Background: We know relatively little about how healthcare personnel (HCP) in long-term care facilities (LTCFs) integrate hand hygiene (HH) and personal protective equipment (PPE; e.g., gloves) use into their care processes. To address this gap, we are examining HH and PPE adherence at critical and contaminating moments in LTCFs. Methods: We conducted ethnographic observations of HCP’s processes of care in 2 LTCFs in Iowa to examine HH and PPE adherence during contaminating tasks in resident care sequences. We captured care observations and additional data on topics related to our study focus (e.g., unit/room layouts, PPE storage, facility policies/procedures) in field notes. We transcribed and imported fieldnotes into MAXQDA qualitative data management software and analyzed the data using a combined deductive-inductive coding approach. Results: Between 1/2023-7/2023, we observed 60 (30 per facility) care episodes. Most observations included toileting activities and perineal care during which HCP would be expected to use gloves and/or do HH. Most HCP appropriately donned/doffed gloves and practiced HH at key moments (e.g., before clean/aseptic procedures, after perineal care), but were less compliant before/after touching residents’ clothing or bare skin during these activities. In addition, some held soiled items next to their scrubs between tasks, which could contaminate their clothing and arms and could facilitate transmission of pathogens to other residents. Moreover, HCP’s interactions with floors emerged inductively as a topic of interest during our observations and preliminary analyses. We observed HCP interact with the floor during these activities in ways that could increase risk of pathogen transmission. HCP frequently dropped soiled towels or wipes used in perineal care onto the floor during tasks for later pick up. HCP also moved or placed trash bags containing soiled or contaminated items on the floor. HCP routinely knelt on, sat on, or touched their hands on the same floor when talking with residents, helping residents change clothes or diapers, changing bedding, or adjusting wheelchair footpads. In one case, the HCP picked up clean towels that fell to the floor near soiled towels and then used the “clean towels” in resident perineal care. Conclusion: Despite practicing HH and appropriate PPE use, HCP in LTCFs may increase the risk of pathogen transmission unintentionally through their interactions with soiled items and the environment, including floors. Given the nature of resident care in LTCFs, HCP in LTCF may be more likely than HCP in acute care settings to interact with contaminated floors.

Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.

Disclosure: Marin Schweizer: Speaker- 3M; Contracted research-3M; Anitha Vijayan: Honoraria - Quanta, Baxter, Fresenius Consulting, Astute, NxStage

We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL (P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.

Background: Nasal decolonization significantly decreases the incidence of Staphylococcus aureus surgical-site infections (SSIs). Patient adherence with self-administration of a decolonization ointment (ie, mupirocin) is low, especially among patients having urgent surgery. Povidone-iodine decolonization may overcome patient adherence challenges because povidone-iodine needs to be applied only on the day of surgery. We assessed the effectiveness and acceptability of povidone-iodine decolonization given on the day of surgery among patients having orthopedic trauma surgery. Methods: Adult patients who underwent operative fixation of traumatic lower extremity fractures were consented to receive 10% intranasal povidone-iodine solution. Povidone-iodine was applied ~1 hour before surgical incision and was reapplied the evening after surgery. Patients were tested for S. aureus nasal colonization before surgery, the evening after surgery (before povidone-iodine reapplication), and the day after surgery. Swabs were inoculated into Dey-Engley neutralizer and processed in a vortexer. A series of dilutions were performed and plated on mannitol salt agar plates. S. aureus cultures were quantitatively assessed to determine the reduction in S. aureus after povidone-iodine use. Reductions in S. aureus nasal growth were evaluated using the Skillings-Mack test. SSIs manifesting within 30 and 90 days of surgery were identified using NHSN definitions. A survey was administered the morning after surgery to determine the acceptability of intranasal povidone-iodine. Results: In total, 51 patients participated in this pilot study between February 2020 and June 2021. Nasal samples from 12 participants (23.5%) grew S. aureus. The S. aureus concentration decreased significantly across the time points (P = .03) (Fig. 1). No SSIs were identified within 30 days of surgery. One SSI occurred within 90 days of surgery; this patient did not carry S. aureus, and cultures from the infected site were negative. Also, 31% of patients reported at least 1 mild side effect while using povidone-iodine: dripping (n = 7), itching (n = 6), dryness (n = 4), stinging (n = 4), staining (n = 3), unpleasant taste (n = 3), runny nose (n = 2), burning (n = 1), sneezing (n = 1), sore throat (n = 1), tickling (n = 1), and/or cough (n = 1). Also, 86% of patients stated that povidone-iodine felt neutral, pleasant, or very pleasant, and only 14% stated that it felt unpleasant or very unpleasant. Discussion: In this pilot study, 2 applications of nasal povidone-iodine on the day of surgery were acceptable for patients, and this protocol significantly reduced S. aureus concentration in nares of patients. Future large clinical trials should evaluate whether this 2-application regimen of povidone-iodine significantly decreases rates of SSI among orthopedic trauma surgery patients.

Funding: PDI Healthcare

Disclosures: None

We evaluated barriers and facilitators to patient adherence with a bundled intervention including chlorhexidine gluconate (CHG) bathing and decolonizing Staphylococcus aureus nasal carriers in a real-world setting. Survey data identified 85.5% adherence with home use of CHG as directed and 52.9% adherence with home use of mupirocin as directed.

Hand hygiene compliance decreased significantly when opportunities exceeded 30 per hour. At higher workloads, the number of healthcare worker types involved and the proportion of hand hygiene opportunities for which physicians and other healthcare workers were responsible increased. Thus, care complexity and risk to patients may both increase with workload.

Background: Appropriate doffing of personal protective equipment (PPE) prevents healthcare worker (HCW) self-contamination and spread of pathogens. HCWs may encounter an array of PPE types (eg, gloves, gowns, masks) and designs (eg, masks with elastic ear loops vs ties) during their duties, some of which may be unfamiliar. We know little about how HCWs strategize when doffing unfamiliar PPE. As part of a larger study examining the doffing process and the risk of self-contamination, we used qualitative methods to explore factors influencing HCW PPE doffing strategies. Methods: In total, 70 HCW participants from 2 Midwestern academic hospitals were assigned to 1 of 4 doffing simulation scenarios. In the first 3 scenarios, participants were asked to doff 3 mask designs (n = 10), 2 gown designs (n = 10), or 2 glove designs (n = 10). In the fourth scenario, HCWs with different levels of training (n = 40) participated in 2 doffing simulations randomized per participant: a distraction simulation and a nondistraction simulation (using identical PPE types and designs). In all scenarios, participants were instructed to doff in their usual manner. Doffing performances were video-recorded. Participants then reviewed the recordings and took part in short semistructured interviews about their performance. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Results: When faced with unfamiliar PPE during the simulations, participants were required to problem solve. In so doing, participants reported drawing on their day-to-day routine practices with familiar PPE to inform their doffing strategies. Aspects of routine practice identified as influential included PPE types typically worn, PPE donning and doffing order, doffing frequency, familiar PPE design cues, and experience tailoring strategies to specific patient care contexts. Participants frequently reported the desire to avoid self-contamination as driving doffing strategies and problem solving, but they also noted unique patient care demands related to their specific roles when they explained their doffing decisions. At the same time, HCWs identified lack of familiarity, lack of training, and nonintuitive design as barriers to doffing appropriately when encountering unfamiliar PPE. Conclusions: Different PPE designs may not be interchangeable, and proper doffing techniques may not be intuitive. The previous experiences of HCWs informed their strategies when doffing unfamiliar PPE. However, this practice sometimes caused them to use inappropriate doffing techniques and resulted in self-contamination. This finding has important implications for hospital policies and procedures regarding the introduction of new PPE and indicates that HCWs need training when new items are introduced.

Funding: None

Disclosures: None

Background: Personal protective equipment (PPE) effectiveness can be undermined by inappropriate doffing methods. Objective: We used human factors engineering methods to evaluate self-contamination during PPE doffing. Methods: In this study, 30 participants at a Midwestern academic hospital (A) donned and doffed 3 mask styles (n = 10), 2 gown styles (n = 10), and 2 glove styles (n = 10; the Doffy glove has a tab to facilitate doffing). Also, 30 additional participants at hospital A (residents or fellows, nurses, special isolation trained staff [SITS]) and 10 SITS at academic hospital B doffed a surgical mask, a breakaway neck gown, and exam gloves (PPE ensemble) twice: once while distracted with conversation and once when not distracted. We randomized the order in which participants used different PPE styles or they did the doffing scenario. We collected demographic data. We applied Glo Germ Mist (1.5 dilution in water) with a mucosal atomizer to participants’ PPE before they doffed. We video-recorded participants as they doffed, and we photographed their scrubs and exposed skin before and after each donning and doffing episode. We reviewed videos for doffing errors and photographs for fluorescent spots. We counted fluorescent spots and noted their locations. Results: Overall, 45 (64.3%) participants were women, 31 (44.3%) were nurses, 24 (34.3%) were physicians. Among the participants, 25 (35.7%) had >15 years of experience and 61 (87.1%) had some training in doffing. Participants frequently contaminated their skin or clothing while doffing (Table 1). For all scenarios, hands followed by the torso were contaminated most frequently. Analysis of the videos found that touching the gown front with bare hands was the most common doffing error. Fewer participants self-contaminated when using the Doffy glove without training than when using the standard exam glove. Although most participants in the glove trial indicated that they did not need to watch the Doffy glove training video again, most had difficulty doffing the Doffy glove with the beak method. Many participants stopped doffing to answer questions when they doffed the PPE ensemble during the interruption scenario. Conclusions: Self-contamination was very common with all PPE styles and during all scenarios. Distraction did not increase the risk of contamination. However, participants often stopped doffing to answer questions, which they rarely do in practice. Watching a video was inadequate training for the beak glove-doffing method. The Doffy glove, which decreased contamination compared with the standard glove in the untrained scenario, may have advantages over standard exam gloves and should be evaluated further.

Funding: None

Disclosures: None