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Using Institutional Controls to Improve PPE Compliance

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According to 2014 occupational incident surveillance data from nearly 30 U.S. hospitals, when an employee experiences a splash or splatter of blood or body fluid (e.g. blood or bloody urine) into the eye they are only wearing eye-appropriate personal protective equipment (PPE) 3.5 percent of the time. These mucotaneous exposures are extremely high risk. Just as the eyes are the windows to the soul, they are the frontlines for risk of disease transmission from patient to worker. If we experience fatigue, allergies, irritation, or infection our eyes become even more susceptible to microorganisms that come into contact with them.

With the emergence of global infectious disease like Ebola and Zika, we would expect compliance with PPE to be at an all-time high given healthcare facilities focus on public health preparedness.  In fact, the opposite seems to be true. Compared to 2014, in 2013 20.9 percent of all eye exposures reported were employees wearing eye-appropriate PPE (i.e., goggles, faceshield). In 2012, 9.6 percent were wearing eye-appropriate PPE during an eye exposure.

PPE use is sporadic from year to year, despite growing infectious risk associated with the same types of exposures.  When thinking about how to improve occupational protection with the use of PPE specifically, and as it relates to blood and body fluid exposures (BBFE), what guidance, standards, or controls are good enough?

To note, for the purposes of this article, we will be focusing on eye exposures as a means to focus on some of the highest risk exposures first.  This isn’t to say that other types of exposures are not frequent or can’t be high risk, they are and they can -- but this gives us a definitive place to start.

Is Infection Prevention Guidance Good Enough?
No. When turning to CDC for their definition of “standard precautions,” eye protection is not mentioned explicitly.

Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or con-firmed infection status of the patient, in any setting where healthcare is delivered. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation. 
Standard Precautions include:  1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, facemasks), depending on the anticipated exposure, 3) respiratory hygiene and cough etiquette, 4) safe injection practices, and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment.

Additionally, in CDC’s 1998 Guideline for infection control in healthcare personnel. PPE and eye protection used for patient care are not mentioned at all.  In their 2003 guidance Guidelines for Environmental Infection Control in Health-Care Facilities we do begin to see mention of eye protection for airborne viral diseases only, more specifically they recommend “(f)ace shields or goggles will help to prevent mucous-membrane exposure to potentially-aerosolized infectious material in these situations.”

Could lack of specification about PPE use in infection prevention guidance contribute to why compliance with eye protection during what could be the highest risk type of occupational exposures is so low?  Let’s explore this further. 

Are Behavioral Models Enough?
No. In Powers, et al.'s 2016 paper and highlighted in detail in ICT’s May Issue by Kelly Pyrek, we wonder if we create enough “cues” to mo-tivate behavior among healthcare practitioners to improve PPE compliance.  This concept is fundamental to the Health Belief Model (HBM) fea-tured by Powers, Rosenstock, and others over the past several decades. 

Healthcare facilities are paid for performance or punished for not preventing healthcare acquired conditions (HACs) like HAIs, but is there any incentive or motivation to influence worker wellbeing? Is the contrary true?  If healthcare workers are motivated to wear PPE because they perceive it to be beneficial to reduce becoming ill, but their employer does not make it available where and when it is needed – meaning there is no access to it – have we actually created cues for inaction? Does that actually demotivate a preferred behavior or action?

Are OSHA Standards and NIOSH Guidance Enough?
No. While OSHA does require the use PPE in both its Bloodborne Pathogens Standard (BPS) (29 CFR 1910.1030) and its Personal Protective Equipment Standard (29 CFR 1910.132), its language is intentionally generic and performance-based.  Specifically, the BPS standard states: When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered appropriate only if it does not permit blood or oth-er potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

OSHA does not provide specific requirements for when and where, using the example above, that eye protection should be used.  It also does not dictate where it should be kept and how quickly it should be accessible to employees.  Again, the purpose of OSHA standards is to keep the employer at an institutional level accountable for the safety and health of its workers. 

Is depending on individual worker behavior, training, and education enough to increase the use of and compliance with wearing PPE?  Many would argue, no.  Are having standards in place that are designed to protect individual workers but that focus on compliance, program plans, annual reviews, recordkeeping, and abatement on a higher facility or employer level contributing to lower than ideal PPE use? 

Granted, compliance is based on performing exposure assessments and documenting those in the employer’s Exposure Control Plan, but in a changing healthcare environment with constantly changing parameters, cost structures, employee turnover, new technologies, and expansion of healthcare out into communities – is that review really possible on an annual basis?  Is it possible enough that individual worker controls – having access to and wearing PPE in dynamic times – trickles down to those at-risk employees in real time?

NIOSH recommends the following in its 2009 Information for Employers 
Complying with OSHA’s Bloodborne Pathogens Standard: Provide and ensure the use of appropriate personal protective equipment, such as gloves, gowns, lab coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.

This language is identical to OSHA language and offers little in the way of recommendations for what to use during what procedures or for what patients.  Again, these recommendations are workplace-specific and risk-based.  In NIOSH’s 2011 Occupational HIV Transmission and Prevention among Health Care Workers, the agency recommends, “routinely using barriers (such as gloves and/or goggles) when anticipating con-tact with blood or body fluids.”

Again, this is not prescriptive enough to be as useful as we need it to be to improve compliance and PPE use for the workers that need it.  Many are hoping that the new OSHA Infectious Disease Standard will help clarify and specific direction and controls.  More likely, however is that the standard will also be as generic regarding PPE as its predecessor – the CalOSHA Aerosol Transmissible Disease (ATD) Standard.

Is the Occupational Hierarchy of Controls Enough?
Maybe. Since traditional infection prevention guidance is not good enough to improve compliance with PPE and prevent occupational transmission of infectious disease; and since behavioral models, OSHA standards, nor NIOSH guidance seem to do enough in their separate components – what is enough?  Is it a combination of all of those things? Absolutely. But let’s think about this hierarchically.  Can we change behavior – in this case increase PPE use by workers – focusing at a level higher than the worker themselves?

The idea behind the industrial hygiene or occupational hierarchy is that the control methods at the top are potentially more effective and protective than those at the bottom. Following this hierarchy normally leads to the implementation of inherently safer systems, where the risk of illness or injury to the worker has been substantially reduced.

Elimination and substitution, while most effective at reducing hazards, also tend to be the most difficult to implement in an existing process because major changes in equipment and procedures may be required to eliminate or substitute for a hazard.  Consider here, eliminating all skin sutures in place of skin adhesives where possible or substituting glutaraldehyde (“glute”) used for instrument high level disinfection for its less hazardous counterpart -- ortho-phthalaldehyde (OPA) or substituting glass for plastic used in diagnostics.

Engineering controls are favored over administrative controls and PPE for controlling existing worker exposures in the workplace because they are designed to remove the hazard at the source, before it comes in contact with the worker. Well-designed engineering controls can be highly effective in protecting workers.  
Examples of engineering controls used to protect workers from BBFEs are safety engineered medical devices (or sharps with engineered sharp injury protection “SESIPS” in OSHA terms).  While safety devices (e.g., retracting needles or sheathing features on disposable syringes) have been effective in reducing needlesticks in the last 15 years, they still rely on the worker to activate the safety feature. 

According to International Safety Center Exposure Prevention Information Network (EPINet®) 2014 data, 42.3 percent of employees are injured with devices that have an incorporated safety design.   Of those using a safety device, only 36 percent actually fully or partially activate the safety feature.  This can be interpreted to mean that even engineering controls can rely heavily on components of administrative or individual action that fall lower on the hierarchy.  
We still have a ways to go on building better and safer practices, and on building new and different safety designs for sharp medical devices. This includes not just training and education, but also identification, evaluation and selection of effective devices by frontline non-managerial employees as required by OSHA.  
Finally, administrative controls and PPE are frequently used with existing processes where hazards are not particularly well controlled, like BBFEs. Administrative controls and PPE programs may be relatively inexpensive but, over the long term, can be very costly to sustain. These methods for protecting workers have also proven to be less effective than other measures, requiring significant effort by the affected workers and as such less than desired compliance with their use.

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