Hostname: page-component-5f56664f6-287w5 Total loading time: 0 Render date: 2025-05-07T12:03:16.263Z Has data issue: false hasContentIssue false
  • English
  • Français

Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions

Published online by Cambridge University Press:  20 March 2019

Koh Okamoto Open the ORCID record for Koh Okamoto [Opens in a new window] ,
Yoona Rhee ,
Michael Schoeny ,
Karen Lolans ,
Jennifer Cheng ,
Shivani Reddy ,
Robert A. Weinstein ,
Mary K. Hayden ,
Kyle J. Popovich  and
for the Centers for Disease Control and Prevention Epicenters Program
Koh Okamoto*
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
Yoona Rhee
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois
Michael Schoeny
Affiliation:
College of Nursing, Rush University Medical Center, Chicago, Illinois
Karen Lolans
Affiliation:
Department of Pathology, Rush University Medical Center, Chicago, Illinois
Jennifer Cheng
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois
Shivani Reddy
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois
Robert A. Weinstein
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois
Mary K. Hayden
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois Department of Pathology, Rush University Medical Center, Chicago, Illinois
Kyle J. Popovich*
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois
for the Centers for Disease Control and Prevention Epicenters Program
Affiliation:
Department of Medicine, Rush University Medical Center, Chicago, Illinois Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan College of Nursing, Rush University Medical Center, Chicago, Illinois Department of Pathology, Rush University Medical Center, Chicago, Illinois Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois
*
Author for correspondence: Koh Okamoto, Email: [email protected]; Kyle J. Popovich, Email: [email protected]
Author for correspondence: Koh Okamoto, Email: [email protected]; Kyle J. Popovich, Email: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

We assessed the impact of personal protective equipment (PPE) doffing errors on healthcare worker (HCW) contamination with multidrug-resistant organisms (MDROs).

Design:

Prospective, observational study.

Setting:

The study was conducted at 4 adult ICUs at 1 tertiary-care teaching hospital.

Participants:

HCWs who cared for patients on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, or multidrug-resistant gram-negative bacilli were enrolled. Samples were collected from standardized areas of patient body, garb sites, and high-touch environmental surfaces in patient rooms. HCW hands, gloves, PPE, and equipment were sampled before and after patient interaction. Research personnel observed PPE doffing and coded errors based on CDC guidelines.

Results:

We enrolled 125 HCWs; most were nurses (66.4%) or physicians (19.2%). During the study, 95 patients were on contact precautions for MRSA. Among 5,093 cultured sites (HCW, patient, environment), 652 (14.7%) yielded the target MDRO. Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including 4 (3.2%) on hands and 38 (30.4%) on PPE. Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction (risk ratio [RR], 4.69; P = .04). All 4 HCWs with hand contamination made doffing errors. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing (RR, 11.76; P = .025).

Conclusion:

When caring for patients on CP for MDROs, HCWs appear to have differential risk for hand contamination based on their method of doffing PPE. An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 5 , May 2019 , pp. 559 - 565
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Scott, RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention website. https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Published 2009. Accessed February 12, 2019.Google Scholar
Klevens, RM, Edwards, JR, Richards, CL Jr., et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160–166.10.1177/003335490712200205CrossRefGoogle Scholar
Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle ScholarPubMed
Hidron, AI, Edwards, JR, Patel, J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 2008;29:996–1011.CrossRefGoogle ScholarPubMed
Brusselaers, N, Vogelaers, D, Blot, S. The rising problem of antimicrobial resistance in the intensive care unit. Ann Intensive Care 2011;1:47.CrossRefGoogle ScholarPubMed
Kollef, MH, Fraser, VJ. Antibiotic resistance in the intensive care unit. Ann Intern Med 2001;134:298–314.10.7326/0003-4819-134-4-200102200-00014CrossRefGoogle ScholarPubMed
Bonten, MJ, Weinstein, RA. Bird’s-eye view of nosocomial infections in medical ICU: blue bugs, fungi, and device-days. Crit Care Med 1999;27:853–854.CrossRefGoogle ScholarPubMed
Bonten, MJ, Slaughter, S, Ambergen, AW, et al. The role of “colonization pressure” in the spread of vancomycin-resistant enterococci: an important infection control variable. Arch Intern Med 1998;158:1127–1132.10.1001/archinte.158.10.1127CrossRefGoogle ScholarPubMed
Weinstein, RA. Hand hygiene—of reason and ritual. Ann Intern Med 2004;141:65–66.CrossRefGoogle Scholar
Morgan, DJ, Rogawski, E, Thom, KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Crit Care Med 2012;40:1045–1051.CrossRefGoogle ScholarPubMed
Hayden, MK, Blom, DW, Lyle, EA, Moore, CG, Weinstein, RA. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant Enterococcus or the colonized patients’ environment. Infect Control Hosp Epidemiol 2008;29:149–154.CrossRefGoogle ScholarPubMed
Duckro, AN, Blom, DW, Lyle, EA, Weinstein, RA, Hayden, MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005;165:302–307.CrossRefGoogle ScholarPubMed
Ray, AJ, Hoyen, CK, Taub, TF, Eckstein, EC, Donskey, CJ. Nosocomial transmission of vancomycin-resistant enterococci from surfaces. JAMA 2002;287:1400–1401.10.1001/jama.287.11.1395CrossRefGoogle ScholarPubMed
Tomas, ME, Kundrapu, S, Thota, P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med 2015;175:1904–1910.10.1001/jamainternmed.2015.4535CrossRefGoogle ScholarPubMed
Guo, YP, Li, Y, Wong, PL. Environment and body contamination: a comparison of two different removal methods in three types of personal protective clothing. Am J Infect Control 2014;42:e39–e45.CrossRefGoogle ScholarPubMed
Casanova, L, Alfano-Sobsey, E, Rutala, WA, Weber, DJ, Sobsey, M. Virus transfer from personal protective equipment to healthcare employees’ skin and clothing. Emerg Infect Dis 2008;14:1291–1293.CrossRefGoogle ScholarPubMed
Kwon, JH, Burnham, CD, Reske, KA, et al. Assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing. Infect Control Hosp Epidemiol 2017;38:1077–1083.10.1017/ice.2017.121CrossRefGoogle ScholarPubMed
Krein, SL, Mayer, J, Harrod, M, et al. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. JAMA Intern Med 2018; 178:1051–1057.10.1001/jamainternmed.2018.1898CrossRefGoogle ScholarPubMed
Sequence for donning and removing personal protective equipment. Centers for Disease Control and Prevention website. https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf. Published 2015. Accessed July 25, 2018.Google Scholar
Okamoto, K, Rhee, Y, Schoeny, M, et al. Flocked nylon swabs versus RODAC plates for detection of multidrug-resistant organisms on environmental surfaces in intensive care units. J Hosp Infect 2018;98:105–108.CrossRefGoogle ScholarPubMed
McAllister, SK, Albrecht, VS, Fosheim, GE, et al. Evaluation of the impact of direct plating, broth enrichment, and specimen source on recovery and diversity of methicillin-resistant Staphylococcus aureus isolates among HIV-infected outpatients. J Clin Microbiol 2011;49:4126–4130.10.1128/JCM.05323-11CrossRefGoogle ScholarPubMed
Ieven, M, Vercauteren, E, Descheemaeker, P, van Laer, F, Goossens, H. Comparison of direct plating and broth enrichment culture for the detection of intestinal colonization by glycopeptide-resistant enterococci among hospitalized patients. J Clin Microbiol 1999;37:1436–1440.Google ScholarPubMed
Fleiss, JL. Measuring nominal scale agreement among many raters. Psychollogical Bulletin 1971;76:378–382.CrossRefGoogle Scholar
Altman, DG. Practical Statistics for Medical Research. 1st edition. London: Chapman and Hall; 1990.Google Scholar
Thom, KA, Rock, C, Jackson, SS, et al. Factors leading to transmission risk of Acinetobacter baumannii. Crit Care Med 2017;45:e633–e639.CrossRefGoogle ScholarPubMed
Morgan, DJ, Liang, SY, Smith, CL, et al. Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infect Control Hosp Epidemiol 2010;31:716–721.CrossRefGoogle ScholarPubMed
Snyder, GM, Thom, KA, Furuno, JP, et al. Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol 2008;29:583–589.CrossRefGoogle ScholarPubMed
Hayden, MK, Bonten, MJ, Blom, DW, Lyle, EA, van de Vijver, DA, Weinstein, RA. Reduction in acquisition of vancomycin-resistant Enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis 2006;42:1552–1560.CrossRefGoogle ScholarPubMed
Jackson, SS, Harris, AD, Magder, LS, et al. Bacterial burden is associated with increased transmission to health care workers from patients colonized with vancomycin-resistant Enterococcus. Am J Infect Control 2019;47:13–17.10.1016/j.ajic.2018.07.011CrossRefGoogle ScholarPubMed
Doll, M, Feldman, M, Hartigan, S, et al. Acceptability and necessity of training for optimal personal protective equipment use. Infect Control Hosp Epidemiol 2017;38:226–229.CrossRefGoogle ScholarPubMed
John, A, Tomas, ME, Hari, A, Wilson, BM, Donskey, CJ. Do medical students receive training in correct use of personal protective equipment? Med Educ Online 2017;22:1264125.CrossRefGoogle ScholarPubMed
Tenorio, AR, Badri, SM, Sahgal, NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis 2001;32:826–829.CrossRefGoogle ScholarPubMed
Olsen, RJ, Lynch, P, Coyle, MB, Cummings, J, Bokete, T, Stamm, WE. Examination gloves as barriers to hand contamination in clinical practice. JAMA 1993;270:350–353.CrossRefGoogle ScholarPubMed
Zellmer, C, Van Hoof, S, Safdar, N. Variation in health care worker removal of personal protective equipment. Am J Infect Control 2015;43:750–751.10.1016/j.ajic.2015.02.005CrossRefGoogle ScholarPubMed
Boyce, JM, Potter-Bynoe, G, Chenevert, C, King, T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol 1997;18:622–627.CrossRefGoogle ScholarPubMed
Supplementary material: File

Okamoto et al. supplementary material

Okamoto et al. supplementary material 1

Download Okamoto et al. supplementary material(File)
File 21.5 KB