Auditing and Feedback of PPE Use
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Presenter
Linda R. Greene, RN, MPS, CIC, FAPIC
University of Rochester Medical Center
Highland Hospital
Contributions by
Karen Jones, RN, MPH, CIC
Infection Preventionist
St. John Hospital and Medical Center
Lona Mody, MD, MSc
University of Michigan
Ann Arbor VA Health System
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Learning Objectives
Summarize why auditing and providing feedback are
essential to ensuring personal protective equipment
(PPE) adherence
Identify ways in which to audit PPE use
Describe strategies to use audit and feedback to
improve staff PPE performance
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Why audit PPE use?
In order to improve practice it is important that the correct
use of PPE be rigorously and consistently applied
A recent study demonstrated that only half of healthcare
personnel removed PPE correctly under normal conditions
Audits can provide immediate feedback and identify gaps in
practice
(Zellmer C et al., AJIC, 2015)
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Who Should Be Audited?
Anyone who has to use PPE in the course of their job
duties. This includes:
• All licensed health care personnel
• All unlicensed health care personnel
• Physicians
• Volunteers
• Trainees
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What does the audit process involve?
Starts with competency based training
Demonstration of selection of
appropriate PPE
Ability to locate PPE
Demonstration of correct donning and
doffing
Trainee demonstration of correct
donning and doffing
Regular audits for adherence
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Frequency of Audit and Re-Education
Audit should take place at regular intervals as defined
by the organization
It is also important to re-educate and audit whenever
there is a change in equipment or supplies and if rates
of HAIs are high or increasing.
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Planned vs. Random Observations
PLANNED OBSERVATIONS
PROS CONS
Can be scheduled to ensure that all
Unable to determine behavior during
individuals demonstrate regular
the routine course of duties
competency
Scenarios can provide feedback on
individual’s ability to choose PPE
appropriate for the situation
RANDOM OBSERVATIONS
PROS CONS
Ability to assess adherence during Requires large number of
normal work observations on all shifts
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Direct Observation Checklist
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Family Members
There are no standards for auditing family members
Organizations should develop policies to address
specific PPE that family members are required to wear
(Image from AHRQ Module)
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What about Feedback ?
Specific
Timely
Manner
Feedback should be: (Image from AHRQ, TeamSTEPPS, Module 3. Communication)
• Specific – When a break in protocol is identified, it should be
specific
• Timely – immediate feedback is the most effective
• Non-threatening – the feedback should be given in a manner
that is non-threatening
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Types of Feedback
Type of
How it Works Benefits
Feedback
Feedback given at the Can be given by anyone;
Immediate
time of the including observers, managers,
Feedback occurrence supervisors or peers
Feedback given at
pre-determined Usually the responsibility of a
Planned
intervals through a designated department or
Feedback type of measurement assigned role
system
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Culture of Safety
A "culture of safety" encompasses the following:
• Acknowledgment of the high-risk nature of an
organization's activities and the determination to achieve
consistently safe operations
• A blame-free environment where individuals are able to
report errors or near misses without fear of reprimand or
punishment
• Encouragement of collaboration across ranks and
disciplines to identify unsafe practices and seek
solutions to patient safety problems
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How do we use audit data?
Data on adherence should provide valuable
information to drive improvement.
Aggregate information can identify gaps in
practices which helps the organization set
priorities and develop improvement plans
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PPE Auditing Data
Initial gaps observed:
• Glove and gown donning and doffing
• Failure to wear gown if indicated
• Touching face when removing face mask
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Aggregate Audit Data
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What’s the Bottom Line ?
Regular audits to monitor adherence to PPE should include:
• Appropriate selection
• Donning
• Doffing
• Hand hygiene
• Environmental contamination
• Evaluation of appropriate supplies and equipment
• Proximity of supplies to point of use
Aggregate data can be provided to identify opportunities for improvement.
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References
Farin A. Compliance with routine use of gowns by healthcare workers (HCWs) and
non-HCW visitors on entry into the rooms of patients under contact precautions. ICHE.
2007; 28(3): 337-40.
Kilinc B. Isolation gowns in health care settings: Laboratory studies, regulations and
standards, and potential barriers of gown selection and use. AJIC. 2016; 44;1: 104-111.
PPE use in Healthcare Settings. Centers for Disease Control and Prevention.
[Link]
Sequence for Donning and Removing Personal Protective Equipment. Centers for
Disease Control and Prevention. [Link]
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Speaker Notes
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Speaker Notes: Slide 1
Hello, and welcome to this module titled “Auditing and Feedback
of PPE Use.” This is the fourth module of the Personal Protective
Equipment, or PPE, course. We will review the critical role of
auditing for effective PPE use and key strategies for providing
feedback to prevent healthcare-associated infection.
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Speaker Notes: Slide 2
This module was developed by nation infection prevention
experts devoted to improving patient safety and infection
prevention efforts.
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Speaker Notes: Slide 3
There are three objectives for this module. The first is to be able
to summarize why auditing and providing feedback are essential
to ensuring personal protective equipment or PPE adherence.
The second is to identify ways in which to audit PPE use; and the
third is to describe strategies to use audit and feedback to
improve staff PPE performance. Understanding these three core
objectives will set the groundwork to improve the culture of
safety related to infection prevention in your health care
organization.
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Speaker Notes: Slide 4
The Ebola crisis highlighted the need for meticulous attention to
donning and doffing PPE. Though PPE is essential, it does have
limitations that not only stem from being employed correctly,
but also from being removed safely. A recent publication
highlighted a systematic evaluation of health care worker
removal of PPE for Contact Isolation . This publication
demonstrated that only about half of health care personnel
remove PPE correctly. What can we do about this? One
important action is to conduct audits. Audits can provide
immediate feedback to staff using PPE incorrectly and can also
help identify gaps in practice and training.
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Speaker Notes: Slide 5
So who should be audited?
Anyone who has to use PPE in the course of their duties. This
includes all licensed health care personnel, all unlicensed health
care personnel, physicians, volunteers and trainees.
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Speaker Notes: Slide 6
The first two modules on Standard Precautions and
Transmission-Based Precautions provide basic education on PPE.
However, it is extremely important to audit and provide
feedback to health care personnel on PPE use.
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Speaker Notes: Slide 6 Continued
Audit and feedback are important foundational elements to
ensure that health care personnel are competent to perform
their duties. Competency-based training means that staff not
only receive education, but can demonstrate adequate
performance of their job duties. This training involves education
regarding the selection and use of appropriate PPE followed by a
step by step return demonstration of how to properly use it. It is
also important that the step-by-step training mirror the
organizational policy or procedure. In addition, there should be
documentation of training and written confirmation that the
person has demonstrated the ability to select, don and doff PPE
correctly based on the situation.
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Speaker Notes: Slide 7
The health care organization should define the process and time
frame for PPE audits. In order to assess adherence, it’s ideal to
conduct random audits during actual provision of care. However,
it is also possible to obtain important information during an
activity and demonstration of selection and use of PPE.
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Speaker Notes: Slide 8
There are two different types of auditing called random and
planned observation. The pros and cons of each observation
strategy are highlighted on this slide. One method of planned
observation is to conduct regularly scheduled assessments of all
persons who may use PPE. This method may be supplemented
by random observations, which provide valuable information
regarding real life practice and the ability to provide feedback
and teaching in the moment. Ideally, an organization should use
a combination of both of these strategies.
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Speaker Notes: Slide 9
This slide shows a planned observation checklist which can be
used to audit adherence of PPE. This form is adapted from
similar tools developed by the CDC. Tools and checklists are very
helpful during audits. You may wish to consider using and
adapting a similar checklist to match your hospitals’ policies and
procedures.
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Speaker Notes: Slide 10
When family members are required to use PPE, health care
personnel should provide education and training on hand
hygiene and appropriate donning and doffing. Auditing and
feedback for this group should be immediate and non-
threatening. For example you may say something like:
– “Mrs. Smith, let me stop and show you how to apply that
face mask correctly….Now, let me see you apply it like I
demonstrated. We just want to make sure we keep you
and Mr. Smith safe.”
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Speaker Notes: Slide 11
Let’s now move on to talk about strategies for providing effective
feedback, if you notice errors in PPE use or your auditing reveals
user gaps. This slide identifies the three essential components of
feedback: it must be specific, it must be timely and it must be
given in a non-threatening manner.
Health care personnel should be given feedback as soon as
possible and the specific issue should be addressed. For example,
you might say something like, “Hi Sally, when you removed your
face mask, you accidently touched your face and contaminated
yourself. I just want to make sure we keep you safe.” Feedback
should also be given in a manner that will help improve
performance. And often, this provides a coaching opportunity.
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Speaker Notes: Slide 12
Let’s now talk about some of the different types of feedback.
First type, is immediate feedback. Information is identified and
shared as soon as it’s directly noticed during a patient care
activity.
The second category of feedback is planned feedback and it is
designed to be given at regular intervals through a measurement
system. For example, a hospital’s overall adherence with
appropriate PPE for the quarter or that the most common PPE
error occurred during glove removal.
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Speaker Notes: Slide 12 Continued
As indicated on the slide, immediate feedback can be given by
anyone. In organizations with a robust safety culture, peer
feedback is very effective. For example, any individual would feel
free to speak up when they witness someone about to perform
an unsafe act. Planned feedback on the other hand, is usually in
the form of a regular report, which might go to your infection
prevention, quality or safety committee.
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Speaker Notes: Slide 13
Ideally, we want feedback to become part of an organization’s
safety culture. So, what is a culture of safety? Well, a "culture of
safety" encompasses the following:
• Acknowledgment of the high-risk nature of an organization's
activities and the determination to achieve consistently safe
operations;
• A blame-free environment where individuals are able to report
errors or near misses without fear of reprimand or punishment;
and
• Encouragement of collaboration across ranks and disciplines to
remind each other when unsafe practices are identified and to
seek solutions to patient safety problems.
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Speaker Notes: Slide 14
Problem identification through the use of audits may provide
information which can identify specific risks. Using these data on
adherence can provide valuable information and should be used
to drive improvement. In addition, aggregate information can
identify gaps in practices, which can help the organization set
priorities and develop improvement. Further analysis of these
risks may help identify solutions to the problem. For example,
when looking at PPE use, there may be a need to re-educate or a
need to re-evaluate a particular PPE item that may be difficult to
use or apply.
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Speaker Notes: Slide 15
This is an example of an aggregate analysis, and it’s taken from
my own experience. As I previously mentioned, this type of
aggregate information may be helpful in identifying gaps and
opportunities for improvement.
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Speaker Notes: Slide 16
Here is another example from my experience which graphically
displays the information collected from PPE audits. Graphically
displaying the data can be a powerful tool to drive improvement.
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Speaker Notes: Slide 17
To ensure effective PPE use and that staff and patients are safe,
it is important to conduct audits on a regularly scheduled basis.
It is important that these regular audits to monitor PPE
adherence include:
– Appropriate Selection of PPE,
– Donning,
– Doffing,
– Hand Hygiene,
– Environmental contamination,
– An evaluation of appropriate supplies and equipment,
– The proximity of supplies to point of use, and
– Aggregate data can be provided to identify opportunities
for improvement.
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Speaker Notes: Slide 18
No notes.
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