Assessment of Healthcare Worker Protocol Deviations and Self-Contamination During Personal Protective Equipment Donning and Doffing

Abstract

Objective. To evaluate healthcare workers’ (HCWs) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage. Design. Prospective pilot study. Setting. Tertiary care hospital. Participants. 36 HCWs: 18 donned/doffed contact precautions (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE. Interventions. HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped and protocol deviations were recorded. Results. 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning. 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (p=0.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, vs. 1 among CP PPE HCWs. 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 (44%) of EVD PPE HCWs and 5 (28%) CP PPE HCWs, most commonly on hands. MS2 was recovered from 2 (11%) EVD PPE HCWs and 3 (17%) CP PPE HCWs. Conclusions. Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCWs’ doffing assistant and/or trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study.

‘VIOLET’: a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment

“…The value of UV visible markers has been highlighted from previous studies of both simulated and real-life doffing [9,11,36,37]. However, most used only one exposure event, or used multiple events but only one fluorochrome-limiting analysis of contamination source, or contaminants were applied directly on to PPE rather than exposure through simulated exercise [6,22,33,38,39]. When multiple transmission routes have been simulated using mannequins or even 'human volunteer' patients, they used single-fluorochrome methods and, because the focus was on EVD, omitted respiratory transmission [24].…”

“…The ability of UV markers to mimic viral load, or dynamics such as effect of disinfection, has previously been challenged, with a preference for non-pathogenic viral surrogates [6,39]. However, their use is technically more complex and lacks instant visual results.…”

“…Reassuringly, work using both methods showed no difference in rates of contamination events on healthcare workers, suggesting that both are suitable for PPE assessment. Furthermore, in the absence of minimum infecting dose of HCID pathogens through cross-contamination, presence or absence of contamination is the valid basis of safety assessment [6,20,38]. Using qualitative fluorescent markers therefore provides an evidence base for real-time training.…”

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

“…37 Although there is room to improve the realism of this type of product testing, it is equally important to evaluate how PPE ensembles perform in the field, where human behavior and individual pieces of PPE influence protection. The 2014-2015 EVD outbreak motivated substantial research about the potential for self-contamination associated with doffing complex PPE ensembles, 26 and more work about ensemble performance during care activities. Hall et al 38 evaluated 5 PPE ensembles intended for use with suspected EVD patients, using a complex health care activity simulation with fluorescent simulated body fluids, and found contamination under the PPE and other flaws with all ensembles tested.…”

“…Unlike bacteriophage tracers, fluorescent materials can be readily visualized in training and simulation settings. 26 Lower-tech options include colored liquid (Kool-Aid; The Kraft-Heinz Co, Glenview, IL) or chocolate syrup. User evaluation may include self-report or survey, observation, and biological measures of physiological parameters.…”