The Increasing Visibility of the Threat of Health Care Worker Self-contamination.

Abstract

The vulnerability of health care workers to acquisition and propagation of infectious agents has received global attentionbecause of recent outbreaks of highly communicable and fataldiseases, includingEbola virusdiseaseandsevereacute respiratory syndrome. The emergenceof thesehigh-profilepathogenshaspromptedcalls for better personal protective equipment (PPE), specifically, masks, gowns, and gloves, to protect health care workers and patients. In this issue of JAMA Internal Medicine, Tomas and colleagues1 provide a timely addition to the existing literature on the limitations of our current PPE. In a series of related studies thatusepreviouslydescribedmethods2 tosimulatecontaminatedPPE, the investigatorsconvincinglydocumentahigh frequencyofhealthcareworkerself-contaminationwhenusing PPE. Thebulk of their data come from435 simulations of donning and/or doffing of gowns and gloves contaminatedwith a fluorescent lotion: 234were soiled glove simulations, and 201 were soiled gown simulations. Almost half (46.0%) of these simulations resulted in health care worker self-contamination of skin or clothing. Specific sites of contamination varied butmost commonly involved thehands during glove removal and the neck during gown removal. Furthermore, 39.5% of participantswereobserved tobeusing improper techniqueby 2 independent observers who compared participants’ techniques with the Centers for Disease Control and Prevention (CDC) procedure3 for donning and/or doffing PPE. The probabilityof self-contaminationwasmuchgreaterwhenusing improper technique (70.3%vs 30.0%). In a separate experiment, the investigators document that fluorescent lotion contamination is a reliablepredictor ofmicrobe contaminationbymixing bacteriophage MS2 to the solution and performing additional simulations; contamination with the lotion vs MS2 was not statistically different.1 Theseresultshaveclear implications for thesafetyofhealth careworkers and the spread of hospital-acquired infections. It has been documented that higher levels ofmicrobial contamination of hospital surfaces lead to higher rates of health care worker contamination with multidrug-resistant organisms.4 Because environmental bioburden is a concern for the crosstransmission of hospital-acquired pathogens, the microbial burden of health care worker hands and apparel represents another element in this equation. Collectively, this increased contamination of the animate and inanimate environment contributes to the risk of hospital-acquired infections. Tomas et al report a potential for improvement in the intervention portion of their study. A subset of participants were able to decrease self-contamination after a training session that includeda 10-minute instructional videowith structured practice using simulated contamination with fluorescent lotion. The authors found that this real-time assessment with “immediate visual feedback” was able to reduce health careworker self-contaminationby68%(from60.0%to18.9%). This reductionwassustainedat 1-and3-monthfollow-upswith no additional training.1 A standardized training procedure for health care workers on the recommended techniques for donning and/or doffing gowns and gloves is long overdue. The training should include educational context, proficiency monitoring, and feedback. The “immediate visual feedback”usedbyTomas et al1 appears to be particularly effective in altering staff behaviors.However, a standard,accepted,andvalidatedtrainingprogram has unfortunately not been developed, and debate remains as to what constitutes best practice for donning and doffing. The CDC’s recommendations are widely adopted. However, even theCDC’sprocedureshavebeen foundbysome to be insufficient.2 In fact, notwithstanding the significant benefit of the intervention reported in this issue, therewas still 30% residual contamination of intervention participants.1 Double gloving and cleaning of gloves before doffing have beensuggestedasadditions to thecurrentCDCpractices,1,2 but evidence of the effectiveness of these interventions for routine patient care interactions is lacking. Any standardized procedure and training program will need to take into account the individual health care worker’s comfort, scope of duty, previous training, and typical workload. Minute attention to details of donning and/or doffing is of vital importancetowardthegoalofprotectingpatientsandstaff, yet these efforts are undercut by poor adherence to the use of PPE.Healthcareworker fatiguewithcontactprecautions iswell documented,withdeficiencies increasinginproportiontoworkload and percentage of patients adhering to precautions in a givenunit.5,6 Inaddition,handhygienehasbeenreportedtodecreasewith increased glove use.7 Therefore, a prioritization of patients for contact precautions is needed to optimize adherencewithgloveandgownprecautions in the instanceswhen it will be most important. Patients should be targeted for isolation based on the presence of highly transmissible, nonendemicorganismsassociatedwithsignificantmorbidityandmortality.Aselectiveapproachto isolationmaximizesstaffattention to the transmission risk posedbypriority organisms and limits theadverseeffectsof contactprecautionsonpatientsandstaff. In the absence of such anorganism, efforts are best focusedon the fundamental horizontal infection control strategies that should be used for every patient care interaction. Last, the residual contamination of health care workers, even with optimal donning and/or doffing technique, highlights the ongoing importance of hand hygiene on completion of doffing activities. Of interest, Tomas et al applied their Related article page 1904 Health Care Personnel Contamination During Protective Equipment Removal Original Investigation Research