4
Using PPE: Individual and Institutional Issues

Personal protective equipment (PPE) is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members, and others who interact in the healthcare setting.

Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE.

This chapter focuses on ensuring appropriate use of PPE in the healthcare workplace and maintaining worker safety as one of the highest priorities in the healthcare organization. Healthcare workers are a heterogeneous group with a range of skills from administrative to clinical expertise (see Chapter 1). As has been demonstrated with seasonal influenza, an influenza pandemic will bring a variety of potential expo-



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4 Using PPE: Individual and Institutional Issues Personal protective equipment (PPE) is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members, and others who interact in the healthcare setting. Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficul- ties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiologi- cal burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interper- sonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provi- sion of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE. This chapter focuses on ensuring appropriate use of PPE in the healthcare workplace and maintaining worker safety as one of the highest priorities in the healthcare organization. Healthcare workers are a hetero- geneous group with a range of skills from administrative to clinical ex- pertise (see Chapter 1). As has been demonstrated with seasonal influenza, an influenza pandemic will bring a variety of potential expo- 113

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114 PREPARING FOR AN INFLUENZA PANDEMIC sure scenarios with the potential for long work hours, high patient loads, and profound physical and emotional stress. The current limited surge capacity of emergency departments and healthcare facilities will be over- stretched. Infection control knowledge and capacity will thus need to be fostered throughout the organization so that as many personnel as possi- ble will have immediate knowledge that they can impart to emergency responders, temporary workers, and volunteers who may be actively in- volved in emergency care. Although this chapter can not explore all of the specific issues, it is hoped that the strategies presented can be used in tailoring future efforts to improve worker safety. The chapter begins with an overview of studies regarding PPE use by healthcare workers and the context of PPE use in the healthcare setting. Four strategies for improving worker safety are then discussed in detail with a focus on collaborative efforts and commitments by employers and healthcare workers to: provide leadership and commitment to worker safety, emphasize education and training, improve feedback and en- forcement, and clarify relevant work practices. USING PPE: IDENTIFYING THE CHALLENGES Despite expert recommendations and high-risk conditions, healthcare workers exhibit low rates of PPE use (Hammond et al., 1990; Kelen et al., 1990; Afif et al., 2002). Although the use of PPE is often examined by observational studies or survey questionnaires of individual workers, assessments of the explanations for noncompliance and the solutions to these issues need to focus beyond the individual and address the institu- tional issues that prevent, allow, or even favor noncompliance. Studies on this issue have focused on adherence to standard precau- tions1 and few studies have examined interventions to improve adherence rates. Although the knowledge base on compliance with standard precau- tions is not extensive, pandemic influenza will likely present even further complications. Madan and colleagues (2001) observed emergency department per- sonnel in a New Orleans hospital and recorded an overall compliance rate of 38 percent with the application of barrier precautions. Of the 104 nurses and physicians studied, 41 percent used protective gowns, while 1 The report uses the broader term standard precautions (see Chapter 1), except in de- scribing research in which the authors specifically use the term universal precautions.

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115 INDIVIDUAL AND INSTITUTIONAL ISSUES only 10 percent wore masks2 and eye protection approved by the Occu- pational Safety and Health Administration (OSHA). The lack of adher- ence to appropriate use of respirators and protective eyewear is especially prevalent throughout the literature; on the other hand, health- care workers frequently wear gloves, with adherence often well above 90 percent (Helfgott et al., 1998; Evanoff et al., 1999). However, rates of adherence to hand hygiene best practices are often low; for example, in an observational study, Pittet and colleagues (2004) found 57 percent overall adherence to hand hygiene protocols among 163 physicians. Given the poor use of PPE, particularly respiratory PPE, and the high risk of exposure of healthcare workers to bloodborne and airborne patho- gens and other hazardous materials, it is crucial to use the data described below and in Table 4-1 to develop and implement strategies to improve the rates of adherence to PPE protocols and to mitigate risk. Table 4-1 provides examples of studies that examined the use of PPE and summarizes the barriers identified by healthcare workers when asked why they did not use the proper equipment in situations where use was appropriate. Lack of time is the most common reason healthcare workers give for not adhering to safety regulations. Kelen and colleagues (1990) note the time constraint barrier is consistent with their finding that much lower levels of compliance were observed when immediate medical at- tention was needed. Job hindrance, or the perception that using PPE in- terferes with healthcare workers’ ability to perform their jobs, has also been cited as a major reason for noncompliance (Kelen et al., 1990; Willy et al., 1990; DeJoy et al., 1995). Nickell and colleagues (2004) conducted a study in a Toronto hospital during the outbreak of severe acute respiratory syndrome (SARS) in 2003 and found that wearing a mask was cited as the most bothersome precaution for doctors and nurses. Physical discomfort (92.9 percent), difficulty communicating (47.0 percent), difficulty recognizing people (23.9 percent), and a sense of isolation (13.0 percent) were the reasons given by the respondents who had concerns about wearing masks. Focus groups of health profes- sionals who wore PPE for extended periods of time during the SARS outbreaks noted, “The masks weren’t very comfortable. . . . Obviously, 2 In discussing the literature on respiratory protection, this report uses the terminology (masks or respirators) used by the investigators or authors of the cited journal article or report. In some cases, it is not possible to determine whether the authors’ use of the term masks refers to medical masks, respirators, or both.

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116 PREPARING FOR AN INFLUENZA PANDEMIC TABLE 4-1 Studies Examining PPE Use and Barriers to Use Reasons Reported in the Study Population Overview of Results Study for Noncompliance Hammond et Surgical residents 16% compliance 20% Too busy or no al., 1990 engaged in observed with strict time trauma room universal precau- 20% Forgot tionsa (UP) in 81 resuscitations 18% Patient did not trauma room resusci- appear to be high risk tations. Observations 13% Stated that UP of breaks in tech- were unnecessary nique included 37% not wearing a mask; 18% not using an apron or gown Kelen et al., Emergency de- Universal precautions 46.7% Insufficient time 1990 partment person- were fully adhered to 33.3% Interferes with nel observed in 44% of the 1,274 skill during critical interventions ob- 22.7% Precautions un- care procedures served. For interven- comfortable tions requiring all 9.3% Can tell which precautions, observed patients are a risk use: masks (22.4%); 2.7% Precautions don’t gowns (49.6%); eye work protection (45.0%); 2.7% Can’t easily find gloves (75.7%) supplies Willy et al., Certified mid- 55% of the 1,784 79.4% Interferes with 1990 wives, self-reports midwives returning nurse-patient relation- the survey reported ship using universal pre- 66.6% Decreases dexter- cautions. Of those ity stating they practiced 38.4% Precautions per- universal precautions, ceived as unnecessary 44.3% reported wear- 19.9% Barriers difficult ing a surgical mask to obtain for deliveries, 53.4% 19.6% Cost of barriers reported wearing eye prohibitive protection for deliv- 10.3% Unaware of uni- eries, and 74.7% versal precautions reported wearing gloves when handling soiled linens

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117 INDIVIDUAL AND INSTITUTIONAL ISSUES Reasons Reported in the Study Population Overview of Results Study for Noncompliance Hoffman- Surgical and No data on use of Reasons and opinions Terrry et al., medical resident protective equipment regarding noncompli- 1992 physicians who ance: had exposure to Time constraints (61% HIV-infected medical; 31% surgical) inpatients Lack of ready access to equipment (33% medi- cal; 43% surgical) Concern over upsetting the patient (8% medi- cal; 6% surgical) Precautions are ineffec- tive (0% medical; 17% surgical) Gershon et Healthcare work- Of 1,716 respondents Factors associated with al., 1995 ers from three to a self-administered compliance: geographically questionnaire, 23.7% Organizational climate distinct hospitals were found to be of safety, training, compliant in all 11 availability of PPE, and items of precautions. perception of risk Reported use: gloves (96.7%), protective eye shield (63.1%), gowns (62.0%), face mask (55.5%) DiGiacomo Staff involved Videotape review of Compliance improved et al., 1997 in trauma 66 resuscitations with pre-notification of resuscitation found full compli- patient arrival ance with barrier precautions by 89.1% of healthcare workers Helfgott et Obstetrics and Total compliance 64% Time constraints al., 1998 gynecology stu- with universal pre- 52% Too much trouble dents and resi- cautions by 89% of 34% Judged patient as dents in Houston the 61 participants not infected observed during during 459 proce- 23% Do not consider deliveries and dures recommending themselves at risk surgeries after PPE use. Observed 15% Ignorance completing a use: gloves (100%); 0% Concerns about cost questionnaire on gowns during deliv- knowledge of eries (87%); gowns universal during surgeries precautions (98%); eye protection (67%); booties during Continued

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118 PREPARING FOR AN INFLUENZA PANDEMIC Reasons Reported in the Study Population Overview of Results Study for Noncompliance deliveries (79%); Helfgott et al., booties during sur- 1998 (cont’d) geries (90%) Evanoff et Emergency de- One or more breaks Noncompliance data not al., 1999 partment person- with universal pre- collected nel videotaped cautions in 33.6% of during trauma 304 invasive proce- care dures: failure to wear a mask (32.2% of procedures), inade- quate eyewear (22.2%), no gown (5.6%), no gloves (3.0%) Madan et al., Hospital health- Overall compliance Noncompliance data not 2001 care workers with barrier precau- collected in New Orleans tions during 12 re- observed during suscitations (with 104 trauma healthcare workers) resuscitations was 38%. Compli- ance rates observed: gloves (98%); any eye protection (51%); gowns (41%); masks (10%); OSHA- approved eye protec- tion (10%) Tokars et al., Healthcare work- N95 or other high- Noncompliance data not 2001 ers and visitors efficiency air respira- collected observed entering tors were used by 65% hospital rooms of 385 nurses, 53% of of tuberculosis 225 housekeepers, patients 49% of 226 nurse aides, 42% of physi- cians, 20% of 100 visitors (patients’ fami- lies and friends), and 12% of 143 dietary workers

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119 INDIVIDUAL AND INSTITUTIONAL ISSUES Reasons Reported in the Study Population Overview of Results Study for Noncompliance Afif et al., Healthcare work- Of the 488 healthcare Noncompliance data not 2002 ers and visitors workers and visitors collected observed at a observed, the average university health rate of total compli- center in ance with the methi- Montreal cillin-resistant Staphylococcus aureus precautions was 28%. Compli- ance with glove and gown precautions, 65%; hand hygiene, 35% Nickell et al., Hospital employ- Survey focused on Reasons given by those 2004 ees working dur- psychosocial effects who reported that the ing the SARS of SARS on hospital mask was bothersome: outbreak in staff was returned by 92.9 % Physical discom- Toronto 2,001 hospital em- fort ployees. Masks were 47.0% Difficulty reported by 70.2% of communicating the workers as the 23.9% Difficulty recog- most bothersome nizing people SARS-related pre- 13.0% Sense of isolation cautionary measure Sadoh et al., Healthcare work- 433 healthcare work- Noncompliance data not 2006 ers selected from ers stated how often collected multiple facilities they used gloves, in Nigeria and aprons, and gowns responding to an during surgery and interviewer- deliveries: administered never (16.5%); occa- questionnaire sionally (19.7%); always (63.8%). For protective eyewear: never (56.5%); occasionally (27.2%); always (16.3%) NOTE: The terms (masks, surgical masks, respirators) used in this table are those used by the inves- tigators or authors of the cited journal article or report. In some cases, it is not possible to determine whether the authors use the term masks to refer to medical masks, respirators, or both. a The report uses the broader term standard precautions (see Chapter 1), except in describing re- search in which the authors specifically use the term universal precautions.

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120 PREPARING FOR AN INFLUENZA PANDEMIC everybody found the respirators, in particular, cramped or irritating too. You sweat with them, so that’s going to affect the compliance. . . . There were some [that were] very strange in their function and they looked funny and they felt funny and they smelt funny” (Yassi et al., 2004, p. 64). For PPE to be used in the consistent manner necessary in the event of pandemic influenza, healthcare workers must feel comfortable wear- ing the equipment while retaining the ability to adequately communicate with and effectively relate to their patients. PPE compliance has also been found to be inversely proportional to the amount of experience of the healthcare workers, and as discussed later in this chapter, physicians are often less compliant with PPE than nurses, students, and support staff. Helfgott and colleagues (1998) found that rates of PPE use decreased each year from first- to fourth-year resi- dents, while Gershon and colleagues (1995) reported that hospital work- ers with fewer than 16 years of education complied more than those who had additional years of educational experience. Researchers are unsure of the reason behind this trend but have suggested a feeling of increased invulnerability as a possible explanation (Moore et al., 2005a). It is im- portant for physicians and senior staff to comply with safety regulations, not only to protect themselves, but also to serve as a model for other staff members. FRAMEWORK FOR A CULTURE OF SAFETY Improving worker safety necessitates an organization-wide dedica- tion to the creation, implementation, evaluation, and maintenance of ef- fective and current safety practices—a culture of safety. An organization that has a functional and healthy safety culture is one in which all em- ployees show a concern for safety issues within the infrastructure and act to maintain or update safety standards. Further, the organizational com- mitment to safety is evidenced by the organization’s policies, procedures, management support, and resources dedicated to safety, which include access to effective, appropriate, and state-of-the-art safety equipment. An

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121 INDIVIDUAL AND INSTITUTIONAL ISSUES institutional commitment to a culture of safety3 establishes systems, poli- cies, and practices to ensure that safety is the highest priority of the or- ganization. If need be, productivity or efficiency are willingly sacrificed in order to maintain safety (ECRI, 2005). This prioritization of safety has been carefully examined in industries, such as chemical and power plants, with a focus on achieving high-reliability organizations based on safety factors at the individual level (e.g., attitudes and training), micro- organizational level (e.g., management support, safety representatives, accountability), and macroorganizational level (e.g., communication, organization of technology and work processes, workforce specializa- tion) (Hofmann et al., 1995). A positive work safety culture has been described as a just culture, a learning culture, a reporting culture, and a flexible culture (Reason, 1997). In the healthcare setting, a strong culture of safety has been shown to result in a higher rate of adherence to standard infection control precau- tions among employees, a decreased incidence of exposure mishaps in hospitals, and fewer workplace injuries among employees (Gershon et al., 1995, 2000). As noted in Chapter 1, standard and transmission-based precautions have been detailed by the Centers for Disease Control and Prevention. The infectious characteristics of the particular strain of influ- enza resulting in a pandemic will not be fully known until after the pan- demic emerges. Consequently, infection control plans should be adaptable to the current knowledge of transmission and altered as addi- tional information becomes available. Legal responsibility for employee PPE usage and adherence falls upon the employer. For example, OSHA standards and regulations re- garding respiratory protection state that the employer is responsible for designing and implementing a respiratory protection program, monitor- ing and evaluating program effectiveness, and maintaining proper records regarding the program. Employers are also responsible for select- ing the appropriate type of National Institute for Occupational Safety and Health (NIOSH)-certified respirators, making them available to employees at no charge, fit testing, cleaning, and storing them. Further, 3 Most of the empirical data discussed in the chapter involves measures that meet the definition of safety climate rather than safety culture. The term safety climate is also of- ten used in studies on this issue to refer to workers’ perceptions of the importance of safety in their organization (Zohar, 1980). Safety climate has generally been measured by asking workers how they rate their organization’s commitment to safety and has been positively correlated with fewer occupational injuries and good safety performance in hospitals and in non-healthcare settings (Cohen and Cleveland, 1983; Isla Diaz and Diaz Cabrera, 1997; Gershon et al., 2000).

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122 PREPARING FOR AN INFLUENZA PANDEMIC OSHA regulations specify that it is the employer’s responsibility “to establish and implement procedures for the proper use of respirators. These requirements include prohibiting conditions that may result in facepiece seal leakage, preventing employees from removing respirators in hazardous environments [and] taking actions to ensure continued effective respirator operation throughout the work shift” (29 CFR 1910.134[g]). In order to establish an effective culture of safety, responsibility for both personal safety and the safety of others should be a joint employer- employee responsibility. Although much of the responsibility for creat- ing and monitoring a safety program is managerial, staff members should be responsible for applying the safety practices to their work environ- ment. It will be important for management, professional associations, labor organizations, and others to emphasize the shared responsibilities and stress the goal of improving worker safety. Although a more in-depth discussion of organizational safety culture is beyond the scope of this chapter, the references provided throughout the chapter are resources for further discussion of the concepts and approaches. Ensuring the Continuum of Safety Controls The use of PPE is only one component of instilling and promoting a safety culture in a healthcare institution. For example, during the SARS outbreaks in 2003, changes implemented to ensure patient and worker safety included quarantine, temperature checks on hospital employees, restricting visitors, and hospital closures (Yassi et al., 2004). As described in Chapter 1, the continuum of infection prevention and safety controls includes environmental and engineering controls (e.g., number of air exchanges, availability of isolation rooms with negative pressure ventilation) and administrative or work practice controls (e.g., protocols to ensure early disease recognition, vaccination policies, dis- ease surveillance, infection control guidelines for patients and visitors, decontamination of healthcare equipment and patient care rooms, risk assessment education programs for healthcare workers) (Thorne et al., 2004). The hierarchy of controls is meant to address hazards through di- rect control at the source of the infection and along the path between the infectious source and the employee. PPE is implemented at the individ- ual level and is one component of effective infection prevention and con- trol measures that particularly emphasize hand hygiene as a critical

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123 INDIVIDUAL AND INSTITUTIONAL ISSUES action for reducing disease transmission. When all of these measures are integrated and implemented, a continuum of safety exists; deploying evidence-based improvements at any level can enhance the safety cul- ture. DeJoy and colleagues (1996) examined approaches to minimizing the risk from bloodborne pathogens that emphasized a work-systems ap- proach integrating individual, job or task, and organizational or environ- mental factors. Factors Underlying Safety Culture in Healthcare Facilities Much of the analysis of the safety cultures in healthcare organiza- tions has focused on controlling the risk of bloodborne pathogens. A fac- tor analysis of the results of a survey of 789 healthcare workers identified six organizational factors underlying the hospital safety climate: senior management support for safety programs; absence of workplace barriers to safe work practices; cleanliness and orderliness of the worksite; mini- mal conflict and good communications among staff; frequent safety- related feedback and training by supervisors; and availability of PPE and engineering controls (Gershon et al., 2000). Three of these factors— senior management support, absence of workplace barriers, and cleanli- ness or orderliness—were significantly associated with adherence to safe work practices. In examining the individual and institutional factors re- ported by nurses to be associated with their compliance with PPE rele- vant to bloodborne pathogens, DeJoy and colleagues (2000) found that ready availability of PPE predicted increased compliance with its use as did receiving informal feedback on safety performance. A tool currently used to assess the culture of safety in hospitals with regard to exposure to bloodborne pathogens could be expanded to other routes of exposure (Anderson et al., 2000; Gershon et al., 2000). Few studies have specifically examined the individual, environ- mental, and institutional factors related to PPE use in the healthcare workplace. The most extensive recent effort was conducted by the Occu- pational Health and Safety Agency for Healthcare in British Columbia, which reviewed the literature on the use of PPE by healthcare workers and conducted a set of 15 focus groups with healthcare workers in Ot- tawa, Toronto, and Vancouver (Yassi et al., 2004, 2005; Moore et al., 2005b). The literature review identified organizational, environmental, and individual factors (Figure 4-1) that impact PPE-related behaviors and adherence among healthcare workers. The 105 focus group participants

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136 PREPARING FOR AN INFLUENZA PANDEMIC ate PPE use and proper procedures in donning and doffing PPE gear. This approach is used in other work environments. For example, standard practice in surgical operating rooms is for one nurse to be designated with the explicit responsibility of ensuring a sterile work environment and proper use of PPE. Similarly, before entering the scene of a fire, fire- fighters must receive clearance from a supervisor that they have donned all the proper equipment. A less invasive approach would be a require- ment for staff to complete an adherence checklist, on which they would note the protocols and PPE used. Responsibility for completing the ad- herence checklist could be on an individual basis or used in conjunction with the buddy system. Since the step-by-step process to avoid contami- nation in doffing the equipment can be quite complex, a buddy system might include going through the checklist together and completing the adherence forms. Use of staff members as PPE champions is another option. Staff workers well trained in PPE issues and behaviors could identify both facilitators and barriers to use of PPE, as well as serving as the lead in working with other staff to develop adherence and en- forcement policies. Another avenue for promoting PPE use would be patient-based reminders, which could serve as an adjunct to other moni- toring systems. Patients would be encouraged and informed about speak- ing up to ask workers to put on respirators, wash their hands, put on gloves, and so forth—similar to now well-accepted reminders to fasten seatbelts before driving. Efforts are needed to identify and disseminate a set of best practices for feedback, monitoring, and enforcement policies and mechanisms regarding use of PPE. Challenges to be examined include developing and disseminating effective supervisory and reporting procedures that encourage feedback and fairly enforce adherence to infection pre- vention practices. Clarifying Relevant Work Practices Much remains to be learned about specific issues related to wearing PPE in the healthcare setting particularly during an influenza pandemic. Research is needed to identify medical procedures and patient care proc- esses (e.g., cleaning of patient rooms) that are particularly high risk for influenza transmission. For aerosol-borne infections, those procedures that generate mists and small droplets (e.g., nebulization, intubation, bronchoscopy, laryngoscopy, upper gastrointestinal endoscopy, oral sur-

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137 INDIVIDUAL AND INSTITUTIONAL ISSUES gery and dental procedures) have been of concern regarding transmission of some respiratory diseases. During the SARS outbreak, these types of procedures were associated with infection of healthcare workers (Fowler et al., 2004; Loeb et al., 2004). Research should be conducted to deter- mine if noninvasive positive-pressure ventilation (e.g., continuous posi- tive airway pressure) increases the risk for influenza transmission to healthcare workers. If proven to be relatively safe, these noninvasive ventilatory modes would be highly desirable to improve surge capacity when treating large numbers of patients with severe respiratory disease. Additionally, research is needed regarding the most effective proce- dures for donning and doffing PPE in caring for patients with influenza. The potential for an ensemble approach to healthcare PPE should also be explored. The piece-by-piece process by which PPE must be taken on and off is more likely to result in self-contamination than the process by which a powered air-purifying respirator and a double-layered suit are donned and doffed (Zamora et al., 2006). PPE ensembles have not been the norm for healthcare workers and could be explored as could refine- ments to the proper sequencing of putting on or taking off PPE. Examin- ing effective approaches may include the use of pictorial reminders at every PPE station or a buddy system to assist and reinforce the proper use of PPE. Infection control practices, including appropriate PPE use, vary widely among hospitals and other healthcare facilities, private offices, and in-home care. A concerted effort to identify best practices in infec- tion control and disseminate this information to other healthcare facilities could increase worker and patient safety and have positive ramifications well beyond preparedness for an influenza pandemic. Model hospital wards or units with high numbers of patients on respiratory isolation (e.g., TB wards, burn units) should be identified and their infection control practices, including PPE protocols and training methods, should be shared as should model practices in other healthcare settings. Identify- ing best practices in infection control and worker safety will provide the standards to be expected for units with similar patient mix during a pandemic. OPPORTUNITIES FOR ACTION As discussed throughout this chapter, there are a number of areas to be explored for promoting worker safety in healthcare facilities. In-

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138 PREPARING FOR AN INFLUENZA PANDEMIC creased efforts are needed to identify and disseminate best practices, conduct pilot studies, and conduct research. Immediate Opportunities Efforts to improve PPE compliance could have an immediate impact (in the next 6 to 12 months) in improving the nation’s readiness for pan- demic influenza (as well as protecting healthcare workers against other infectious diseases or hazardous exposures). • A commitment by healthcare employers to promoting, training, and enforcing PPE compliance could increase adherence to PPE proto- cols and foster the expectation and norm for appropriate PPE use. • Efforts by the Joint Commission and state health departments to emphasize PPE compliance in accreditation and other assessments could focus attention on PPE issues and enhance adherence to PPE protocols. Key Research Needs Opportunities abound for improving worker safety and promoting the culture of safety in healthcare facilities. Important areas for research include • Define and promote strategies to increase adherence to infection control. • How can the safety culture of healthcare facilities be improved? What approaches best facilitate a healthcare organizational culture that promotes safety? • What are the best mechanisms to communicate with and receive feedback from frontline healthcare workers in order to ensure that infec- tion control measures are practical and feasible while still enhancing safety? • What are the best ways to train healthcare workers on appropri- ate use of PPE? What is the feasibility of fit testing and “just-in-time” training? • How do worker safety and patient safety interact? How can pri- orities be balanced where they conflict? • Is a continued focus on procedure-driven PPE feasible?

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139 INDIVIDUAL AND INSTITUTIONAL ISSUES • How can influenza patients best be identified early? • What interventions prevent healthcare-acquired influenza? SUMMARY AND RECOMMENDATIONS Despite expert recommendations and high-risk conditions, healthcare workers often do not wear PPE in situations that warrant its use, and PPE compliance rates are low. Lack of time is frequently reported as the rea- son for not adhering to PPE requirements, as is the perception that using PPE interferes with the healthcare worker’s ability to perform his or her job. Use of gloves appears to be more frequent than use of other types of PPE, particularly respirators. Improving worker safety necessitates an organization-wide dedica- tion to the creation, implementation, and maintenance of safety practices—a culture of safety. In order for a culture of safety to work effectively, responsibility for both personal safety and the safety of oth- ers must be a joint employer-employee responsibility. Key components in promoting a culture of safety in healthcare facilities focus on provid- ing leadership and commitment to worker safety, emphasizing education and training, improving feedback and enforcement of PPE policies and use, and clarifying work practices and policies. A concerted effort is needed to identify best practices in infection control and disseminate this information to all sites where health care is provided. These best prac- tices could increase worker and patient safety and have positive ramifica- tions well beyond preparedness for an influenza pandemic. The committee has developed the following set of recommendations aimed at improving the use of PPE by healthcare workers and developing best practices.

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140 PREPARING FOR AN INFLUENZA PANDEMIC Recommendation 6 Emphasize Appropriate PPE Use in Pa- tient Care and in Healthcare Management, Accreditation, and Training Appropriate PPE use and healthcare worker safety should be a priority for healthcare organizations and healthcare work- ers, and in accreditation, regulatory policy, and training. • Healthcare employers should strengthen their or- ganization’s commitment to a culture of safety by providing leadership in worker safety; instituting comprehend-sive, state-of-the-art training and educa- tion programs; facilitating easy access to PPE; giving feedback to supervisors and employees on PPE ad- herence; and enforcing disciplinary actions for non- compliance. • Healthcare workers should take responsibility for their safety by working to enhance the culture of safety in the workplace and by adhering to PPE pro- tocols. • Healthcare accrediting organizations (including the Joint Commission and state health departments) should set, implement, and enforce work standards in hospitals and other healthcare facilities to ensure that proper use of PPE is a priority and a sentinel event subject to controls at the administrative, supervisory, and individual levels. • Healthcare accrediting and credentialing organiza- tions should ensure that PPE training is part of the accreditation and testing curricula of health profes- sional schools of nursing, medicine, and allied health and that PPE concepts and practice are included on certification examinations and as continuing educa- tion training requirements. Recommendation 7 Identify and Disseminate Best Practices for Improving PPE Compliance and Use CDC and AHRQ should support and evaluate demonstration projects on improving PPE compliance and use. This effort would identify and disseminate relevant best practices that are being used by hospitals and other healthcare facilities to

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141 INDIVIDUAL AND INSTITUTIONAL ISSUES • Demonstrate, implement, evaluate, and improve the integration of worker safety into the protocols and practice of the organization. • Develop, implement, and evaluate evidence-based training programs on risk assessment and the use of PPE, including addressing practical realities of wear- ing PPE, donning and doffing, decontamination, and waste disposal. • Develop, implement, and evaluate worker safety communication programs focusing on infection con- trol, PPE, and reduction of risk and barriers during an influenza pandemic. • Monitor, enforce, and provide feedback to supervi- sors and employees regarding appropriate use of PPE. • Evaluate and determine which practices are most ef- fective regarding PPE use by healthcare workers, pa- tients, and visitors, with a focus on respirator use. Recommendation 8 Increase Research and Research Transla- tion Efforts Relevant to PPE Compliance NIOSH, the National Institutes of Health, AHRQ, and other relevant agencies and organizations should support research on improving the human factors and behavioral issues re- lated to ease and effectiveness of PPE use for extended peri- ods and in patient care-interactive work environments. Translational research efforts should include a focus on • identifying effective approaches to donning and doffing PPE, including enhancements in PPE ensem- ble design; • developing standard-of-use protocols based on infec- tion prevention and control policy with clear, simple- to-use algorithms; and • examining behavioral implementation strategies for sustained use of PPE, including a focus on patient and community education as well as healthcare pro- vider education.

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