Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015

Assessing Patterns of Body Contamination after Personal Protective Equipment Removal among Healthcare Workers: A Scoping Review

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.

Impact of Face-to-Face Teaching in Addition to Electronic Learning on Personal Protective Equipment Doffing Proficiency in Student Paramedics: Randomized Controlled Trial

Personal protective equipment doffing is a complex procedure that needs to be adequately performed to prevent health care worker contamination. During the COVID-19 pandemic, junior health care workers and students of different health care professions who had not been trained to carry out such procedures were often called upon to take care of infected patients. To limit direct contact, distance teaching interventions were used, but different trials found that their impact was rather limited. We therefore designed and carried out a randomized controlled trial assessing the impact of adding a face-to-face intervention using Peyton's four-step approach to a gamified e-learning module. Sixty-five student paramedics participated in this study. The proportion of doffing sequences correctly performed was higher in the blended learning group (33.3% (95%CI 18.0 to 51.8) versus 9.7% (95%CI 2.0 to 25.8), p = 0.03). Moreover, knowledge and skill retention four to eight weeks after the teaching intervention were also higher in this group. Even though this study supports the use of a blended learning approach to teach doffing sequences, the low number of student paramedics able to adequately perform this procedure supports the need for iterative training sessions. Further studies should determine how often such sessions should be carried out.

Prácticas de retiro del equipo de protección personal para personal sanitario

RESUMENCuando se retira el equipo de protección personal (EPP), los patógenos pueden transferirse desde el EPP al cuerpo de los trabajadores de la salud, poniendo en riesgo de exposición e infección tanto a ellos mismos como a sus pacientes. Entre marzo de 2017 y abril de 2018 se observaron las prácticas de retirada del EPP del personal sanitario que atendía pacientes con infecciones respiratorias virales en un hospital de atención de enfermedades agudas. Un observador capacitado registró el desempeño del personal sanitario cuando retiraba el EPP dentro de las habitaciones de los pacientes, utilizando una lista de verificación predefinida basada en las directrices de los Centros para el Control y Prevención de Enfermedades (Centers for Disease Control and Prevention, CDC). Se observaron 162 prácticas de retirada durante el cuidado de 52 pacientes infectados con patógenos virales respiratorios. De estos 52 pacientes, 30 estaban en aislamiento por gota y contacto, 21 en aislamiento por gota y uno en aislamiento de contacto. En general, en 90% de los casos la retirada del EPP observada se realizó de manera incorrecta, ya sea en cuanto a la secuencia de retirada, la técnica de retirada o el uso del EPP apropiado. Los errores más comunes consistieron en quitarse la bata por adelante, retirar la pantalla facial de la mascarilla y tocar superficies y EPP potencialmente contaminados durante el proceso. Las desviaciones del protocolo recomendado para retirar el EPP son comunes y pueden aumentar el potencial de contaminación de la ropa o la piel del personal sanitario después de proporcionar atención. Existe una clara necesidad de cambiar el enfoque utilizado para capacitar al personal en las prácticas de retirada del EPP.

Mask shortage during epidemics and pandemics: a scoping review of interventions to overcome limited supply

OBJECTIVE

To characterise published evidence regarding preclinical and clinical interventions to overcome mask shortages during epidemics and pandemics.

DESIGN

Systematic scoping review.

SETTINGS

All healthcare settings relevant to epidemics and pandemics.

SEARCH STRATEGY

English peer-reviewed studies published from January 1995 to June 2020 were included. Literature was identified using four databases (Medline-OVID, EMBASE, CINAHL, Cochrane Library), forwards-and-backwards searching through Scopus and an extensive grey literature search. Assessment of study eligibility, data extraction and evidence appraisal were performed in duplicate by two independent reviewers.

RESULTS

Of the 11 220 database citations, a total of 47 articles were included. These studies encompassed six broad categories of conservation strategies: decontamination, reusability of disposable masks and/or extended wear, layering, reusable respirators, non-traditional replacements or modifications and stockpiled masks. Promising strategies for mask conservation in the context of pandemics and epidemics include use of stockpiled masks, extended wear of disposable masks and decontamination.

CONCLUSION

There are promising strategies for overcoming face mask shortages during epidemics and pandemics. Further research specific to practical considerations is required before implementation during the COVID-19 pandemic.

Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey

Background

Using personal protective equipment (PPE) is one of several fundamental measures to prevent the transmission of infection and infectious diseases and is particularly pertinent in the current COVID-19 pandemic. Appropriate use of PPE by healthcare workers is, however, often suboptimal. Training and monitoring of PPE competency are essential components of an infection prevention and control program but there is a paucity of research and data on the content of such training programs across Australasia. This paper reports the results of a survey that characterised the nature of PPE training in Australian and New Zealand hospitals.

Methods

A population-based online survey was distributed to members of three major Australasian colleges representing infection prevention and control.

Results

Results indicate that, although training is frequently provided at orientation, many healthcare workers do not receive regular updates. Training programmes combine online and classroom sessions, but over a third do not include a practical component. The frequency of monitoring PPE competency is variable with one third of respondents indicating that no auditing occurs. PPE items used for high-level training are variable, with use of powered air purifying respirators (PAPRs) uncommon.

Conclusion

The results of this study suggest that HCWs’ confidence, competence and familiarity with PPE are a concern, which in the context of the current global COVID-19 pandemic is problematic. More research is needed into how PPE training programs could be better designed, to prepare HCWs for practice using PPE safely and confidently.

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Most HCW orientation programmes include PPE training but fewer than half are updated annually.

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One third of PPE programmes do not include a practical component.

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Only two thirds of PPE training programmes monitor PPE compliance.

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Future research should consider the design of PPE training programs to optimise HCW PPE practice.

A systematic risk-based strategy to select personal protective equipment for infectious diseases

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Selection of personal protective equipment (PPE) can be systematic and risk-based.

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Potential exposures are compared with sites susceptible to infection.

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Facilitates transparent decision-making about personal protective equipment.

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PPE evaluation includes: donning/doffing/changing, usability, and fit for purpose.

Background

Personal protective equipment (PPE) is a primary strategy to protect health care personnel (HCP) from infectious diseases. When transmission-based PPE ensembles are not appropriate, HCP must recognize the transmission pathway of the disease and anticipate the exposures to select PPE. Because guidance for this process is extremely limited, we proposed a systematic, risk-based approach to the selection and evaluation of PPE ensembles to protect HCP against infectious diseases.

Methods

The approach used in this study included the following 4 steps: (1) job hazard analysis, (2) infectious disease hazard analysis, (3) selection of PPE, and (4) evaluation of selected PPE. Selected PPE should protect HCP from exposure, be usable by HCP, and fit for purpose.

Results

The approach was demonstrated for the activity of intubation of a patient with methicillin-resistant Staphylococcus aureus or Severe Acute Respiratory Syndrome coronavirus. As expected, the approach led to the selection of different ensembles of PPE for these 2 pathogens.

Discussion

A systematic risk-based approach to the selection of PPE will help health care facilities and HCP select PPE when transmission-based precautions are not appropriate. Owing to the complexity of PPE ensemble selection and evaluation, a team with expertise in infectious diseases, occupational health, the health care activity, and related disciplines, such as human factors, should be engaged.

Conclusions

Participation, documentation, and transparency are necessary to ensure the decisions can be communicated, critiqued, and understood by HCP.

Perceived Benefits and Challenges of Ebola Preparation Among Hospitals in Developed Countries: A Systematic Literature Review

The 2014–2016 Ebola epidemic in West Africa provided an opportunity to improve our response to highly infectious diseases. We performed a systematic literature review in PubMed, Cochrane Library, CINAHL, EMBASE, and Web of Science of research articles that evaluated benefits and challenges of hospital Ebola preparation in developed countries. We excluded studies performed in non-developed countries, and those limited to primary care settings, the public health sector, and pediatric populations. Thirty-five articles were included. Preparedness activities were beneficial for identifying gaps in hospital readiness. Training improved health-care workers’ (HCW) infection control practices and personal protective equipment (PPE) use. The biggest challenge was related to PPE, followed by problems with hospital infrastructure and resources. HCWs feared managing Ebola patients, affecting their willingness to care for them. Standardizing protocols, PPE types, and frequency of training and providing financial support will improve future preparedness. It is unclear whether preparations resulted in sustained improvements.

Prospero Registration. CRD42018090988.

Personal protective equipment doffing practices of healthcare workers

During the doffing of personal protective equipment (PPE), pathogens can be transferred from the PPE to the bodies of healthcare workers (HCWs), putting HCWs and patients at risk of exposure and infection. PPE doffing practices of HCWs who cared for patients with viral respiratory infections were observed at an acute care hospital from March 2017 to April 2018. A trained observer recorded doffing performance of HCWs inside the patient rooms using a pre-defined checklist based on the Centers for Disease Control and Prevention (CDC) guideline. Doffing practices were observed 162 times during care of 52 patients infected with respiratory viral pathogens. Out of the 52 patients, 30 were in droplet and contact isolation, 21 were in droplet isolation, and 1 was in contact isolation. Overall, 90% of observed doffing was incorrect, with respect to the doffing sequence, doffing technique, or use of appropriate PPE. Common errors were doffing gown from the front, removing face shield of the mask, and touching potentially contaminated surfaces and PPE during doffing. Deviations from the recommended PPE doffing protocol are common and can increase potential for contamination of the HCW's clothing or skin after providing care. There is a clear need to change the approach used to training HCWs in PPE doffing practices.