Improved compliance with universal precautions in the operating room following an educational intervention

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.

Personal Protective Equipment Adherence of Pediatric Resuscitation Team Members During the COVID-19 Pandemic

STUDY OBJECTIVE

During the COVID-19 pandemic, health care workers have had the highest risk of infection among essential workers. Although personal protective equipment (PPE) use is associated with lower infection rates, appropriate use of PPE has been variable among health care workers, even in settings with COVID-19 patients. We aimed to evaluate the patterns of PPE adherence during emergency department resuscitations that included aerosol-generating procedures.

METHODS

We conducted a retrospective, video-based review of pediatric resuscitations involving one or more aerosol-generating procedures during the first 3 months of the COVID-19 pandemic in the United States (March to June 2020). Recommended adherence (complete, inadequate, absent) with 5 PPE items (headwear, eyewear, masks, gowns, gloves) and the duration of potential exposure were evaluated for individuals in the room after aerosol-generating procedure initiation.

RESULTS

Among the 345 health care workers observed during 19 resuscitations, 306 (88.7%) were nonadherent (inadequate or absent adherence) with the recommended use of at least 1 PPE type at some time during the resuscitation, 23 (6.7%) of whom had no PPE. One hundred and forty health care workers (40.6%) altered or removed at least 1 type of PPE during the event. The aggregate time in the resuscitation room for health care workers across all events was 118.7 hours. During this time, providers had either absent or inadequate eyewear for 46.4 hours (39.1%) and absent or inadequate masks for 35.2 hours (29.7%).

CONCLUSION

Full adherence with recommended PPE use was limited in a setting at increased risk for SARS-CoV-2 virus aerosolization. In addition to ensuring appropriate donning, approaches are needed for ensuring ongoing adherence with PPE recommendations during exposure.

The Influence of Professional Subculture on Information Security Policy Violations: A Field Study in a Healthcare Context

The Influence of Professional Subculture on Information Security Policy Violations: A Field Study in a Healthcare Context

Universal precautions

The purpose of this literature review is to consider key themes from empirical research relating to the knowledge and compliance of universal precautions amongst healthcare practitioners. Utilising international studies, strategies to improve universal precautions are analysed. The review identifies areas of limited knowledge, synthesises existing research and suggests aspects of universal precautions that need to be studied further.

A literature search of studies listed in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database was conducted from 1990–2003, using a number of key words. Review, analysis and synthesis of selected studies were performed.

The findings of this review showed that universal precautions are considered an effective means of protecting patients and staff and controlling infection. The consensus from this body of evidence is that, globally, knowledge of universal precautions is inadequate and compliance low. Studies from many countries have shown that specific intervention strategies, such as education, are influential in improving knowledge and compliance.

This review concludes that it is imperative that future research examines how the attitudes and beliefs of practitioners can be influenced and changed to reenforce adherence to universal precautions within the clinical practice setting. There remains a lack of evidence on the long-term benefits of practice interventions to improve compliance, and what specific barriers are influential in affecting how healthcare practitioners adopt universal precautions more effectively in their practice.

Compliance with barrier precautions during paediatric trauma resuscitations

PURPOSE

Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations.

METHODS

Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance.

RESULTS

Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p<0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p<0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR=3.97 [95% CI: 1.35-11.70], p=0.01), during resuscitations triaged to the highest activation level (OR=2.61 [95% CI: 1.34-5.10], p=0.005), and among team members present before patient arrival (OR=4.14 [95% CI: 2.29-7.39], p<0.001).

CONCLUSIONS

Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations.

Use of hands-free technique among operating room nurses in the Republic of Korea

BACKGROUND

The recently introduced concept of hands-free technique (HFT) currently has no recommendations or formal educational program for use in the Republic of Korea. This study evaluated the level of HFT use and investigated factors related to HFT use among Korean operating room nurses.

METHOD

Data were obtained through a self-administered questionnaire from 158 operating room nurses in 7 general hospitals in Busan, Republic of Korea, in April and May 2006. The questionnaire elicited information on demographics, exposure to education on HFT, attitude toward the need for HFT, concerns about exposure to bloodborne pathogens, and experience with HTF use. Multilevel multiple logistic regression analysis with generalized estimating equations was used, and adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated.

RESULTS

We found that 56% of the participants had used HFT, and 50% had received education on HFT. The use of HFT had a significant association with both education on HFT (OR = 12.02; 95% CI = 7.50 to 19.25) and attitude toward the need for HFT (OR = 4.22; 95% CI = 2.43 to 7.35).

CONCLUSION

Increasing education about HFT could be the most important approach to increasing the use of HFT among Korean operating room nurses. Thus, routine teaching about HFT should be provided to these nurses.

Compliance with standard precautions among operating room nurses in South Korea

BACKGROUND

Standard precautions are widely adopted to prevent the transmission of bloodborne pathogens among health care workers. There is no system to monitor compliance with standard precautions among health care workers, and few studies have been done to identify the level of compliance with standard precautions among health care workers in South Korea.

OBJECTIVES

This study aimed to determine the level of compliance with and education on standard precautions among operating room nurses in South Korea.

METHODS

A cross-sectional survey was done with 158 operating room scrub nurses from 7 general hospitals that each had 500 beds or more in Busan, South Korea, from April to May 2006. Data were collected using self-administered questionnaires on compliance with double gloving, using protective eyewear, and no recapping of needles.

RESULTS

Twelve percent (19/158) of the participants always used double gloving, 2% (3/158) always used protective eyewear, and 10% (15/158) always practiced not recapping used needles. All hospitals investigated in the study had regular educational programs lasting less than 1 hour on the control of hospital infection for new employees. Only 1 hospital has provided on the job training on the infection control for current operating room nurses.

CONCLUSION

Operating room nurses in this study rarely complied with standard precautions, especially with using protective eyewear. Training on a more regular basis should be established to increase the compliance with standard precautions among operating room nurses in South Korea.

Review of personal protection equipment used in practice

Standard precautions offer a consistent approach to infection control that does not rely on knowledge or suspicion of infection, and contributes to staff and patient safety by reducing the risk of exposure to potentially infectious material. One of the cornerstones of standard precautions is the appropriate use of personal protective equipment (PPE) whenever contact with blood or body fluids is anticipated. However, evidence suggests that compliance with standard precautions including correct use of PPE is inadequate. Demographic and epidemiological changes in the U.K., and the drive to provide more complex patient care outside acute hospitals may lead to increased infection risks for both patients and community healthcare workers. This review examines the importance and use of PPE by community nurses and discusses the implications for practice of poor compliance with standard precautions. Recommendations for practice will be made aimed at improving compliance with this important element of standard precautions.

Compliance with personal precautions against exposure to bloodborne pathogens among laboratory workers: a Canadian survey

A survey was conducted in laboratories across Canada to determine rates of compliance with recommended safety precautions against exposure to bloodborne pathogens and the rationale for current behaviors. Laboratory workers reported high rates of exposure to bodily fluids and poor rates of compliance with personal protective behaviors. This national study has identified several deficiencies and strategies for improvement.

A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions

AIMS

The review examines from international research: the extent to which practitioners comply with infection control precautions; the pertinent issues that are considered influential in compliance; what strategies have been evaluated to instigate positive behaviour changes amongst practitioners and the effect of these interventions.

BACKGROUND

Internationally, standard/universal precautions (UP) are regarded as fundamental in the prevention and control of infection, and effective in protecting practitioners and patients. However, adherence has been problematic and the practice of standard/UPs is globally suboptimal.

DESIGN AND METHODS

Literature review where relevant evidence was identified using several electronic databases, from 1994 to 2006, with number of key terms utilized. Data were extracted by using key headings, which facilitated analysis.

RESULTS

Thirty-seven studies were appraised. Twenty-four related to measuring practitioner compliance and 13 studies that evaluated the effect of a research intervention on compliance. In addition, other studies were included which examined the specific reasons for suboptimal compliance, or discussed infection control precautions generally.

CONCLUSIONS

Compliance to infection control precautions is internationally suboptimal. The evidence confirms that compliance to specific aspects of standard/UPs varies, and practitioners are selective in their application of recommended practice. Compliance does improve following a structured intervention; however, research fails to indicate for how long the intervention affects practitioner compliance, or whether compliance after a period of time returns to the norm. Several reasons for non-compliance are discussed, and recommendations for future research are suggested. Relevance to clinical practice. Suboptimal compliance has significant implications for staff safety, patient protection and the care environment. Infection control teams and researchers need to consider the reasons for non-compliance and provide a supportive environment that is conducive to the routine, long-term application of standard precautions.

Double gloving to reduce surgical cross-infection

BACKGROUND

The invasive nature of surgery, with its increased exposure to blood, means that during surgery there is a high risk of transfer of pathogens. Pathogens can be transferred through contact between surgical patients and the surgical team, resulting in post-operative or blood borne infections in patients or blood borne infections in the surgical team. Both patients and the surgical team need to be protected from this risk. This risk can be reduced by implementing protective barriers such as wearing surgical gloves. Wearing two pairs of surgical gloves, triple gloves, glove liners or cloth outer gloves, as opposed to one pair, is considered to provide an additional barrier and further reduce the risk of contamination.

OBJECTIVES

The primary objective of this review was to determine if additional glove protection reduces the number of surgical site or blood borne infections in patients or the surgical team. The secondary objective was to determine if additional glove protection reduces the number of perforations to the innermost pair of surgical gloves. The innermost gloves (next to skin) compared with the outermost gloves are considered to be the last barrier between the patient and the surgical team.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (January 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 4, 2005). We also contacted glove manufacturing companies and professional organisations.

SELECTION CRITERIA

Randomised controlled trials involving: single gloving, double gloving, triple gloving, glove liners, knitted outer gloves, steel weave outer gloves and perforation indicator systems.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the relevance and quality of each trial. Data was extracted by one author and cross checked for accuracy by the second author.

MAIN RESULTS

Two trials were found which addressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections. Thirty one randomised controlled trials measuring glove perforations were identified and included in the review. Fourteen trials of double gloving (wearing two pairs of surgical latex gloves) were pooled and showed that there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). Eight trials of indicator gloves (coloured latex gloves worn underneath latex gloves to more rapidly alert the team to perforations) showed that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17). Two trials of glove liners (a glove knitted with cloth or polymers worn between two pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), three trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and one trial of triple gloving (three pairs of latex surgical gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the innermost glove of a standard double glove in all comparisons.

AUTHORS' CONCLUSIONS

There is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, however the review has insufficient power for this outcome. The addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves. Triple gloving, knitted outer gloves and glove liners also significantly reduce perforations to the innermost glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery.

Knowledge, attitude, and practices related to standard precautions of surgeons and physicians in university-affiliated hospitals of Shiraz, Iran

OBJECTIVE

To measure levels of knowledge, attitudes, and practice toward standard precautions (SP) in medical practitioners of Shiraz University of Medical Sciences affiliated hospitals in Iran.

METHOD

In this cross-sectional study, knowledge, attitude, and practice related to SP among four medical staff groups - surgeons, surgical residents, physicians and medical residents - were assessed using a questionnaire.

RESULTS

Across the four medical staffing groups the median levels of knowledge ranged from 6 to 7 (maximum score 9), median attitude scores were high ranging from 35 to 36 (maximum score 45), while median practice scores were low, ranging from 2 to 3 (maximum score 9). A moderate relationship between knowledge and attitudes was found in surgical residents and medical residents (r=0.397, p=0.030 and r=0.554, p=0.006, respectively). No significant correlation was found between knowledge and practice between the groups. A significant but poor (r=0.399, p=0.029) relationship between attitude and practice was found in surgical residents.

CONCLUSION

Specific training programs may have to target newly graduated medical practitioners to establish acceptance of appropriate practices that will enable them to adopt and adhere to SP while their older counterparts may require more intense continuous assistance.

Self-reported infection control practices and perceptions of HIV/AIDS risk amongst emergency department nurses in Botswana

This descriptive exploratory study investigated the reported practices and perceptions of emergency nurses related to infection control in the context of the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic in Botswana. Quantitative and qualitative data were collected using a self-administered questionnaire. Forty questionnaires were distributed to nurses with emergency department experience in Botswana, with a response rate of 55% (n = 22). Quantitative data were analysed using descriptive statistics while qualitative data were subjected to thematic and content analysis. The majority of respondents reported compliance with universal precautions at the hospital emergency department. However, qualitative data highlighted resource constraints that may hinder compliance with universal precautions such as a lack of appropriate facilities, a shortage of equipment and materials, inadequate staffing and absence of sustainable in-service education programs. Further, the reported compliance with Universal Precautions had not removed the fear of exposure to HIV/AIDS and perceived risk of transmission to family. The authors recommend in-service education and practice initiatives to promote sustainable compliance with universal precautions and realistic risk perception among nurses. Further research is required to evaluate nurses' compliance with universal precautions in developing countries using observational methods or in-depth interviews. This would enable exploration of nurses' actions regarding compliance with universal precautions.

Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines

BACKGROUND

Traditional infection control policies have focused on engineering controls, specific protocols, and personal protective equipment (PPE). In light of the variable success in protecting health care workers (HCWs) from Severe Acute Respiratory Syndrome (SARS) in 2003, organizational and individual factors related to self-protective behavior in health care settings may also play an important role.

METHODS

A critical review of the literature was conducted, directed at understanding what organizational and individual factors are important in protecting HCWs from infectious diseases at work.

RESULTS

Organizational factors, such as a positive safety climate, have been associated with increased HCW adherence to universal precautions. There is some evidence that appropriate training of HCWs could be effective in changing HCW behavior if appropriate follow-up is applied. Very little research into these factors has been conducted with regard to preventing exposures to respiratory tract pathogens, but there was evidence from the SARS outbreaks that training programs and the availability of adequate PPE were associated with a decrease risk of infection.

CONCLUSION

Variations in organizational and individual factors can explain much of the variations in self-protective behavior in health care settings. It is likely that these factors were also important determinants during the SARS outbreaks, but they have not been extensively studied.