Donna Moralejo, PhD Memorial University School of Nursing Newfoundland, Canada

Transcription

1 Donna Moralejo, PhD Memorial University School of Nursing Newfoundland, Canada 1

2 Achieving Evidence-Based Practice in PPE Use: Is it Realistic? Evidence Factors/issues to be addressed in implementation of evidence Interventions to improve practice Conclusion: is it realistic? Recommendations 2

3 Evidence Strong theoretical basis: chain of infection, MOA of PPE Moderate evidence that PPE decreases transmission Pro-con: Crit Care 2012; 16(1): 202 Evidence-based guidelines Standard and transmissionbased precautions Microorganism or infectionspecific Implementation Factors to be addressed! 3

4 Cognitive Affective Psychomotor Logistical Do they know when to use PPE? Do they know what PPE to use? Do they have a positive attitude towards PPE? Are they able to use PPE properly? Putting it on Wearing it during care Removing it Do they have PPE to use? Are there are logistical issues to address? 4

5 Multiple studies have assessed knowledge Variable results Low to high knowledge scores Variation by type of HCW, by and within country, setting Variation in attitude Fewer studies assess it Harder to define e.g., acceptance, unit culture, role modelling Suggests need to do own assessment to identify local needs and issues 5

6 Poor recognition of transmission risk zone predicted intention to not wear mask (Gulton et al. AJIC 2013; 41(1): 2-7) Lower rates of correct PPE choices with use of incorrect terminology (Landers et al. J Adv Nurs 2013; 66(10): ) Parmeggiani et al. (BMC Inf Dis 2010; 10:35) surveyed 307 HCWs in 8 ERs in Italy: High knowledge scores and over 94% agreed with guidelines but <100% selfreported compliance: 85% always changed gloves after each patient 79% did hand hygiene after glove removal 6

7 Reid et al. (CJEM 2011; 13(2): 71-78) gave case scenarios to 123 paediatric ER MDs across Canada: Self reported PPE choices matched guidelines: <5% for 2 scenarios, 8-16% for 3 scenarios, 54% for 1 Chose correct type of isolation precautions: <15% in 4 scenarios, 40-55% in 2 scenarios, 65-75% in 4 scenarios and 82% for CDAD scenario Specific PPE selected when not indicated (Landers 2013) Mitchell et al. (AJIC 2013; 41(3): ) observed HCWs selecting and removing PPE when caring for patients with febrile respiratory illness Mask and gloves chosen 88%, eye protection 37% 7

8 Beam et al. (AJIC 2014; 42(11): ) video recorded simulation of CP and AP, 24 Nurses Donning: Gown: 14 right side out, 8 correctly tied N95: 0 fit checked, 12 correctly tied/positioned Correct fit gloves/gowns: 16 In room activities: Touched unprotected face with glove:4 Adjusted N95 or other PPE: 9 Contact of unprotected body areas with potentially contaminated surface or object: 22 8

9 Beam et al.: Proper removal: gloves 12, gowns 6, N95 5 [of 24] Proper disposal of gloves: 21/24 Mitchell et al.: 54% removed PPE in correct sequence 46% correct hand hygiene during removal Hung et al. (Comput Inform Nurs 2015; 33(2): 49-57) did computer simulation with 25 HCWs 33 errors during PPE removal Multiple studies show contamination of hands, shoes and environment with removal of PPE 9

10 Overall, studies indicate we have not yet achieved EBP! Need to improve knowledge and skills Also need to address situational/logistics 10

11 Multiple studies show knowledge scores can be increased with education Rigour of studies not always high! May not translate to actual practice Ward: No really convincing evidence that education improves PPE use in practice long term (Nurs Educ Today 2011; 31: 9-17) Less research has been done on PPE use and Standard Precautions than on hand hygiene 11

12 Practice with removal of PPE using recommended technique can decrease contamination (Lai et al. AJIC 2011; 39(2): ; Guo et al. AJIC 2014; 42(4): e39-45) Simulations show more improvement than conventional education (Hung et al. 2015; Hon et al. AJIC 2008; 26(10): e33-37) Post-intervention scores may be higher but are they high enough? Al-Hassami & Darawad (AJIC 2013; 41: 332-6): Post test scores: 67% to 83% vs. 13%-53% pre 12

13 Studies rarely evaluate actual practice post education! Beam et al sent follow-up questionnaire 1 month after video recording session: 14 of 24 responded; all said changed behaviour in some way but how varied Carrico et al. (AJIC 2007; 35(1): 14-9): Training with visual demo of respiratory particle dispersion. Follow up on ward: Significant improvement in correct use of mask Some studies identified predictor of correct PPE use as recent IC training (Shigayeva et al. ICHE 2007; 28(11): ), or knowledge score (Landers et al. 2010) 13

14 Availability of PPE 1,2, 3 PPE conveniently placed 1 Patient identified as potential risk 1, 5 Reminders re what to wear, removal 1 Hand hygiene facilities convenient 1 Positive attitude to PPE use 3, 4 Reprimand for non compliance from supervisors 3 Workload 4, 5 1. Reid et al. 2. Chughtai et al. AJIC 2015; 43(1): Hu et al. PLoS One 2012; 7(9): e Beam et al Shigayeva et al

15 Yes but So many barriers! 100% of time? Required sustained effort at multiple levels: Basic and continuing education, reinforcement Changes in local environment and at institutional level We need more than information giving We can improve PPE use and decrease transmission but 15

16 We also need: Hand hygiene Clean equipment Clean environment Appropriate patient placement Cough etiquette Standard Precautions and Transmission- Based Precautions 16

17 Increase education, involving actual practice and problem solving All levels, different strategies Focus on behaviour change, risk assessment and supportive environments, not just knowledge Address logistical issues Organizational and unit culture Workload PPE availability and placement Other standard precautions More research to identify what interventions work 17

18 It is realistic to believe that we can achieve improved PPE selection and use Use HAIs to assess adequacy We need better evidence on which strategies are effective Not just education We need to focus on more than PPE in order to protect HCWs and patients, and reduce HAIs 18

19 Questions?