Environmental and Personal Protective Equipment Contamination During Simulated Healthcare Activities

Certain healthcare activities may increase the risk of infectious disease transmission. We sought to understand how aerosol-generating, routine care, and venous access procedures contaminate healthcare personnel (HCP) and the environment. We conducted a laboratory-based simulation study. Experienced HCP performed tasks in a simulated patient room with task-trainer mannequins containing fluorescent material to represent bodily fluids of an infectious patient. Seven healthcare activities were simulated: intubation/extubation and suctioning (aerosol-generating procedures, or AGPs), central venous access and IV access and venipuncture (venous access), and physical exam, vital signs, and bathing (routine care). Fluorescence was quantitatively measured on participants’ personal protective equipment (PPE), on environmental surfaces, and in the air. Data analysis used descriptive statistics, nonparametric Mann-Whitney-Wilcoxon tests (W) and Kruskal-Wallis (KW) statistical tests, and correlations using Spearman’s method. Significance level was defined at alpha less than 0.05. Thirty-nine participants completed 74 healthcare activity simulations. Intubation/extubation and bathing led to the highest fluorescein contamination on the upper bed, while bathing and vitals contributed to the highest contamination on the lower bedrail and cart. All activities resulted in low contamination on the upper bedrail, cart, and IV pole. Overall, bathing contaminated the largest number of surfaces, while venous access procedures – central venous access and IV access and venipuncture -contaminated the least number of surfaces. Fluorescein contamination in ambient air and personal air was significantly different among healthcare activities (P < 0.05), but a large proportion of samples were below the limit of detection. The highest concentrations of fluorescein in ambient air occurred during physical exam (median 3.90 ng/m3), suctioning (median 3.33 ng/m3), and bathing (median 3.23 ng/m3). Fluorescein contamination measured during AGPs was significantly higher than non-AGPs (W=330, P = 0.01). Gloves and gowns were highly contaminated across healthcare activities, except for venous access activities, and fluorescein concentration of gowns and gloves were positively associated (rho=0.55, P < 0.001). Intubation/extubation led to the highest face shield contamination (median 0.24 µg), followed by physical exam (median 0.22 µg), and face shield contamination during AGPs was significantly higher than routine care and venous access activities (KW, P < 0.001). In conclusion, bathing was associated with substantial contamination of the environment, demonstrating the value of compliance with isolation precautions. Face shield contamination during physical exam and intubation/extubation activities indicate the importance of PPE to protect the facial mucous membranes. Low facemask and face contamination shows that the face shield acted as a barrier and prevented fluorescent material from deposited on the face or being inhaled. Contamination in the air across many activities suggests that further work is needed to characterize aerosols in the healthcare environment to protect HCP and patients.