[Maureen Canning]

Hi everyone,

Would anyone be interested in sharing an existing competency assessment and/or audit tool they might be using in the clinical space around donning and doffing using the Australian Government guideline recommendations. We are looking at implementing auditing on our wards by Back for Life OH&S auditors and spotters once trained.

Thank you for your assistance in advance
Maureen

Maureen Canning
Infection Prevention Nurse Consultant
Infection Prevention Department
Western Health COVID-19 microsite http://www.coronavirus.wh.org.au

Western Health
Footscray Hospital
Gordon Street, Footscray VIC 3011
Ph. 03 8345 6783
Email. maureen.canning@wh.org.au
Web. http://www.westernhealth.org.au

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[Maureen Canning]

Hi Glenys, I think this has probably been a topic of robust discussion amongst many IC teams with differing views, so thank you for the necessary challenging conversations. Maybe it is time for a paradigm shift in our thinking and teaching of PPE.

The CDC interim recommendations include 2 examples of doffing PPE with the second being somewhat the one you are querying step wise. Both CDC examples have additional hand hygiene proviso between doffing steps with this statement at the bottom PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
The Australian guidelines only give the 1 (first) example. The question then should be what determines contamination assessment visible soiling or potential risk based on transmissibility of the organism of concern or in general for risk mitigation. Most of us observe poor standards of doffing routinely with cross contamination and we certainly see staff illnesses during gastro and influenza outbreaks linked to practice and cross contamination from doffing and the environment.

I was taught the CDC example 2 PPE doffing version and have taught that way for a number of years so as to avoid any accidental cross contamination, especially to face. In my last position, we probably added in an additional step of removing the gloves, performing hand hygiene before then removing the gown during Ebola given the high risk to HCWs. We long term taught this approach routinely especially in gastro or influenza outbreaks to protect staff. Given all of the resource investment in upgrading the PPE training then, it had become normal practice to do this approach sequentially with the additional hand hygiene moments. That way the HCW can be better prepared for any escalation of risk in future preparedness plans. I know other organisations are doing this approach as well having seen some of their COVID-19 guidelines. The Commonwealths interim PPE recommendations for consideration for PAPR for ICU staff that spend more than an hour with a patient does raise this essentially to Biological PPE that was used for EVD and the additional risk of cross transmission with doffing from the PAPR hoods and power packs plus suits if used.

If a health care professional is required to remain in the patients room continuously for a long period (e.g. more than one hour) because of the need to perform multiple procedures, the use of a powered air purifying respirator (PAPR) may be considered for additional comfort and visibility. A number of different types of relatively lightweight, comfortable PAPRs are now available and should be used according to the manufacturers instructions. Only PPE marked as reusable should be reused, following reprocessing according to the manufacturers instructions. All other PPE must be disposed of after use. ICU staff caring for patients with COVID-19 (or any other potentially serious infectious disease) should be trained in the correct use of PPE, including by an infection control professional. This also applies to the use of PAPRs, if required. Particular care should be taken on removal of PAPR, which is associated with a risk of contamination.

I see the CDC example 1 (and the Australian Guideline example used) as more the minimum OH&S risk mitigation standard for PPE doffing. In the current climate of heightened staff anxiety over COVID-19 this 2nd example is a simpler approach to teach with additional hand hygiene moments between each step and reinforce as best practice risk mitigation to protect staff so they feel safe. I think we also need to consider novice versus expert practice and teach accordingly.

From the JAMA publication Feb 24 the numbers of HCWs infected in Wuhan is of concern. Yes, there are likely multifactorial reasons; but I think it prudent we take a more cautionary approach with an impending pandemic, which may impact significantly on healthcare services delivery in responding to patient presentations especially coming into our peak winter demand period.
Health care personnel infected
3.8% (1716 of 44672)
63% in Wuhan (1080 of 1716)
14.8% cases classified as severe or critical (247 of 1668)
5 deaths

Given the current staff fear factor of looking after these patients and potential for high levels of absenteeism or sick leave in the workforce the more we can simplify the process for staff the more they are likely to come to work confidant in caring for these patients and stay safe. Social media with full body suits, PAPR etc makes staff feel they wont be protected with just droplet and contact TBP. Reinforcing basic doffing good practices with additional hand hygiene steps can help allay those concerns.

Part of my current seconded preparedness role is looking at a variety of training methods for staff as part of the organisations risk mitigation strategic plan of what we will do if we see large numbers of patients, changes to models of care, closure of services, staff redeployments and upskilling of nurses and clinicians from areas closed that perhaps havent used PPE in many years. We have initiated a train the trainer model this last week with all of our clinical educators and Liaison/Link nurses who will take over doing all of the refresher education to the clinical workforce across all disciplines. We have used glow germ and UV light to demonstrate ease of cross transmission in training sessions. It needs to be simplified under this model for consistency and ease of delivery. This then frees up the IP team to do their core work and support clinical areas. PSAs and environmental services will be critical during this so anything that simplifies and streamlines donning and doffing practices helps them and reassures them. Even skilled staff have expressed significant concerns out of the fear factor.

Informing, engaging and empowering our staff to feel safe at work is our number one goal at present to ensure they continue to come to work and are not infected whilst working. It will be interesting to hear future conversations and outcomes.

Kind regards
Maureen

Maureen Canning
Infection Prevention CNC
Western Health COVID-19 Preparedness Team
Informing, Engaging and Empowering staff

Western Health COVID-19 microsite http://www.coronavirus.wh.org.au

Sunshine Hospital
Western Health
176 Furlong Rd St Albans Vic 3021

Email. maureen.canning@wh.org.au
Web. http://www.westernhealth.org.au

Sent from Mail for Windows 10

Thanks for the explanation Phil.

I will refer my enquiry to the Commonwealth via the email address suggested, however it does seem to be a fairly cumbersome process in the setting of the activation of the Australian Health Sector Emergency Response Plan (27/2) and an emerging pandemic.

Given our college representatives on this ICEAG group are not able to comment I will re-phrase my query and request guidance from the ACIPC College as the peak body for infection prevention and control in Australia.

My query to the college is as follows:

Does the college recommend performing hand hygiene on the following occasions when removing PPE during droplet, contact and airborne precautions which are recommended for Coronavirus?
o after remove gown and gloves
o after removal of eye protection and
o after removal of mask

It will be of interest to the members that on reviewing the following infection control guidelines there is no requirement to performing hand hygiene on all of the above occasions when removing PPE during droplet, contact and airborne precautions and/or when removing PPE for Coronavirus.
Australia – The Australian Guidelines for the Prevention and Control of Infection in Healthcare were co-funded by the National Health and Medical Research Council and Australian Commission on Safety and Quality in Health Care, 2019.
CDC guidelines – Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. Updated February 21, 2020
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refValhttps%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

WHO – Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, Interim guidance 25 January 2020
https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19

Victoria Health and Human Services how to take of your PPE
https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19

Many ACIPC members including myself look forward to college guidance in relation to this query.

regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.au

For ACIPC members who have inquiries regarding advice posted on theCommonwealth website regarding COVID-19.

ACIPC is well represented on theICEAG who provide advice to the Commonwealth when requested. Recommendations are provided to the Commonwealth and undergo several reviews by other expert bodies before they are published. As such individual ICEAG members are not authorised to respond directly to queries posted on Infexion Connexion.

The Commonwealth welcomes and encourages all feedback and comments be sent toHealth.Ops@health.gov.auand also recommend that you provide a meaningful subject line so it can be reviewed quickly.

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