Reducing the risk of hospital-acquired infection

Eighty percent of hospitals in the US use single-use gowns and drapes. Why? Clinical users are satisfied with the performance of single use gowns and drapes in terms of barrier properties, safety, consistency, and comfort. Safety issues, especially those related to adequate protection of professional staff and patients, are of paramount importance.

Necessity of barrier protection

The necessity of barrier protection and the adherence to regulations and professional guidelines make single-use gowns and drapes the ideal choice.

Barrier properties are of great importance with the shift from user comfort and cost to user and patient protection. Dual protection for HCWs (Health Care Workers) and patients is paramount. Issues of safety and infection control are now being quantified by risk managers; these issues must be in the total equation when choosing between reusable and single-use gowns and drapes. Gowns and drapes act as barriers to prevent transmission of microorganisms from nonsterile to sterile areas. The ability to prevent fluid penetrating (preventing “strike-through”) is a critical factor in choosing materials for gowns and drapes.

Protection of HCWs from coagulase-negative staphylococcus aureus, methicillin-resistant staphylococcus aureus (MRSA) and other resistant organisms and bloodborne pathogens is necessary for safe practices; choices are made on safety issues as well as cost. Exposure to blood has for years been recognised as a risk for infection, so barriers are needed.

As stated in the recently published Infection Control Guidelines published by the Australian Government Department of Health & Ageing, “It is the responsibility of all health care establishments to have PPE that complies with relevant Australian Standards readily available for all HCWs”. Personal Protective Equipment (PPE) or clothing, such as gowns, are required in situations where blood or other potentially infectious materials (OPIM) may pass through and reach the HCW’s clothes, skin, eyes, or mouth. The type of gown required is dependent on the task and the degree of exposure anticipated.

Clearly, an informed and prudent choice between reusable and single-use gowns and drapes requires more than a simplistic cost comparison; more facilities are choosing single-use products to meet mandatory standards.

The Association of periOperative Registered Nurses (AORN) states that barrier materials should prevent penetration of microorganisms, particulates, and fluids. The protective barrier ability is of primary concern when evaluating materials (e.g. can withstand tears, punctures, fibre strains and abrasions that could allow passage of fluids and microbes from nonsterile to sterile areas, exposing HCWs to bloodborne pathogens). Liquid-resistant aprons, gowns and shoe covers are worn when exposure to blood or other potentially infectious materials is anticipated.

AORN notes that reusable fabrics (woven materials) should maintain a protective barrier through multiple launderings and sterilisations. The Centers for Disease Control and Prevention (CDC) states that gowns and drapes are used to create a barrier between the surgical field and potential sources of bacteria. Both should prevent strike-through of liquids and viruses. Gowns and drapes should be effective barriers when wet (i.e. consist of materials that resist liquid penetration).

At present, there is no universally adopted method for counting the number of uses of a reusable gown or drape. Reusable gown users have the dilemma of not knowing if a used and relaundered gown retains the liquid resistance claimed for it and they may not know the number of recyclings that each gown has undergone. One U.S. study reported informal queries of hospital central supply and commercial hospital laundry personnel in the U.S. and found that many were not aware of the grid marking system^† or were using it incorrectly. As long as the gowns looked serviceable, they said, they would probably be used.

Without proper education, this may allow widespread use of gowns with reduced protective value. For reusable products, one must consider not only the characteristics of the purchased items, but also the characteristics of the laundered products. Maintaining manufacturers’ specifications is easier for single-use items. Therefore, potential problems with reusables can be:

• Perception of less barrier protection
• Actual loss of barrier properties as a result of wear, abrasions, and breakdown of fabric during laundering and sterilisation
• Uneven consistency of product with multiple reprocessings
• Lack of confidence in laundering and sterilisation of reusables
• Warnings from manufacturers regarding lack of guarantees of performance or results
• Limited mandatory quality standards for laundries.

The importance of protection

Years of proven clinical performance, protection of the patient from infection and protection of the staff from bloodborne diseases, is the reason that a large majority of the surgical market chooses single-use surgical drapes and gowns. In both Australia and the U.S., it is recommended that HCWs assume that all patients are seropositive for bloodborne diseases and always employ Standard Precautions. Additional precautions, for example a protective gown, are to be worn whenever there is a potential for blood contact.

At least seven cases of job-related HIV seroconversion reported in the U.S. in 2002 were tentatively attributed to mucous membrane or skin splashes with contaminated blood. Blood strike-through, absorbed by a scrubsuit, directly contaminated a surgeon’s skin. Even small amounts of contaminated “strike-through” blood can have sufficient inoculum to possibly infect HCWs. When protective garments are penetrated by infectious body liquids, micro-organisms from the patient can infect the medical staff.

Even though the risk is low, reports of HCW seroconversion to positive after contamination by infected blood have been noted. HBV, HCV, and HIV can be acquired via contact of contaminated body fluids with non-intact skin or mucous membranes.

These recommendations were made to minimise HCWs’ risk of acquiring bloodborne pathogen diseases. Potentially fatal diseases such as HBV and HIV can be transmitted to medical personnel through body fluids from the patient. Although skin is an efficient barrier, its barrier qualities may be compromised when exposed to patients’ body fluids for prolonged periods of time, or when the barrier qualities have been compromised by abrasions or areas of inflammation.

Summary

Against any standard, the choice is clear: Single-use items offer substantial benefits. The reasons are sound: Single-use gowns and drapes provide optimum barrier protection, consistent quality, and dependability each time they are used. The result is peace of mind; there is… satisfaction in using single-use items with their proven positive properties.

The following factors should be carefully considered in decisions to use single-use vs. reusable gowns and drapes:

• Dual protection for both healthcare professionals and patients. Prevention of fluid penetration (“strike-through”) is a significant criterion in choosing appropriate gowns and drapes. Also, adherence to regulations and professional guidelines is critical, e.g. the Guidelines for Infection Control published by the Australian Government Department for Health & Ageing.
• Placing high importance on protection. Garment and draping materials that allow penetration of infectious body fluids and microorganisms can lead to “strike-through”, contamination and disease.
• Wisely selecting gowns and drapes. Assurance of asepsis, barrier effectiveness, comfort, economics, and environmental issues must be given priority in the selection process. Gowns and drapes are to be effective barriers when wet. For reusable materials, the ability to maintain barrier qualities through multiple washings is critical but also has been questioned.
• Correctly assessing reusable materials. The ability of reusable gowns to resist strike-through varies with the number of uses, washings and sterilisation cycles. There are no universally adopted methods for counting numbers of uses of a reusable gown or drape. Laundry workers can risk exposure to bloodborne pathogens from contaminated gowns and drapes.
• Analysing environmental issues. Single-use items are often falsely implicated for certain costs of waste disposal. Improper waste segregation, rather than use of single-use gowns and drapes, is usually the cause of increased amounts of regulated medical waste. There are advantages and disadvantages to both reusable and single-use systems.
• Reviewing costs. Accurate assessments of costs are difficult at best. A comprehensive evaluation of costs requires a review of all related costs, some of which may initially not be apparent. Credible conclusions of costs have not been published.
• Single-use items provide excellent barrier properties, consistent and reliable quality, and remarkable positive benefits to hospital staff and patients.

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