of the evidence in simulation studies and because
of risk of bias.
Let’s examine the findings of Verbeck, et al.
(2020).
Types of PPE
The use of a powered, air‐purifying respirator
with coverall may protect against the risk of
contamination better than a N95 mask and gown
but was more difficult to don. In one RCT (59
participants), people with a long gown had less
contamination than those with a coverall, and
coveralls were more difficult to doff. Gowns may
protect better against contamination than aprons.
PPE made of more breathable material may lead to
a similar number of spots on the trunk compared
to more water‐repellent material but may have
greater user satisfaction.
Modified PPE versus standard PPE
The following modifications to PPE design may
lead to less contamination compared to standard
PPE: sealed gown and glove combination; a better
fitting gown around the neck, wrists and hands;
a better cover of the gown‐wrist interface; added
tabs to grab to facilitate doffing of masks or gloves.
Donning and doffing
Using CDC recommendations for doffing
may lead to less contamination compared to no
guidance. One‐step removal of gloves and gown
may lead to less bacterial contamination but not
to less fluorescent contamination than separate
removal. Double‐gloving may lead to less viral
or bacterial contamination compared to single
gloving but not to less fluorescent contamination.
Additional spoken instruction may lead to fewer
errors in doffing and to fewer contamination spots.
Extra sanitation of gloves before doffing with
quaternary ammonium or bleach may decrease
contamination, but not alcohol‐based handrub.
Training
The use of additional computer simulation may
lead to fewer errors in doffing. A video lecture
on donning PPE may lead to better skills scores
than a traditional lecture. Face‐to‐face instruction
may reduce noncompliance with doffing guidance
more than providing folders or videos only.
As Verbeck, et al. (2020) observe, “We still
need RCTs of training with long‐term follow‐up.
We need simulation studies with more participants
to find out which combinations of PPE and which
doffing procedure protects best. Consensus on
simulation of exposure and assessment of outcome
is urgently needed. We also need more real‐life
evidence. Therefore, the use of PPE of healthcare
workers exposed to highly infectious diseases
should be registered and the healthcare workers
20
should be prospectively followed for their risk
of infection.”
The researchers say that there is a need
re‐evaluate how PPE is standardized, designed
and tested: “What is missing is a harmonized set
of PPE standards and a unified design for PPE to
be used when taking care of patients with highly
infectious diseases. This holds for PPE as used for
preventing contact transmission as well as other
ways of transmission. There is, for example, no
unified technical standard for isolation gowns.
There is also a need for a more transparent and
uniform labeling of infection control measures,
such as droplet precautions, and the protection
level of PPE for healthcare workers. We believe that
this is an important prerequisite for the universal
implementation of infection control measures for
healthcare workers.”
They continue, “To find out how PPE behaves
under real exposure, we need prospective follow‐
up of healthcare workers involved in the treatment
of patients with highly infectious diseases, with
careful registration of PPE, donning and doffing
and risk of infection. Here, the effect sizes would
be smaller and thus the sample size should be
bigger than 60. In addition, case‐control studies
comparing PPE use among infected healthcare
workers and matched healthy controls, using
rigorous collection of exposure data, can provide
information about the effects of PPE on the risk of
infection. The sample sizes should be much bigger
than the current case studies because we would
like to detect small but important differences
in effect between various combinations of PPE
such as gowns versus coveralls. There is a need
for collaboration between organizations serving
epidemic areas to carry out this important research
in circumstances with limited resources, and during
the throes of an outbreak.”
Problematic PPE Use
Even before the COVID-19 outbreak, it was
challenging for healthcare institutions to get it
right when it came to consistent, proper use of
PPE. Echoing many other researchers, Verbeck, et
al. (2020) confirm, “Compliance with guidance on
correct PPE use in healthcare is historically poor.
Healthcare workers sometimes distrust infection
control, and using PPE is stressful. For respiratory
protection such as masks and respirators, compli-
ance has been reported to be around 50 percent
on many occasions. Due to lack of proper fitting
and incorrect use, real-field conditions almost
never match laboratory standards. Also, reports of
hand hygiene show that there is still much room
for improvement, and guidelines recommend
education and training in combination with other
implementation measures.”
To find out
how PPE
behaves under
real exposure,
we need
prospective
follow–up
of healthcare
workers
involved in
the treatment
of patients
with highly
infectious
diseases,
with careful
registration
of PPE,
donning
and doffing
and risk of
infection.”
Despite problematic PPE use, we know from
studies conducted during the SARS and Ebola virus
may 2020 • www.healthcarehygienemagazine.com