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Longer sleeves reduce contamination during PPE removal
Increasing the coverage of personal protective equipment, or PPE, to include the hands and wrists reduces the contamination of personnel during removal, according to findings from two nonblinded cross-over trials.
“Personal protective equipment that is designed to minimize the risk for contamination of personnel is needed to protect patients and personnel,” Curtis J. Donskey, MD, professor of medicine at Case Western Reserve University and a staff physician at Louis Stokes Cleveland VA Medical Center, and colleagues wrote. “Contamination of the hands and/or wrists of personnel occurred frequently during simulations with the standard gown used in our facility, even when no lapses in technique were observed and even after education on correct technique.”
The researchers cited a previously developed gown that provided a tighter fit at the wrist and increased wrist coverage, as well as allowed the user to remove it at the neck. Simulations of PPE removal with the modified gown revealed significantly reduced contamination of personnel, and Donskey and colleagues aimed to improve upon these results further by designing and testing a gown that provided “a substantial increase in skin coverage including the entire wrist and the palms and dorsum of the hands to just above the fingers.”
In the first trial, 60 health care personnel were randomly assigned to use either the standard gown or the modified gown during simulations of PPE donning and doffing. No education on proper removal techniques was given. After a minimum 5-minute washout period, participants performed the simulation again with the alternate gown. A black light was used to assess hand and wrist contamination.
The researchers observed 53% contamination of the hands and wrists with the standard gown compared with 27% with the modified gown, and 40% of the donning and doffing simulations were considered incorrect.
In trial 2, 42 personnel were similarly randomly assigned, and the procedures were identical to trial 1. However, trial 2 differed from trial 1 in that participants were provided education on appropriate donning and doffing practices, based on CDC protocols.
There was a 5% rate of contamination for the modified gown in the second trial compared with 23% for the standard gown.
“A gown designed to increase skin coverage at the hands and wrists significantly reduced contamination of personnel during simulations of contaminated PPE removal,” Donskey and colleagues wrote. “The frequency of contamination was further reduced by education. Studies are needed to determine whether such modifications of PPE design can reduce contamination in clinical settings.” – by Marley Ghizzone
Disclosures: Donskey reports receiving research grants from Boehringer Laboratories, Clorox, GOJO, PDI and Pfizer. All other authors report no relevant financial disclosures.
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The main thing that got me excited about this study is how it shows that design/redesign are key to improving patient safety and health care worker safety, in addition to education/training. In my field of expertise, which is human factors engineering, we believe that, in general, the most effective and sustainable way to improve safety is through design. Aim at designing out our errors/risks as much as possible and make it failure proof. Of course, that is much harder or costly to do in practice than in theory. But that does not mean education is the only intervention that can be possible to improve health care quality and safety. Yes education/re-education are critical but, in most cases, are not sufficient. This is because we are all humans no matter how educated and experienced we are in our occupations. We, humans, have strengths and weaknesses. So, for example, we are great at coming up with innovative ideas and solutions. But we are not that great at doing somewhat repetitive tasks, such as PPE doffing, and cannot be as careful as we should every time because we may be fatigued, tired and under stress and time pressure. Hence, it is possible to make an error no matter how educated we are. This paper shows exactly that, as exemplified by this excerpt: “In the initial trial without education, contamination of the hands and/or wrists was significantly lower for the alternative gown in comparison to the standard gown (16 of 60 [27%] versus 32 of 60 [53%]; P < .01). Contamination occurred most frequently on the fingers and palms. PPE donning and/or doffing technique was deemed incorrect in 48 of 120 simulations (40%), with similar percentages of incorrect technique for the standard and alternative gowns (26 of 60 [43%] and 22 of 60 [37%], respectively; P = .58).”
In summary, health care is delivered in complex, sociotechnical systems where humans (eg, clinicians, patients) and tools/technologies (eg, PPE) interact to get the care delivered. How well these interactions work or are designed is critical for human (eg, clinician) performance and overall system performance. To improve performance of humans and the overall work system, we need to look at this complex sociotechnical system as a whole, rather than looking at only humans and focusing ONLY on educating/re-educating them as a way to reduce safety risks. We need multicomponent interventions, based on both design/ redesign and education/training to have more effective and sustainable solutions. I would also recommend researchers interested in infection prevention and control to team up with human factors engineers who have expertise in designing/redesigning complex, safety critical work systems, such as health care.
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