Proper Use of Personal Protective Equipment in Healthcare Settings

While outbreaks of infectious diseases have always required access to personal protective equipment (PPE) in the healthcare workplace, the COVID-19 pandemic has elevated its proper use to a top priority in every practice. Any employee who is onsite — from top management to custodian — as well as vendors and patients are required to use PPE in nearly all jurisdictions. And even where not legally compelled, medical ethics and legal liability have led most medical facilities to implement rules requiring the use of PPE. 

In normal times, large corporate practices have the resources necessary to develop and deploy protocols for safely and effectively utilizing PPE provided to staff. But the rapidly shifting landscape of the current pandemic — and the severity of a seasonal influenza season yet to be determined — has led to even large respected institutions scrambling to not only source increasingly scarce PPE, but to quickly develop instructions and training for using the equipment.

Shortages of N95 respirators, for instance, have left many frontline medical workers with only basic cloth masks — the design and efficacy of which can vary widely, even more so if they aren’t properly worn.

And, of course, today there is more to PPE than respirators, gowns and gloves: Check-in desks may now have plexiglass shields between patients and staff; credit-card readers may have a clear plastic cover over the keypad. Goggles or safety glasses may be required for everyone onsite, including nurses performing temperature checks at the entrance. And new cleaning protocols for all exam rooms and even restrooms have support staff as engaged in the use of PPE as nurses and doctors.

The Three-Headed Monster

David Lo, MD, PhD, senior associate dean of research at the University of California, Riverside, School of Medicine, says every practice faces three distinct challenges for ensuring the proper use of PPE to protect both patients and staff:

• Procuring reliable equipment

• Training staff in its proper use

• Following up to ensure staff is complying with protocols

Procurement is the area where a medical practice is most vulnerable to the whims of outside forces, he says. “There’s so much variability in terms of what’s available, as well as whether you can trust the source,” says Dr. Lo. “That’s an ongoing issue.” As Dr. Lo points out, no matter how good a facility’s training and compliance protocols, if it’s using defective goods, they’re not going to protect anyone from infection.

What’s more, with the surge in demand for PPE, there has been a global shortage. A recent survey of more than 21,000 nurses in the U.S. found that as we were heading into autumn, 42 percent were still reporting shortages of PPE.¹ Due to these shortages, a healthcare facility’s normal suppliers may be unable to source needed equipment, leaving staff to look to unfamiliar providers. And, in some cases, long-trusted suppliers may, while trying to serve its customers, procure equipment of questionable origin. 

Indeed, the entire supply chain is susceptible to fraud. The Wall Street Journal reported on Sept. 15 that a growing number of the 70 billion medical gloves imported each year are substandard and do not offer the protection they promise.² Then, on Sept. 17, U.S. Customs and Border Protection agents in Boston seized more than 20,000 counterfeit N95 respirators.³ Similarly, customs agents at O’Hare International Airport are finding record numbers of counterfeit protective gear. And, as a customs agent told a reporter, there is no dog on Earth that can sniff out counterfeit respirators.⁴ 

The counterfeiting situation has become so rampant that the Centers for Disease Control and Prevention (CDC) has issued an alert through the National Personal Protective Technology Laboratory. The site (www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html) includes tips for spotting potentially counterfeit goods, as well as photographic samples of dozens of seized counterfeits that have recently appeared on the market, to help purchasing agents identify fraudulent supplies.

Security consultant Pinkerton also has published an online checklist to help healthcare providers navigate the increasingly murky waters of procuring legitimate PPE (pinkerton.com/our-insights/blog/identifying-and-combating-counterfeit-ppe). 

Training Staff

After legitimate, quality protective gear is acquired, it is imperative staff are trained to properly use it. Improperly used equipment can be just as ineffective at stopping the spread of infection as using no gear at all, and merely having the equipment can give people a false sense of safety. “You can get a high-quality respirator, and if you wear it improperly, then it’s useless,” says Dr. Lo. “Similarly, if you wear just a regular face mask — not an N95 — and if you don’t cover your nose or if you have a heavy beard, it won’t be effective.” Dr. Lo also points out that PPE is not difficult to learn to use correctly: “It’s not heavy training on how to use it. Technically, it’s not challenging; it’s people being consistent.”

PPE providers should include illustrated instructions on the proper use of each item. If they don’t, most manufacturers have user manuals and instructions posted on their websites for download. And, any reputable supplier or manufacturer will gladly provide additional copies of user documents if they weren’t included in the shipment.

But, facilities should be sure the source providing instructions for using PPE products is credible. While there are thousands of how-to instructional videos on YouTube, Vimeo and other video-sharing services, many are created by hobbyists or other end users and may not represent proper, effective usage. Despite what they say, the videos may also not be illustrating the exact same model or variant of the PPE obtained. In fact, YouTube is great for instructions on assembling your 12-year-old’s new backyard trampoline, but not so much for the appropriate use of respirators or face guards.

For standard equipment of all makes and models, particularly equipment used in an infection isolation environment, CDC has step-by-step instructions both for putting it on before entering an infection-control room and removing it before exiting at www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html. Also found on this site are printable posters in PDF format providing visual guides for the instructions, as well as proper wear of respirators and masks, all of which are in English and Spanish and are appropriate for posting either in nurses’ stations, changing/locker rooms or outside isolation rooms where they can be referenced by staff as they don the equipment.

According to Dr. Lo, many trade groups and associations serving a variety of healthcare facilities also offer PPE training materials and videos. The clinics he works with at the University of California, Riverside Health System, for instance, have access to materials from the Association of American Medical Colleges. And, various state and county health departments may have training materials that can be obtained from local public health offices or association representatives.

What’s most important is training should be delivered consistent with an organization’s existing training program, and new employees should receive PPE training along with their onboard training. 

Measuring Compliance

Staff can be provided all the training in the world, but if they don’t follow that training consistently on a daily basis, it won’t do any good. For example, one need look no further than the issue of healthcare acquired infections. CDC reports nearly every one of these infections would have been preventable if standard protocols had been followed. Floor staff know how to disinfect an exam room and instruments, and they have received training and follow-up reinforcement. Yet, each year, some two million Americans get infected at a medical facility⁵ because the training wasn’t followed.

The first step to ensuring compliance is keeping accurate records of PPE training for all staff. Some PPE training is already covered by Occupational Safety and Health Administration requirements for bloodborne pathogens training.⁶ Including airborne PPE training into an existing training regimen will help ensure no employees are falling through the cracks, putting themselves, their co-workers and patients at heightened risk of spreading the novel coronavirus.

Periodic retesting is also a useful tool to determine whether employees are retaining and implementing the training. In addition, unannounced audits, in which employees are observed in their normal duties to see if they are following the training, are an effective method for measuring compliance.

But Lo says the single biggest factor in whether employees consistently follow safety protocols regarding PPE is the workplace culture: “Whether or not we had a pandemic, there are a lot of team mentalities operating all the time.” He points out that the procedures in properly using PPE are well-known to all healthcare workers, and they’ve been in place for decades. “In clinical settings, in patient settings, even when you had isolation wards for tuberculosis, nothing’s really significantly changed,” Dr. Lo explains. “When I was back in medical school when HIV was getting out there, and you had a lot of isolation, not a lot has had to change. All of this was true before you had COVID.”

Dr. Lo says the biggest changes in infection control and the use of PPE over the decades haven’t been technological so much as cultural — an increasing emphasis on consistently following protocols every single time: “Over the years, there’s been so much more attention to just washing your hands! Doing rounds, we didn’t used to wash our hands between patients when I was first starting.”

The Wildcard

The biggest wildcard, says Dr. Lo, is whether patients follow the posted rules when visiting a clinic or office. Administrators and supervisors have far less control over patient behavior than they do over staff. “The patients don’t get the training,” he points out. “I think it’s a question of how the culture is going to change over the next months and years, where the patients are going to be more attentive to these things. A lot depends on the psychology [of an organization]. In our research labs on campus, we still haven’t had a case of COVID traced to our labs, which is really impressive.”

As an example of how an organizational culture can affect patient compliance with behavioral expectations, Dr. Lo points to the experience of medical professionals in some Asian countries where patients have been wearing masks in healthcare settings for so many years that it has become ingrained habit.

Moving Forward

Dr. Lo warns that healthcare supervisors are going to have to be vigilant about training and compliance regarding PPE for the foreseeable future: “I think we’re going to be dealing with this for at least another year or two.”

Unfortunately, as the novelty of life with COVID-19 has worn off, Dr. Lo says the biggest challenge for administrators will be to watch for staff burnout and people letting their guard down over time. “I think the whole shutdown has its whole psychiatric overlay. People are to the point of, ‘Oh, who cares if I get infected.’”

On reflection, though, everything being done to stop the spread of the novel coronavirus is what has been done in short stretches to stop particularly heavy outbreaks of influenza or other airborne infectious diseases in years past. “The precautions they’ve been pushing every year for the flu are just as valid for COVID,” explains Dr. Lo. “That’s also true for the common cold. If you don’t wash your hands, you touch everything and then you touch your face: That’s how you get it.”