Visitor Noncompliance to Personal Protection Equipment

Infection transmission is a continuing problem in healthcare centers. Precautions, such as the use of personal protection equipment and handwashing, are set in place for both health care staff and visitors to prevent the spread of infection when being near an individual with a communicable disease; however, visitors of the patients may not always comply to these set standards which puts not only their safety at risk, but the staff’s and other healthy members of society.

Joseph Medical Center have had multiple occurrences of visitors being non-adherent to wearing personal protection equipment with patients on isolation precautions, which may lead to an increase in the spread of communicable diseases. Isolation precautions may be labeled either as contact, droplet, or airborne; regardless the type of isolation, each require both staff and visitors to perform hand hygiene. With this issue being observed on multiple units by nursing staff members of the float pool and the Director of Nursing, it is clear there may be a high risk for infection transmission throughout the facility.

The goal of the project is to increase Joseph Medical Centers visitor’s compliance to the use of personal protection equipment in isolation rooms. This will decrease the risk of hospital acquired infections and spread of communicable disease, increase patient satisfactory rates, and properly adhere to both facility protocol and Centers for Disease Control and Prevention recommendations.

Literature Review of Problem

Most studies have been performed on the use of PPE with health care workers and have not included visitors. There are varying reasons as to why visitors do not comply to wearing personal protection equipment; however, research shows a common reason as to why visitors do not use PPE is because visitors fail to see the importance due to the lack of education.

Kang et al. (2014), performed a qualitative study to evaluate visitor’s compliance, knowledge, and perceptions of personal protection equipment with patients on contact precautions for clostridium difficile, a major hospital acquired infection. The study took place over three months and randomly surveyed visitors of adult inpatients, in which 90% of these visitors were family members. Open ended questions were asked, and responses were reviewed using the Systems Engineering Initiative for Patient Safety (SEIPS), which contains 5 components: tasks, person, physical environment, tools and technology, and organization (Kang et al., 2014). Results found that only 42% of visitors were compliant with contact precautions even though they knew the location of PPE equipment. The most common reason visitors did not wear PPE is because they did not think they were at much of a risk for infection since they live with the patient. Others reported that if the health care staff were not wearing them, visitors did not think they needed to either. Several reported that posting information and explanations on how and why they must wear PPE would be beneficial and increase awareness.

Seibert et al. (2018), designed an online survey used across the state of North Carolina hospitals to determine the range of developed hospital policies on visitors wearing personal protective equipment and adhering to precautions when entering an isolation room. A total of 136 hospitals participated and were a part of the Statewide Program for Infection Control and Epidemiology (SPICE). The survey was held for one month and determined that even though 71% of hospitals have a hospital visitor policy, only 14% of hospitals monitor visitor compliance with personal protection equipment and 28% reported visitors became hostile and refused to comply. The study showed that an increase in public awareness and importance on visitor isolation precautions is needed, as well as standardized hospital visitor polices across departments to decrease non-adherence.

Literature Review of Solution

Improving visitor’s adherence to the use of personal protection equipment can occur in several different ways; however, two major forms include education and electronic video monitoring.

A study completed in Humber River Hospital developed an Infection Prevention team and created a quality improvement plan that included education on the reason for isolation precautions and how to properly use personal protection equipment; this was done using a three-prong approach: the use of a communication tool between staff and visitors for patients on isolation precautions, infection preventionists unit rounds to ensure precautions were both valid and being followed, and development of a pictorial “Visitors Guide to Additional Precaution and Personal Protective Equipment” (Levers & Farshait, 2014). Results show visitors found the education and communication tools helpful, as well as increased adherence to the use of PPE; it was found that with daily unit rounds, there was an increase in visitor compliance, correct staff documentation, and appropriate use of isolation signs (Levers & Farshait, 2014).

Katanami et al. (2018) implemented video monitoring to effectively monitor the adherence of wearing personal protection equipment amongst staff. Results have shown it is a useful tool to monitor both visitors and healthcare members who enter rooms with isolation precautions. Direct observation is more susceptible to observer bias and does not provide continuous monitoring which allows room for error; therefore, video monitoring is shown to be the preferred method of monitoring. Monitoring via electronic video also allows a constant survey on whether or not anyone entering the room is wearing PPE and if there is correct donning and doffing of personal protection equipment (Katanami et al., 2018).

Implementation

The final project to be implemented at Joseph Medical Center will use video monitoring and provide education that was previously reviewed to increase visitor compliance to personal protection equipment. Nurses will be required to perform and document education on personal protection equipment with all new visitors who come in contact with patients on isolation precautions; all staff must also use a communication tool and mark unit rounds. Video monitoring will be used to track the progress of the interventions and monitor adherence.

The project will be implemented over four months, with a mid-term evaluation at the second month to determine if the project is on track to increasing adherence rates in using PPE. A quality improvement committee will be developed which will consist of nurses, physicians, and research assistants; these members will be responsible for tracking the progress of the project as well as using both education and communication tools and training that will be distributed amongst all units to ensure policy remains constant.

Nurses will be responsible for performing education with new visitors and providing verbal, written, and visual information on why and how to use PPE; an educational pamphlet listing the specific isolation precaution that is documented for the patient will include written instructions and pictures of the specific equipment needed, why it is needed, and the proper way to wear and remove personal protection equipment. The nurse will then perform the correct way to put on and remove the equipment and have the visitor return the demonstration to determine if the education was successful; these interventions will be required to be documented to confirm proper information was provided to all visitors. A communication tool will be used with visitors by all staff which will require team members to report the reason and importance of visitor use of PPE anytime they are in the room to promote compliance and education; staff will then document to confirm the communication tool was used in every visit to the room.

All healthcare staff that is involved in the care of the patient must use the communication tool to ensure anytime they enter the room the isolation sign matches what is documented in the client’s medical chart to verify accurate recommendations are provided to visitors. In addition to hourly rounding performed by the nurse to verify visitors continue the use of recommended PPE, video monitoring will be established in the area of donning and doffing of each patient’s room. Since the nurse cannot always be there to confirm who enters the patient’s room, video monitoring will increase surveillance of any person entering the isolation room without PPE in which a team member would then be required to enforce the precautions. Research shows visitors are more likely to comply to wearing PPE if members of the healthcare team are compliant; with this being said, video monitoring is useful with both staff and visitors.

At the end of the second and fourth month, data will be collected from documentation of education and video surveillance to record the rates of visitor adherence with personal protection equipment and proper education provided. The results of this project should portray a decrease in the risk of hospital acquired infections and spread of communicable disease, increase patient satisfactory rates, and properly adhere to both facility protocol and Centers for Disease Control and Prevention recommendations.

References

Kang, J., Weber, D. J., Mark, B. A., & Rutala, W. A. (2014). Survey of North Carolina hospital

policies regarding visitor use of personal protective equipment for entering the rooms of patients under isolation precautions. Infection Control And Hospital Epidemiology, 35(3), 259–264. https://doi-org.resu.idm.oclc.org/10.1086/675293

Katanami, Y., Hayakawa, K., Shimazaki, T., Sugiki, Y., Takaya, S., Yamamoto, K., Kutsuna, S.,

Kato, Y., & Ohmagari, N. (2018). Adherence to contact precautions by different types of healthcare workers through video monitoring in a tertiary hospital. The Journal Of Hospital Infection, 100(1), 70–75. https://doi-org.resu.idm.oclc.org/10.1016/j.jhin.2018.01.001

Levers, C. M., & Farshait, N. (2014). Engaging patient’s family and visitors in patient safety by

providing education about additional precautions (isolation) and routine practices (standard precautions). American Journal of Infection Control, 42, S74. https://doi-org.resu.idm.oclc.org/10.1016/j.ajic.2014.03.177

Seibert, G., Ewers, T., Barker, A. K., Slavick, A., Wright, M.-O., Stevens, L., & Safdar, N.

(2018). What do visitors know and how do they feel about contact precautions? American Journal of Infection Control, 46(1), 115–117. https://doi-org.resu.idm.oclc.org/10.1016/j.ajic.2017.05.011