Running head: SYNTHESIS PAPER SUMMATIVE 1

Synthesis Paper Summative

Robert M. Williams

University of South Florida



























SYNTHESIS PAPER SUMMATIVE 2
Abstract
The proper use and procedure of personal protective equipment (PPE) is a
hospital practice that aims at preventing the spread and transmission of hospital-acquired
infections. The clinical problem in dealing with PPE is in the issue of compliance from
the hospital staff. Not practicing the proper procedure for PPE use can result in a more
rapid spread of infection from patient to patient in the hospital setting. This paper aims to
find ways that can address the issue of non-compliance and proper procedure when using
PPE. By finding ways to enhance the education of hospital staff when it comes to the
importance of the use of PPE, there then can be a hope to reduce the number of hospital-
acquired infections. In researching for this synthesis paper, Google, PubMed and
National Guideline Clearinghouse were all used as search engines in order to find
material. Key words such as, PubMed, and National Guideline Clearinghouse were
used on Google to find databases that had evidence-based articles. The key word of
personal protective equipment was used on the search engines PubMed and National
Guideline Clearinghouse in order to find more specific research information. Based on
the journal articles and other research done for this synthesis paper, the use of PPE is
absolutely required and important in order to prevent the spread of hospital-acquired
infections.





SYNTHESIS PAPER SUMMATIVE 3
Synthesis Paper Summative
The proper use of personal protective equipment (PPE) is a clinical problem that
needs more focus on assuring that guidelines are complied with. In the hospital setting,
when a patient is under contact precautions PPE is required to be worn before entry into
the patients room. The use and compliance with contact precaution guidelines help to
prevent the spread of hospital-acquired infections between patients and even hospital
staff. According to the Centers for Disease Control and Protection (CDC), hospital-
acquired infections occur in just about one out of every twenty patients in the hospital
setting (CDC, 2010). According to R. Douglas Scott II, an economist, in a 2009 article on
the cost of these infections, the amount of money spent by U.S. hospitals on treating these
infections, ranges from 28.4 to 33.8 billion dollars a year (Scott, 2009). This paper aims
to discover if PPE used properly in the care of contact precaution patients, compared to
not using the PPE properly affects the rates of hospital-acquired infections.
Literature Search
The first search engine used in finding research for this paper was that of Google.
The key word PubMed was searched using Google in order to find the PubMed
database website. Once on this site, the key words Personal Protective Equipment were
searched in order to find the systematic reviews used for research for this synthesis paper.
The National Clearinghouse Guidelines website was also used for research for this paper.
The same key words of personal protective equipment were used again on this website.
Literature Review
According to a BioMed Central article, compliance from nurses on standard
precautions is low (Efstathiou, Papastavrou, Merkouris, & Raftopoulos, 2011). This study
SYNTHESIS PAPER SUMMATIVE 4
takes a look at the exposure possibilities that health care workers are exposed to while
taking care of contact precaution patients. It looks into the matter even further by trying
to expose and discover the reason that compliance is low when it comes to the use of
PPE. The study aims to change the current behaviors towards the use of PPE. Some
weaknesses of the study included a small sample size and only the use of two hospitals.
After analyzing, factors that influenced nurses' compliance emerged. Factors included
benefits, barriers, severity, susceptibility, cues to action, and self-efficacy (Efstathiou et
al., 2011). This study is included because it aims at finding the reasons as to why
compliance is down when is comes to use PPE. The study is relevant to the Picot
question presented for this assignment.
This article from the Emerging Infectious Disease Journal, was based on a study
that took into account the contamination of the actual healthcare worker after they had
removed their personal protective equipment (PPE) (Casanova, Alfano-Sobsey, Rutala,
Weber, & Sobsey, 2008). In the study, participants would go into a simulated room that
was pre-contaminated and perform healthcare tasks while properly wearing their PPE.
After tasks had been completed, participants would remove their PPE following the
correct Center for Disease Control (CDC) procedure. In the studys conclusion, it was
evidenced that even with proper removal of PPE, healthcare worker contamination was
still present (When an a priori value of 25% was used for the 95% upper confidence limit
when p (transfer) = 0, the sample size was N = 10) (Casanova et al., 2008). The study and
article went on to deal with alternative methods for removal of PPE. Some of these
suggestions included a more surgical process of PPE removal. This included such
things as double gloving, and the use of PPE with impregnated antimicrobial agents
SYNTHESIS PAPER SUMMATIVE 5
(Casanova et al., 2008). This study is included and relevant to the topic because it also
aims at improving the handling and use of PPE.
This article from the American Journal of Infection Control, takes a look at the
recommended practices for contact precaution patients, along with the actual practices
seen in the health care setting (Clock, Bevin, Maryam, Barbara, & Larson, 2010). The
article is based on a study from the New York Presbyterian Hospital system in New York
City. In the study, professional observers would watch staff and visitors who entered
patient rooms that were marked for contact precaution. It took into account the use of
hand hygiene before and after leaving the room, donning of gowns, use of masks and the
proper removal of these articles before leaving the infected patients room. A downside to
this article would be that the survey is only taking place at one specific hospital in New
York, and only over a certain period of time. Therefore the results and trends of the study
can be limited as to what procedures are actually being followed correctly or incorrectly.
According to Table 1, this study resulted in an overall adherence rates upon room entry
and exit, respectively, were 19.4% and 48.4% for hand hygiene, 67.5% and 63.5% for
gloves, and 67.9% and 77.1% for gowns. Adherence was significantly better in intensive
care units (p<0.05) and by patient-care staff (p<0.05), and patient-care staff compliance
with one contact precautions behavior was predictive of adherence to additional
behaviors (p<0.001). This study is relevant and included because it measures compliance
to the use of PPE.
This study from the Massachusetts Department of Public Health, deals with
standard precautions in hospitals (Massachusetts Department of Public Health, 2008).
The study provides guidelines for standard precautions in hospitals in order to improve
SYNTHESIS PAPER SUMMATIVE 6
and prevent the transmission of hospital-acquired infections. This study used hand
searches of public literature and also searches of electronic databases in order to find their
evidence (Massachusetts Department of Public Health, 2008). Through the hand and
electronic searches, over a thousand articles that dealt with precautions in hospitals were
used to comprise their findings and recommendations for this study. Their results
included major recommendations for hospitals, which included hand hygiene, standard
precautions in hospitals, environmental measures for the preventions and management of
multi-drug resistant organisms, preventions of ventilator-associated pneumonia,
preventions of surgical site infections, preventions of bloodstream infections and
prevention of catheter-associated urinary tract infections. According to the expert
analysis of the articles collected and the total amount of articles and evidence researched
in order to come to these recommendations for standard precautions. This guideline
provides evidence-based recommendations for infection control and ways to prevent to
spread and acquirement of hospital-acquired infections.
Synthesis
The proper use and compliance with personal protective equipment (PPE) is a
huge issue in dealing with and managing the transmission of hospital-acquired infections,
not only amongst patients but in hospital staff as well. Personal protective equipment use
is very important, and that is evidenced by the fact that there are guidelines put in place
for every hospital when it comes to the proper use and procedure for PPE (Massachusetts
Department of Public Health, 2008). Compliance from all members of hospital staffing is
the most important issue when dealing with PPE. This is because without compliance, or
the willingness to follow the guidelines put in place there can be no protection from the
SYNTHESIS PAPER SUMMATIVE 7
spread and transmission of these hospital-acquired infections (Efstathiou et al., 2011).
After the issue of compliance is dealt with, the proper use of this PPE is just as
important in the prevention of these infections. Studies show that with the proper use and
procedure for PPE, hospital-acquired infections can be reduced amongst patients and staff
(Casanova et al., 2008). Although, even when the proper procedure is followed, there has
still been evidence that hospital staffing can become contaminated when removing their
PPE Casanova et al., 2008). Suggestions for bettering the removal procedures of PPE are
being looked at and include ideas such as taking a more surgical approach to the removal,
double gloving and even using PPE with impregnated antimicrobial agents (Casanova et
al., 2008). The use of PPE will always be an important issue in the health care setting,
and one that continues to explore better means of prevention and implementation when it
comes to hospital staffing and their compliance.
Clinical Recommendations
In order to put in place the best practice aimed at preventing the acquirement and
spread of hospital-acquired infections, there needs to be more education provided to
hospital staffing. By holding educational classes that staff are required to attend, the
proper use and procedure for PPE can be better complied with by the hospital staff.
Along with education, a stronger accountability from the hospital and health care system
needs to be adapted in order to better manage the proper use of PPE. The health care
system could do so by changing the way PPE is handled in hospitals. By creating a
system where hospital staff are required to account for the number of gloves, gowns and
masks used for each precaution patient, hospitals can start to address the issue of
compliance for PPE. Education and more accountability from the health care system can
SYNTHESIS PAPER SUMMATIVE 8
start to shift clinical practice that follows clinical guidelines more accurately. When the
proper use and procedure of PPE is complied with by all hospital staff members there can
start to be a change towards a more evidenced based health care system.








































SYNTHESIS PAPER SUMMATIVE 9
References

Casanova, L., Alfano-Sobsey, E., Rutala, W. A., Weber, D. J., & Sobsey, M. (2008).
Virus transfer from personal protective equipment to healthcare employees skin and
clothing. Emerging Infectious Disease, 14(8), 1291-1293. doi:
10.3201/eid1408.080085
CDC. (2010, December 25). Healthcare-associated infections. Retrieved from
http://www.cdc.gov/HAI/burden.html
Clock, S. A., Bevin, C., Maryam, B., Barbara, R., & Larson, E. L. (2010). Contact
precautions for multidrug-resistant organisms (MDROs): Current recommendations
and actual practice. American Journal of Infection Control, 38(2), 105-111. doi:
10.1016/j.ajic.2009.08.008
Efstathiou, G., Papastavrou, E., Merkouris, A., & Raftopoulos, V. (2011). Factors
influencing nurses' compliance with standard precautions in order to avoid
occupational exposure to microorganisms: A focus group study. BioMed Central,
10(1), doi: 10.1186/1472-6955-10-1
Massachusetts Department of Public Health. (2008). Standard precautions in hospitals.
In: Prevention and control of healthcare-associated infections in Massachusetts.
National Guideline Clearinghouse, 42-49. Retrieved from
http://www.guideline.gov/content.aspx?id=12917
Scott, R., II. (2009). The direct medical cost of healthcare-associated infections in U.S.
hospitals and the benefits of prevention. Centers for Disease Control and
Prevention. Retrieved from
http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
SYNTHESIS PAPER SUMMATIVE 10
Table 1

Reference Aims Design and
Measures
Sample Outcomes /
statistics
Clock, S. A., Bevin, C.,
Maryam, B., Barbara, R.,
& Larson, E. L. (2010).
Contact precautions for
multidrug-resistant
organisms (MDROs):
Current recommendations
and actual practice.
American Journal of
Infection Control, 38(2),
105-111. doi:
10.1016/j.ajic.2009.08.008

To find the
actual rate
of practice
when it
comes to the
following of
standard
precautions.
Observers
watched and
recorded the
compliance
of hospital
staff in using
standard
precautions
when dealing
with patients
who were
under
precaution
measures.
Three sites
within the
New York-
Presbyterian
Hospital
system in
New York
City: (1) a
221-bed
adult
community
hospital; (2)
a 283-bed
childrens
academic
acute-care
facility; and
(3) a 692-
bed adult
academic
tertiary-care
facility.
Overall
adherence
rates upon
room entry
and exit,
respectively,
were 19.4%
and 48.4% for
hand hygiene,
67.5% and
63.5% for
gloves, and
67.9% and
77.1% for
gowns.
Adherence
was
significantly
better in
intensive care
units (p<0.05)
and by
patient-care
staff (p<0.05),
and patient-
care staff
compliance
with one
contact
precautions
behavior was
predictive of
adherence to
additional
behaviors
(p<0.001).
Casanova, L., Alfano-
Sobsey, E., Rutala, W. A.,
Weber, D. J., & Sobsey,
M. (2008). Virus transfer
from personal protective
equipment to healthcare
To find
ways in
order to
reduce the
exposure of
hospital
In the study,
participants
would go
into a
simulated
room that
Ten study
participants
were
enrolled in
this study: 9
women and
PPE is vital
for protecting
hospital staff
from hospital-
acquired
infections,
SYNTHESIS PAPER SUMMATIVE 11
employees skin and
clothing. Emerging
Infectious Disease, 14(8),
1291-1293. doi:
10.3201/eid1408.080085

staff to
infection
from their
own PPE.
was pre-
contaminated
and perform
healthcare
tasks while
properly
wearing their
PPE. After
tasks had
been
completed,
participants
would
remove their
PPE
following the
correct
Center for
Disease
Control
(CDC)
procedure.
The presence
of infectious
organisms
was then
measured.
1 man. particularly
from droplet-
or airborne-
transmitted
diseases.
However,
removing PPE
after patient
care without
contaminating
skin or
clothes is
important.
PPE is worn
for only a
short period
of time, but
many
infections can
survive for
multiple hours
at a time.
(When an a
priori value of
25% was used
for the 95%
upper
confidence
limit when p
(transfer) = 0,
the sample
size was N =
10)
Efstathiou, G.,
Papastavrou, E.,
Merkouris, A., &
Raftopoulos, V. (2011).
Factors influencing nurses'
compliance with standard
precautions in order to
avoid occupational
exposure to
microorganisms: A focus
group study. BioMed
Central, 10(1), doi:
10.1186/1472-6955-10-1
Looks to
discover the
reason that
compliance
is low when
it comes to
the use of
PPE. The
study aims
to change
the current
behaviors
towards the
Four focus
groups (N =
30) were
organized to
elicit nurses'
perception of
the factors
that influence
their
compliance
with
Standard
Precautions.
Four focus
groups of
nurses (N =
30).
After
analyzing,
factors that
influence
nurses'
compliance
emerged.
Factors
included
benefits,
barriers,
severity,
susceptibility,
SYNTHESIS PAPER SUMMATIVE 12
use of PPE. The Health
Belief Model
(HBM) was
used as the
theoretical
framework
and the data
were
analyzed.
cues to action,
and self-
efficacy.
(Please
review study,
there was no
P value
given.)