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Abstract
Background
The current COVID-19 pandemic has demonstrated that personal protective equipment
(PPE) is essential, to prevent the acquisition and transmission of infectious diseases,
yet its use is often sub-optimal in the clinical setting. Training and education are
important to ensure and sustain the safe and effective use of PPE by medical interns,
but current methods are often inadequate in providing the relevant knowledge and skills.
The purpose of this study was to explore medical graduates’ experiences of the use
of PPE and identify opportunities for improvement in education and training programmes,
to improve occupational and patient safety.
Methods
This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney,
Australia, to explore medical interns’ self-reported experiences of PPE use, at the
beginning of their internship. Reflexive groups were conducted immediately after theoretical
and practical PPE training, during hospital orientation. Transcripts of recorded discussions
were analysed, using a thematic approach that drew on the COM-B (capability, opportunity,
motivation - behaviour) framework for behaviour.
Results
80% of 90 eligible graduates participated. Many interns had not previously received
formal training in the specific skills required for optimal PPE use and had developed
potentially unsafe habits. Their experiences as medical students in clinical areas
contrasted sharply with recommended practice taught at hospital orientation and impacted
on their ability to cultivate correct PPE use.
Conclusions
Undergraduate teaching should be consistent with best practice PPE use, and include
practical training that embeds correct and safe practices.
Many nosocomial outbreaks exhibit "superspreading events" in which cross-transmission occurs via a single individual to a large number of patients. We investigated how heterogeneity in Health-Care Worker (HCW) behaviors, especially compliance to hand hygiene, may cause superspreading events. In particular, we compared the superspreading potential of peripatetic (noncohorted) HCWs with that of other HCWs. We developed an agent-based model for hand transmission of a pathogen in a hospital ward. Three HCW profiles were allowed: 2 assigned profiles, one with frequent contacts with a limited number of patients, another with fewer contacts but with more patients; and one peripatetic profile, with a single daily contact with all patients. We used data from the literature on common nosocomial pathogens (Staphylococcus aureus, Enterococci). The average number of patients colonized over 1 month increases with noncompliance to hand hygiene. Importantly, we show that this increase depends on the profile of noncompliant HCWs; for instance, it remains low for a single noncompliant assigned HCW but can be quite large for a single noncompliant peripatetic HCW. Outbreaks with this single fully noncompliant peripatetic HCW (representing only 4.5% of the staff) are similar to those predicted when all HCWs are noncompliant following 23% of patient contacts. Noncompliant peripatetic HCWs may play a disproportionate role in disseminating pathogens in a hospital ward. Their unique profile makes them potential superspreaders. This suggests that average compliance to hygiene may not be a good indicator of nosocomial risk in real life health care settings with several HCW profiles.
The Ebola virus disease outbreak in west Africa and the rapid spread of other emerging viruses, such as the severe acute respiratory syndrome or the Middle East respiratory syndrome coronaviruses, showed how limited or non-existent infection prevention and control (IPC) programmes, combined with an inadequate water supply, poor sanitation, and a weak hygiene infrastructure in health facilities, can threaten global health security. In such outbreaks, instead of serving as points where disease was controlled, health-care facilities became dangerous places for outbreak amplification among staff and patients and transmission back to communities. According to WHO, defective IPC practices during everyday health-care delivery also cause harm to hundreds of millions of patients worldwide every year.1, 2 The European Centre for Disease Prevention and Control estimated that more than 2·6 million new cases of health-care-associated infection occur every year in Europe, with a cumulative burden estimated in disability-adjusted-life-years that is higher than all other reported 32 communicable diseases. 3 The burden of health-care-associated infections was also recently highlighted in southeast Asian countries. 4 Many health systems fail to build strong foundations to reduce the risks and spread of health-care-associated outbreaks. They also tolerate an unacceptably poor level of IPC in everyday practice. It is now urgent to consider IPC capacity building and actual implementation as global health priorities. This would create a unique opportunity to make IPC a strong contributor to the achievement of the health-related UN's Sustainable Development Goals (particularly, 3.1-3, 3.b, 3.d, and 6), including quality universal health coverage (3.8). 5 It would also help effective implementation of other major global health priorities, including the International Health Regulations, antimicrobial resistance (AMR) action plans, patient and health worker safety, and integrated people-centred care.6, 7 Among its efforts in this field, WHO coordinates the Global IPC (GIPC) Network. This brings together major IPC organisations with the aim to enhance local, national, and international collaboration. It also supports country efforts in strengthening IPC systems and programmes, outbreak preparedness and response, and capacity building for surveillance. In early 2017, GIPC Network participants and WHO identified priorities for the next 5 years at both the country and global (panel ) level. Together with the recent WHO guidelines on core components of IPC programmes, 8 the new priorities will be a source of direction and focus for decision-makers and influencers at national and international health-care levels. Panel Call for action Priorities for IPC at country level Countries where IPC has just started • Decisive and visible political commitment, including IPC policy development and enforcement • Availability of resources (both human and infrastructure) • Establishment and execution of IPC programmes at the national and acute health facility levels to ensure advocacy, training and data for future improvement and sustainability • Action to increase availability of in-country IPC knowledge and expertise Countries with advanced IPC programmes • Increased accountability with IPC as a quality indicator • Development of advanced information technology tools to support IPC monitoring and implementation • Translation of information through enhanced communications to sustain awareness and engagement • Credible incentives considering the local context to increase compliance rates • Enhanced education and training to embed IPC knowledge across all disciplines Priorities for IPC at the global level Strengthen IPC in the health system perspective • Strengthen IPC visibility and advocacy: convince decision-makers and stakeholders • Lead on IPC knowledge development: create standardised curricula templates that can be adapted locally (“adapt to adopt”) and stimulate further research on priority areas • Foster and promote IPC as a marker of quality: establish international IPC minimum standards • Build active networks and stronger communications:- ensure that patient safety and quality improvement leaders, as well as other health workers across all disciplines, are engaged to advocate for IPC Elevate the role of IPC specifically to better combat AMR • Strengthen the power to act: secure support for a “top-down” chief executive approach, empower IPC leads • Improve evidence presentation to leaders: effectively outline available data and other information on the impact of IPC solutions on AMR • Expand the narrative: help people visualise how IPC programmes can lead to AMR risk reduction IPC=infection prevention and control. AMR=antimicrobial resistance. Ebola virus disease and other outbreaks, as well as the seriousness of the seemingly inexorable march of AMR, 9 have been wake-up calls to political and public health leaders around the world. However, the relationship between these big picture global threats and the need to secure real and sustained IPC improvements in every country (panel) is not always fully appreciated. Inevitably, the pace at which change can be achieved in countries will vary for historical, logistical, and financial reasons. This should not detract from the realisation that political engagement, constant provision of the necessary resources for such a vital function, and the need for greater awareness and training, should be a priority everywhere. At the global level (panel), there is a need for international organisations to recognise that global health security relies on effective IPC to control emerging health threats (including AMR) and that there is a need to intensify IPC support to countries and the international community. An early opportunity to convince global and national leaders of the value of IPC action is this year's World Antibiotic Awareness Week which emphasises IPC among its core messages. While efforts such as new drug development are certainly needed, IPC is a tried-and-true approach that is likely to be cost-effective and with the capacity to sustain or even potentiate successes gained through new drug development or improving antibiotic use. A number of common challenges and barriers still exist to accomplish these priorities, such as competing political agendas, resource constraints, and multiple promotional health messages. Additionally, despite strong evidence for the effectiveness of IPC, further research is needed to identify and validate innovative technologies and equipment to support IPC, provide a stronger demonstration of the cost-effectiveness of IPC interventions, and identify feasible implementation approaches and local solutions for low-resource settings. There are strong economic and ethical reasons to enhance IPC within the national and global health security agendas given both the burden and priorities outlined by the GIPC Network. Very recently, Tedros Adhanom Gehebreyesus, the new Director-General of WHO, has said, “Universal health coverage and health emergencies are cousins…. Strong health systems are our best defense to prevent outbreaks from becoming epidemics”. 10 Efforts should capitalise upon evidence-based recommendations, proven and feasible implementation strategies, and awareness raised by AMR and epidemic-prone disease threats. The GIPC Network Call for Action promotes coordination, synergy, accountability, and communication as essential means to make this happen.
ABSTRACT Background: Healthcare personnel often use incorrect technique for donning and doffing of personal protective equipment (PPE). Objective: We tested the hypothesis that medical students receive insufficient training on correct methods for donning and doffing PPE. Methods: We conducted a cross-sectional survey of medical students on clinical rotations at two teaching hospitals to determine the type of training they received in PPE technique. The students performed simulations of contaminated PPE removal with fluorescent lotion on gloves and were assessed for correct PPE technique and skin and/or clothing contamination. To obtain additional information on PPE training during medical education, residents, fellows, and attending physicians completed written questionnaires on PPE training received during medical school and on knowledge of PPE protocols recommended by the Centers for Disease Control and Prevention. Results: Of 27 medical students surveyed, only 11 (41%) reported receiving PPE training, and none had received training requiring demonstration of proficiency. During simulations, 25 of 27 (92.5%) students had one or more lapses in technique and 12 (44%) contaminated their skin with fluorescent lotion. For 100 residents, fellows and attending physicians representing 67 different medical schools, only 53% reported receiving training in use of PPE and only 39% selected correct donning and doffing sequence. Conclusions: Our findings suggest that there is a need for development of effective strategies to train medical students in correct use of PPE. Abbreviations: PPE: Personal protective equipment; MRSA: Methicillin-resistant Staphylococcus aureus; SARS: Severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; WHO: World Health Organization; CDC: Centers for Disease Control and Prevention; OSCE: Objective structured clinical examination
[1
]Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research,
176 Hawkesbury Rd, Westmead, NSW 2145 Australia
[2
]GRID grid.1013.3, ISNI 0000 0004 1936 834X, Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney,
; Sydney, NSW Australia
[3
]GRID grid.1013.3, ISNI 0000 0004 1936 834X, Westmead Clinical School, Faculty of Medicine and Health, , The University of Sydney, ; Sydney, NSW Australia
[4
]GRID grid.117476.2, ISNI 0000 0004 1936 7611, Centre for Health Services Management, Faculty of Health, , University of Technology Sydney, ; Sydney, Australia
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History
Date
received
: 1
July
2020
Date
accepted
: 9
September
2020
Funding
Funded by: Australian Partnership for Preparedness Research on Infectious Disease Emergencies
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