Healthcare Workers and PPE: Lessons from SARS

Healthcare Workers and PPE: Lessons from SARS

Allison McGeer, MSc, MD, FRCPCMount Sinai HospitalUniversity of Toronto

Allison McGeer, MSc, MD, FRCPCMount Sinai HospitalUniversity of Toronto

Conditions required for PPE to protect health care workersConditions required for PPE to protect Conditions required for PPE to protect health care workershealth care workers

At-risk patients must be recognized as such

Healthcare workers must choose to wear PPEPPE must be appropriate and functional

At-risk patients must be recognized as such

Healthcare workers must choose to wear PPEPPE must be appropriate and functional

UNRECOGNIZED AS SARS: 2.2 infections/ patient dayRECOGNIZED: 0.0034 infections/ patient day

HCW – source of infectionHCW HCW –– source of infectionsource of infection

10%

2%

15%

73%

10%

2%

15%

73%

Unrecognized patientsNo precautionsPrecautions ordered

Recognized patientsPrecautions not useSome precautions

ProblemsProblemsProblems

If you ask HCWs to use inconvenient preventive practice when they think it is unnecessary–THEY WON’T DO IT

Barrier precautions are associated with highly significant rates of PATIENT adverse effects– Half as many HCW visits, 33% less contact time, increased rates of

depression, anxiety, anger, – 12% risk of preventable adverse events per one week admission

If you ask HCWs to use inconvenient preventive practice when they think it is unnecessary–THEY WON’T DO IT

Barrier precautions are associated with highly significant rates of PATIENT adverse effects– Half as many HCW visits, 33% less contact time, increased rates of

depression, anxiety, anger, – 12% risk of preventable adverse events per one week admission

To assess adherence to barrier precautions among staff who cared for critically ill SARS

patients during the Toronto SARS outbreak

ObjectiveObjectiveObjective

Design –Retrospective cohort analysisCohort – HCWs providing care for SARS patients immediately (<24h) before and during intubation during the Toronto outbreak (March-June, 2003)Cohort identification - HCWs identified from charts, staffing assignment forms, managers, and colleagues Data collection - Face-to-face interview using structured questionnaire, with chart available

Design –Retrospective cohort analysisCohort – HCWs providing care for SARS patients immediately (<24h) before and during intubation during the Toronto outbreak (March-June, 2003)Cohort identification - HCWs identified from charts, staffing assignment forms, managers, and colleagues Data collection - Face-to-face interview using structured questionnaire, with chart available

MethodsMethodsMethods

Outcome: – Consistent adherence to PPE

eye protection, mask, gloves, and gown“always wore”

Secondary: Removal practices

Outcome: – Consistent adherence to PPE

eye protection, mask, gloves, and gown“always wore”

Secondary: Removal practices

MethodsOutcome measuresMethodsMethodsOutcome measuresOutcome measures

PPE removalPPE removalPPE removalSafest– Gloves removed first– Consistent hand disinfection BEFORE hands touch face– Hand disinfection as terminal event

Some risk– Gloves removed first– Hand disinfection at least once

At risk– Gloves NOT removed first– No hand disinfection described

Safest– Gloves removed first– Consistent hand disinfection BEFORE hands touch face– Hand disinfection as terminal event

Some risk– Gloves removed first– Hand disinfection at least once

At risk– Gloves NOT removed first– No hand disinfection described

• Patient-related: –Patient’s diagnosis, Severity of illness (APACHE II

score), Precautions orderedHCW-related:

–Age, gender, occupation–Hospital, type of ward (SARS unit, ICU, ED, other)–Time spent in patient’s room–Number of room entries– Involvement in patient care activities (N=34)– Infection control training

• Patient-related: –Patient’s diagnosis, Severity of illness (APACHE II

score), Precautions orderedHCW-related:

–Age, gender, occupation–Hospital, type of ward (SARS unit, ICU, ED, other)–Time spent in patient’s room–Number of room entries– Involvement in patient care activities (N=34)– Infection control training

MethodsPredictor variablesMethodsMethodsPredictor variablesPredictor variables

ResultsResultsResults

56 patients intubated15 hospitals (4 teaching, 11 community) diagnosis at time of care– 49 SARS– 3 pneumonia (during outbreak)– 1 contact + airborne– 1 MRSA (gown, glove, mask)– 2 pneumonia (prior to outbreak recognition)

56 patients intubated15 hospitals (4 teaching, 11 community) diagnosis at time of care– 49 SARS– 3 pneumonia (during outbreak)– 1 contact + airborne– 1 MRSA (gown, glove, mask)– 2 pneumonia (prior to outbreak recognition)

795 HCWs (90% of 879 eligible) enrolled46% (368) nurses 14% (113) respiratory therapists 14% (113) physicians10% (82) X-ray technologists16% (125) Other (eg. paramedic, physiotherapists

Most HCWs cared for 1 patient (range 1-8) – 164 (20%) cared for more than one patient

5146 patient care activities/procedures assessed

795 HCWs (90% of 879 eligible) enrolled46% (368) nurses 14% (113) respiratory therapists 14% (113) physicians10% (82) X-ray technologists16% (125) Other (eg. paramedic, physiotherapists)

Most HCWs cared for 1 patient (range 1-8) – 164 (20%) cared for more than one patient

5146 patient care activities/procedures assessed

ResultsResultsResults

55.7

97.4

5.6

81.7

53.9

34.6

0

20

40

60

80

100

March April May June

Shifts with patients recognized as SARS

Shifts with patients not known to be SARS

55.7

97.4

5.6

81.7

53.9

34.6

0

20

40

60

80

100

March April May June

Shifts with patients recognized as SARS

Shifts with patients not known to be SARS

Pts with diagnosis of SARS

Pts not recognized as SARS

ResultsAdherence with PPE over timeResultsResultsAdherence with PPE over timeAdherence with PPE over time

64.372.274.5

84

59.780.9

86.5

57.176.4

88.2

6485.5

29.284.6

0 10 20 30 40 50 60 70 80 90 100

PATIENT RECOGNIZED AS SARS Recognized 2.5, P=.002Not Recognized 1

PATIENT'S APACHE II score Less than 20 1More than 20 0.4, P<.0001

HOSPITAL LOCATIONSARS Unit 4.0, P=.0006ICU 4.3, P=.0001Other ward 1

INFECTION CONTROL TRAINING In person 2.7, P<.0001Written Instructions only 1.7, P=.05None 1

NUMBER OF TIMES ENTERED A ROOM 1 -2 times 13-5 times 0.6, P=.036-10 times 0.5, P=.03> 10 times 0.3, P=.0007

% adherence

64.372.274.5

84

59.780.9

86.5

57.176.4

88.2

6485.5

29.284.6

0 10 20 30 40 50 60 70 80 90 100

PATIENT RECOGNIZED AS SARS Recognized 2.5, P=.002Not Recognized 1

PATIENT'S APACHE II score Less than 20 1More than 20 0.4, P<.0001

HOSPITAL LOCATIONSARS Unit 4.0, P=.0006ICU 4.3, P=.0001Other ward 1

INFECTION CONTROL TRAINING In person 2.7, P<.0001Written Instructions only 1.7, P=.05None 1

NUMBER OF TIMES ENTERED A ROOM 1 -2 times 13-5 times 0.6, P=.036-10 times 0.5, P=.03> 10 times 0.3, P=.0007

% adherence

Results: Multivariable analysisResults: Multivariable analysisResults: Multivariable analysis

20

30

40

50

60

70

80

90

100

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Airway procedures Any other procedures

P<0.0001

1-5 times 6 and more

p=0.0001

TYPE OF PROCEDURE NUMBER OF ROOM ENTRIES

20

30

40

50

60

70

80

90

100

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Perform

edAss

isted

Observ

ed

Airway procedures Any other procedures

P<0.0001

1-5 times 6 and more

p=0.0001

TYPE OF PROCEDURE NUMBER OF ROOM ENTRIES

ResultsAdherence by type of procedureResultsResultsAdherence by type of procedureAdherence by type of procedure

Results Removal practicesResults Results Removal practicesRemoval practices

Safest – 15%Some risk – 62%At risk – 22%

Safest – 15%Some risk – 62%At risk – 22%

3.4 (1.3 - 9.3) P=.021.9 (0.7 - 5.0) P=.22

1 (ref)

SARS UnitICUOther

7.6 (4.8 - 11.9) P<.0001Teaching vs. Community hospital

2.0 (1.3 - 3.2 ) P=.002Nurses vs. other job category

OR (95% CI)Multivariate GEE Model

ResultsFactors associated with safe removalResultsResultsFactors associated with safe removalFactors associated with safe removal

6 weeks into the SARS outbreak, HCWs were still not making sufficiently conservative decisions about using PPE

6 weeks into the SARS outbreak, HCWs were still not making sufficiently conservative decisions about using PPE

55.7

97.4

5.6

81.7

53.9

34.6

0

20

40

60

80

100

March April May June

Shifts with patients recognized as SARS

Shifts with patients not known to be SARS

All shifts

55.7

97.4

5.6

81.7

53.9

34.6

0

20

40

60

80

100

March April May June

Shifts with patients recognized as SARS

Shifts with patients not known to be SARS

All shifts

Conclusions - IConclusions Conclusions -- II

Decreased adherence with increased APACHE score suggests that HCWs may make decisions based on patient safety despite risk to themselves

This cohort did not make PPE decisions based on the procedure they were about to undertake

Decreased adherence with increased APACHE score suggests that HCWs may make decisions based on patient safety despite risk to themselves

This cohort did not make PPE decisions based on the procedure they were about to undertake

Conclusions - IIConclusions Conclusions -- IIII

Education is critical– In person training>written materials>none– SARS units>other hospital areas– Teaching hospitals vs community for PPE

removalDespite education, most HCWs did not clearly understand self-contamination with PPE removal

Education is critical– In person training>written materials>none– SARS units>other hospital areas– Teaching hospitals vs community for PPE

removalDespite education, most HCWs did not clearly understand self-contamination with PPE removal

Conclusions - IIIConclusions Conclusions -- IIIIII

Research questionsResearch questionsResearch questionsWhy was education so important during SARS outbreak, when other research suggests that knowledge is not a particularly important factor in HCW PPE adherence?How to worker and patient safety interact? How do we balance priorities if they conflict?Is a continued focus on procedure-driven PPE feasible?

Why was education so important during SARS outbreak, when other research suggests that knowledge is not a particularly important factor in HCW PPE adherence?How to worker and patient safety interact? How do we balance priorities if they conflict?Is a continued focus on procedure-driven PPE feasible?

Toronto SARS Hospital Investigation Team:E. Bontovics, D. Gravelle, B. Henry, M. Loeb, C.

MacDonald, S. Paton, J.M. Raboud, D. Scales, S. Shen, A.E. Simor, M. Vearncombe, D. Zoutman

Patients with SARS, their families and friendsThe staff, visitors and patients of greater Toronto area hospitals and public health departments and their families

Toronto SARS Hospital Investigation Team:E. Bontovics, D. Gravelle, B. Henry, M. Loeb, C.

MacDonald, S. Paton, J.M. Raboud, D. Scales, S. Shen, A.E. Simor, M. Vearncombe, D. Zoutman

Patients with SARS, their families and friendsThe staff, visitors and patients of greater Toronto area hospitals and public health departments and their families

AcknowledgementsAcknowledgementsAcknowledgements