Personal Protective Equipment Whats new and a handson review

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Personal Protective Equipment Whats new and a
hands-on review

• June 1, 2006
• MCHC Bioagent Hands-On Train the Trainer Session
• Stephanie R. Black, MD
• Rush University Medical Center
• Section of Infectious Diseases

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Overview

• Precautions
• Opportunistic Airborne Infections
• Aerosol Generating Procedures
• Augmenting your IC program
• Skills stations

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Epidemic Risk Comparison
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Modes of Transmission of Infectious Agents

• Contact
• Direct (body-to-body)
• Indirect (e.g., fomites/environment, HCWs
  hands)
• Large Droplet (gt5µm travel 3 feet)
• Small Droplet (droplet nuclei 5µm airborne)
• Endogenous (auto-inoculation device-related)
• Common source
• Vectorborne

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Precautions are Based on Modes of Transmission
When possible cohort if not possible. Avoid
rooming with immunosuppressed or high risk
patients.
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Standard

• Gloves
• contact blood or body fluids
• mucous membranes
• non-intact skin
• Remove gloves after wearing
• Hand hygiene after glove removal

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Contact

• Gloves each time enter room
• Remove gloves and disinfect after
• Disinfect equipment (eg stethoscopes)
• Gown if clothing may come in contact with patient
  or linen

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Droplet

• Surgical mask within 3 feet of patient
• Hand hygiene after providing care
• Disinfect equipment (eg stethoscope) after use
• Patient wears surgical mask during transport
• Children on droplet may not use common playrooms

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Airborne

• N-95 mask or PAPR in patient room
• Hand hygiene after patient care
• Negative air-flow room
• Patient wears surgical mask during transport
• Room vacant for 1 hour after patient discharge

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Aerobiologic Pathway for the Transmission of
Communicable Respiratory Disease
Roy CJ et al, N Engl J Med 20043501710-2.
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Airborne Opportunists

• Influenza
• SARS
• Others???
• Initiate infection by a small dose delivered to
  lung on a single airborne particle

• Roy CJ et al, N Engl J Med 20043501710-2.,
  Booth et al. JID 20051911472-7

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Model of the Movement of the SARS Virus-Laden
Plume
Yu et al, N Engl J Med 20043501731-9.
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Aerosol Generating Procedures

• Endotrachial intubation
• Aerosolized/nebulized medication
• Diagnostic sputum induction
• Bronchoscopy
• Airway suctioning
• Trach care
• Chest physiotherapy
• Nasopharyngeal aspirate
• CPAP/BiPAP
• High-frequency ocillatory ventilation
• Postmortem excision of lung tissue

WHO Interim Infection Control Guideline for
Health Care Facilities, amended 2/9/06
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Healthcare Worker Exposure Risk
Adapted from NEJM 2005 353 1374-85
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Studies of Influenza Transmission

• Mice Droplets droplet nuclei transmit
  influenza
• Humans
• Fomites/environment hands -- culture data
• Transmission studies
• Higher preexisting antibody titers require larger
  inocula for transmission of clinical illness
• Shedding correlates with severity of illness and
  fever
• Small droplet aerosols require lower inoculum
  (e.g., 10-100 lt nasal instillation)

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Experiments of Nature

• Review of 12 acute-care nosocomial outbreaks
  (Lancet Infectious Diseases 2002 2145-55)
• 1957 flu pandemic (J Clin Invest 1959
  38199-212)
• Homer, Alaska Airplane outbreak (Am J Epidemiol
  1979 1101-6)

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Epidemiology of 12 Nosocomial Acute-Care
Influenza Outbreaks

• Strains A (11 mostly H3N2), B (2)
• Years 1960s (1), 1970s (4), 1980s (2), 1990s
  (3), 2000s (2)
• Outbreak durations 2-69 (median 7) days
• Attack rates Patients 3-50 (affected wards)
• 0.7-20
  (hospital-wide)
• HCWs 11-59 (flu caregivers)
• Patient mortality rates 0 (5) 10-67 (7)
• Control measures Vaccination, heightened
  diagnostics surveillance, isolation hygiene,
  antiviral drugs

Salgado CD, et al. Lancet Infect Dis 2002
2145-55.
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Blumenfeld HL, et al. J Clin Invest 1959
38199-212.
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Blumenfeld HL, et al. J Clin Invest 1959
38199-212.
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Moser MR, et al. Am J Epidemiol 1979 1101-6.
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Moser MR, et al. Am J Epidemiol 1979 1101-6.
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Factors Shown to be Important in the Transmission
of Common Respiratory Agents
Musher DM, N Engl J Med 2003 3481256-65.
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Influenza Transmission and Precautions Bottom
Line

• Airborne transmission probably occurs --
  opportunistic
• Relative importance of small vs. large droplets
  and contact transmission in modern healthcare
  facilities is not known -- older literature vs.
  current experience/anecdotes and seasonal vs.
  pandemic flu
• Airborne isolation rooms (negative pressure) or
  other single rooms or cohorting prudent but may
  not be feasible during large outbreaks
• Implications for national recommendations
  droplet precautions and cohort ILI pts for
  seasonal flu more stringent (N-95) for pandemic
  flu ?

Borrowed from Weinstein who adapted from Bridges
et al, CID, 2003371094-1101
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Hand Hygiene-soap and water

• Indications
• Visibly dirty/contaminated/blood/body fluids
• Before eating
• After restroom
• Caring for patients with C. difficile
• Methods
• Wet hands
• Apply product
• Rub hands together for 15 seconds
• Use towel to dry and turn off sink
• Avoid hot water due to increased risk of
  dermatitis

Institute for Healthcare Improvement,
www.IHI.org, www.who.int/patientsafety/events/05/H
H en.pdf
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Hand Hygiene-Alcohol-based Hand Gel

• Indications
• patient contact
• Donning sterile gloves to place TLC
• Inserting indwelling urinary catheter, PIV,
  invasive device
• Contact with skin, body fluids, wounds, mucous
  membranes
• Move from contaminated body site to clean body
  site
• Contact with inanimate objects in immediate pt
  vicinity
• After removing gloves
• Method
• Apply product to palm of one hand
• Rub hands together covering all surfaces of hands
  and fingers until dry

Institute for Healthcare Improvement,
www.IHI.org, www.who.int/patientsafety/events/05/H
H en.pdf
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Risk Factors for Poor Adherence

• Physician
• Nursing Assistant
• Male sex
• Working in ICU
• Working during the week (vs. weekend)
• Automated sink
• Activities w/ high risk cross-transmission
• No. of opportunities for hand hygiene per hour of
  patient care

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Self-reported reasons for poor adherence with
hand-hygiene

• Irritation/dryness from agents
• Location/no. of sinks
• Lack of soap and paper towels
• Too busy
• Understaffing/overcrowding
• Patient needs take priority
• Interferes with HCW relationship w/ pt
• Low risk acquiring infection from pt
• Gloves obviate need for hand hygiene
• No role model
• Forgetting
• Skepticism/disagreement

Pittet D. ICHE 200021381-6, MMWR 2002 51/RR-16
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Putting it on

• Gown
• Mask/Respirator
• Secure ties
• Fit flexible band at nose bridge
• Fit snug to face and below chin
• Fit check respirator
• Goggles or Face Shield
• Gloves
• Extend to cover wrist of isolation gown

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Taking it off-gloves first!!

• Remove PPE at doorway/anteroom
• Remove respirator
• after leaving pt room
• closing door

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Taking it off-gloves first !!

• Gloves
• Outside of gloves contaminated
• Goggles or faceshield
• Handle by headband or earpieces
• Gown
• pull away touching inside only
• Mask or Respirator
• Grasp by ties or headbands to remove
• Hand Hygiene

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PAPR

• Aerosol generating procedures
• DO NOT USE
• fire
• low oxygen
• chemical emergency
• sx of intolerance
• Equipment inspection and set up
• Conducting air-flow checks
• Donning PAPR unit

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PAPR

• Check face seal
• Sign/symptoms of malfunction
• Where/when to remove unit
• Remove unit
• Cleaning and storage of unit
• Connecting to battery chargers

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Augmenting Your IC Program

• Precaution Badges
• Personal protection stations
• Respiratory Etiquette in clinics, ED triage
• PPE surge capacity
• Administration buy-in

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Infection Control Card
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Infection Control Card
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PPE Surge Capacity

• Review list of current supplies to determines
  needs
• Review expired items and reorder
• Flashlights should be onsite
• Labeling of boxed items in warehouse
• Environmental, Pharmacy, Pediatrics, Respiratory,
  ED, Infection Control, Food Service input
• Keep master list of supplies at command center

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the secret in the care of the patient is in
caring for patient

• -Francis Peabody, MD 1927

Lancet Infectious Diseases 20022145-55