Development and Comparison of Complementary Methods to Study Potential Skin and Inhalational Exposure to Pathogens During Personal Protective Equipment Doffing.

BACKGROUND: Fluorescent tracers are often used with ultraviolet lights to visibly identify healthcare worker self-contamination after doffing of personal protective equipment (PPE). This method has drawbacks, as it cannot detect pathogen-sized contaminants nor airborne contamination in subjects' breathing zones. METHODS: A contamination detection/quantification method was developed using 2-µm polystyrene latex spheres (PSLs) to investigate skin contamination (via swabbing) and potential inhalational exposure (via breathing zone air sampler). Porcine skin coupons were used to estimate the PSL swabbing recovery efficiency and limit of detection (LOD). A pilot study with 5 participants compared skin contamination levels detected via the PSL vs fluorescent tracer methods, while the air sampler quantified potential inhalational exposure to PSLs during doffing. RESULTS: Average PSL skin swab recovery efficiency was 40% ± 29% (LOD = 1 PSL/4 cm2 of skin). In the pilot study, all subjects had PSL and fluorescent tracer skin contamination. Two subjects had simultaneously located contamination of both types on a wrist and hand. However, for all other subjects, the PSL method enabled detection of skin contamination that was not detectable by the fluorescent tracer method. Hands/wrists were more commonly contaminated than areas of the head/face (57% vs 23% of swabs with PSL detection, respectively). One subject had PSLs detected by the breathing zone air sampler. CONCLUSIONS: This study provides a well-characterized method that can be used to quantitate levels of skin and inhalational contact with simulant pathogen particles. The PSL method serves as a complement to the fluorescent tracer method to study PPE doffing self-contamination.

Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing.

BACKGROUND: More than 28 000 people were infected with Ebola virus during the 2014-2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission. METHODS: A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing. These interventions were tested in a randomized controlled trial of 48 participants with no prior experience doffing enhanced PPE. Contamination was simulated using a fluorescent tracer slurry and fluorescent polystyrene latex spheres (PLSs). Self-contamination of scrubs and skin was measured using ultraviolet light visualization and swabbing followed by microscopy, respectively. Doffing sessions were videotaped and reviewed to score standardized teamwork behaviors. RESULTS: Participants in the intervention group contaminated significantly fewer body sites than those in the control group (median [interquartile range], 6 [3-8] vs 11 [6-13], P = .002). The median contamination score was lower for the intervention group than the control group when measured by ultraviolet light visualization (23.15 vs 64.45, P = .004) and PLS swabbing (72.4 vs 144.8, P = .001). The mean teamwork score was greater in the intervention group (42.2 vs 27.5, P < .001). CONCLUSIONS: An intervention package addressing the PPE doffing task, tools, environment, and teamwork skills significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to reduce the risk of pathogen transmission.

Validation of Autoclave Protocols for Successful Decontamination of Category A Medical Waste Generated from Care of Patients with Serious Communicable Diseases.

In response to the Ebola outbreak in 2014, many hospitals designated specific areas to care for patients with Ebola and other highly infectious diseases. The safe handling of category A infectious substances is a unique challenge in this environment. One solution is on-site waste treatment with a steam sterilizer or autoclave. The Johns Hopkins Hospital (JHH) installed two pass-through autoclaves in its biocontainment unit (BCU). The JHH BCU and The Johns Hopkins biosafety level 3 (BSL-3) clinical microbiology laboratory designed and validated waste-handling protocols with simulated patient trash to ensure adequate sterilization. The results of the validation process revealed that autoclave factory default settings are potentially ineffective for certain types of medical waste and highlighted the critical role of waste packaging in successful sterilization. The lessons learned from the JHH validation process can inform the design of waste management protocols to ensure effective treatment of highly infectious medical waste.

A Central Sterile Processing and Hospital Epidemiology and Infection Control Collaboration to Ensure Safe Patient Care.

Cleaning, disinfection, and sterilization (CDS) practices and protocols are the cornerstone of infection control and patient safety. Central sterile processing (CSP) leaders are responsible for updating policies and procedures for sterile processing and ensuring CSP staff members process instruments correctly. Monitoring staff member practices can be a demanding and difficult task, but it is critical for safe patient outcomes. The CSP and perioperative leaders at our facility found that regular consultation and collaboration with the Department of Hospital Epidemiology and Infection Control (HEIC) is an effective way to ensure that patient safety is at the forefront of CDS practices. These leaders established an oversight committee to address a variety of infection prevention concerns, including environment of care rounds, implementation of manufacturers' instructions for use, and CDS standardization. This article highlights how CSP and HEIC leaders and staff members partnered to implement and sustain CDS best practices and protocols.

Human factors-based risk analysis to improve the safety of doffing enhanced personal protective equipment.

OBJECTIVE: To systematically assess enhanced personal protective equipment (PPE) doffing safety risks. DESIGN: We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts. SETTING: A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.ParticipantsEight IP experts. METHODS: The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions. RESULTS: Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes. CONCLUSIONS: Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.

Patient and health care worker perceptions of daily use of ultraviolet-C technology as an adjunct to daily cleaning in an academic hospital: Secondary study of Ultra Violet-C Light Evaluation as an Adjunct to Removing Multi-Drug Resistant Organisms.

A cluster randomized crossover trial is in progress at The Johns Hopkins Hospital to investigate the impact of daily ultraviolet (UV)-C light disinfection on the acquisition of health care-associated pathogens. To understand perceptions and challenges to daily use of UV-C, we surveyed health care workers (HCWs) and patients. Most HCWs think daily UV-C decreases the patients' risk of acquiring infection. Daily UV-C is acceptable to patients and may enhance their overall hospital experience.

Comparison of nylon-flocked swab and cellulose sponge methods for carbapenem-resistant Enterobacteriaceae and gram-negative organism recovery from high-touch surfaces in patient rooms.

The ideal sampling method and benefit of qualitative versus quantitative culture for carbapenem-resistant Enterobacteriaceae (CRE) recovery in hospitalized patient rooms and bathrooms is unknown. Although the use of nylon-flocked swabs improved overall gram-negative organism recovery compared with cellulose sponges, they were similar for CRE recovery. Quantitative culture was inferior and unrevealing beyond the qualitative results.

Saving costs through the decontamination of the packaging of unused medical supplies using hydrogen peroxide vapor.

OBJECTIVE. Individually packaged sterile supply items may become contaminated and act as vectors for nosocomial transmission of multidrug-resistant organisms (MDROs). Thus, many hospitals have a policy to dispose of these unused, packaged supply items at patient discharge from the hospital, which has considerable cost implications. We evaluated the frequency of contamination of these items, the efficacy of hydrogen peroxide vapor (HPV) in disinfecting them, and costs associated with discarded supplies. DESIGN. Before-after study. METHODS. A pilot study was performed in the rooms of 20 patients known to be colonized or infected with vancomycin-resistant enterococci (VRE), and a follow-up study was performed in an additional 20 rooms of patients under precautions for various MDROs in 6 high-risk units. Five pairs of supply items were selected. One item of each pair was sampled without exposure to HPV, and the other was sampled after HPV exposure. The cost of discarded supplies was calculated by examining stock lists of supplies stored on the study units. RESULTS. Seven (7%) of 100 items were contaminated with VRE in the pilot study, and 9 (9%) of 100 items were contaminated with MDROs in the follow-up study. None of the items were contaminated after exposure to HPV (P < .02 in both the pilot and the follow-up study). The annual cost of supplies discarded at patient hospital discharge was $387,055. This figure does not include the cost of waste disposal and is therefore likely to be an underestimation of the financial burden. CONCLUSIONS. HPV effectively disinfected the packaging of supply items, which could generate considerable financial and environmental benefits.

Caveat emptor: the role of suboptimal bronchoscope repair practices by a third-party vendor in a pseudo-outbreak of pseudomonas in bronchoalveolar lavage specimens.

OBJECTIVE: To describe a pseudo-outbreak associated with loose bronchoscope biopsy ports caused by inadequate bronchoscope repair practices by third-party vendors and to alert healthcare personnel to assess bronchoscope repair practices. DESIGN: Outbreak investigation. SETTING: A 925-bed tertiary care hospital in Baltimore, Maryland. PATIENTS: Patients who underwent bronchoscopy with certain bronchoscopes after they had been repaired by a third-party vendor. METHODS: An epidemiologic investigation was conducted to determine the cause of Pseudomonas putida growth in 4 bronchoalveolar lavage (BAL) specimens within a 3-day period in May 2008. All bronchoscopes were inspected, and cultures were obtained from bronchoscopes and the environment. Bronchoscope cleaning and maintenance practices were reviewed. Microbiologic results from BAL specimens and medical records were reviewed to find additional cases. RESULTS: All 4 case patients had undergone bronchoscopy with one of 2 bronchoscopes, both of which had loose biopsy ports. Bronchoscope cultures grew P. putida, Pseudomonas aeruginosa, and Stenotrophomonas. The P. putida strains from the bronchoscopes matched those from the patients. Specimens from 12 additional patients who underwent bronchoscopy with these bronchoscopes grew P. putida, P. aeruginosa, or Stenotrophomonas. No patients developed clinical signs or symptoms of infection, but 7 were treated with antibiotics. Investigation revealed that the implicated bronchoscopes had been sent to an external vendor for repair; examination by the manufacturer revealed irregularities in repairs and nonstandard part replacements. CONCLUSIONS: Third-party vendors without access to proprietary information may contribute to mechanical malfunction of medical devices, which can lead to contamination and incomplete disinfection.