reintroducing prac/cal logic to ppe use · 2020. 6. 3. · reintroducing prac/cal logic to ppe use:...

Reintroducing Prac/cal Logic To PPE Use: A Video-Based Survey Dr Su-yin Hor 1,4 , Dr Mary Wyer 1 , Prof Lyn Gilbert 1,2 , Dr Rachel Urwin 1 , Dr Margo Turnbull 2 , Ms Margaret Murphy 3 , A/Prof ChrisHne Jorm 2 , and Ms Ruth BarraM 2 SCENARIO 1 (abbreviated) • 40 y.o. male; triage category 2 (see within 10 mins) • PresenHng complaint: 2 days SOB; producHve cough; fever; lethargy • Recent overseas travel. • O/E: drowsy, producHve cough; pale; temp. 38.5 o C; HR 140; RR 35; BP 135/70; GCS 14; SpO2 95%. The nurse can see through the window that the paHent is pale, breathless and is coughing violently; his oxygen mask has fallen off. The nurse dons PPE before entering the room SCENARIO 2 (abbreviated) • 80 y.o. female; triage category 3 (see within 30 mins) • PresenHng complaint: 24 hours fever; watery diarrhea (approx. hourly) • Lives in aged care facility; brought in by ambulance • O/E: pale, dry mucous membranes; c/o nausea; temp 37.5 o C; HR 109; RR 16; BP 105/82; GCS 15; SpO2 95%. The doctor can see through the window that the paHent is lying in her bed with her eyes closed, holding an emesis bag but has clearly vomited on the bedclothes. The doctor dons PPE before entering the room. CONSENSUS CONTENTIONS Respondents were evenly split on whether the procedures shown in the video were PRACTICAL or IMPRACTICAL (except doffing in Scenario 2) 49% 12% 36% Scenario 2 Donning PracHcal Neither ImpracHcal Unsure 54% 14% 28% Scenario 2 Doffing 44% 11% 42% Scenario 1 Donning PracHcal Neither ImpracHcal Unsure 48% 12% 37% Scenario 1 Doffing There was general agreement about the likely routes of transmission, and that these PPE elements were ALWAYS REQUIRED for the respecHve scenarios (> 75% of respondents) Items: • Mask • Gloves Hand hygiene: • Before gowning • Aier removing gloves • Aier removing gown • Aier removing mask • Aier touching door handle in room Items: • Fluid-resistant gown • Gloves Hand hygiene: • Before gowning • Aier removing gloves • Aier removing mask Process: • Donning PPE outside room • Donning PPE in the sequence shown Process: • Donning PPE outside the room • Removing the mask outside the room Methods of: • Applying & fit-checking mask • Removing gloves, gown and mask Methods of: • Applying gloves • Removing gloves and gown • ICPs and ID physicians were more likely to say it was pracHcal than ED doctors and nurses (p <.05 on 3 out of 4 quesHons) • ED nurses were more likely to say it was pracHcal than ED doctors (p < .05 on all 4 quesHons) 1 The Westmead InsHtute For Medical Research, Westmead, Australia, 2 The University of Sydney, Camperdown, Australia, 3 Western Sydney Local Health District, Australia, 4 Faculty of Health, University of Technology, Sydney, Australia You are busy and rushed and some1mes don’t have the correct informa1on If your life depends on it, your safety comes first Scan these QR codes to watch the videos: 55% 34% 86% 2% 0% 100% Es/mated route(s) of transmission (Scenario 1) 9% 94% 37% 1% 0% 100% Es/mated route(s) of transmission (Scenario 2) QUESTION: What PPE do healthcare workers think is required and prac/cal, when examining ED paHents with unknown infecHous risks? METHOD: Online survey of 270 clinicians naHonally (83 IPC pracHHoners, 36 ED doctors, 90 ED nurses, 51 infecHous disease physicians and 10 nurses), presenHng two scenarios, and video clips of experienced clinicians donning and doffing PPE for each scenario. Scan these QR codes to watch the videos: A majority (75%) of those who selected airborne and/or droplet (and not contact) transmission in Scenario 1, nevertheless required gowns and/or gloves. However, 7% of those who selected contact transmission in Scenario 2, also indicated that gowns and/or gloves were either opHonal or not required. If there is blood or body fluid contact an1cipated [I would] wear gloves and if I have to be up and close with the pa1ent I will wear an apron. Staff will put themselves at risk if the pa1ent is rapidly deteriora1ng, rather than take the allocated 1me to wear PPE Gloves on only if coming into contact with blood/ body fluids & [I would] don inside the pa1ent zone. GOWNS & GLOVES à Risk-assessed rather than pre-determined? Probably difficult to do - but isn't that what we said about hand hygiene in 2009 when compliance was below 30%? The PPE trolley is not re-stocked, oTen used as a dumping ground for extra items (such as urine jars, pa1ent meals etc). I've never watched someone use alcohol based handrub for that long With ED having a rush culture. Staff don't want to be seen to be lazy or slow. If the pa1ent is not crashing, then it's prac1cal.

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ReintroducingPrac/calLogicToPPEUse:AVideo-BasedSurvey

DrSu-yinHor1,4,DrMaryWyer1,ProfLynGilbert1,2,DrRachelUrwin1,DrMargoTurnbull2,MsMargaretMurphy3,A/ProfChrisHneJorm2,andMsRuthBarraM2

Acknowledgements

Background: EmergencyDepartment(ED)staffareatgreaterriskthanotherstaff,ofacquiringinfecHousdiseasesandinadvertentlytransmiUngpathogenspriortodiagnosis.PersonalprotecHveequipment(PPE)iscrucialinreducingtheserisks,butwhatPPEisbothsufficientlyprotecHveandpracHcableforrouHneuseiscontested.Aim: TocontributeknowledgetowardsdevelopingrecommendaHonsforminimumappropriatePPEadherenceforfrontlineEDstaff,whenassessingnewlyadmiMedpaHentswithunknowninfecHousrisks.Method: AnaHonalvideo-basedonlinesurvey.Respondents(n=270)were:83IPCpracHHoners,36EDdoctors,90EDnurses,51infecHousdiseasephysiciansand10nurses

SCENARIO1(abbreviated)•  40y.o.male;triagecategory2(seewithin10mins)•  PresenHngcomplaint:2daysSOB;producHvecough;fever;lethargy•  Recentoverseastravel.•  O/E:drowsy,producHvecough;pale;temp.38.5oC;HR140;RR35;BP135/70;GCS14;SpO295%.

ThenursecanseethroughthewindowthatthepaHentispale,breathlessandiscoughingviolently;hisoxygenmaskhasfallenoff.ThenursedonsPPEbeforeenteringtheroom

SCENARIO2(abbreviated)•  80y.o.female;triagecategory3(seewithin30mins)•  PresenHngcomplaint:24hoursfever;waterydiarrhea(approx.hourly)•  Livesinagedcarefacility;broughtinbyambulance•  O/E:pale,drymucousmembranes;c/onausea;temp37.5oC;HR109;RR16;BP105/82;GCS15;SpO295%.

ThedoctorcanseethroughthewindowthatthepaHentislyinginherbedwithhereyesclosed,holdinganemesisbagbuthasclearlyvomitedonthebedclothes.ThedoctordonsPPEbeforeenteringtheroom.

CONSENSUS

•  Wearingalong-sleevedorfluid-resistantgown•  WearingeyeprotecHon•  Removinggloves,gogglesandgowninsidepaHentroom•  UndoinggownHesintheordershown

•  Wearingamask,wearingasurgicalmask•  WearingeyeprotecHon•  UndoinggownHesinordershown

CONTENTIONS

Respondentswereevenlysplitonwhethertheproceduresshowninthevideowere

PRACTICALorIMPRACTICAL

(exceptdoffinginScenario2)

49%

12%

36%

Scenario2Donning

PracHcalNeitherImpracHcalUnsure

54%

14%

28%

Scenario2Doffing

44%

11%

42%

Scenario1Donning

PracHcalNeitherImpracHcalUnsure

48%

12%

37%

Scenario1Doffing

Therewasgeneralagreementaboutthelikelyroutesoftransmission,andthatthesePPEelementswereALWAYSREQUIREDfortherespecHvescenarios

(>75%ofrespondents)

Items:•  Mask•  Gloves

Handhygiene:•  Beforegowning•  Aierremovinggloves•  Aierremovinggown•  Aierremovingmask•  Aiertouchingdoorhandleinroom

Items:•  Fluid-resistant

gown•  Gloves

Handhygiene:•  Beforegowning•  Aierremovinggloves•  Aierremovingmask

Process:•  DonningPPEoutsideroom•  DonningPPEinthesequenceshown

Process:•  DonningPPEoutsidetheroom•  Removingthemaskoutsidetheroom

Methodsof:•  Applying&fit-checkingmask•  Removinggloves,gownand

mask

Methodsof:•  Applyinggloves•  Removinggloves

andgown

<60%ofrespondentsidenHfiedthesePPEelementsasALWAYSREQUIREDfortheir

respecHvescenarios

•  ICPsandIDphysiciansweremorelikelytosayitwaspracHcalthanEDdoctorsandnurses(p