Barriers to the use of face protection for standard precautions by health care providers

Hospital health care workers' use of facial protective equipment before the COVID-19 pandemic, implications for future policy

BACKGROUND

Prepandemic routine use of facial (respiratory and eye) protective equipment (FPE) by health care workers was suboptimal. Understanding factors affecting routine use would facilitate escalation to high level use during infectious disease emergencies. This study explored health care workers FPE-related knowledge, attitudes and behaviors.

METHODS

Mixed methods were used in a respiratory ward and adult and pediatric emergency departments (EDs), prior to the COVID-19 pandemic. Study design and thematic analysis were based on the theoretical domains framework. Emergent themes were categorized, using the COM-B behavior model, into capability(C), opportunity(O) and motivation(M), which influence behavior(B).

RESULTS

22 emergent themes, representing factors influencing FPE use, were mapped to theoretical domains framework domains. Personal experience and departmental cultures influenced motivation. Compared with respiratory ward staff, ED clinicians were less knowledgeable about FPE; the unique ED environment and culture inhibited opportunities and motivation for FPE use. Eye protection was infrequently used.

DISCUSSION

Optimal FPE use is challenged by ED care models and settings. Changes are needed to translate pandemic-related improvements into routine care of other respiratory infections.

CONCLUSIONS

This study identified key determinants of FPE behavior. A review of context-specific FPE guidance for ED by infection prevention and control professionals would help to promote practicable, sustainable compliance.

Understanding routine (non-outbreak) respiratory protective equipment behaviour of hospital workers in different clinical settings - lessons for the future post COVID-19

BACKGROUND

The COVID-19 pandemic has drawn attention to the importance of facial (respiratory and eye) protective equipment (FPE). Optimal use of FPE in non-outbreak situations, will enable frontline staff, such as emergency department (ED) clinicians, to adapt more rapidly and safely to the increased demands and skills required during an infectious disease outbreak.

METHODS

A survey, designed to determine the attitudes, beliefs and knowledge of HCWs around the use of FPE for protection against respiratory infections, was distributed to staff in a respiratory ward, an adult ED and a paediatric ED in Sydney, Australia prior to COVID-19.

RESULTS

The survey revealed differences between the respiratory ward and the EDs and between professional groups. ED staff, particularly paediatric clinicians, were less likely than ward staff to use FPE appropriately during routine care. Medical staff were more likely to work outside of IPC policies.

DISCUSSION

The busy, relatively chaotic ED environment presents unique challenges for optimal compliance with safe FPE use when caring for patients with respiratory symptoms.

CONCLUSIONS

Building upon the lessons of the pandemic, it is timely to address the specific infection prevention and control needs of the ED environment to improve FPE compliance during non-outbreak situations.

THE USE OF MASKS AMONG BRAZILIAN NURSING WORKERS DURING THE COVID-19 PANDEMIC

ABSTRACT Objective: to assess the use of masks among Brazilian nursing workers during the COVID-19 pandemic. Method: cross-sectional study addressing nursing workers between March and May 2020. Data were collected online using a form addressing demographic variables and the Brazilian Portuguese version of the Face Mask Use Scale (FMUS-PB). Data were analyzed using descriptive and inferential statistics, central tendency and dispersion measures, Student’s t-test, and analysis of variance. Results: a total of 3,294 workers participated; most were nurses (85.9%), women (90.2%), lived in the southeast (36.9%), and had had contact with the COVID-19 (77.8%). The participants reported using masks in public places and at work (63.1% and 78.8%, respectively). However, only 25.8% wore masks at home. Individuals aged between 35 and 45 (p=0.002) living in the south (p<0.001) reported more frequent use of masks. Nursing technicians (p<0.001), aged ≥ 45 (p<0.001), living in the south (p<0.001), scored higher in the use of masks for self-protection and to protect others (p=0.002). Prior contact with COVID-19 resulted in the more frequent use of masks for self-protection and to protect others (p<0.001). Conclusion: the use of masks by nursing workers in public places and health settings was more frequent than at home. Additionally, masks were more frequently use for self-protection than to protect others. These results show a need to promote cultural changes toward masks for personal protection and within the family and social contexts.

Predictors of nursing interns' standard precautions compliance during internship training in four teaching hospitals in Saudi Arabia

AIM

The aim of this study was to assess compliance with standard precautions by Saudi nursing interns who were undergoing their internship training in four governmental tertiary teaching hospitals in Riyadh, Kingdom of Saudi Arabia, and to determine factors predictive of this.

BACKGROUND

Cross-transmission and infection prevention when delivering care must be strictly followed by nursing interns by complying with standard precautions during internship training.

DESIGN

The study employed a descriptive-correlational and cross-sectional design.

METHODS

A total of 224 nursing interns participated in the study by completing the Compliance with Standard Precautions Scale Arabic version between March 2017 and June 2017.

RESULTS/FINDINGS

A high overall compliance rate (84.8%) was observed. Nursing interns reported the highest compliance score in changing gloves between each patient contact and the lowest score in disposing of sharps boxes only when full. Nursing interns in hospital D showed the highest compliance rate over those in other hospitals. Age, sex, marital status, months in internship training and attendance of nursing interns in infection control seminars/trainings influenced their standard precautions compliance.

CONCLUSION

The study revealed good compliance by nursing interns with standard precautions. However, regular educational and clinical interventions are still needed to improve some areas and to ensure the continuity of high levels of compliance in other areas of standard precautions among nursing interns.

Medical interns' reflections on their training in use of personal protective equipment

BACKGROUND

The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety.

METHODS

This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour.

RESULTS

80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use.

CONCLUSIONS

Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.

Using bottleneck analysis to examine the implementation of standard precautions in hospitals

BACKGROUND

Service providers are often inadequately compliant with standard precaution protocols. This study used bottleneck analysis to identify the weakest link in standard precaution implementation and its associated challenges in hospitals.

METHODS

Bottleneck analysis was conducted in 12 hospitals in Fujian Province, China. In each hospital, a focus group was organized among the key informants to illustrate the sequential steps of standard precaution implementation graphically. The level of difficulty and the specific challenges associated with each step were discussed.

RESULTS

The sequential activities of standard precaution implementation generally start with making budget for personal protection equipment (PPE), followed by procurement, storage/inventory, in-hospital distribution, in-department distribution, usage/monitoring, and recycling of PPE. Service providers' improper use of PPE was the primary bottleneck. The reasons for improper use of PPE included high workload, time constraints, the sense of wearing PPE would interfere with clinical judgment, and various misconceptions. Making financial planning, recycling, and procurement of PPE were the secondary bottlenecks.

CONCLUSIONS

Bottleneck analysis is useful to illustrate workflow in healthcare systems and pinpoint constraints in standard precaution implementation. Institutional changes, including targeted provider training, adjustment of providers' workloads, and allocation of budget, are suggested strategies to address the identified bottlenecks in standard precaution.

A systematic risk-based strategy to select personal protective equipment for infectious diseases

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Selection of personal protective equipment (PPE) can be systematic and risk-based.

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Potential exposures are compared with sites susceptible to infection.

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Facilitates transparent decision-making about personal protective equipment.

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PPE evaluation includes: donning/doffing/changing, usability, and fit for purpose.

Background

Personal protective equipment (PPE) is a primary strategy to protect health care personnel (HCP) from infectious diseases. When transmission-based PPE ensembles are not appropriate, HCP must recognize the transmission pathway of the disease and anticipate the exposures to select PPE. Because guidance for this process is extremely limited, we proposed a systematic, risk-based approach to the selection and evaluation of PPE ensembles to protect HCP against infectious diseases.

Methods

The approach used in this study included the following 4 steps: (1) job hazard analysis, (2) infectious disease hazard analysis, (3) selection of PPE, and (4) evaluation of selected PPE. Selected PPE should protect HCP from exposure, be usable by HCP, and fit for purpose.

Results

The approach was demonstrated for the activity of intubation of a patient with methicillin-resistant Staphylococcus aureus or Severe Acute Respiratory Syndrome coronavirus. As expected, the approach led to the selection of different ensembles of PPE for these 2 pathogens.

Discussion

A systematic risk-based approach to the selection of PPE will help health care facilities and HCP select PPE when transmission-based precautions are not appropriate. Owing to the complexity of PPE ensemble selection and evaluation, a team with expertise in infectious diseases, occupational health, the health care activity, and related disciplines, such as human factors, should be engaged.

Conclusions

Participation, documentation, and transparency are necessary to ensure the decisions can be communicated, critiqued, and understood by HCP.

Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians

Background

The risk of healthcare-acquired infection increases during outbreaks of novel infectious diseases. Emergency department (ED) clinicians are at high risk of exposure to both these and common communicable diseases. Personal protective equipment (PPE) is recommended to protect clinicians from acquiring, or becoming vectors of, infection, yet compliance is typically sub-optimal. Little is known about factors that influence use of PPE—specifically gloves and masks—during routine care in the ED.

Methods

This was an ethnographic study, incorporating documentation review, field observations and interviews. The theoretical domains framework (TDF) was used to aid thematic analysis and identify relevant enablers of and barriers to optimal PPE use.

Results

Thirty-one behavioural themes were identified that influenced participants’ use of masks and gloves. There were significant differences, namely: more reported enablers of glove use vs more barriers to mask use. Reasons included more positive unit culture towards glove use, and lower perception of risk via facial contamination.

Conclusion

Emerging infectious diseases, spread (among other routes) by respiratory droplets, have caused global outbreaks. Emergency clinicians should ensure that, as with gloves, the use of masks is incorporated into routine cares where appropriate. Further research which examines items of PPE independently is warranted.