWs of all types was suboptimal. The relationship between safety climate, particularly staffing, and adherence to SPs warrants further testing.

Bridging the gap between guidelines and practice in the management of emerging infectious diseases: a qualitative study of emergency nurses

AIMS AND OBJECTIVES

To explore the difficulties and strategies regarding guideline implementation among emergency nurses.

BACKGROUND

Emerging infectious diseases remain an underlying source of global health concern. Guidelines for accident and emergency departments would require adjustments for infectious disease management. However, disparities between guidelines and nurses' practice are frequently reported, which undermines the implementation of these guidelines into practice. This article explores the experience of frontline emergency nurses regarding guideline implementation and provides an in-depth account of their strategies in bridging guideline-practice gaps.

DESIGN

A qualitative descriptive design was used.

METHODS

Semi-structured, face-to-face, individual interviews were conducted between November 2013-May 2014. A purposive sample of 12 frontline emergency nurses from five accident and emergency departments in Hong Kong were recruited. The audio-recorded interviews were transcribed verbatim and analysed with a qualitative content analysis approach.

RESULTS

Four key categories associated with guideline-practice gaps emerged, including getting work done, adapting to accelerated infection control measures, compromising care standards and resolving competing clinical judgments across collaborating departments. The results illustrate that the guideline-practice gaps could be associated with inadequate provision of corresponding organisational supports after guidelines are established.

CONCLUSIONS

The nurses' experiences have uncovered the difficulties in the implementation of guidelines in emergency care settings and the corresponding strategies used to address these problems. The nurses' experiences reflect their endeavour in adjusting accordingly and adapting themselves to their circumstances in the face of unfeasible guidelines.

RELEVANCE TO CLINICAL PRACTICE

It is important to customise guidelines to the needs of frontline nurses. Maintaining cross-departmental consensus on guideline interpretation and operation is also indicated as an important component for effective guideline implementation.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or 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 HCWs use PPE as instructed.

OBJECTIVES

To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types 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 intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here.

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. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.

Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature

Standard precaution (SP) adherence is universally suboptimal, despite being a core component of healthcare-associated infection (HCAI) prevention and healthcare worker (HCW) safety. Emerging evidence suggests that patient safety climate (PSC) factors may improve HCW behaviours. Our aim was to examine the relationship between PSC and SP adherence by HCWs in acute care hospitals. A systematic review was conducted as guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Three electronic databases were comprehensively searched for literature published or available in English between 2000 and 2014. Seven of 888 articles identified were eligible for final inclusion in the review. Two reviewers independently assessed study quality using a validated quality tool. The seven articles were assigned quality scores ranging from 7 to 10 of 10 possible points. Five measured all aspects of SP and two solely measured needlestick and sharps handling. Three included a secondary outcome of HCW exposure; none included HCAIs. All reported a statistically significant relationship between better PSC and greater SP adherence and used data from self-report surveys including validated PSC measures or measures of management support and leadership. Although limited in number, studies were of high quality and confirmed that PSC and SP adherence were correlated, suggesting that efforts to improve PSC may enhance adherence to a core component of HCAI prevention and HCW safety. More clearly evident is the need for additional high-quality research.

Health care workers' reported discomfort while wearing filtering face-piece respirators

Filtering face-piece respirators (FFRs) are one method of protecting health care workers from airborne particles; however,research suggests adherence is poor, perhaps due to worker discomfort. Three separate focus groups were conducted at two Veterans Affairs health care facilities. Seventeen health care workers who reported using FFRs as part of their job duties were in the focus groups. Focus group transcripts were coded using qualitative descriptive coding techniques. Participants described experiences of discomfort and physical mask features they believed ,contributed to discomfort. Participants believed FFRs influenced patient care because some patients felt uneasy and changed healthcare workers' behaviors (e.g., doffing procedures, loss of concentration, rushed patient care, and avoidance of patients in isolation resulting from FFR discomfort). Assessment of comfort and tolerability should occur during fit-testing. These factors should also be taken into account by management when training employees on the proper use of FFRs, as well as in future research to improve comfort and tolerability.

Barriers to the Use of PPE to Prevent Pertussis Exposures in a Pediatric Primary Care Network

BACKGROUND

The resurgence of pertussis is contributing to mounting healthcare worker (HCW) exposures, especially within pediatric outpatient settings. Infection prevention and control (IPC) guidelines for ambulatory sites exist, but are not uniformly implemented. Our aim was to identify facilitators and barriers to the use of IPC practices to prevent pertussis transmission in ambulatory pediatric settings.

METHODS

HCWs at 18 of 25 (72%) clinics in a pediatric ambulatory network completed a theory-based questionnaire about pertussis and personal protective equipment (PPE). The questionnaire contained randomly distributed versions of two vignettes to create an experimental design assessing barriers to PPE use.

RESULTS

Three hundred forty-three of 467 (73%) HCWs completed the survey: 234 (68%) clinical and 109 (32%) nonclinical. Seventy-one percent of clinical HCWs reported wearing PPE when caring for a patient with suspected pertussis; only 27% used PPE for patients with any respiratory symptoms. Among clinical HCWs, reported PPE use when caring for patients with suspected pertussis was independently associated with attitudes toward PPE (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.8, 16.6), knowledge and skills (OR 4.6, 95% CI 1.4, 15.2), and lack of perceived barriers (OR 3.2, 95% CI 1.3, 7.9). HCWs who did not perceive PPE use as a norm were less likely to report using PPE (OR 0.2, 95% CI 0.1, 0.6) or distributing masks to patients with cough (OR 0.02, 95% CI 0.00, 0.2). Reported PPE use was not influenced by perceived infection risk or mask accessibility.

CONCLUSION

Our results identified barriers to PPE use and targets for education to prevent pertussis transmission in ambulatory pediatric settings.

Health Care Workers' Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada

Although nurses are knowledgeable regarding the risk of exposure to antineoplastic drugs, they often do not adhere with safe work practices. However, the knowledge, perceptions, and behavior of other health care job categories at risk of exposure has yet to be determined. This study aimed to survey a range of health care workers from British Columbia, Canada about their knowledge, perceptions, and behaviors regarding antineoplastic drugs. A self-administered questionnaire was sent to participants querying the degree of contact with antineoplastics, knowledge of risks associated with antineoplastics, perceptions of personal risk, previous training with respect to antineoplastics, and safe work practices. Subjects were recruited from health care facilities in and around Vancouver. Fisher's exact tests were performed to ascertain whether there were differences in responses between job categories. We received responses from 120 participants representing seven different job categories. Pharmacists, pharmacy technicians, and nurses were more knowledgeable regarding risks than other job categories examined (statistically significant difference). Although 80% of respondents were not afraid of working with or near antineoplastics, there were concerns about the suitability of current control measures and practices employed by co-workers. Only half of respondents felt confident that they could handle all situations where there was a potential for exposure. Only one of the perception questions, self-perceived risk of exposure to antineoplastic drugs, differed significantly between job categories. Not all respondents always wore gloves when directly handling antineoplastic drugs. Further, hand hygiene was not regularly practiced after glove usage or after being in an area where antineoplastic drugs are handled. The majority of responses to questions related to safe work practices differed significantly between job categories. Our results suggest that knowledge regarding risks associated with antineoplastic drugs can be improved, especially among job categories that are not tasked with drug preparation or drug administration. There is also a gap between knowledge and compliance with glove usage and hand hygiene.Training is also recommended to improve health care workers' perceptions of the risks associated with antineoplastic drugs.

Evaluation of Minnesota and Illinois hospital respiratory protection programs and health care worker respirator use

The objective of this study was to assess respiratory protection programs for aerosol-transmissible diseases in acute care hospitals for conformance with regulatory requirements and public health guidelines. Twenty-eight representative hospitals were selected by size, location, and ownership in Minnesota and Illinois. Interviews were conducted with 363 health care workers and 171 managers from high-risk departments. Written programs from each hospital were reviewed for required elements. Seventy-seven health care workers were observed donning and doffing a FFR. The most serious deficiency in many written programs was failure to identify a program administrator. Most written programs lacked adequate details about medical evaluation, fit-testing, and training and did not include a comprehensive risk assessment for aerosol transmissible diseases; tuberculosis was often the only pathogen addressed. Employees with the highest probability of tuberculosis exposure were most likely to pick a respirator for close contact, but higher levels of respiratory protection were rarely selected for aerosol-generating procedures. Surgical masks were most commonly selected for close contact with droplet disease- or influenza-infected patients; better protection (e.g., respirator) was rarely selected for higher-risk exposures. Most of the observed health care workers had access to a NIOSH-certified N95 FFR, properly positioned the facepiece, and formed the nose clip. The most frequent deficiencies were failure to correctly place straps, perform a user seal check, and remove the respirator using straps.

Occupational health nurses’ achievement of competence and comfort in respiratory protection and preferred learning methods results of a nationwide survey

Additional findings are presented from a 2012 nationwide survey of 2,072 occupational health nurses regarding how they achieved competence in respiratory protection, their preferred methods of learning, and how they motivated employees to use respiratory protection. On-the-job training, taking a National Institute for Occupational Safety and Health spirometry course, or attending professional conferences were the primary ways occupational health nurses gained respiratory protection knowledge. Attending professional conferences was the preferred method of learning, varying by type of industry and years of occupational health nurse experience. Employee motivational strategies were not widely used; the most common strategy was to tailor respiratory protection training to workplace culture. Designing training methods that match learning preferences, within the context of the organization's safety and quality improvement culture, is a key recommendation supported by the literature and these findings. Including respiratory protection content and competencies in all levels of academic nursing education is an additional recommendation. Additional research is needed to link training strategies with consistent and correct use of respiratory protection by employees.

Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals

BACKGROUND

The proper use of personal protective equipment (PPE) by health care workers (HCWs) is vital in preventing the spread of infection and has implications for HCW safety.

METHODS

An observational study was performed in 11 hospitals participating in the Canadian Nosocomial Infection Surveillance Program between January 7 and March 30, 2011. Using a standardized data collection tool, observers recorded HCWs selecting and removing PPE and performing hand hygiene on entry into the rooms of febrile respiratory illness patients.

RESULTS

The majority of HCWs put on gloves (88%, n = 390), gown (83%, n = 368), and mask (88%, n = 386). Only 37% (n = 163) were observed to have put on eye protection. Working in a pediatric unit was significantly associated with not wearing eye protection (7%), gown (70%), gloves (77%), or mask (79%). Half of the observed HCWs (54%, n = 206) removed their PPE in the correct sequence. Twenty-six percent performed hand hygiene after removing their gloves, 46% after removing their gown, and 57% after removing their mask and/or eye protection.

CONCLUSION

Overall adherence with appropriate PPE use in health care settings involving febrile respiratory illness patients was modest, particularly on pediatric units. Interventions to improve PPE use should be targeted toward the use of recommended precautions (eg, eye protection), HCWs working in pediatric units, the correct sequence of PPE removal, and performing hand hygiene.

Perceived Competence and Comfort in Respiratory Protection

In response to the Institute of Medicine (2011) report Occupational Health Nurses and Respiratory Protection: Improving Education and Training, a nationwide survey was conducted in May 2012 to assess occupational health nurses' educational preparation, roles, responsibilities, and training needs in respiratory protection. More than 2,000 occupational health nurses responded; 83% perceived themselves as competent, proficient, or expert in respiratory protection, reporting moderate comfort with 12 respiratory program elements. If occupational health nurses had primary responsibility for the respiratory protection program, they were more likely to perceive higher competence and more comfort in respiratory protection, after controlling for occupational health nursing experience, highest education, occupational health nursing certification, industry sector, Association of Occupational Health Professionals in Healthcare membership, taking a National Institute for Occupational Safety and Health spirometry course in the prior 5 years, and perceiving a positive safety culture at work. These survey results document high perceived competence and comfort in respiratory protection. These findings support the development of targeted educational programs and interprofessional competencies for respiratory protection.

Health care workers' perceptions predicts uptake of personal protective equipment

BACKGROUND

Health care workers' (HCW) compliance with infection control measures is influenced by organizational, environmental and individual factors. However, it is unknown whether HCWs' perceptions of transmission risk and protectiveness of infection control measures influences the uptake of infection control measures.

METHODS

A questionnaire of perceptions and intentions to use infection control measures was completed by 74 HCWs at 2 hospitals. HCWs also indicated a 1-m transmission risk zone and their perceived transmission risk zone. Responses were used in logistic regression models to predict intended behaviors.

RESULTS

Poor recognition of the importance of employing a 1-m transmission risk zone predicted intention not to don a mask in single rooms where patient contact was unexpected (adjusted odds ratio [AOR], 0.5; P = .032). When contact was expected, perceived protectiveness of pre-exposure prophylaxis (AOR, 7.9; P < .001), vaccination (AOR, 3.6; P = .023), and a minimum 1-m risk zone (AOR, 9.8; P = .022) predicted mask use. HCWs perceived transmission risk zones within 2.45 m from attending an adult and 1.12 m from attending pediatric patients.

CONCLUSION

Intention to use a facemask was poor for care in single rooms but improved if patient contact was expected and in multibed rooms. HCWs attending pediatric patients measured a smaller transmission risk zone than what is currently recommended under droplet precautions.

Behind the mask: Determinants of nurse's adherence to facial protective equipment

BACKGROUND

As the predominant occupation in the health sector and as the health worker with the most patient interaction, nurses are at high risk for occupational transmission of communicable respiratory illness. The use of facial protective equipment (FPE) is an important strategy to prevent occupational transmission.

METHODS

A 2-phased study was conducted to examine nurse's adherence to recommended use of FPE. Phase 1 was a cross-sectional survey of nurses in selected units of 6 acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses.

RESULTS

Of the 1,074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of FPE. Multivariable analysis revealed 6 predictors of adherence: unit type, frequency of equipment use, equipment availability, training, organizational support, and communication. Following the survey, 100 observations in 14 intensive care units were conducted that revealed a 44% competence rate with proper use of N95 respirators and knowledge as a significant predictor of competence.

CONCLUSION

Whereas increasing knowledge should enhance competence, strategies to improve adherence to recommended use of FPE in a busy and complex health care setting should focus on ready availability of equipment, training and fit testing, organizational support for worker health and safety, and good communication practices.

Impact of the 2009 influenza A (H1N1) pandemic on Canadian health care workers: a survey on vaccination, illness, absenteeism, and personal protective equipment

BACKGROUND

Data are limited on the impact of the 2009 H1N1 influenza A pandemic on health care worker (HCW) vaccination, illness, absenteeism, and personal protective equipment (PPE) use.

METHODS

A survey was completed by HCWs from 14 hospitals participating in the Canadian Nosocomial Infection Surveillance Program who provided direct care to patients with pH1N1 influenza in high-risk units between September and December 2009.

RESULTS

Surveys were returned from 986 HCWs (80% nurses, 14% respiratory therapists, and 6% physicians). HCWs working in an intensive care unit (78%) or a designated influenza ward (67%) were more compliant with wearing an N95 respirator for aerosol-generating medical procedures than those working in an emergency department (47%; P < .001). HCWs who worked in health care for >11 years were more compliant with wearing protective eyewear than those who worked for ≤11 years (69% vs 54%; P < .001). A total of 815 HCWs (83%) reported having received the pH1N1 influenza vaccine, and 372 (38%) reported having received the 2009-2010 seasonal influenza vaccine. Influenza-like illness was reported by 236 (24%) HCWs, 170 of whom (72%) reported missing work.

CONCLUSIONS

Experience working in health care improves PPE use and HCWs in emergency departments should be targeted for interventions to improve PPE compliance. pH1N1 influenza vaccine coverage was high, but seasonal influenza vaccine coverage was low, and significant HCW illness and absenteeism were reported.

Collaboration between infection control and occupational health in three continents: a success story with international impact

Globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. Post-SARS, Canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. This led to developing information and communication technology (ICT) tools. The research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ICT. When invited to join Ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. The South African government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. As the H1N1 pandemic struck, the online infection control course was adapted and translated into Spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. This tool was originally developed in collaboration with the countries from the Caribbean region and the Pan American Health Organization (PAHO). Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work.The products developed have been widely heralded as innovative and interactive, leading to their inclusion into "toolkits" used internationally. The tools used in Canada were substantially improved from the collaborative adaptation process for South and Central America and South Africa. This international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.

Factors influencing nurses' compliance with Standard Precautions in order to avoid occupational exposure to microorganisms: A focus group study

BACKGROUND

Nurses may acquire an infection during the provision of nursing care because of occupational exposure to microorganisms. Relevant literature reports that, compliance with Standard Precautions (a set of guidelines that can protect health care professionals from being exposed to microorganisms) is low among nurses. Additionally, high rates of exposure to microorganisms among nurses via several modes (needlesticks, hand contamination with blood, exposure to air-transmitted microorganisms) occur. The aim of the study was to study the factors that influence nurses' compliance with Standard Precaution in order to avoid occupational exposure to pathogens, by employing a qualitative research design.

METHOD

A focus group approach was used to explore the issue under study. Four focus groups (N = 30) were organised to elicit nurses' perception of the factors that influence their compliance with Standard Precautions. The Health Belief Model (HBM) was used as the theoretical framework and the data were analysed according to predetermined criteria.

RESULTS

Following content analysis, factors that influence nurses' compliance emerged. Most factors could be applied to one of the main domains of the HBM: benefits, barriers, severity, susceptibility, cues to action, and self-efficacy.

CONCLUSIONS

Changing current behavior requires knowledge of the factors that may influence nurses' compliance with Standard Precautions. This knowledge will facilitate in the implementation of programs and preventive actions that contribute in avoiding of occupational exposure.