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Introduction
Background
Safeguarding the health of the people within the community is one of the most important functions of the Health Authority. In case of an outbreak of communicable diseases such as influenza pandemic, Ebola Virus Disease (EVD) and Middle East Respiratory Syndrome leading to public health emergencies, each hospital will soon activate departmental contingency plan and response measures according to the corresponding Governments preparedness and response plans. Thus, all nursing staff should be vigilant and well prepared to take actions in alignment with departmental policy.
In case of public health emergencies, both medical and nursing employees take up high responsibilities in triage and patient care at medical or health surveillance points of different clinical settings on top of the hospital setting. These clinical settings include outpatient clinics, quarantine camps, ground crossings, harbour boundary control points and airports. As there are opportunities for direct or close contact with patients with suspected or confirmed communicable diseases, they should be particularly alert and well equipped with effective practices in infection prevention and control.
Risk management
Direct or close contact with patients with suspected or confirmed infectious diseases at different medical or health surveillance points is usually inevitable. Risks of human-to-human transmission exist, for instance, during healthcare delivery in the current Ebola outbreak in West Africa. According to several overseas reports, healthcare providers were infected while treating patients with suspected or confirmed EVD. In addition, these reports have determined that proper infection prevention and control practices in personal protective equipment (PPE) donning and doffing was the most effective in reducing or eliminating risks of EVD infection.
PPE may include items such as facemasks, respirators, goggles, face shields, caps, gowns, gloves, boots and shoe covers among others. They constitute parts of equipment used to protect healthcare providers from exposure to or contact with infectious materials, and to protect against transmission of communicable diseases. However, PPE may fail to prevent transmission and spread the infection if all the PPEs are not safely designed, fit and/or not removed properly.
To prepare staff to handle case of communicable diseases outbreaks effectively, a series of risk management measures had been implemented from June to November 2014. These measures were specially organised by the Infection Control Branch (ICB) and the Central Nursing Division (CND) for staff to enhance knowledge on infection prevention and control and to strengthen skills in donning and doffing of full PPE. The notable risk management measures taken covered all departments, and they were delivered through distribution of relevant protocols and modified procedures, staff training seminars, and individual based measures such as regular mandatory self-training and self-assessment.
The ICB prepared a Personal Protective Equipment (PPE) Donning/Doffing and Hand Hygiene (HH) Assessment Checklist for staff to carry out mandatory training and practice in June 2014. These checklists were subsequently revised in October 2014 and November 2014 in response to the most up-to-date recommendations from the World Health Organisation. Further, posters on PPE donning and doffing were issued in November 2014. Both checklists and posters had provided practical guidelines on proper techniques for performing full PPE donning and doffing and HH throughout the procedures.
The CND initiated a variety of promotion activities accordingly. First, internal assessments of staff performance in PPE donning and doffing based on the ICB checklists were conducted from April to August 2014. Second, dozens of similar infection control seminars mandatory for all nursing staff were organised in November 2014. Third, the CND advised all Department Operation Managers (DOMs) of respective service units to ensure that all updated information regarding current communicable disease outbreak and related infection control be accessible to all frontline staff. Finally, all DOMs were reminded to strengthen staff training on infection prevention and control practices, and skills in donning and doffing of full PPE as recommended by the ICB.
However, both monitoring of and evaluation on safe and effective use of PPE in the hospital had not been in place after the implementation of all risk management measures. This programme, led by the CND, was conducted to give a comprehensive evaluation of infection prevention and control practices and recommendations for improvement in PPE donning and doffing in the hospital/clinics.
Aim and objectives
The aim of the programme was to improve infection prevention and control practices in PPE donning and doffing during the provision of care for patients with suspected or confirmed infectious diseases in clinical and ward settings.
The objectives were:
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To assess the level of practices in supporting safe and effective use of PPE in clinics or wards;
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To assess the level of staff competency in practising infection prevention and control during donning and doffing of full PPE; and
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To identify areas for further improvement and make recommendations for sustaining good practices and enhancing improvement
Method
Formation of the Evaluation Team
The Evaluation Team was formed by the end of October 2014. The Team consisted of 19 nursing staff from different service units of the hospital. Of whom, 10 were Advance Practice Nurses (APN) and nine were Registered Nurses (RN). They all had received training on either quality assurance or quality management.
At the first team meeting, members got a thorough understanding of the aim and objectives of the programme. They reviewed the existing guidelines and visual references related to PPE donning and doffing. In addition, the Team identified main areas for assessment by brainstorming. Finally, members drafted action plans for the programme, including the evaluation and continuous improvement.
Sampling
The evaluation was conducted in all service units within the hospital with nursing staff posted, and 23 service units were identified.
Fifty clinics/wards were selected from all service units. In which, 35 were selected from ward settings while 15 were chosen from clinical settings. Each clinic/ward was visited once for the evaluation. During the evaluation visit, two or three nurses would be selected to take part in individual assessment. The selection of these staff was assigned by the APN in-charge of the selected clinic/ward on the spot.
Checklist development
Three checklists were used to collect data during the evaluation visits at wards/centres. The assessors would rate the evaluation finding of each checking item under one of three options: Yes, No and Not-applicable.
The checklists were:
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Clinic/Ward Checklist (Appendix A)
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Staff Assessment Checklist 1: PPE donning (Appendix B)
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Staff Assessment Checklist 2: PPE doffing (Appendix C)
The Clinic/Ward Checklist was formulated by the Evaluation Team with reference to the Guidelines on Infection Control Practice in Clinical Setting (Infection Control Committee, DH, HKSARG, 2011) and the Audit Tools for Monitoring Infection Control Guidelines within the Community Setting (Infection Control Nurses Association, DH, England, 2005). It comprised of 23 checking items. Item no. 1 to Items no. 7 consisted of structure criteria to measure the standard of current mechanism that delivered updated knowledge on the use of PPE and proper HH. On the other hand, Item no. 8 to Item no. 23 consisted of process criteria to check the existence of evidence that showed the principles of donning and doffing of PPE were followed.
Staff Assessment Checklists were used to assess staff competency in performing the procedures of PPE donning and doffing. These two checklists were designed by the Evaluation Team based on the updated Personal Protective Equipment (PPE) Donning/Doffing and HH Assessment Checklists issued by the ICB on 12 November 2014 (ICB, CHP, HKSARG, 2014). To facilitate the evaluation process, key elements of effective use of mask and proper HH were also incorporated into the checklists. These key elements were retrieved from pamphlets of Use Mask properly to protect ourselves and protect others (CHP, HKSARG, 2010) and HH: an easy way to prevent infection (CHP, HKSARG, 2010).
Pilot evaluation
A pilot visit was conducted on 27 November 2014 in one of the selected clinics/wards. Immediately after the pilot visit, the Evaluation Team met to streamline the evaluation process and to get ready for conducting a full-fledged evaluation. In addition, members went through details of all assessment checklists and success criteria (Appendix D) and any other relevant report forms.
Data analysis
The data analysis was performed using Microsoft Excel. Spreadsheets were designed for data entry, data cleaning and sorting. Summary statistics on categories of staff recruited and clinics/wards involved were reviewed.
Compliance rate was calculated by the number of Yes and divided by the total number of Yes and No , which had been set in the spreadsheets while each question in the checklist was equally weighted. The total compliance and individual compliance rate on different categories of checking items were calculated. Bar charts on different compliance rates were displayed for comparison.
Findings
The evaluation was performed in selected clinics/wards through surprise visits. At each clinic/ward visit, performance of both individual clinic/ward and selected staff in safe and effective use of PPE while providing care for patients with suspected or confirmed communicable diseases was assessed. Clinic/Ward performance was assessed against the standard of structure and process criteria (Appendix A). On the other hand, staff performance was assessed against the Staff Assessment Checklist 1: PPE donning (Appendix B) and Staff Assessment Checklist 2: PPE doffing (Appendix C).
Results of the evaluation below were presented and analysed into three categories, including clinic/ward performance, staff performance in PPE donning procedures and staff performance in PPE doffing procedures.
Summary of the evaluation visits
Fifty clinics/wards under 23 service units in the hospital were visited during the evaluation period. Apart from the assessment on practice of selected clinic/ward, performance of 110 staff was assessed. Table 1 shows details of the visits.
Table 1: Details of the evaluation visits
Evaluation results
As observed, the overall clinic/ward performance was the highest (97.3% compliance), followed by the overall staff performance in PPE donning procedures (89.4% compliance) and finally, the overall staff performance in PPE doffing procedures (80.9% compliance).
Centre performance
Performance of clinic/ward practice in supporting safe and effective use of PPE was assessed against the standard of 23 checking items in structure criteria and process criteria. Structure criteria are standards for evaluating the practices in delivering updated knowledge on the use of PPE and proper HH. Conversely, process criteria are standards of assessing practices in supporting and following principles of donning and doffing of PPE.
As shown in Table 2, 86.0% of clinics/wards visited (that is 43 out of 50 clinics/wards) had full compliance (100.0%) with both structure and process criteria. On the other hand, one clinic did not have any evidences that showed practices of delivering updated knowledge in the clinic (0.0% compliance).
The range of compliance rates was 90.3% to 100.0%. Full compliance (100.0%) was attained in seven items, including Item no. 1, no. 5, no. 8, no. 9, no. 10, no. 11 and no. 13).
Non-compliance practices observed in clinics/wards were summarised in Table 3. As shown, the incident rates of clinics/wards found to have these non-compliance practices in structure criteria (that is Item no. 1 to Item no.7) were 1/50 to 2/50; and in process criteria (that is Item no. 8 to Item no. 23) were 1/35 to 3/35.
Table 3: Summary of non-compliance practices observed in clinics/wards
The compliance rates of individual staff in PPE donning procedures were shown in Table 4. in which 23.6% (that is 26 out of 110) of staff assessed achieved 100.0% compliance in all donning steps.
Table 4: Staff performance in all checking steps during PPE donning
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As shown in Table 5, the overall compliance rate of all PPE donning procedures among staff was 89.4%. However, the compliance rate was raised to 93.8% when all HH steps in donning were excluded.
The compliance rate of all HH checking steps in PPE donning among staff was 72.4%. In all these HH checking steps, the compliance rate of the 7 steps and duration of hand rubbing was only 45.9% (Table 5).
The individual steps included donning of surgical mask, donning of face shield, donning of cap, donning of gown, donning of shoe covers, donning of gloves and all HH steps. Among these checking steps, the compliance rate of all HH steps was the lowest (72.4%) while the compliance of donning of surgical mask was the highest (97.9%).
Table 6 displayed compliance rates of individual steps in PPE donning among staff.
Table 6: Staff performance in individual steps during PPE donning
Table 7 summarised the observed non-compliance practices during the evaluation of staff performance during PPE donning procedures.
Table 7: Summary of non-compliance practice observed during PPE donning
Staff performance in PPE doffing
The compliance rates of individual staff in PPE doffing were shown in Table 8. Only 8.2% (9 out of 110 staff) of staff assessed achieved 100% compliance in all doffing steps.
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The compliance rate of all doffing procedure among staff was 80.9% (Table 9). However, the compliance rate was raised to 86.1% when all HH steps in doffing were excluded.
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The compliance rate of all HH checking steps in PPE doffing among staff was 68.4%. In all these HH checking steps, the compliance rate of the 7 steps and duration of hand rubbing was only 48.9% (Table 9).
Compliance rates of individual steps in PPE doffing among staff were summarised in Table 10. The individual steps included removal of shoe covers, removal of gloves, removal of gown, removal of cap, removal of face shield, removal of surgical mask and all HH steps. Among these checking steps, the compliance rate of all HH steps was the lowest (68.4%) while the compliance rate of removal of surgical mask was the highest (94.5%).
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The non-compliance practices observed in the evaluation of staff performance in PPE doffing were shown in Table 11.
Table 11: Summary of non-compliance practices observed during PPE doffing