Infection Prevention: Focus on Enforcing PPE Protocols

The pandemic has caused us all to re-examine our infection prevention strategies, including those related to personal protective equipment (PPE). Staff and physicians who properly wear PPE protect themselves from harmful pathogens and prevent accidental contamination of the sterile field, so it's baffling when they don't always comply with something as straightforward as surgical attire policies. There are many reasons this can occur: decades of individual practice, tradition, insufficient and sometimes conflicting research backing the importance of properly wearing PPE and professional disagreement.

You needn't look any further than the recent public debate between surgeons and nurses about the protection provided by surgical caps and bouffants to know head coverings are a hot topic. Some surgeons believe there's no reason to change what they've always worn, and some nurses believe the hot dog guy at Costco does a better job of covering his hair than do most surgeons.

In individual facilities, problems of PPE compliance often relate to ineffective governance and lack of oversight. What matters most is your team agreeing to an acceptable standard, then ensuring compliance to it — the mere existence of a strict policy is often not enough. Taking the following steps will help to ensure members of your surgical team are properly covered from head to toe.

• Establish expectations. There is a lack of indisputable science and agreement on best PPE practices, even though common sense suggests it's best to cover hair and skin as much as possible. Establishing a surgical attire protocol is ultimately about your clinical leaders, surgeons, anesthesia providers and nursing staff agreeing to a standard that's in line with regulatory requirements, and then conducting consistent training and oversight. Setting clear expectations will help you enforce the policy.

A PPE policy should include the following mandates: Wear facility or professionally laundered scrubs; do not wear scrubs outside the facility; wear facility-dedicated shoes; cover hair on head completely, including visible facial hair; and always wear eye protection at the surgical field.

• Reinforce the policy. Regularly scheduled training sessions about proper barrier protection are not necessarily intended to ensure staff are educated about your PPE policy as much as they ensure they're accountable for following it. Have staff members sign forms indicating they have read, understand and will comply with the material. Make online training modules available and schedule real-time coaching conducted by charge nurses.

Clinical leaders should round on a regular basis to ensure surgical team members are wearing PPE properly. Consider having them conduct 10 observations a day and enter compliance data into a spreadsheet so you can track staff performance and monitor trends. Share and discuss the number of days your team achieves 100% compliance and make compliance data available as a dashboard for members of the surgical department to access as needed. Also consider displaying daily compliance rates on a prominent bulletin board or share them through regular email updates. Sharing transparent compliance data will help to ensure higher accountability among team members.

• Make it easy. Gaining 100% compliance with your policy requires incorporating ways to make compliance easier. Adding doffing stations at each entrance to the surgical department serve as reminders to gear up properly. Mirrors installed beside each scrub sink and at doffing stations serve as visual reminders for staff to check themselves before scrubbing or entering the OR. They can also verify that the attire they're wearing is properly covering their skin and hair.

Individual preference and anatomy are highly variable, so ensuring staff have access to numerous sizes of PPE — such as larger head coverings for staff with long hair or tie caps for members of your team with a sensitivity to elastic bands — will help them comply with the standards you establish.

• Get buy-in. Involving members of your team in efforts to enforce PPE protocols will help to create widespread compliance. Take pictures of staff members modeling "good" and "bad" attire practices and post the images at donning stations and near the scrub sink mirrors. At one of my former hospitals, a surgeon recorded a short, light-hearted video on proper attire standards and common practices that did not align with the policy. The video was entertaining, but also informative, and was well-received by staff. We posted the video on the hospital's internal network and included it as part of the facility's online training module.

The few studies that have addressed the link between implementation of a strict surgical attire policy and rates of surgical site infections have reached conflicting conclusions. Many, if not all, are missing critical data measuring actual compliance to written policies. Having strict surgical attire protocols in place is not enough. Ultimately, your staff has to comply with them. OSM