How Well Do You Think You Are Protected?

Understanding proper use and disposal of protective gowns for healthcare workers

The prevalence of infectious diseases, such as Hepatitis B, Hepatitis C, HIV, SARS and avian flu, have raised the concern of hospital personnel over the possibility of acquiring such infections. Healthcare workers (HCWs) in or outside hospitals who have contact with patients, body fluids, or specimens may easily acquire infections from or transmit infections to patients, other personnel, or loved ones. Personal protective equipment (PPE) is a critical component in the hierarchy of controls used to protect HCWs from infectious hazards. HCW PPE may include gowns, respirators, face masks, gloves, eye protection, face shields, and head and shoe coverings.Even though protective ensembles are worn to protect hospital workers and patients alike, if not used or disposed of correctly, this equipment may pose a considerable risk for the public health. Although laboratory studies have produced mixed results for the effectiveness of gown use, appropriate gowns are recommended to prevent or reduce HCW exposure to bloodborne pathogens. However, those using the gowns may have limited information on the performance of the gowns they wear every day.

 Protecting Healthcare Workers

Healthcare is the fastest-growing sector of the U.S. economy, employing over 18 million workers. An estimated 17-57 employed HCWs per million die annually from occupational infections and injuries and 9-42 HCWs per million die per year exclusively from occupational infections (Sepkowitz and Eisenberg 2005). Because of this risk of exposure to infectious diseases, in 1991 the Occupational Safety and Health Administration (OSHA) mandated the use of universal precautions during treatment of all patients in order to minimize HCWs’ risks of acquiring bloodborne pathogens (Department of Labor, 1991). This rule requires over five million HCWs to wear personal protective equipment (PPE) and employers to provide HCWs with the appropriate PPE such as gowns, eye protection, masks, face shields, and gloves. PPE is now a critical component of isolation precautions and is used widely in healthcare facilities as part of the strategy to minimize passage of pathogenic microbes to patients and exposure of HCWs and visitors to infectious agents, especially bloodborne pathogens.

In addition to the Bloodborne Pathogens Rule published by OSHA, organizations such as the CDC have promoted guidelines for HCW protection, recommending vaccination, early patient screening, isolation precautions, and the use of PPE.

Transmission of Microorganisms

Transmission of infectious agents in healthcare settings requires three elements: a source of infectious agents, a susceptible host with a portal of entry receptive to the agent, and a mode of transmission for the agent. Sources of infectious agents in the hospital include patients (bodily fluids and tissues, secretions, and excretions), HCWs, visitors, textiles (e.g., drapes, clothing, sheets, towels, and blankets), medical equipment, and other surfaces. Some organisms can survive several months on virtually any surface with patient or HCW contact, such as pagers, stethoscopes, pens, bed rails, and doorknobs. Therefore proper use of PPE is crucial in preventing the contact transfer of infections to patients, visitors, and other HCWs (Werner et al., 2009).

Furthermore, the medical and financial complications associated with healthcare-acquired infections have had a significant impact on hospitals (Elixhauser and Steiner 2007, WHO, 2013, Shannon 2011). While several practices have been demonstrated to be effective controls, the success of infection control depends on compliance of the proper use of PPE by HCWs.

Protective Clothing in Healthcare Settings

Gowns are identified as the second-most-used piece of PPE, following gloves, in the healthcare setting (Pear and Smith 2008, Holguin 2011). According to the CDC’s Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting 2007, isolation gowns are used to protect HCWs’ arms and exposed body areas during procedures and patient-care activities when anticipating contact with clothing, blood, bodily fluids, secretions and excretions (Siegel et al 2007). Many different types of isolation gowns with varying protection levels are available. The need for, and type of isolation gown selected, is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. End users are recognized as the best judges of the barrier level required, based on experience and the potential of known exposure risks. However, end-users have limited information on the performance of the existing isolation gowns on the marketplace. For example, several studies reported that when liquid containing microorganisms penetrate a material, microorganisms are carried with it and those microorganisms can penetrate a reinforced material without liquid being visible. However, many end-users feel protected when there is no visible liquid on their gowns. Guidance documents or standards that specify the minimum performance and design requirements for isolation gowns can help end-users and infection control departments of hospitals greatly in the selection of the most appropriate gown for use.

Guidelines and Standards for Protective Clothing in Healthcare

Many organizations have published guidelines for the use of PPE in medical settings. In addition, American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI) published a standard for the classification of protective clothing based on its liquid barrier performance (ANSI/AAMI, 2012). However, there is currently no existing standard on isolation gowns that includes performance and design criteria and addresses the interface (area where gloves and gown meet at the wrists) problems. As a result, several difficulties are faced in the selection process. Recently, the American Society for Testing and Materials (ASTM) International formed a task group to develop a specification standard for isolation gowns. In collaboration with ASTM and the Food and Drug Administration (FDA), the NIOSH National Personal Protective Technology Laboratory has started a research project to understand the effectiveness of current isolation gowns and to determine performance and design requirements.

This standard document will explain critical performance and design properties and will:

• Aid HCWs in the selection process,
• Improve end-users’ understanding of the levels of protection provided by isolation gowns,
• Serve as a resource guide to facilitate proper selection of the best gown to provide the best protection for the procedure, and increase compliance.

Increasing the knowledge of end-users and infection control personnel regarding the performance of the gowns will assist them in correct gown selection, resulting in increased use compliance and resultant decreased transmission of pathogens to HCWs.

We would like to hear from you regarding your experience with the gowns you have worn while providing health care services.

Selcen Kilinc-Balci, PhD, MBA

Dr. Kilinc-Balci is a physical scientist for NIOSH’s National Personal Protective Technology Laboratory.

Work cited:

ANSI/AAMI (2012) Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Healthcare Facilities. ANSI/AAMI:PB70:2012, Association for the Advancement of Medical Instrumentation. Arlington, VA: AAMI

Department of Labor (1991) Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; Final rule. Federal Register 1991;56(235):64175-64182

Elixhauser, A. and Steiner, C. (2007). Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993-2005. HCUP Statistical Brief #35, July. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf, Accessed in June 2013

Holguin M. (2011) Standard Precautions for Healthcare Workers and the Role of Isolation Gowns, www. HealthVIE.com, Accessed in June 2013

Pear SM and Smith SM (2008) Standard precautions confirmed. The Clinical Issue, Issue 6. Knowledge Network, Kimberly-Clark Healthcare Education. Kimberly-Clark Worldwide, Inc.

Sepkowitz KA and Eisenberg L. (2005) Occupational deaths among healthcare workers. Emerg Infect Dis. 2005 July; 11(7): 1003–1008

Shannon R.P. (2011) Eliminating Hospital Acquired Infections: Is it Possible? Is it Sustainable? Is it Worth it?, Transactions of the American Clinical and Climatological Association, 122:103-14

Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee (2007) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June

Werner P, Boothe J, Hinsch M, (2009) How to Evaluate Personal Protective Equipment Products, Infection Control Today, March 30

WHO (2013) http://www.who.int/features/factfiles/patient_safety/en/index.html, Accessed in June 2013