ARTICLE IN PRESS

American Journal of Infection Control ■■ (2016) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Brief report

Are health care personnel trained in correct use of personal protective

equipment?
Amrita John MBBS a, Myreen E. Tomas MD b, Jennifer L. Cadnum BS c,
Thriveen S.C. Mana MS c, Annette Jencson BS, CIC d, Aaron Shaikh MSW c,
Trina F. Zabarsky RN e, Brigid M. Wilson PhD b, Curtis J. Donskey MD b,c,*
a
Department of Medicine, Division of Infectious Diseases and HIV Medicine, University Hospitals Case Medical Center, Cleveland, OH
b
Geriatric Research, Education, and Clinical Center, Cleveland VA Medical Center, Cleveland, OH
c
Case Western Reserve University School of Medicine, Cleveland, OH
d Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
e Infection Control Department, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH

Key Words: Effective use of personal protective equipment (PPE) is essential to protect personnel and patients in health
Training care settings. However, in a survey of 222 health care personnel, PPE training was often suboptimal with
no requirement for demonstration of proficiency. Fourteen percent of physicians reported no previous
training in use of PPE.
Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and
Epidemiology, Inc.

Personal protective equipment (PPE) reduces, but does not elim- surveyed personnel in a Veterans Affairs hospital to determine the
inate, the risk that health care personnel may contaminate their skin methods used for PPE training and perceived effectiveness.
and clothing with pathogens.1-3 Despite wearing gloves and gowns,
2%-24% of personnel caring for patients colonized with multidrug-
METHODS
resistant bacteria or Clostridium difficile infection acquired the
pathogens on their hands after glove removal.2,3 Such contamina-
The Cleveland Veterans Affairs Medical Center includes a 215-
tion contributes to transmission of pathogens and places personnel
bed teaching hospital and adjacent 250-bed long-term-care facility.
at risk for infection with potentially fatal pathogens.
New employees receive an infection prevention presentation during
One strategy to reduce the risk for contamination during donning
orientation and all personnel complete annual computer modules
and doffing of PPE is to educate personnel on proper technique based
that include slides on PPE donning and doffing. In addition, the in-
on Centers for Disease Control and Prevention recommended
fection control department intermittently provides education to
protocols.4 In simulations, use of these protocols has been associ-
nursing staff on use of PPE. No personnel are required to complete
ated with less frequent hand and clothing contamination in
formal proficiency assessments in PPE donning or doffing.
comparison to nonstandardized methods.5 However, observations
Due to the finding of frequent contamination during PPE removal,1
of personnel have demonstrated that use of incorrect technique for
we surveyed a convenience sample of physicians, nurses, and allied
donning and doffing of PPE is common.1,6 These findings suggest that
health professionals regarding their experiences and perceptions re-
more effective methods for education on PPE donning and doffing
garding PPE training. Personnel from 5 medical wards and 1 surgical
are needed. However, limited information is available on current
ward were approached during work hours on both day and evening
methods used for training personnel in PPE technique. Here, we
shifts. Written surveys were presented in person and participants
completed the questions at the time of delivery. In addition to de-
* Address correspondence to Curtis J. Donskey, MD, Geriatric Research, Education, mographic information, the survey included multiple choice and
and Clinical Center, Cleveland Veterans Affairs Medical Center, 10701 East Blvd, Likert scale questions relating to PPE training during professional
Cleveland, OH 44106. education, while working in health care, training methods em-
E-mail address: curtisd123@yahoo.com (C.J. Donskey). ployed, and provider confidence in correct use of PPE.
This study was supported by a Merit Review grant from the Department of Vet-
erans Affairs to CJD.
To assess whether training in use of PPE at our facility is similar
Conflicts of Interest: CJD has received research grants from Steris, Clorox, Merck, to others in the region, we sent electronic surveys to 10 northeast-
AvidBiotics, and GOJO, and has served on scientific advisory boards for 3M and Seres. ern Ohio hospitals and long-term-care facilities. Infection prevention

0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
http://dx.doi.org/10.1016/j.ajic.2016.03.031
 ARTICLE IN PRESS
2 A. John et al. / American Journal of Infection Control ■■ (2016) ■■-■■

personnel were asked if they provide training in donning and doffing
of standard contact precaution PPE, the timing, and type of training.
Pearson χ2 test was used to compare the frequency and types
of training reported among the 3 groups. Data were analyzed using
R version 3.1.1 (R Foundation for Statistical Computing, Vienna,
Austria). The Cleveland Veterans Administration Medical Center In-
stitutional Review Board approved the study protocol.
RESULTS
The survey response rate was 96% (222 out of 230). Of 222 re-
spondents, 74 (33.3%) were physicians, 74 (33.3%) were nurses, and
74 (33.3%) were allied health professionals.
Table 1 shows the survey results. Of the 3 groups, nurses were
more likely to use gloves, to report PPE training, and to express con-
fidence that they could use PPE effectively to prevent acquisition
of multidrug-resistant organisms and teach others correct PPE tech-
nique. For all groups, the most common method of instruction was
on-the-job training by coworkers or supervisors. Fourteen percent
of physicians reported no prior PPE training. Overall, 18% of re-
spondents (range, 10%-19%) agreed with the statement that there
is no need for hand hygiene if gloves are used. Only 29% of respon-
dents reported an interest in receiving training in correct use of
PPE.
Ten northeastern Ohio health care facilities were surveyed, with
a response rate of 80%. All 8 facilities provided training in donning
and doffing of PPE. The most frequent methods used were computer-
based modules (6 facilities) and video or live demonstrations (5
facilities). Seventy-five percent of facilities provided PPE training
during new employee orientation and 63% had annual PPE train-
ing. All facilities provided training to nurses, but only 4 (50%)
provided training for physicians.
DISCUSSION
Effective use of PPE is essential to protect personnel and pa-
tients in health care settings. However, recent studies suggest that
personnel frequently use incorrect technique for donning and doffing
of PPE,1,6 leading to an increased risk for contamination of skin and
clothing.1 Our findings suggest that suboptimal education in correct
use of PPE may be an important contributor to suboptimal prac-
tices. In our facility, the most common training method reported
by personnel was on-the-job instruction by coworkers or supervi-
sors. A mandatory yearly infection prevention computer module
included information on PPE donning and doffing, but fewer than
half of personnel recalled receiving any computer-based training.
None of the training methods required that personnel demon-
strate knowledge or proficiency in correct use of PPE. Finally, the
fact that 18% of respondents agreed with the statement that there
is no need for hand hygiene if gloves are used suggests that many
personnel are unaware of the risk for contamination during PPE
removal.1
The recent cases of Ebola virus acquisition despite use of PPE have
highlighted the need to develop more effective training strategies
in correct use of PPE.7 Improving knowledge of and adherence to
current Centers for Disease Control and Prevention protocols for PPE
use and removal is likely to be beneficial.4 However, contamina-
tion may frequently occur even when no lapses in technique are
observed.1,8 Thus, additional approaches are likely to be needed. For
example, incorporation of fluorescent lotions or powders into PPE
training sessions to provide visual feedback on contamination can
be a valuable method to reduce contamination of skin and
clothing.1,9,10
Our study has some limitations. First, personnel from a single
center were surveyed. However, surveys of infection control per-
sonnel from 8 facilities in northeastern Ohio suggest that our training
methods are similar to other facilities in the region. Second, in-
depth or focus group interviews were not conducted. Such
approaches may provide more comprehensive information on ex-
periences and opinions of personnel regarding PPE training. Finally,
we did not include an evaluation of PPE technique. However, we
have previously reported that nearly half of personnel from 4 north-
eastern Ohio hospitals contaminated their skin and clothing during
simulations of contaminated PPE removal.1

Table 1
Personal protective equipment (PPE) training and perceptions by personnel type

Allied health
Physicians Nurses professionals
Survey response (n = 74) (n = 74) (n = 74) P value
Years of experience working in health care 10.0 (1-38) 16.2 (0-43) 13.6 (0-42) .005
Use gloves daily 50 (67.6) 72 (97.3) 49 (66.2) < .0001
Use isolation gowns daily 13 (17.6) 24 (32.4) 17 (23.0) .103
Sites of training in use of PPE
Only in school and/or during clinical training rotations 21 (28.4) 5 (6.8) 8 (10.8) < .0001
Only in current workplace 10 (13.5) 4 (5.4) 10 (13.5)
In school and/or clinical rotations and current workplace 32 (43.2) 64 (86.5) 49 (66.2)
No prior training in use of PPE 11 (14.9) 1 (1.4) 7 (9.5)
Methods of PPE training*
On-the-job training by supervisor or coworker 21 (28.4) 31 (41.9) 35 (47.3) .052
Video or live presentation on correct PPE technique 8 (10.8) 24 (32.4) 19 (25.7) .006
Computer module 23 (31.1) 30 (40.5) 31 (41.9) .336
PPE training in current workplace
During new employee orientation 18 (24.7) 39 (52.70) 23 (31.5) .001
Annually 9 (12.3) 35 (47.3) 34 (46.6) < .0001
No training in current workplace 32 (43.2) 6 (8.1) 16 (21.6)
Agree with statement “There is no need for hand hygiene if gloves are used” 12 (16.4) 10 (13.7) 19 (26.0) .134
Confident that I can avoid contamination when caring for a patient in isolation for an MDRO 52 (71.2) 68 (91.9) 62 (86.1) .0023
Confident that I can avoid when caring for a patient in isolation for Ebola virus disease infection 25 (35.2) 37 (50) 47 (65.3) .0012
Confident that I could teach others correct PPE technique 30 (41.1) 56 (75.7) 47 (64.4) < .0001
Interested in receiving additional training in correct use of PPE 22 (30.1) 20 (27.0) 23 (31.5) .830

NOTE. Values are presented as mean (range) or n (%).

MDRO, multidrug-resistant organism.
*None of the training methods included a requirement for demonstration of proficiency in donning and doffing PPE.
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A. John et al. / American Journal of Infection Control ■■ (2016) ■■-■■
CONCLUSIONS
Our results suggest that PPE training is suboptimal in our insti-
tution and in other health care facilities in northeastern Ohio. We
recommend that all personnel involved in direct patient care receive
PPE training that includes a requirement for demonstration of pro-
ficiency. We are conducting additional studies to identify effective
methods to train personnel that can be incorporated into the routine
health care facility workflow. In the future, multicenter studies are
needed to compare the effectiveness of current PPE training methods
and to develop standardized training protocols.
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