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Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals

Published:October 15, 2012DOI:https://doi.org/10.1016/j.ajic.2012.04.332

      Background

      The proper use of personal protective equipment (PPE) by health care workers (HCWs) is vital in preventing the spread of infection and has implications for HCW safety.

      Methods

      An observational study was performed in 11 hospitals participating in the Canadian Nosocomial Infection Surveillance Program between January 7 and March 30, 2011. Using a standardized data collection tool, observers recorded HCWs selecting and removing PPE and performing hand hygiene on entry into the rooms of febrile respiratory illness patients.

      Results

      The majority of HCWs put on gloves (88%, n = 390), gown (83%, n = 368), and mask (88%, n = 386). Only 37% (n = 163) were observed to have put on eye protection. Working in a pediatric unit was significantly associated with not wearing eye protection (7%), gown (70%), gloves (77%), or mask (79%). Half of the observed HCWs (54%, n = 206) removed their PPE in the correct sequence. Twenty-six percent performed hand hygiene after removing their gloves, 46% after removing their gown, and 57% after removing their mask and/or eye protection.

      Conclusion

      Overall adherence with appropriate PPE use in health care settings involving febrile respiratory illness patients was modest, particularly on pediatric units. Interventions to improve PPE use should be targeted toward the use of recommended precautions (eg, eye protection), HCWs working in pediatric units, the correct sequence of PPE removal, and performing hand hygiene.

      Key Words

      Personal protective equipment (PPE) is used to protect health care workers (HCWs) and patients from health care-associated infections. Specifically, the appropriate PPE items must be selected and removed correctly to minimize the risk of exposure. However, several studies suggest that PPE use is inadequate
      • Weber D.J.
      • Sickbert-Bennett E.E.
      • Brown V.M.
      • Kittrell I.P.
      • Adams T.L.
      Compliance with Isolation Precautions at a University Hospital.
      • Swaminathan A.
      • Martin R.
      • Gamon S.
      • Aboltins C.
      • Athan E.
      • Braitberg G.
      • et al.
      Personal protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza.
      • Gammon J.
      • Morgan-Samuel H.
      • Gould D.
      A review of the evidence of suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
      • Ganczack M.
      • Szych Z.
      Surgical nurses and compliance with personal protective equipment.
      • Daugherty E.L.
      • Perl T.M.
      • Needham D.M.
      • Rubinson L.
      • Bilderback A.
      • Rand C.S.
      The user of personal protective equipment for control of influenza among critical care clinicians: a survey study.
      • Visentin L.M.
      • Bondy S.J.
      • Schwartz B.
      • Morrison L.J.
      Use of protective equipment during infectious disease outbreak and nonoutbreak conditions: a survey of emergency medical technicians.
      • Akduman D.
      • Kim L.E.
      • Parks R.L.
      • L'Ecuyer P.B.
      • Mutha S.
      • Jeffe D.B.
      • et al.
      Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery.
      and that correct use varies by type of HCW
      • Afif W.
      • Huor P.
      • Brassard P.
      • Loo V.
      Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital.
      and clinical area.
      • Manian F.A.
      • Ponzillo J.J.
      Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions.
      Experience during the severe acute respiratory syndrome outbreak and the 2009 H1N1 influenza pandemic have highlighted the need for the appropriate use of PPE to reduce HCW exposure to respiratory infections.
      • Gamage B.
      • Moore D.
      • Copes R.
      • Yassi A.
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      Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.
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      • Hlywka T.
      • et al.
      SARS among critical care nurses in Toronto.
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      Personal protective equipment for preventing respiratory infections: what have we really learned?.
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      • et al.
      Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).
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      • Black S.R.
      • et al.
      Transmission of Pandemic (H1N1) 2009 Influenza to Personnel in the United States.
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      • Bentz R.
      • Waller K.
      • et al.
      Novel influenza A (H1N1) virus infections among health-care personnel: United States, April-May 2009.
      There are many published studies that have focused on hand hygiene compliance
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      • Vos M.C.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
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      • Pang S.W.M.
      An evaluation of hospital hand hygiene practice and glove use in Hong Kong.
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      • et al.
      Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance.
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      Evaluation of hand hygiene adherence in a tertiary hospital.
      or the use of 1 type of PPE
      • Manian F.A.
      • Ponzillo J.J.
      Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions.
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      • et al.
      Surgical masks vs. N95 respirator for preventing influenza among health care workers.
      among HCWs. To our knowledge, there have been no observational studies examining overall PPE use among HCWs entering and leaving the rooms of patients with febrile respiratory illness (FRI). We therefore conducted an audit to observe the selection and removal of PPE, as well as to determine when hand hygiene is performed by HCWs upon entry and exit into the rooms of FRI patients in Canadian hospitals.

      Methods

      An observational study was conducted in 11 tertiary, acute care hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) between January and March 2011. All hospital personnel (eg, nurses, physicians, housekeeping, laboratory technicians, respiratory therapists, and others) who entered the room of a patient with FRI were eligible for inclusion and are referred to generally as HCWs. FRI was defined as a patient with a fever >38°C and with a new or worsening cough or shortness of breath. Visitors and volunteers were excluded from this study. All hospital inpatient or Emergency Department (ED) units that cared for FRI patients were included; outpatient ambulatory care units other than ED were excluded.
      The Public Health Agency of Canada's Infection Control Research Working Group adapted the audit form from an observational tool used to assess an online infection control course in British Columbia.
      • Hon C.Y.
      • Gamage B.
      • Bryce E.A.
      • LoChang J.
      • Yassi A.
      • Maultsaid D.
      • et al.
      Personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use?.
      The audit form was piloted by 6 CNISP participating hospitals from February 9 to April 10, 2010. Observers collected data on the selection and removal of PPE. Hand hygiene following the removal of gloves, gown and mask, and/or eye protection was also observed. Trained observers included infection control professionals or students who were provided with instructions on how to complete the audit form and how to best observe HCWs. Whereas staff on care units were not informed in advance of the audit, no attempt was made to disguise the purpose of the observations. Patient rooms in which the HCWs PPE selection and removal could not be observed were excluded (eg, an anteroom without a window). Signs were posted outside of patient rooms describing additional precautions and what PPE were required. The Public Health Agency of Canada's guidelines Prevention and Control of Influenza During a Pandemic for all Healthcare Settings (Annexe F) was used to determine PPE requirements for an FRI patient.

      Public Health Agency of Canada. Prevention and control of influenza during a pandemic for all healthcare settings. Annexe F. Available from: http://www.phac-aspc.gc.ca/cpip-pclcpi/annf/index-eng.php. Accessed April 16, 2012.

      Instructions for the correct procedure to remove PPE were provided on the audit form and were further defined, when necessary, according to the facility's infection prevention and control policy. The correct sequence of PPE removal was defined in the following order: gloves, gown, eye protection, and then mask.

      Public Health Agency of Canada. Prevention and control of influenza during a pandemic for all healthcare settings. Annexe F. Available from: http://www.phac-aspc.gc.ca/cpip-pclcpi/annf/index-eng.php. Accessed April 16, 2012.

      A mask was defined as either an N95 respirator or surgical (procedure) mask. Eye protection was defined as either a face shield/mask combination or goggles. Eyeglasses were not considered to be eye protection.

      Public Health Agency of Canada. Prevention and control of influenza during a pandemic for all healthcare settings. Annexe F. Available from: http://www.phac-aspc.gc.ca/cpip-pclcpi/annf/index-eng.php. Accessed April 16, 2012.

      Observers were asked to identify the occupation of the observed HCW to the best of their ability, without asking the HCW. If they did not know the occupation, they selected the “don't know” response. A nurse was defined as a nursing assistant, nursing aid, or registered nurse. Allied health professional included respiratory therapists, occupational therapists, laboratory technicians and x-ray technicians. A student was defined as an intern, a resident, or a health care profession student.
      Because the study was observational and did not involve any alteration in patient care, informed consent from the patient and HCW were not required. Because auditing of infection prevention and control practices is part of routine infection prevention and control activities institutional ethics review board approval was not sought. The data collected were confidential; no personal identifying information was collected. Proportions were calculated to describe the study population and for each PPE item and hand hygiene moment by occupation and clinical area. Logistic regression was performed to identify associations between PPE use, clinical areas, and occupations. Odds ratios were reported; 95% confidence intervals and P values reflect a 2-tailed α level of .05. Missing data and unable to assess responses were removed from all calculations. Statistical analysis was performed using Stata version 11 (StataCorp, College Station, TX).

      Results

      There were 442 observations collected from 11 CNISP participating hospitals across 6 provinces. Thirty-four percent of the observations were collected from hospitals in Ontario (n = 149), 30% (n = 131) from Alberta, 9% (n = 41) from Manitoba, 9% (n = 41) from Nova Scotia, 9% (n = 40) from Québec, and 9% (n = 40) from British Columbia. Of the 434 observations for which occupation was reported, 53% (n = 228) were nurses, 13% (n = 57) were students, 12% (n = 53) were physicians, 10% (n = 42) were allied health professionals, and 4% (n = 19) were housekeeping staff. Forty-five percent of the observations were collected on a medical unit (n = 200), 27% (n = 121) on a pediatric unit, 16% (n = 70) on an intensive care unit (ICU), and 6% (n = 27) in an ED.

      PPE selection

      Thirty-four percent of HCWs (n = 149) put on all PPE (gloves, gown, mask, and eye protection). The majority of HCWs put on gloves (88%, n = 390), gown (83%, n = 368), and mask (88%, n = 386). Only 37% (n = 163) were observed to have put on eye protection. Of those HCWs who put on a mask, 71% (n = 274) put on a surgical mask; 18% (n = 70) put on an N95 respirator; and, in 11% (n = 42), the type of mask worn was not specified. Allied health professionals and students were significantly more likely to put on gloves than physicians, and students were also more likely to put on a mask than physicians (Table 1). HCWs working in a pediatric unit were significantly less likely to put on all PPE as compared with HCWs working in an ICU, an ED, or a medical unit (Table 2).
      Table 1Logistic regression: Personal protective equipment selection and removal by occupation
      No. (%)Odds ratio95% CIP value
      Glove selection
       Physician42 (79)1Reference
       Nurse200 (88)1.870.86-4.05.112
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      40 (95)5.241.09-25.12.038
       Student53 (93)3.471.03-11.68.045
       Housekeeping18 (95)4.710.57-39.29.152
      Gown selection
       Physician43 (81)1Reference
       Nurse188 (82)1.090.51-2.36.82
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      39 (93)3.020.78-11.79.111
       Student47 (82)1.090.41-2.88.857
       Housekeeping15 (79)0.870.24-3.20.837
      Eye protection selection
       Physician14 (26)1Reference
       Nurse93 (41)1.920.99-3.73.055
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      14 (33)1.390.57-3.38.463
       Student15 (26)0.990.43-2.32.991
       Housekeeping8 (42)2.030.68-6.07.207
      Mask selection
       Physician42 (79)1Reference
       Nurse201 (89)2.020.93-4.41.076
       Allied health professional37 (88)1.940.62-6.10.258
       Student53 (93)3.471.03-11.68.045
       Housekeeping15 (79)0.980.27-3.56.978
      Glove removal
       Physician38 (97)1Reference
       Nurse157 (84)0.140.02-1.08.059
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      32 (82)0.120.01-1.03.053
       Student47 (98)1.240.08-20.43.882
       Housekeeping141 (82)0.120.01-1.28.08
      Gown removal
       Physician31 (76)1Reference
       Nurse150 (84)1.670.74-3.77.219
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      30 (79)1.210.42-3.48.724
       Student35 (81)1.410.49-4.02.519
       Housekeeping13 (67)4.190.49-36.19.192
      Eye protection removal
       Physician8 (67)1Reference
       Nurse68 (78)1.790.49-6.59.382
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      9 (69)1.130.21-6.05.891
       Student11 (85)2.750.40-18.88.303
       Housekeeping5 (63)0.830.13-5.40.848
      Mask removal
       Physician21 (53)1Reference
       Nurse144 (75)2.711.35-5.47.005
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      27 (75)2.711.02-7.21.045
       Student40 (82)4.021.56-10.43.004
       Housekeeping10 (67)1.810.52-6.25.349
      Correct removal sequence
       Physician15 (36)1Reference
       Nurse110 (56)2.201.14-4.54.020
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      22 (55)2.200.91-5.34.081
       Student25 (50)1.800.78-4.17.170
       Housekeeping14 (78)6.301.76-22.61.005
      CI, Confidence interval.
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      Table 2Logistic regression: Personal protective equipment selection and removal by clinical area
      No. (%)Odds ratio95% CIP value
      Glove selection
       Pediatric unit93 (77)1Reference
       ICU63 (90)2.711.11-6.58.028
       Medical unit185 (93)3.701.89-7.29<.001
       Emergency department27 (100)
      Gown selection
       Pediatric unit85 (70)1Reference
       ICU62 (86)3.281.43-7.55.005
       Medical unit177 (89)3.261.82-5.84<.001
       Emergency department26 (96)11.011.44-84.26.021
      Eye protection selection
       Pediatric unit9 (7)1Reference
       ICU37 (53)13.956.11-31.85<.001
       Medical unit94 (47)11.045.30-22.98<.001
       Emergency department11 (41)8.563.07-23.84<.001
      Mask selection
       Pediatric unit95 (79)1Reference
       ICU64 (91)2.921.14-7.49.026
       Medical unit178 (89)2.321.24-4.34.008
       Emergency department26 (96)7.120.92-54.94.060
      Glove removal
       Pediatric unit78 (88)1Reference
       ICU48 (91)1.350.44-4.14.595
       Medical unit148 (87)0.910.42-1.96.805
       Emergency department22 (85)0.760.22-2.68.688
      Gown removal
       Pediatric unit67 (82)1Reference
       ICU48 (92)2.690.84-8.6.096
       Medical unit136 (80)0.900.46-1.76.748
       Emergency department20 (80)0.900.29-2.77.848
      Eye protection removal
       Pediatric unit7 (78)1Reference
       ICU23 (85)1.640.25-10.95.608
       Medical unit63 (70)0.670.13-3.42.627
       Emergency department7 (70)0.670.08-5.30.702
      Mask removal
       Pediatric unit64 (68)1Reference
       ICU47 (89)3.671.41-9.53.008
       Medical unit120 (70)1.100.64-1.90.724
       Emergency department17 (68)0.100.39-2.56.994
      Correct removal sequence
       Pediatric unit25 (28)1Reference
       ICU53 (83)12.535.65-27.78<.001
       Medical unit94 (51)2.751.60-4.73<.001
       Emergency department19 (70)6.182.40-15.90<.001
      CI, Confidence interval.

      PPE removal

      Of those HCWs who put on PPE, the majority correctly removed their gloves (87%, n = 313), gown (82%, n = 282), mask (72%, n = 264), and eye protection (74%, n = 110). Nurses, allied health professionals, and students were significantly more likely to correctly remove their masks than physicians (Table 1). HCWs working in an ICU were significantly more likely to correctly remove their masks than those working in a pediatric unit (Table 2).
      Half of the observed HCWs (54%, n = 206) removed their PPE in the correct sequence. Nurses and housekeeping staff were significantly more likely to remove PPE in the correct sequence compared with physicians (Table 1). HCWs working in a pediatric unit were significantly less likely to remove PPE in the correct sequence as compared with those working in an ICU, an ED, or a medical unit (Table 2).

      Hand hygiene

      Twenty-six percent of HCWs (n = 99) performed hand hygiene after removing their gloves, 46% (n = 163) after removing their gown, and 57% (n = 212) after removing their mask and/or eye protection. Nine percent of HCWs (n = 36) did not perform any hand hygiene. Difference in hand hygiene moments between clinical areas and occupations are shown in Table 3.
      Table 3Logistic regression: Hand hygiene by clinical area and occupation
      No. (%)Odds ratio95% CIP value
      HH after glove removal
       Pediatric unit28 (31)1Reference
       ICU12 (20)0.570.26-1.23.15
       Medical unit52 (29)0.910.52-1.57.73
       Emergency department1 (4)0.850.01-0.66.02
      HH after gown removal
       Pediatric unit52 (64)1Reference
       ICU22 (37)0.330.17-0.67.002
       Medical unit77 (44)0.440.25-0.75.003
       Emergency department8 (31)0.250.10-0.64.004
      HH after face and/or eye protection removal
       Pediatric unit28 (32)1Reference
       ICU55 (86)13.15.68-30.20<.001
       Medical unit95 (55)2.601.52-4.50<.001
       Emergency department17 (63)4.001.61-10.20.003
      HH after glove removal
       Physician8 (20)1Reference
       Nurse57 (30)1.680.73-3.86.23
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      12 (30)1.710.61-4.79.30
       Student11 (22)1.100.40-3.06.86
       Housekeeping5 (28)1.540.42-5.59.51
      HH after gown removal
       Physician15 (36)1Reference
       Nurse90 (50)1.780.89-3.57.10
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      17 (45)1.450.59-3.58.41
       Student19 (41)1.270.54-3.00.59
       Housekeeping9 (60)2.700.80-9.06.11
      HH after face and/or eye protection removal
       Physician17 (43)1Reference
       Nurse118 (61)2.071.04-4.13.038
       Allied health professional
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.
      21 (62)2.190.86-5.56.101
       Student25 (49)1.300.57-3.00.536
       Housekeeping10 (67)2.710.78-9.38.117
      CI, Confidence interval; HH, hand hygiene.
      Includes respiratory therapists, occupational therapists, laboratory technicians, and x-ray technicians.

      Discussion

      Findings from our audit suggest that, whereas the majority of HCWs put on gloves, mask, and gown upon entry into the room of an FRI patient, few put on eye protection or removed their PPE in the correct sequence. HCWs working in pediatric units were less likely to use PPE when entering the room of an FRI patient. Furthermore, hand hygiene was infrequently performed after the removal of PPE. These findings indicate breaches in PPE use and hand hygiene that may provide opportunities for the transmission of respiratory infections to HCWs and thus should inform infection prevention and control education of HCWs.
      Overall, PPE selection was unsatisfactory because only 76% of HCWs wore mask, gown, and gloves upon entry into the room of an FRI patient, and even fewer HCWs (34%) were observed to have used eye protection. There are several potential reasons why PPE selection was not 100%. Although we did not collect data on availability of PPE, it is possible that PPE was not readily available.
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      • et al.
      Hospital safety climate and its relationship with safe work practices and workplace exposure incidents.
      In addition, risk perception has been known to influence the use of PPE.
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      • Moore D.
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      • Bryce E.
      • Copes R.
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      • Fernandez-Ruiz M.
      • de la Camara A.G.
      • et al.
      Seasonal and pandemic A (H1N1) 2009 influenza vaccination coverage and attitudes among health-care workers in a Spanish University Hospital.
      For example, HCWs working in pediatric units may feel less at risk of being infected and therefore less likely to wear PPE. Time pressures, perceived or real, may also influence the decision to wear PPE and may explain the poor adherence with PPE in EDs and among physicians.
      Findings from the literature have shown that inconsistent or improper use of PPE has been significantly associated with respiratory infection among HCWs.
      • Beam E.L.
      • Gibbs S.G.
      • Boulter B.A.
      • Beckerdite M.E.
      • Smith P.W.
      A method for evaluating health care worker’s personal protective equipment technique.
      Our study found that only half of HCWs were observed to remove their PPE in the correct sequence, thereby creating opportunities for self-contamination. Hand hygiene adherence was suboptimal. The literature describes possible methods to improve hand hygiene adherence such as increasing the number of private rooms and ensuring easy access to alcohol hand rub dispensers in and outside patient rooms.
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      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
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      • Wenzel R.P.
      Handwashing compliance by health care workers.
      These are strategies that should be applied to improve hand hygiene performance after PPE removal.
      Our study has several limitations. First, the Hawthorne effect is common in observational studies. This potential bias arises when the act of being observed influences the behavior of the individual being observed. It is possible that the presence of an auditor may have artificially increased adherence with PPE use. Nonetheless, observational studies have been very useful in demonstrating gaps in recommended infection prevention and control measures despite the potential for overestimation of adherence.
      • Weber D.J.
      • Sickbert-Bennett E.E.
      • Brown V.M.
      • Kittrell I.P.
      • Adams T.L.
      Compliance with Isolation Precautions at a University Hospital.
      • Gammon J.
      • Morgan-Samuel H.
      • Gould D.
      A review of the evidence of suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
      • Akduman D.
      • Kim L.E.
      • Parks R.L.
      • L'Ecuyer P.B.
      • Mutha S.
      • Jeffe D.B.
      • et al.
      Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery.
      • Afif W.
      • Huor P.
      • Brassard P.
      • Loo V.
      Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital.
      • Manian F.A.
      • Ponzillo J.J.
      Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions.
      Second, our findings may not be generalizable to all HCW populations because only HCWs in large, acute care, tertiary hospitals were observed. Finally, our findings included only those situations in which HCWs could be observed. If there was a systematic difference in the adherence to PPE and hand hygiene according to whether the HCW was or was not observed, this could have altered the findings of our study in a direction that is difficult to predict. Our sense is that PPE and hand hygiene would be performed even more poorly in situations in which the HCW could not be observed, and our findings actually represent a best case scenario.
      Our audit highlights gaps in PPE selection and removal that may increase the opportunity for transmission of respiratory infections and that represent educational opportunities in the health care setting. Few HCWs selected eye protection for patients with FRI. Working in a pediatric unit was associated with not wearing PPE when entering the room of an FRI patient. Only half of HCWs removed their PPE in the correct sequence, and hand hygiene was not routinely performed after removal of PPE. Therefore, interventions to improve PPE use should be targeted toward the use of recommended precautions, HCWs working in pediatric units, the correct sequence of PPE removal, and performing hand hygiene.

      Acknowledgment

      The authors thank Krista Wilkinson, Ethan Hermer, and the infection control professionals in each participating hospital.

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