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Comparing inpatient versus emergency department clinician perceptions of personal protective equipment for different isolation precautions
ARTICLE IN PRESS American Journal of Infection Control 000 (2019) 1−3
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Brief Report
Comparing inpatient versus emergency department clinician perceptions of personal protective equipment for different isolation precautions Sarah L. Krein PhD, RN a,b,*, Steven L. Kronick MD, MS c, Vineet Chopra MD, MSc a,b, Leah L. Shever PhD, RN d, Lauren E. Weston MPH a, Lynn Gregory MSN, FNP-BC b, Molly Harrod PhD a a
Center for Clinical Management Research, Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI Department of Internal Medicine, University of Michigan, Ann Arbor, MI Department of Emergency Medicine, University of Michigan, Ann Arbor, MI d Department of Nursing Research, Quality and Innovation, University of Michigan, Ann Arbor, MI b c
Key Words: Disease transmission Infection prevention Survey research
Adherence to isolation precaution practices, including use of personal protective equipment (PPE), remains a challenge in most hospitals. We surveyed inpatient and emergency department clinicians about their experiences and opinions of various isolation policies, specifically those related to wearing PPE. Our findings show several differences between inpatient and emergency department clinicians involving perceptions related to safety, and the difficulty associated with using PPE for certain types of organisms. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Hospitals employ transmission-based isolation precautions to prevent spread of microorganisms by various routes including airborne, droplet, and contact.1 These precautions are recommended for “patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens,”1 and often require the use of personal protective equipment (PPE). Such precautions tend to be applied across all hospital settings to prevent disease transmission. Prior research suggests that adherence to isolation precaution practices in hospitals, and specifically PPE use, is suboptimal.2,3 Reasons for nonadherence include knowledge gaps, risk perceptions, and environmental factors.4,5 Different perceptions among health care personnel in diverse hospital settings could also influence PPE use,
* Address correspondence to Sarah L. Krein, PhD, RN, Center for Clinical Management Research, Department of Veterans Affairs (VA) Ann Arbor Healthcare System, 2800 Plymouth Rd, NCRC, Bldg 16, 333W, Ann Arbor, MI 48109. E-mail address: [email protected] (S.L. Krein). Funding/support: Funding for this work was provided by the Centers for Disease Control and Prevention, Prime contract no. 2002011-42039, Task Order 0007; Centers for Disease Control and Prevention, 1 U54 CK000456-01; and supported by the VA Health Services Research & Development Service (RCS 11-222). The funding source played no role in study design, data acquisition, analysis, or decision to report these data. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Department of Veterans Affairs, or the US Federal Government. Conflicts of interest: None to report.
but have not been thoroughly studied. We compared inpatient and emergency department (ED) clinician experiences and opinions about isolation policies, specifically those related to wearing PPE for different types of isolation precautions. METHODS We conducted an electronic (Qualtrics, Provo, UT) survey of health care personnel at a midwestern tertiary medical center between November 6 and December 11, 2017. The survey was distributed to ED personnel, hospital medicine physicians, resident physicians, inpatient nurses, and physical/occupational therapists via existing e-mail lists. The survey instrument (available on request) consisted of 3 sections, and was developed for this study to explore qualitative findings suggesting differences in perceptions across clinical location and by type of organism.5 The first section asked about experiences and opinions on isolation policies for methicillin-resistant Staphylococcus aureus (MRSA), the second section was for Clostridium difficile, and the third was for tuberculosis. Each section included the same 10 statements about PPE use applied to the section’s isolation type. Respondents were asked to rate their agreement with each statement on a scale from 1-7, with 1 being strongly disagree, 4 neutral, and 7 strongly agree. We also collected basic demographic information including the type(s) of unit(s) (intensive care, medical/surgical, progressive care, ED) in which the respondent provided care, personnel type (eg, attending physician, nurse, physical or occupational therapist), and years of experience. Institutional review board approval was provided by the medical center.
https://doi.org/10.1016/j.ajic.2019.08.029 0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
ARTICLE IN PRESS S.L. Krein et al. / American Journal of Infection Control 00 (2019) 1−3
2
For analysis, we created binary variables for each statement with 1 indicating agree (rating of 5-7) and 0 being neutral or disagree (rating of 1-4). Responses were compared between clinicians who reported working in inpatient units (intensive care, medical/surgical, and progressive care) only versus ED only using the Pearson x2 test. Analyses were conducted using Stata version 15 (StataCorp, College Station, TX).
Respondents in both groups included a broad range of personnel types and years of experience (Table 1). The most notable difference between groups was the absence of physical/occupational therapists in the ED group. Most respondents in both groups supported wearing PPE for all isolation types and agreed that information about the requirements was provided by the facility (Table 2). For MRSA isolation, 66.5% of inpatient versus 40.7% of ED clinicians agreed they felt safer wearing PPE (P = .001), similarly 75% of inpatient compared with 57.4% of ED clinicians believed their patients were safer (P = .013). A higher percentage of inpatient clinicians compared with their ED counterparts also agreed with statements about the potential transfer (to themselves or other patients) of MRSA, C difficile, or tuberculosis when PPE are not worn, although not all differences were statistically significant. Among inpatient clinicians, 41.5% agreed that wearing PPE for MRSA isolation makes patient care more difficult versus 64.8% of ED clinicians (P = .003). Results were comparable for C difficile with 39.6% of inpatient clinicians agreeing PPE makes care more difficult versus 66.7% of ED clinicians (P = .001). Similarly, 35.2% of inpatient versus 64.8% of ED (P < .001), and 37% of inpatient versus 58.8% of ED clinicians (P = .006) agreed that donning PPE takes too much time for MRSA and C difficile isolation, respectively. Perceptions related to PPE use for tuberculosis isolation were generally similar between both provider types.
RESULTS
DISCUSSION
Of 263 direct care survey respondents, 176 worked in inpatient units only, whereas 54 worked in the ED only. Clinicians (n = 33) working in both locations were excluded from subsequent analysis.
Both inpatient and ED clinicians expressed support for wearing PPE as part of isolation precautions for MRSA, C difficile, and tuberculosis. Opinions about PPE for isolation related to tuberculosis were
Table 1 Survey respondent characteristics Inpatient only (N = 176) n (%)
ED only (N = 54) n (%)
11 (6.2) 4 (2.3) 1 (0.6) 108 (61.4) 26 (14.8) 26 (14.8)
11 (20.4) 2 (3.7) 1 (1.8) 35 (64.8) 5 (9.3) 0
27 (15.3) 46 (26.1) 53 (30.1) 50 (28.4)
5 (9.3) 20 (37.0) 11 (20.4) 18 (33.3)
Type of personnel Attending physician Resident physician Physician assistant or nurse practitioner Nurse Nurse assistant/technician Physical therapist or occupational therapist Years of experience Less than 1 year 1-4 years 5-9 years 10 years or more ED, emergency department.
Table 2 Clinician perceptions of wearing PPE: inpatient only versus ED PPE for MRSA isolation precautions Support wearing in MRSA patient rooms Feel safer wearing Feel patients are safer when I wear Likely to get MRSA on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off PPE for Clostridium difficile isolation precautions Support wearing in C difficile patient rooms Feel safer wearing Feel patients are safer when I wear Likely to get C difficile on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off PPE for TB isolation precautions Support wearing in TB patient rooms Feel safer wearing Feel patients are safer if I wear Likely to get TB on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off
Inpatient only (n = 176) % agree
ED only (n = 54) % agree
P value
76.1 66.5 75.0 60.8 77.3 41.5 92.6 92.6 35.2 38.6
66.7 40.7 57.4 50.0 70.4 64.8 85.2 87.0 64.8 16.7
.166 .001 .013 .159 .301 .003 .097 .203 .000 .003
Inpatient only (n = 169) % agree
ED only (n = 51) % agree
98.2 93.5 97.6 89.9 95.3 39.6 96.5 97.0 37.0 42.6
96.1 86.3 94.1 68.6 80.4 66.7 92.2 92.2 58.8 19.6
Inpatient only (n = 163) % agree
ED only (n = 49) % agree
99.4 98.2 93.9 89.6 85.9 58.3 93.9 95.1 46.6 38.7
100.0 95.9 85.7 73.5 77.6 53.1 91.8 91.8 42.9 40.8
ED, emergency department; MRSA, methicillin-resistant Staphylococcus aureus; PPE, personal protective equipment; TB, tuberculosis.
.367 .099 .210 .000 .001 .001 .197 .123 .006 .003
.583 .365 .065 .005 .163 .517 .616 .387 .642 .785
ARTICLE IN PRESS S.L. Krein et al. / American Journal of Infection Control 00 (2019) 1−3
also generally consistent between groups. Significant differences existed, however, between inpatient and ED clinicians regarding feeling safer wearing PPE for MRSA isolation, the impact of PPE on care delivery, and the required effort associated with donning and doffing PPE for MRSA and C difficile isolation. Differences in perceived safety related to PPE use between inpatient and ED clinicians could reflect, in part, that infectious agents are generally only suspected in the ED, rather than confirmed as might be the case on an inpatient unit. Although the Centers for Disease Control and Prevention guidelines recommend isolation precautions be applied empirically based on clinical presentation and potential agent,1 it can be challenging to link PPE compliance with specific clinical consequences, which may make some ED clinicians more skeptical about certain recommended practices.6 Additional research to better understand these different safety-related perceptions is warranted, as the ED can be a first line of defense in preventing the spread of potentially transmissible diseases.7,8 Greater perceived difficulty associated with wearing PPE among ED clinicians may be because of the fast-paced and often unpredictable nature of the work or the work environment. However, whether and how these perceptions might differentially affect PPE adherence is difficult to assess. Aside from hand hygiene practices,9 we found few studies focusing on use of transmission-based precautions in the ED (especially outside certain pandemic or emergency situations)6 or that compared behaviors between clinicians in the ED versus other settings.10
CONCLUSIONS We identified several differences in the reported experiences and opinions of inpatient and ED clinicians regarding the use of PPE as part of isolation policies. This includes perceptions related to safety and the difficulty associated with using PPE, especially for MRSA and C difficile isolation. Although the implications of these different perspectives cannot be determined by this study, and despite certain limitations most notably related to potential survey and samplerelated biases, these findings highlight areas for further study to
3
enhance our understanding and ability to improve the use of PPE as part of transmission-based isolation precaution practices. Acknowledgements The authors wish to thank Laura Petersen for assistance with survey development and data collection. The authors also wish to acknowledge collaborators Frank Drews, Lindsay Visnovsky, Jeanmarie Mayer, and Matthew Samore for their role in survey development. References 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. Accessed October 12, 2019. 2. Krein SL, Mayer J, Harrod M, Weston LE, Gregory L, Petersen L, et al. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. JAMA Intern Med 2018;178:1016-57. 3. Yanke E, Zellmer C, Van Hoof S, Moriarty H, Carayon P, Safdar N. Understanding the current state of infection prevention to prevent Clostridium difficile infection: a human factors and systems engineering approach. Am J Infect Control 2015; 43:241-7. 4. Fix GM, Reisinger HS, Etchin A, McDannold S, Eagan A, Findley K, et al. Health care workers’ perceptions and reported use of respiratory protective equipment: a qualitative analysis. Am J Infect Control 2019 Jun 7. [Epub ahead of print]. 5. Harrod M, Weston LE, Gregory L, et al. A qualitative study of factors affecting personal protective equipment use among healthcare personnel. Am J Infect Control 2019 Oct 11. [Epub ahead of print]. 6. Zimmerman PA, Mason M, Elder E. A healthy degree of suspicion: a discussion of the implementation of transmission based precautions in the emergency department. Australas Emerg Nurs J 2016;19:149-52. 7. Harding AD, Almquist LJ, Hashemi S. The use and need for standard precautions and transmission-based precautions in the emergency department. J Emerg Nurs 2011;37:367-73. 8. Liang SY, Riethman M, Fox J. Infection prevention for the emergency department: out of reach or standard of care? Emerg Med Clin North Am 2018;36:873-87. 9. Seo HJ, Sohng KY, Chang SO, Chaung SK, Won JS, Choi MJ. Interventions to improve hand hygiene compliance in emergency departments: a systematic review. J Hosp Infect 2019;102:394-406. 10. Williams VR, Leis JA, Trbovich P, Agnihotri T, Lee W, Joseph B, et al. Improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study. J Hosp Infect 2019;103:101-5.
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Brief Report
Comparing inpatient versus emergency department clinician perceptions of personal protective equipment for different isolation precautions Sarah L. Krein PhD, RN a,b,*, Steven L. Kronick MD, MS c, Vineet Chopra MD, MSc a,b, Leah L. Shever PhD, RN d, Lauren E. Weston MPH a, Lynn Gregory MSN, FNP-BC b, Molly Harrod PhD a a
Center for Clinical Management Research, Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI Department of Internal Medicine, University of Michigan, Ann Arbor, MI Department of Emergency Medicine, University of Michigan, Ann Arbor, MI d Department of Nursing Research, Quality and Innovation, University of Michigan, Ann Arbor, MI b c
Key Words: Disease transmission Infection prevention Survey research
Adherence to isolation precaution practices, including use of personal protective equipment (PPE), remains a challenge in most hospitals. We surveyed inpatient and emergency department clinicians about their experiences and opinions of various isolation policies, specifically those related to wearing PPE. Our findings show several differences between inpatient and emergency department clinicians involving perceptions related to safety, and the difficulty associated with using PPE for certain types of organisms. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Hospitals employ transmission-based isolation precautions to prevent spread of microorganisms by various routes including airborne, droplet, and contact.1 These precautions are recommended for “patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens,”1 and often require the use of personal protective equipment (PPE). Such precautions tend to be applied across all hospital settings to prevent disease transmission. Prior research suggests that adherence to isolation precaution practices in hospitals, and specifically PPE use, is suboptimal.2,3 Reasons for nonadherence include knowledge gaps, risk perceptions, and environmental factors.4,5 Different perceptions among health care personnel in diverse hospital settings could also influence PPE use,
* Address correspondence to Sarah L. Krein, PhD, RN, Center for Clinical Management Research, Department of Veterans Affairs (VA) Ann Arbor Healthcare System, 2800 Plymouth Rd, NCRC, Bldg 16, 333W, Ann Arbor, MI 48109. E-mail address: [email protected] (S.L. Krein). Funding/support: Funding for this work was provided by the Centers for Disease Control and Prevention, Prime contract no. 2002011-42039, Task Order 0007; Centers for Disease Control and Prevention, 1 U54 CK000456-01; and supported by the VA Health Services Research & Development Service (RCS 11-222). The funding source played no role in study design, data acquisition, analysis, or decision to report these data. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Department of Veterans Affairs, or the US Federal Government. Conflicts of interest: None to report.
but have not been thoroughly studied. We compared inpatient and emergency department (ED) clinician experiences and opinions about isolation policies, specifically those related to wearing PPE for different types of isolation precautions. METHODS We conducted an electronic (Qualtrics, Provo, UT) survey of health care personnel at a midwestern tertiary medical center between November 6 and December 11, 2017. The survey was distributed to ED personnel, hospital medicine physicians, resident physicians, inpatient nurses, and physical/occupational therapists via existing e-mail lists. The survey instrument (available on request) consisted of 3 sections, and was developed for this study to explore qualitative findings suggesting differences in perceptions across clinical location and by type of organism.5 The first section asked about experiences and opinions on isolation policies for methicillin-resistant Staphylococcus aureus (MRSA), the second section was for Clostridium difficile, and the third was for tuberculosis. Each section included the same 10 statements about PPE use applied to the section’s isolation type. Respondents were asked to rate their agreement with each statement on a scale from 1-7, with 1 being strongly disagree, 4 neutral, and 7 strongly agree. We also collected basic demographic information including the type(s) of unit(s) (intensive care, medical/surgical, progressive care, ED) in which the respondent provided care, personnel type (eg, attending physician, nurse, physical or occupational therapist), and years of experience. Institutional review board approval was provided by the medical center.
https://doi.org/10.1016/j.ajic.2019.08.029 0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
ARTICLE IN PRESS S.L. Krein et al. / American Journal of Infection Control 00 (2019) 1−3
2
For analysis, we created binary variables for each statement with 1 indicating agree (rating of 5-7) and 0 being neutral or disagree (rating of 1-4). Responses were compared between clinicians who reported working in inpatient units (intensive care, medical/surgical, and progressive care) only versus ED only using the Pearson x2 test. Analyses were conducted using Stata version 15 (StataCorp, College Station, TX).
Respondents in both groups included a broad range of personnel types and years of experience (Table 1). The most notable difference between groups was the absence of physical/occupational therapists in the ED group. Most respondents in both groups supported wearing PPE for all isolation types and agreed that information about the requirements was provided by the facility (Table 2). For MRSA isolation, 66.5% of inpatient versus 40.7% of ED clinicians agreed they felt safer wearing PPE (P = .001), similarly 75% of inpatient compared with 57.4% of ED clinicians believed their patients were safer (P = .013). A higher percentage of inpatient clinicians compared with their ED counterparts also agreed with statements about the potential transfer (to themselves or other patients) of MRSA, C difficile, or tuberculosis when PPE are not worn, although not all differences were statistically significant. Among inpatient clinicians, 41.5% agreed that wearing PPE for MRSA isolation makes patient care more difficult versus 64.8% of ED clinicians (P = .003). Results were comparable for C difficile with 39.6% of inpatient clinicians agreeing PPE makes care more difficult versus 66.7% of ED clinicians (P = .001). Similarly, 35.2% of inpatient versus 64.8% of ED (P < .001), and 37% of inpatient versus 58.8% of ED clinicians (P = .006) agreed that donning PPE takes too much time for MRSA and C difficile isolation, respectively. Perceptions related to PPE use for tuberculosis isolation were generally similar between both provider types.
RESULTS
DISCUSSION
Of 263 direct care survey respondents, 176 worked in inpatient units only, whereas 54 worked in the ED only. Clinicians (n = 33) working in both locations were excluded from subsequent analysis.
Both inpatient and ED clinicians expressed support for wearing PPE as part of isolation precautions for MRSA, C difficile, and tuberculosis. Opinions about PPE for isolation related to tuberculosis were
Table 1 Survey respondent characteristics Inpatient only (N = 176) n (%)
ED only (N = 54) n (%)
11 (6.2) 4 (2.3) 1 (0.6) 108 (61.4) 26 (14.8) 26 (14.8)
11 (20.4) 2 (3.7) 1 (1.8) 35 (64.8) 5 (9.3) 0
27 (15.3) 46 (26.1) 53 (30.1) 50 (28.4)
5 (9.3) 20 (37.0) 11 (20.4) 18 (33.3)
Type of personnel Attending physician Resident physician Physician assistant or nurse practitioner Nurse Nurse assistant/technician Physical therapist or occupational therapist Years of experience Less than 1 year 1-4 years 5-9 years 10 years or more ED, emergency department.
Table 2 Clinician perceptions of wearing PPE: inpatient only versus ED PPE for MRSA isolation precautions Support wearing in MRSA patient rooms Feel safer wearing Feel patients are safer when I wear Likely to get MRSA on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off PPE for Clostridium difficile isolation precautions Support wearing in C difficile patient rooms Feel safer wearing Feel patients are safer when I wear Likely to get C difficile on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off PPE for TB isolation precautions Support wearing in TB patient rooms Feel safer wearing Feel patients are safer if I wear Likely to get TB on me if I do not wear Not wearing once can result in transfer to another patient Wearing makes patient care more difficult Facility provides information on how to use when approaching room Facility provides information about requirements Takes too much time to put on Convenient to put on and take off
Inpatient only (n = 176) % agree
ED only (n = 54) % agree
P value
76.1 66.5 75.0 60.8 77.3 41.5 92.6 92.6 35.2 38.6
66.7 40.7 57.4 50.0 70.4 64.8 85.2 87.0 64.8 16.7
.166 .001 .013 .159 .301 .003 .097 .203 .000 .003
Inpatient only (n = 169) % agree
ED only (n = 51) % agree
98.2 93.5 97.6 89.9 95.3 39.6 96.5 97.0 37.0 42.6
96.1 86.3 94.1 68.6 80.4 66.7 92.2 92.2 58.8 19.6
Inpatient only (n = 163) % agree
ED only (n = 49) % agree
99.4 98.2 93.9 89.6 85.9 58.3 93.9 95.1 46.6 38.7
100.0 95.9 85.7 73.5 77.6 53.1 91.8 91.8 42.9 40.8
ED, emergency department; MRSA, methicillin-resistant Staphylococcus aureus; PPE, personal protective equipment; TB, tuberculosis.
.367 .099 .210 .000 .001 .001 .197 .123 .006 .003
.583 .365 .065 .005 .163 .517 .616 .387 .642 .785
ARTICLE IN PRESS S.L. Krein et al. / American Journal of Infection Control 00 (2019) 1−3
also generally consistent between groups. Significant differences existed, however, between inpatient and ED clinicians regarding feeling safer wearing PPE for MRSA isolation, the impact of PPE on care delivery, and the required effort associated with donning and doffing PPE for MRSA and C difficile isolation. Differences in perceived safety related to PPE use between inpatient and ED clinicians could reflect, in part, that infectious agents are generally only suspected in the ED, rather than confirmed as might be the case on an inpatient unit. Although the Centers for Disease Control and Prevention guidelines recommend isolation precautions be applied empirically based on clinical presentation and potential agent,1 it can be challenging to link PPE compliance with specific clinical consequences, which may make some ED clinicians more skeptical about certain recommended practices.6 Additional research to better understand these different safety-related perceptions is warranted, as the ED can be a first line of defense in preventing the spread of potentially transmissible diseases.7,8 Greater perceived difficulty associated with wearing PPE among ED clinicians may be because of the fast-paced and often unpredictable nature of the work or the work environment. However, whether and how these perceptions might differentially affect PPE adherence is difficult to assess. Aside from hand hygiene practices,9 we found few studies focusing on use of transmission-based precautions in the ED (especially outside certain pandemic or emergency situations)6 or that compared behaviors between clinicians in the ED versus other settings.10
CONCLUSIONS We identified several differences in the reported experiences and opinions of inpatient and ED clinicians regarding the use of PPE as part of isolation policies. This includes perceptions related to safety and the difficulty associated with using PPE, especially for MRSA and C difficile isolation. Although the implications of these different perspectives cannot be determined by this study, and despite certain limitations most notably related to potential survey and samplerelated biases, these findings highlight areas for further study to
3
enhance our understanding and ability to improve the use of PPE as part of transmission-based isolation precaution practices. Acknowledgements The authors wish to thank Laura Petersen for assistance with survey development and data collection. The authors also wish to acknowledge collaborators Frank Drews, Lindsay Visnovsky, Jeanmarie Mayer, and Matthew Samore for their role in survey development. References 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. Accessed October 12, 2019. 2. Krein SL, Mayer J, Harrod M, Weston LE, Gregory L, Petersen L, et al. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. JAMA Intern Med 2018;178:1016-57. 3. Yanke E, Zellmer C, Van Hoof S, Moriarty H, Carayon P, Safdar N. Understanding the current state of infection prevention to prevent Clostridium difficile infection: a human factors and systems engineering approach. Am J Infect Control 2015; 43:241-7. 4. Fix GM, Reisinger HS, Etchin A, McDannold S, Eagan A, Findley K, et al. Health care workers’ perceptions and reported use of respiratory protective equipment: a qualitative analysis. Am J Infect Control 2019 Jun 7. [Epub ahead of print]. 5. Harrod M, Weston LE, Gregory L, et al. A qualitative study of factors affecting personal protective equipment use among healthcare personnel. Am J Infect Control 2019 Oct 11. [Epub ahead of print]. 6. Zimmerman PA, Mason M, Elder E. A healthy degree of suspicion: a discussion of the implementation of transmission based precautions in the emergency department. Australas Emerg Nurs J 2016;19:149-52. 7. Harding AD, Almquist LJ, Hashemi S. The use and need for standard precautions and transmission-based precautions in the emergency department. J Emerg Nurs 2011;37:367-73. 8. Liang SY, Riethman M, Fox J. Infection prevention for the emergency department: out of reach or standard of care? Emerg Med Clin North Am 2018;36:873-87. 9. Seo HJ, Sohng KY, Chang SO, Chaung SK, Won JS, Choi MJ. Interventions to improve hand hygiene compliance in emergency departments: a systematic review. J Hosp Infect 2019;102:394-406. 10. Williams VR, Leis JA, Trbovich P, Agnihotri T, Lee W, Joseph B, et al. Improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study. J Hosp Infect 2019;103:101-5.