8

Aspects of Implementation

The seventh session of the workshop considered aspects of implementation of more reusable health care textiles (HCTs) within a health care organization, such as implementation strategies, systems and behavior change models, and barriers to adoption of reusable HCT programs. A panel discussion featured perspectives from health care system laundry services, sustainability in clinical care, personal protective equipment (PPE) use in health care settings, and the intersection of regulations and health care worker (HCW) safety. Jayaraman introduced and moderated the session. He remarked that health care executives determining whether to implement reusable PPE should consider various factors, including the risk level of the health care setting, facilitation of HCW safety and comfort, HCW training on appropriate donning and doffing procedures, space for the storage and disposal or laundering of PPE, waste reduction, ethical considerations, and financial aspects.

METHODS TO INCREASE ADOPTION OF REUSABLE HCTS

Jayaraman opened the discussion by asking panelists to share mechanisms to improve the adoption of reusable HCTs. Thurston spoke of the value of champions for reusable HCTs who have administrative support within an organization. A clinical educator, an appropriate committee, or another professional who understands the needs of HCWs who wear PPE can garner support for a reusable HCT program. King echoed the importance of champions to sustainability efforts, noting that a department chair at her hospital has been instrumental in raising awareness and

garnering collaborative support for various projects. She underscored the need for legislation that incentivizes sustainability in health care.

Several panelists spoke on the need to raise awareness regarding the safety and benefits of reusable HCTs. Cassandra L. Thiel, assistant professor at the New York University (NYU) Grossman School of Medicine and founder of Clinically Sustainable Consulting, highlighted that literature indicates that reusable HCTs are much less harmful to the environment than disposable products; thus, organizations working to reduce environmental footprints can do so via a reusable gown program. Edward McCauley, president and chief executive officer at United Hospital Services, a large cooperative laundry that serves over 70 hospitals and 850 clinics in Indianapolis, remarked that end-of-life, sustainability, and environmental studies support the use of reusable isolation gowns; he added that they offer economic cost savings over the life of the product. Noting that health care systems are typically the largest generators of pollution within their communities, King emphasized the importance of a including an ethical imperative to make changes that are beneficial to Earth and to community environments in the calculus of decision making. Thiel remarked that the COVID-19 pandemic revealed that reliance on single-use PPE made health care facilities vulnerable to supply shortages, whereas reusable gowns can increase supply resilience in times of a major crisis. McCauley noted that compliance with Association for the Advancement of Medical Instrumentation (AAMI) standards and consistent tracking of the number of times gowns are washed have alleviated health care provider concerns about the safety of reusable gowns.

REUSABLE HCT IMPLEMENTATION CONSIDERATIONS AND BARRIERS

Jayaraman asked about key factors in decision making and implementation strategy development for a reusable HCT program. Thurston highlighted the importance of contracting with a manufacturer that demonstrates the ability to supply and test PPE products to ensure that the PPE delivers the specified protection. She added that gowns must be laundered and decontaminated according to manufacturer recommendations and packaged in such a way that maintains cleanliness. The negotiated price of the product should be such that the total cost of the program—including transportation, laundering, and distribution of gowns—is within budget. In response to a question from Jayaraman about the procurement of PPE, Thurston described how Intermountain Health employs contract managers who oversee certain commodities and who work with buyers, contractors, and vendors to make deci-

sions regarding PPE and other equipment. A products committee meets biweekly to review new products under consideration for purchasing and to vet substitute products. This committee includes representatives from various service lines to engage a range of perspectives and, when more information is needed to reach a product choice, they consult with the Healthcare Laundry Accreditation Council (HLAC) or the Centers for Disease Control and Prevention (CDC).

Thurston also emphasized the need to garner support for reusable HCT programs from administration and through interdisciplinary teams, ensuring that key stakeholders’ perspectives are heard, understood, and accounted for. Programs that use incremental rollout can learn from each unit as the program expands and adjust as needed to create successful change.

Logistical Barriers to Reusable HCT Program Implementation

In response to a question about barriers to implementation of a reusable gown program, Thurston remarked that because reusable HCTs are bulkier than disposable counterparts, space limitations for storage can hinder efforts to implement a reusable PPE program. Considering space requirements and problem solving before implementing a program can facilitate a smooth rollout. Thiel stated that despite the interest in reusable HCTs during the COVID-19 pandemic PPE supply shortage, she has been unable to successfully implement a reusable isolation gown program in the hospitals in which she has worked. Trial runs conducted at New York University (NYU) with cleaning staff—who are not directly involved in clinical care—did not gain traction for a continued reusable gown program. Storage space for reusable HCTs is a substantial barrier, particularly given NYU’s Manhattan location, where square footage carries a high cost, said Thiel. McCauley echoed that reusable gowns are bulkier and require more storage space than disposable counterparts.

Morgan noted a challenge if reusable HCTs are not integrated into existing workflows. She stated that the infection preventionist at her hospital examined HCW procedures to determine how best to integrate reusable gowns into workflow. For example, the safest location to remove an isolation gown is at the exit of a patient room, but laundry bins may not be located near doors. The infection preventionist recommended that laundry bins be moved to align practice with proper doffing protocols.

Reusable Gown Design Considerations

Noting that reusable gown design could potentially increase the risk of contamination, Morgan emphasized the importance of training HCWs

on proper donning and doffing protocols and validating the safety of these protocols when implementing reusable PPE. She explained that a disposable gown with a breakaway closure can be removed simply by grabbing the material on one’s upper arms and pulling downward. However, reusable gowns often have closures that must be untied, necessitating that the HCW reach up and behind the neck. A variety of factors such as hairstyle, arm length, and flexibility can increase the risk of contaminating oneself via contact with a contaminated sleeve or glove during this process. Morgan stated that she would like to conduct validation studies to determine whether HCWs are able to consistently doff reusable gowns without contaminating themselves. Thurston reiterated that the closures on reusable gowns can be difficult to tie and untie, complicating donning and doffing procedures. Design innovation could facilitate HCW ability to comply with proper protocols. As an example, Morgan noted that a small Velcro closure at the neck in the place of ties could replicate the tearaway closure that facilitates easy doffing and is featured on many disposable gowns. King remarked that a no-closure gown is easier to doff than ties or Velcro. This design features an extra panel that crosses around one’s back and is secured by putting the left arm through a hole in the panel. McCauley replied that the three-armhole isolation gown on the market has a design that eliminates the contamination risk of struggling to untie neck closures.

A participant commented that laundry facilities have told PPE designers that their systems are unable to process three-armhole gowns and asked how design and laundry communities can collaborate to develop PPE that meets the needs of workers and adheres to laundering requirements. McCauley replied that United Hospital Services offers hospitals a range of style options. He added that the material used in three-armhole gowns is the same as that of other isolation gown designs, and therefore processing methods do not change. Thurston echoed that the laundering process is the same for both designs of gowns. However, economic considerations are perhaps at play, as the labor involved in presentation and finishing laundered gowns into packages could vary from one design to the other. Additionally, a laundry facility could be under contract with a certain vendor under terms that might not allow working with another vendor offering the three-armhole gown. She remarked that when Intermountain Health changes to a new product, the previous product is continued until all units reach end of life. Adding new designs to current offerings could provide HCWs safe, effective, and convenient options.

Morgan remarked that design features such as pockets can improve the usability of isolation gowns in enabling HCWs to place items from their lab coats into their gowns when they don PPE before entering a

patient room. She added that a large knit cuff on a reusable gown is undesirable because it can act as a sponge; she prefers gown cuffs that can be tucked under gloves. Such practical considerations could increase adoption of reusable gowns, said Morgan.

ETHICAL AND REGULATORY CONSIDERATIONS

In response to a question about the ethical, regulatory, and legal issues regarding gowns that face health care executives, King explained that ethics is about balancing the needs of identified stakeholders. The goal of reducing transmissible infection rates to zero is not feasible but aiming for as low a rate as possible benefits both HCWs and patients. Using reusable products can help strike a balance between safety needs and environmental needs, said King. She added that Occupational Safety and Health Administration (OSHA) regulations are stringent, and hospitals should comply with these regulations to obey the law and ensure safety. Thurston noted that in addition to OSHA regulations, health care systems and commercial laundry facilities should follow guidelines from other regulatory bodies such as The Joint Commission (TJC) and CDC. She remarked that the development of a recommended best practice for HCTs could enhance the ethical provision of PPE.

Thiel remarked that an additional ethical consideration is supporting local economies through circular supply chains using laundry facilities located near the health system. Given that employees in U.S. factories and facilities are protected by OSHA regulations, labor violations may be more common in overseas single-use supply chains. Reusable HCT programs thereby support workplace safety and U.S. job creation. Jayaraman asked whether the laundry industry is amenable to opening facilities in rural areas to enable local reusable gown supply chains. McCauley remarked that United Hospital Services is in Indianapolis, a city where several smaller laundry facilities have closed. Both commercial laundry facilities and hospital systems have trended toward becoming larger. He noted that some laundry facilities deliver to hospitals located 100 miles away, and delivery routes may include stops to smaller facilities along the way. United Hospital Services launders HCTs for 70 hospitals, 30 of which have 25 or fewer beds. Thus, some rural county hospitals are serviced by large corporate laundry facilities. King commented that a large laundry facility in Boston provides Mass General Brigham health care system with scrubs; this service could likely extend to reusable gowns. She remarked that in making shifts toward reusable materials, businesses that are not yet fully established within a service space would likely partner with health providers to expand service provision. Such partnerships simultaneously create jobs and improve environmental stewardship

within the communities in which health systems are located, representing a more ethical model than current reliance on disposable products.

Jayaraman asked how HCWs can be assured that the post-laundry inspection of reusable HCTs meets the requirements of performance standards. McCauley replied that a health care facility should ask the linen and laundry provider how they process isolation gowns and conduct inspections, noting that vague answers are cause for concern. Additionally, laundry providers should be able to describe their tracking processes to ensure that HCTs are not processed more times than indicated by the manufacturer, and they should conduct annual infection control tours. Thurston remarked that a health care system’s infection preventionist should conduct an annual review and physical observation of the laundry facility. Furthermore, chemical vendors and textile providers can provide test pieces; Intermountain Health tests these on a quarterly basis. Thurston noted that hospital linen committees can raise safety concerns or questions. Accreditation visits, which involve a review of policies and practices, provide an opportunity to demonstrate documentation and policies ensuring that reusable gowns are appropriately cleaned and tracked.

TRAINING AND EDUCATION GAPS

Jayaraman asked about knowledge gaps related to HCW risk assessment, PPE selection, or other areas relevant to reusable HCTs. Morgan responded that most HCWs are not provided with PPE options; instead, they must use whatever is provided on an isolation cart or in the supply closet. Thus, HCWs depend on other people within the organization to make appropriate choices to ensure employee safety. She added that very few HCWs understand PPE ratings, testing, and options of levels that correspond with various duties. Instead, they make creative adjustments to the PPE they are provided. For instance, if an HCW is supplied with an unrated gown that does not offer sufficient fluid barrier resistance for a task such as rolling a patient, they might place a pad or towel between themselves and the body fluid before leaning against the bed. Morgan stated the value of teaching HCWs to examine the risks involved in their duties and helping them understand the tools available to them. An HCW, who will likely be exposed to fluids, may not be provided an AAMI Level 4 gown, but they may have access to a less protective gown and an underpad.

King remarked that she has become involved in sustainability efforts at her facility and evaluates opportunities to pare down the amount of equipment used in ORs. For example, equipment packets that are stocked for surgeons in the OR may include unnecessary items, and staff could be more intentional about only opening packages that will be used rather

than opening all provided packets before a procedure begins. Staff could engage with hospital leadership about the PPE and tools that are provided to help shift practices toward greater sustainability. Additionally, educational efforts can address the variety of equipment available, the purpose of each type of equipment, and HCWs’ duties in using PPE appropriately and intentionally, said King.

Morgan noted that TJC will be issuing new requirements in summer 2024 that will encourage facilities to evaluate preparedness for infectious disease events, including training HCWs on appropriate PPE use. She remarked that health systems sometimes presume staff are competent in using PPE without assessing PPE use as a skill. She recalled that throughout her career, she was never tested on PPE competency until she provided care to patients with Ebola in 2014. Competency in consistently and correctly following PPE protocols should be reinforced much more heavily, said Morgan, referencing the hierarchy of controls for occupational health, where PPE is the last line of defense an HCW has against exposure to a hazard (NIOSH, 2023). She contended that appropriate use of PPE should be added to the competencies that hospitals already assess on an annual basis to verify HCWs’ ability to comply with donning and doffing protocols.

Thurston commented that during the COVID-19 pandemic, some Intermountain Health employees were redeployed as safety officers. Trained by clinical educators and dressed in safety vests, the safety officers observed operations and provided immediate training in cases where protocols were not followed. The officers also conducted reviews and training in huddles to provide timely intervention to ensure safety during the crisis. For instance, a safety officer visited the laundry plant to verify that employees sorting soiled linen were correctly wearing N95 respirators, gowns, and gloves. Thurston remarked on the challenge of providing training when units are understaffed and overworked, and she found the safety officer model to be an innovative, time-sensitive solution. She added that this type of on-the-spot training enables immediate correction of behavior to prevent incorrect procedure from forming into habit. McCauley explained that health care laundries do not have the level of oversight that hospitals have. Approximately 15 years ago, HLAC led a self-governance effort to advance the practices and procedures within laundry facilities. More recently, TRSA issued the Hygienically Clean Healthcare Standard (TRSA, 2021). The American Reusable Textile Association (ARTA) hosts annual conferences and seminars on infection control, which provide education opportunities to laundry professionals to broaden understanding of considerations facing hospitals and HCWs.

Morgan remarked that a survey of infection preventionists revealed that a substantial portion were uncertain as to the level of gowns used at

their hospitals (Kilinc Balci, 2016). She stated her hope that the updated ANSI/AAMI PB70:2022 standard will address this knowledge gap (ANSI/AAMI, 2022). She commented that the term “reusable gown” may foster a misconception that gowns hung on hooks or door handles in rooms can be safely reused during a future visit without first being processed. An HCW may think a gown is uncontaminated and that wearing it again at some point in the future is frugal and responsible, but HCWs have no way of knowing whether a used gown is contaminated, Morgan emphasized. Therefore, the term “reusable” could inadvertently increase potential for cross-contamination and environmental contamination. Until updated terminology is adopted, education efforts should inform HCWs that a gown is only safely reusable after being laundered. King emphasized the need for more education on the conditions that require PPE to be placed in a biohazard bin and which items can appropriately be placed in the bin for recycling.

Jayaraman asked about financial considerations of training and whether any resistance to cost affects educational efforts. Thurston replied that Intermountain Health prioritizes safety and has invested in efforts such as establishing “do not disturb” zones to decrease distraction. Thurston underscored that training and safety efforts carry a cost, but the potential cost of employees contracting infections should also be considered.

LESSONS FROM SUSTAINABLE SYSTEMS

Highlighting research by Thiel indicating that the environmental footprint of surgical procedures completed at Aravind Eye Care System (AECS) in India was 5 percent the size of the same procedures performed in a UK hospital, Jayaraman asked about U.S. barriers to achieving the levels of environmental sustainability attained at AECS (Buchan et al., 2022). Thiel explained that the study focused on cataract surgery, one of the most common procedures in the world. To enable access to patients living in poverty, AECS designed a care structure with the goal of reducing the cost of cataract surgery. AECS has found that providing care at higher volumes lowers costs, both in terms of the cost for the patient and the per-patient overhead expenses for the provider. Reusable HCTs are also a driving force in reducing costs, yet the only disposable HCT used is a small single-base drape placed over the surgical area. The reusable cloth caps, masks, gowns, and scrubs worn by HCWs, as well as blankets and linens, are cleaned at laundry facilities located within AECS hospitals. On-site autoclaves sterilize any equipment requiring sterilization. Thiel remarked that the efficient system created at AECS involves a surgeon alternating between two patients during the procedures.

The U.S. health system could benefit from approaches that maximize efficiency, said Thiel. She noted that NYU is experimenting with performing bilateral cataract surgeries, in which new patients have a visit for preoperative testing and then an additional visit for surgery in both eyes. Thiel collaborates with EyeSustain, a global coalition of eye organizations and ophthalmologists working to implement sustainable ophthalmology practices worldwide.¹ This collaboration with EyeSustain coupled with grant funding from the National Eye Institute have enabled her exploration of legal barriers to adoption of sustainable practices. Health care providers often cite policy or regulation as the reason for current operating room (OR) practices that carry a larger environmental footprint than those utilized at AECS. However, examination of these matters often reveals that the practices do not pertain to firm governmental regulations or, in some cases, hospital policies. Most often, habituated practices have become part of the culture and internalized as “the way things are done” by staff, said Thiel.

King remarked that when visiting underresourced areas to donate surgical services, she has witnessed careful use of resources that includes launderable HCTs. These sustainable practices are compatible with safety, as demonstrated by infection rates at these facilities that are similar to or better than those at her home institution. She suggested that large health systems working to improve sustainability could incorporate the evidence-based practices used in underresourced areas as an initial step in shifting culture.

Cultural attitudes within a workplace yield substantial challenges for an engineer working to change a system, Thiel remarked, noting that her area of expertise is different from that of researchers who study change management. Typically, doctors carry forward the practices they learned during training into the next institutions in which they work. For instance, NYU offers preference cards to newly hired surgeons on which to list the supplies they want in the OR; surgeons tend to indicate that they want the equipment provided in the ORs at their previous institutions, she noted. Similarly, nursing staff tend to prefer practices learned during training or from one another that have become the norm, not necessarily because they are the best practices but because they are familiar. Thiel maintained that health systems could adopt a more sustainable approach by shifting focus from the preferred practices of individuals to institutional processes that are safe, effective, and sustainable. Over time, HCWs would grow accustomed to these new practices and become comfortable with them. Jayaraman reiterated that achieving the decreased environmental footprint of AECS would entail process redesign and culture change.

___________________

¹ More information about EyeSustain is available at eyesustain.org (accessed April 13, 2024).

This page intentionally left blank.