Skip to main content Accessibility help
×
×
Home

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

  • Koh Okamoto (a1) (a2), Yoona Rhee (a1), Michael Schoeny (a3), Karen Lolans (a4), Jennifer Cheng (a1), Shivani Reddy (a1), Robert A. Weinstein (a1) (a5), Mary K. Hayden (a1) (a4), Kyle J. Popovich (a1) (a5) and for the Centers for Disease Control and Prevention Epicenters Program (a1) (a2) (a3) (a4) (a5)...
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.

Copyright
Corresponding author
Author for correspondence: Koh Okamoto, Email: kokamoto-tky@umin.ac.jp; Kyle J. Popovich, Email: kyle_popovich@rush.edu
References
Hide All
1. 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.
2. Klevens, RM, Edwards, JR, Richards, CL Jr., et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160166.
3. Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:11981208.
4. 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;29:9961011.
5. Brusselaers, N, Vogelaers, D, Blot, S. The rising problem of antimicrobial resistance in the intensive care unit. Ann Intensive Care 2011;1:47.
6. Kollef, MH, Fraser, VJ. Antibiotic resistance in the intensive care unit. Ann Intern Med 2001;134:298314.
7. Bonten, MJ, Weinstein, RA. Bird’s-eye view of nosocomial infections in medical ICU: blue bugs, fungi, and device-days. Crit Care Med 1999;27:853854.
8. 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;158:11271132.
9. Weinstein, RA. Hand hygiene—of reason and ritual. Ann Intern Med 2004;141:6566.
10. 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;40:10451051.
11. 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;29:149154.
12. Duckro, AN, Blom, DW, Lyle, EA, Weinstein, RA, Hayden, MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005;165:302307.
13. Ray, AJ, Hoyen, CK, Taub, TF, Eckstein, EC, Donskey, CJ. Nosocomial transmission of vancomycin-resistant enterococci from surfaces. JAMA 2002;287:14001401.
14. Tomas, ME, Kundrapu, S, Thota, P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med 2015;175:19041910.
15. 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:e39e45.
16. 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;14:12911293.
17. 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;38:10771083.
18. 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; 178:10511057.
19. 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.
20. 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;98:105108.
21. 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;49:41264130.
22. 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;37:14361440.
23. Fleiss, JL. Measuring nominal scale agreement among many raters. Psychollogical Bulletin 1971;76:378382.
24. Altman, DG. Practical Statistics for Medical Research. 1st edition. London: Chapman and Hall; 1990.
25. Thom, KA, Rock, C, Jackson, SS, et al. Factors leading to transmission risk of Acinetobacter baumannii . Crit Care Med 2017;45:e633e639.
26. 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;31:716721.
27. 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;29:583589.
28. 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;42:15521560.
29. 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;47:1317.
30. Doll, M, Feldman, M, Hartigan, S, et al. Acceptability and necessity of training for optimal personal protective equipment use. Infect Control Hosp Epidemiol 2017;38:226229.
31. 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.
32. 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;32:826829.
33. Olsen, RJ, Lynch, P, Coyle, MB, Cummings, J, Bokete, T, Stamm, WE. Examination gloves as barriers to hand contamination in clinical practice. JAMA 1993;270:350353.
34. Zellmer, C, Van Hoof, S, Safdar, N. Variation in health care worker removal of personal protective equipment. Am J Infect Control 2015;43:750751.
35. 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;18:622627.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
WORD
Supplementary materials

Okamoto et al. supplementary material
Okamoto et al. supplementary material 1

 Word (21 KB)
21 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed