Effects of Personal Protective Equipment (PPE) on Infection Rates

Literature Review

Introduction

The purpose of this literature review is to analyze ten research articles that study the proper and improper use of personal protective equipment (PPE) and the effect that they have on infection rates. Many precautions to decrease the number of infections acquired from contamination, but even with all these interventions in place the number of related infections continues to be on the rise.  PPE consists of gloves, gowns, aprons, surgical face masks, protective eye wear, and face shield (Neo, Edward, & Mill, 2012).  PPE is a component of standard precautions and the implementation of these precautions is considered the most important strategy for preventing infections.  Best practice guidelines advocate risk appraisal for potential exposure by all health care workers and should provide appropriate equipment to manage the risk (Neo, Edward, & Mill, 2012).

Clinical Question

Does Proper PPE use among nurses compared to improper PPE use lead to a reduction in infection rates?

Background

The first article, “Review of personal protective equipment used in practice”, was a that examined the community nurse and the importance and use of PPE.  It also examined why there is a poor compliance with the use of standard precautions. In total there were thirty-three research articles, one audit report and two national guidelines.  The researchers found that using a gown along with gloves decreased the acquisition rate of Vancomycin resistant enterococci and created a reduction in the transmission of Methicillin resistant Staphylococcus aureus (Hinkin, Gammon, & Cutter, 2008). The researcher also found that the factors that influenced the noncompliance with PPE included workload and staffing levels, availability, perceived risk to healthcare workers, deficient knowledge and decreased dexterity due to PPE use (Hinkin, Gammon, & Cutter, 2008).   PPE must be worn appropriately because inappropriate use of PPE can actually increase the risk of infection.  Results from this study identified the efficacy in the role of PPE in infection control but also identified the shortfalls in compliance.

The second article, “Current evidence regarding non-compliance with personal protective-equipment-an integrative review to illuminate implications for nursing practice”, is an integrative review on current literature regarding the use of PPE in the operating room and the gaps and considerations from a nurses’ perspective.  While PPE provides a barrier between the user and microorganism and blood born viruses, the compliance rate is not where it should be.  There was an American study that observed 88 emergency department personnel and of the 304 procedures observed, 22% of staff did not have adequate protective eye wear and 32.3% did not have a mask (Neo, Edward, & Mill, 2012). Another study surveyed 192 RN’s in a hospital in Sydney, Australia and although 73% said that they used standard precautions for PPE at all times, only 50% wore gloves to take blood and only 77% wore gloves to clean up urine and feces (Neo, Edward, & Mill, 2012. The findings of this review showed that the compliance with standard precautions and PPE is suboptimal amongst healthcare workers.

The third article, “Contamination of Health Care Professionals During Removal of Personal Protective Equipment”, is a point-prevalence study and a quasi-experimental intervention that occurred from October 28, 2014 through March 31, 2015.  There was one test to see the frequency and sites of contamination on the skin and clothing of personnel after PPE removal at baseline vs. after an intervention put into place.  The second endpoint focused on the correlation between contamination of the skin with fluorescent light and bacteriophage MS2 which is a nonpathogenic, non-enveloped virus (Tomas et al., 2015). Of 435 glove and gown simulation removals contamination occurred with the fluorescent lotion in 200 which was 46% but after the intervention the rate of contamination decreased from 60% to 18.9% (Tomas et al., 2015). During the simulations the contamination rate with the fluorescent lotion was 58% vs the bacteriophage MS2 which was 52% (Tomas et al., 2015). Results from this study proves that contamination of health care workers occurs frequently (Tomas et al., 2015).

“Not just gloves”, is a literature review of the use of protective eyewear in the perioperative environment for nurses and other health care workers. The review included 85 related articles related specifically to the topic of interest. Standard precautions are the primary strategy for minimizing the transmission of health care associated infections for patients and occupationally acquired infections and diseases for staff (Mills, Moore, & Edward, 2011). This literature review found that following endoscopic procedures 31.8% of scrub nurses had invisible blood droplets present of their eye shields and mask (Mills, Moore, & Edward, 2011).  Information obtained from this review proves that PPE compliance among nurse and other health care workers is generally low.

The fifth article, “Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review.”, that focused on decreasing the spread of MRSA in NICUs.  19 published works were used for this review that studied MRSA and how it might be spread in the NICU. In 7 out of 45 occurrences (16%) hand-hygiene compliance and PPE   were noted as a facilitator in the prevention of spreading MRSA (Mileski et al., 2018).  The results from this study concluded that adherence to strict hand hygiene, proper use of PPE, and patient and family education are proven most effective in reducing the spread of MRSA in the NICU. (Mileski et al., 2018).

“Importance of hand germ contamination in health-care workers as possible carriers of nosocomial infections,” is a randomized control where 100 nurses were divided evenly into 2 groups.  Group A was without handwashing prior to patient physical examination who showed a bacteria rate of 73.9% and group B who had handwashing prior to patient physical exam who showed 20.7% infection rate (Nogueras, Marinsalta, Roussell, & Notario, 2001).   Surprisingly 16 group B participants were contaminated after seeing a patient which is almost one-third of the group.  The study revealed that handwashing, as well as glove use is highly recommended.

The seventh article, “Knowledge, Attitudes and Practices related to standard precautions among nurses, “is a comparative study performed between February-April 2018.  The method used was a self-administered questionnaire given to 237 Chinese nurses and 120 Ethiopian nurses.  24.9% of Chinese nurses received infection prevention training compared to 38.3% of Ethiopian nurse (Zhu, Kahsay, & Gui, 2019). Most nurses agreed that wearing gloves, masks and goggles were important control measures against health care associated infections and that nurses of both countries showed a favorable attitude towards standard precautions.   The result of this study show that knowledge and attitude alone do not guarantee practice and that more education is needed for strategies to improve infection control (Zhu, Kahsay, & Gui, 2019).

“Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital, “ the researcher observed and examined hand-hygiene compliance of healthcare workers and visitors in the ICU over an 8 hour period.  Hand hygiene is considered to be the most crucial and least expensive measure to prevent cross-contamination of microorganisms.  After the 8-hour observation the hand-hygiene compliance rate with 378 episodes of patient contact there was less than 50% compliance (Patarakul et al., 2005).  The best compliance was observed was observed in the nursing students with 100% compliance, nurses 71.9% compliance and nursing assistants 63.9% compliance (Patarakul et al., 2005).  .  Bases on a total of 322 questionnaires returned most reasons noted for non-compliance were 51.2% not a priority, 35.7%, and 15.5 % hand irritation (Patarakul et al., 2005). The results of this study proved that knowledge, attitudes and beliefs regarding hand hygiene need to be improved.

The ninth article, “Infection control bundles in intensive care: an international cross-sectional survey in low- and middle-income countries,” the study aimed to determine the status of Infection Prevention and Control bundle practice and the most frequent interventional variables in low- and middle-income countries.  A questionnaire was emailed to Infectious Diseases International Research Initiative Group Members and dedicated IPC doctors working in LMICs to examine self-reported practices/policies regarding IPC bundles (Alp et al., 2019). This survey reports practices from one low-income country, 16 middle-income countries and eight high-income countries. Eighteen (95%) MICs had an IPC committee in their hospital and All HICs had at least one invasive device-related surveillance program (Alp et al., 2019).  The results of this study revealed that low- and middle-income countries need to develop their own bundles with low-cost and high-level-of-evidence variables adapted to the limited resources, with further validation in reducing infection rates (Alp et al., 2019)..

The last article, “Are you covered? Safe practices for the use of personal protective           equipment,” explores the use of PPE in droplet and airborne precautions in the emergency room.   Emergency nurse frequently encounter patients with a known or suspected illness.  Droplet precautions can travel between 3-10 feet and transmission of infection occurs through coughing, sneezing, talking and endotracheal intubation or suctioning.  To prevent the spread of infection, emergency nurses should follow appropriate infection control precautions and use PPE as recommended (Valdez, 2015).  The emergency nurse can reduce the risk of injury by adhering to infection control standards.

Conclusion

Each of the ten articles were primary sources that examines PPE use by nurse and whether it effectively decreases infection rates.  “Review of personal protective equipment used in practice” clearly found that using a gown along with gloves decreased the acquisition rate of Vancomycin resistant enterococci and created a reduction in the transmission of Methicillin resistant Staphylococcus aureus.  “Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review” also proved that concluded that adherence to proper use of PPE would help to reduce the spread of MRSA in the NICU.  However, the other studies concluded that hand hygiene is considered to be the most crucial and least expensive measure to prevent cross-contamination of microorganisms.

References

• Alp. E., Cookson, B., Erdem, H., Rello, J., Akhvlediani. T., Akkoyunlu, Y, …Wongsurakıat, P., (2019). Infection control bundles in intensive care: An international cross-sectional survey in low- and middle-income countries. Journal of Hospital Infection, 101(3). Pages 48-256. Retrieved from https://doi.org/10.1016/j.jhin.2018.07.022
• Hinkin J, Gammon J, & Cutter J. (2008). Review of personal protection equipment used in practice. British Journal of Community Nursing, 13(1), 14–19. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105873857&site=ehost-live&scope=site
• Mileski, M., Lee, K., Maung, S., Nelson, D., Palomares, O., & Paredes, N. (2018). Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review. ABNF Journal, 29(2), 46–53. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=129886044&site=ehost-live&scope=site
• Mills, C., Moore, C., & Edward, K-L. (2011).   Not   just gloves. Acorn, 24(4), 14-18. Retrieved from https://search.proquest.com/docview/2068957941?accountid=160851
• Neo, F., Edward, K.-L., & Mills, C. (2012). Current evidence regarding non-compliance with personal protective equipment – an integrative review to illuminate implications for nursing practice. ACORN: The Journal of Perioperative Nursing in Australia, 25(4), 22 30. Retrieved fom https://search.ebscohost.com/login.aspxdirect=true&db=ccm&AN=10             4412980&site=ehost-live&scope=site
• Nogueras, M., Marinsalta, N., Roussell, M., & Notario, R. (2001). Importance of hand germ contamination in health-care workers as possible carriers of nosocomial infections. Revista do Instituto De Medicina Tropical De São Paulo, 43(3), 149-52. Retrieved from https://search.proquest.com/docview/196529797?accountid=160851
• Patarakul, K., Khum, Auchana,  Kanha, Suthad,  Padungpean, Darunee & Jaichaiyapum, O. (2005). Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 88(4). S287-93.
• Tomas, M. E., Kundrapu, S., Thota, P., Sunkesula, V. C. K., Cadnum, J. L., Chittoor Mana, T. S., … Mana, T. S. C. (2015). Contamination of health care personnel during removal of personal protective equipment. JAMA Internal Medicine, 175(12), 1904–1910. Retrieved from https://doi.org/10.1001/jamainternmed.2015.4535
• Valdez, A. M. (2015). Are you covered? Safe practices for the use of personal protective equipment: JEN JEN. Journal of Emergency Nursing, 41(2), 154-157. Retrieved from doi:http://dx.doi.org/10.1016/j.jen.2014.11.011
• Zhu, S., Kahsay, K.M., & Gui, L. (2019). Knowledge, Attitudes and Practices related to standard precautions among nurses: A comparative study.  Journal of Clinical Nursing. 28(19-20).  Pages 3538-3546. Retrieved from https://doi.org/10.1111/jocn.14945

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