VOL: 98, ISSUE: 38, PAGE NO: 55
Vanessa York, BSc, DipPS, RGN, is infection control nurse, Birmingham Public Health Laboratory
The use of protective clothing is an essential element of infection prevention and control. Many items of protective clothing are incorporated within the concept of universal precautions - the precautions necessary to reduce exposure to blood or body fluids (Centre for Disease Prevention and Control, 1987). Protective clothing is also used to prevent the transmission of micro-organisms other than blood-borne viruses - for example, methicillin-resistant Staphylococcus aureus, Staphylococcus aureus and Mycobacterium tuberculosis.
Various studies have shown that there is no consistent approach towards the use of protective clothing and confusion as to which item to wear and when to wear it (McCoy et al, 2001). This may leave health care workers or patients at risk of acquiring an infection. Therefore there is a need for practical, evidence-based guidelines for the use of protective clothing in order to promote best practice.
Summary of the guidelines
Protective Clothing: Principles and Guidelines (Infection Control Nurses’ Association, 2002), clearly states its aims as follows:
- To emphasise the importance of protective clothing as an essential component in reducing cross infection;
- To challenge the ritualistic use of protective clothing by promoting evidence-based practice.
To achieve these aims the contents of the guidelines focus on the use of gloves, gowns, aprons, masks, goggles, visors, caps and theatre footwear.
Explained in the introductory chapter are the principles of risk management, health and safety legislation and the professional duty of care used to underpin the guidelines. Each section thereafter discusses the evidence for use and the function of the item of protective clothing in relation to the prevention of cross-infection as well as problems that may be encountered when using them.
The section on glove use, for example, identifies key aims to be met from the use of gloves. After giving a brief history of their use it goes on to identify the process of risk assessment, necessary in order to select the correct glove material, size, a sterile or non-sterile glove and whether there is a need to double-glove. A useful summary of latex allergy is also provided, indicating when and where to seek advice if this is suspected, and it describes the stages of latex sensitisation.
By discussing the appropriate use of protective clothing and relating its use to risk assessment and available evidence or expert opinion the authors attempt to tackle ritualistic practice. The role of theatre gowns in isolation is discussed and it is recommended that they should not be used where plastic aprons will suffice.
Confusion is common where there is more than one purpose for an item of protective clothing or several different versions of it. This is often the case in the use of masks. These guidelines tackle this issue by clearly outlining the reasons for wearing masks and how the evidence, which often seems contradictory, has influenced this practice.
The shift in emphasis from masks to protect patients in the surgical setting to masks that protect the scrub team is carefully explained. The traditional practice of wearing masks for source isolation of patients is also addressed, in particularly when caring for patients with pulmonary tuberculosis. The more recent introduction of dust/mist masks and the emergence of multi-drug-resistant TB are examined, as these guidelines reinforce those of the Department of Health (1998).
Many items of protective clothing, despite being manufactured for single use, have been ritually reused (for example, gloves, aprons, masks, caps). Where relevant, these guidelines strongly emphasise the importance of single use.
Each section ends with a useful summary incorporating the key guidelines for practice.
Implications for practice
Dissemination of the recommendations for practice from Protective Clothing: Principles and Guidance will be particularly challenging, as the groups of clinical staff affected by their implementation will be multidisciplinary and large in number.
Where practice is ritualistic it is probable that there will be resistance to changes. Therefore a strategy of change management will be necessary to guide the process. Monitoring the adherence to the guidelines will be an important aspect of the evaluation of the change, where liaison with clinical audit departments or the use of a link nurse system may be required.
A key method of dissemination will be through education on the correct use of protective clothing and the need for changes in practice. Traditional approaches towards the education of health personnel in infection control practice has had limited success (Davis-Beattie and de Wit, 1996). Therefore, methods of education need to be carefully planned, innovative and dynamic to be successful at meeting the needs of the diverse groups of health care workers (Rao et al, 2002). The inclusion in the guidelines of teaching material will assist the process of planning educational aims, objectives and content.
Ritualistic practices can be costly - so can health care-associated infection (Plowman et al, 2000). The ritual use of some items of protective clothing, without risk assessment to identify their need, can result in over-use. This can lead to reluctance to introduce new or additional items of protective clothing, fearing their improper use. Moreover, the potential for litigation may be increased as health care-associated infection, in health care workers or patients, can result in large compensation claims. The recommendations from these guidelines will therefore assist in preparing cost-benefit analysis when planning the introduction of items of protective clothing in clinical use.
The prevention and control of infection largely relies on the correct implementation of universal precautions. The wearing of protective clothing is a vital element of this concept. However, improper use of protective clothing can put healthcare workers and patients at risk of acquiring an infection. This has human and financial costs not only for the individual affected but for the organisation.
Protective Clothing: Principles and Guidance will function as both a useful guide to practice and provide support for infection control teams in developing local standards for practice.
Protective Clothing: Principles and Guidance is available from ICNA/Fitwise, Drumcross Hall, Bathgate EH48 4JT, tel: 01506 811077.