Healthcare Hygiene magazine May 2020 | Page 22

Potential Contamination of Healthcare Workers’ Attire During a Pandemic By Peter Graves, BSN, RN, CNOR; and Maureen Spencer, M.Ed., BSN, RN. CIC, FAPIC T oday more than ever, transmission of pathogens is on everyone’s mind. For good reason. SARS CoV-2, the virus that causes COVID-19 infection, is highly transmissible and contagious causing world-wide disease and overwhelming the healthcare system. On the front lines of the battle against the COVID-19 are physicians, nurses, and countless dedicated healthcare workers. These healthcare workers are wearing available personal protective equipment (PPE), sometimes new, and in some facilities, they are re-using their PPE. In either situation, it can be reasonably anticipated that contamination of the healthcare workers clothing (uniform, scrubs) worn under the PPE can become contaminated during their workday. This raises a concern for transmission and cross-contamination. Healthcare Personnel Attire (HPA) It is important to recognize and define the modern healthcare personnel’s attire (HPA) in the era of COVID-19. It is well recognized in the literature, prior to the COVID-19 pandemic, that there is a paucity of studies that allowed professional organizations to make evidenced based recommendations on HPA. 1 Traditional HPA has been viewed as portraying a professional appearance. Today however, scrubs are typically worn throughout the healthcare facility, clinics, and even in public. Historically, scrubs were worn only in the operating room where they were facility provided and laundered in a commercial facility. Today, scrubs are often worn for comfort or may be required based upon the clinical setting as defined by the organization. Prior to the COVID-19 outbreak these were typically laundered at home. Across the globe, healthcare settings are diverse and healthcare workers and support staff often wear uniforms, dresses, suits, trousers, blouses, white coats, fleece, sweaters and other clothing made from various textiles. This creates a conundrum for making standardized recommendations to protect the entire healthcare team, their families, and the community. Compounding the challenges for healthcare workers and healthcare organizations, SARS-CoV-2 is also rapidly spreading in the community. 2 The Centers for Disease Control and Prevention (CDC) acknowledges that the virus can spread person-to-person, through contact with contaminated surfaces, and from one’s hands when touching mucous membranes and the face. 2 Today, concerns for HPA contamination arises from both community exposures and from within the healthcare settings. Healthcare worker uniforms/scrubs are often worn from work to home which 22 raises concerns for potential community spread. In 2014, Bearman and colleagues recognized that studies “have demonstrated contamination of healthcare personnel apparel with potential pathogens.” 1 While the risk for transmission of SARS-CoV-2 from contaminated uniforms/scrubs to the community and into homes has yet to be established, it does raise concerns nonetheless. In some clinical settings (e.g., operating rooms, invasive procedural areas), staff are required to change into facility provided surgical attire. It is also commonplace today to see healthcare workers wearing their uniforms/scrubs in public, not just in proximity to the healthcare facility, but in coffee shops, grocery stores, and other public spaces. In a 2010 study by Nordstrom and colleagues discovered a significantly higher bacteria counts from home-laundered scrubs and unwashed scrubs. In the home-laundered scrubs 44 percent (18/41) were positive for coliform bacteria, but no isolates were Escherichia. 3 Therefore, it is not at all a stretch to consider the possibility that SARS-CoV-2 could reside for a period of time on HPA. Presently, healthcare workers frequently wash or sanitize their hands and don and doff personal PPE. Since some PPE may not completely cover HPA, and they touch and adjust their clothing throughout the workday, contamination could occur. Healthcare workers are also mobile, often moving from area to area, encountering various environmental surfaces, patients, and co-workers. They typically change their uniforms/scrubs once a day, unless they become visibly soiled or contaminated. Contamination of Uniforms There are many studies published on the contamination of HPA in various clinical settings. From scrubs to neck ties, lab coats to head coverings, HPA worn during the care of patients can become contaminated, sometimes with pathogenic organisms. 4-10 Today, we are experiencing a pandemic where SARS-CoV-2 has been demonstrated to survive on various surfaces from a few hours to days. 11 In a study by Bloomfield evaluating the surfaces of nurse’s uniforms at the end of their shift, both Clostridium diifficile (C. diff) and methicillin-resistant Staphylococcus aureus (MRSA) were detected. 12 In a study by Treakle evaluating the contamination of lab coats, 23 percent were contaminated with MSSA and 18 percent with MRSA. 13 In a 2011 study published by Wiener-Well, 60 percent of hospital staff uniforms were contaminated with multidrug-resistant organisms (MDRO). 6 With the recent finding that SARS-CoV-2 can survive for days on common healthcare surfaces, 11 one needs to be concerned with the potential transmission to the healthcare workers uniform which is worn into and out of the healthcare setting. In a 2012 observational study conducted in six intensive care units, it was reported that 21 percent of patient and healthcare worker interactions contaminated the gloves and gown of the care provider. 14 Reuse of PPE due to severe shortages are happening today across the United States. Therefore, there is concern that HPA could be potentially contaminated with pathogenic may 2020 • www.healthcarehygienemagazine.com