Personal protective equipment training for non-healthcare workers in the Covid-19 pandemic: Effectiveness of an evidence-based skills training framework

Application of failure mode and effect analysis in ICU admission of potentially COVID-19 infected patients

BACKGROUND

To analyze the admission and treatment process of potentially COVID-19-infected patients in the intensive care unit under normalization, prevention, and control of the pandemic.

METHODS

A multidisciplinary team was assembled to develop a flowchart of potentially COVID-19-infected patients admitted to the intensive care unit and identify potential failure steps and modes throughout the process using the failure mode and effect analysis method. Through risk priority number (RPN) analysis of each failure mode, those with the highest impact on nosocomial infection were identified, and the priority of implementation was determined. Related corrective measures have been developed to continuously improve clinical practice and management.

RESULTS

Eighty potential failure modes were identified, and 8 potential failure modes were identified with RPNs greater than 100. These high RPNs of the failure modes were associated with careless inquiries of epidemiological histories by nurses, inadequate implementation of management standards by nursing assistants, and exposure of attending physicians to potentially risky environments. Finally, 18 general corrective measures are proposed.

CONCLUSIONS

Application of the failure mode and effect analysis method for quality improvement is a powerful tool for predicting potential failures in the process and can suggest corrective measures that could help avoid nosocomial infection during a pandemic.

Workplace interventions to reduce the risk of SARS-CoV-2 infection outside of healthcare settings

BACKGROUND

Although many people infected with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) experience no or mild symptoms, some individuals can develop severe illness and may die, particularly older people and those with underlying medical problems. Providing evidence-based interventions to prevent SARS-CoV-2 infection has become more urgent with the potential psychological toll imposed by the coronavirus disease 2019 (COVID-19) pandemic. Controlling exposures to occupational hazards is the fundamental method of protecting workers. When it comes to the transmission of viruses, workplaces should first consider control measures that can potentially have the most significant impact. According to the hierarchy of controls, one should first consider elimination (and substitution), then engineering controls, administrative controls, and lastly, personal protective equipment. This is the first update of a Cochrane review published 6 May 2022, with one new study added.

OBJECTIVES

To assess the benefits and harms of interventions in non-healthcare-related workplaces aimed at reducing the risk of SARS-CoV-2 infection compared to other interventions or no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science Core Collections, Cochrane COVID-19 Study Register, World Health Organization (WHO) COVID-19 Global literature on coronavirus disease, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, and medRxiv to 13 April 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies of interventions. We included adult workers, both those who come into close contact with clients or customers (e.g. public-facing employees, such as cashiers or taxi drivers), and those who do not, but who could be infected by coworkers. We excluded studies involving healthcare workers. We included any intervention to prevent or reduce workers' exposure to SARS-CoV-2 in the workplace, defining categories of intervention according to the hierarchy of hazard controls (i.e. elimination; engineering controls; administrative controls; personal protective equipment).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were incidence rate of SARS-CoV-2 infection (or other respiratory viruses), SARS-CoV-2-related mortality, adverse events, and absenteeism from work. Our secondary outcomes were all-cause mortality, quality of life, hospitalisation, and uptake, acceptability, or adherence to strategies. We used the Cochrane RoB 2 tool to assess risk of bias, and GRADE methods to evaluate the certainty of evidence for each outcome.

MAIN RESULTS

We identified 2 studies including a total of 16,014 participants. Elimination-of-exposure interventions We included one study examining an intervention that focused on elimination of hazards, which was an open-label, cluster-randomised, non-inferiority trial, conducted in England in 2021. The study compared standard 10-day self-isolation after contact with an infected person to a new strategy of daily rapid antigen testing and staying at work if the test is negative (test-based attendance). The trialists hypothesised that this would lead to a similar rate of infections, but lower COVID-related absence. Staff (N = 11,798) working at 76 schools were assigned to standard isolation, and staff (N = 12,229) working at 86 schools were assigned to the test-based attendance strategy. The results between test-based attendance and standard 10-day self-isolation were inconclusive for the rate of symptomatic polymerase chain reaction (PCR)-positive SARS-CoV-2 infection (rate ratio (RR) 1.28, 95% confidence interval (CI) 0.74 to 2.21; 1 study; very low-certainty evidence). The results between test-based attendance and standard 10-day self-isolation were inconclusive for the rate of any PCR-positive SARS-CoV-2 infection (RR 1.35, 95% CI 0.82 to 2.21; 1 study; very low-certainty evidence). COVID-related absenteeism rates were 3704 absence days in 566,502 days-at-risk (6.5 per 1000 working days) in the control group and 2932 per 539,805 days-at-risk (5.4 per 1000 working days) in the intervention group (RR 0.83, 95% CI 0.55 to 1.25). We downgraded the certainty of the evidence to low due to imprecision. Uptake of the intervention was 71% in the intervention group, but not reported for the control intervention. The trial did not measure our other outcomes of SARS-CoV-2-related mortality, adverse events, all-cause mortality, quality of life, or hospitalisation. We found seven ongoing studies using elimination-of-hazard strategies, six RCTs and one non-randomised trial. Administrative control interventions We found one ongoing RCT that aims to evaluate the efficacy of the Bacillus Calmette-Guérin (BCG) vaccine in preventing COVID-19 infection and reducing disease severity. Combinations of eligible interventions We included one non-randomised study examining a combination of elimination of hazards, administrative controls, and personal protective equipment. The study was conducted in two large retail companies in Italy in 2020. The study compared a safety operating protocol, measurement of body temperature and oxygen saturation upon entry, and a SARS-CoV-2 test strategy with a minimum activity protocol. Both groups received protective equipment. All employees working at the companies during the study period were included: 1987 in the intervention company and 1798 in the control company. The study did not report an outcome of interest for this systematic review. Other intervention categories We did not find any studies in this category.

AUTHORS' CONCLUSIONS

We are uncertain whether a test-based attendance policy affects rates of PCR-positive SARS-CoV-2 infection (any infection; symptomatic infection) compared to standard 10-day self-isolation amongst school and college staff. A test-based attendance policy may result in little to no difference in absenteeism rates compared to standard 10-day self-isolation. The non-randomised study included in our updated search did not report any outcome of interest for this Cochrane review. As a large part of the population is exposed in the case of a pandemic, an apparently small relative effect that would not be worthwhile from the individual perspective may still affect many people, and thus become an important absolute effect from the enterprise or societal perspective. The included RCT did not report on any of our other primary outcomes (i.e. SARS-CoV-2-related mortality and adverse events). We identified no completed studies on any other interventions specified in this review; however, eight eligible studies are ongoing. More controlled studies are needed on testing and isolation strategies, and working from home, as these have important implications for work organisations.

Post implementation quarantine recommendations that support preparedness: A systematic review and quarantine implementation capability framework

BACKGROUND

During COVID-19, countries utilised various quarantine systems to achieve specific outcomes. At different stages and durations, voluntary and mandatory quarantine occurred in homes, hotels and facilities based on local and national elimination strategies. Countries are incorporating quarantine lessons from COVID-19 into revising pandemic plans as part of the World Health Organization's Preparedness and Resilience for Emerging Threats (PRET) activities. This review aimed to amalgamate quarantine post implementation recommendations from a whole-of-system perspective.

METHODS

This review utilised MEDLINE, Embase, CINAHL, APA, and PsycINFO. To capture all pandemics, no date restriction was applied. Recommendations were synthesised and inductively grouped into quarantine capability categories. This review was registered in PROSPERO (CRD42023420765).

RESULTS

A total of 449 published articles were screened, with 51 articles included and 156 recommendations extracted. Recommendations were grouped into 15 quarantine capability categories, comprising governance, preparation, infection prevention and control, ventilation, compliance, data, information and technology, safety-quality-risk, communication, healthcare model, home quarantine, hotel quarantine, facility quarantine, workforce, and resident considerations. The capability categories were further consolidated into strategic, structural, and operational domains to support the whole-of-system perspective.

CONCLUSION

The quarantine implementation capability framework generated provides comprehensive and deeper insights into the essential capabilities required for quarantine systems to support governments in PRET activities, including reviewing and revising pandemic plans and developing quarantine preparedness exercises.

Learning from the covid-19 outbreaks in long-term care facilities: a systematic review

BACKGROUND

The COVID-19 pandemic has devastatingly affected Long-Term Care Facilities (LTCF), exposing aging people, staff members, and visitors. The world has learned through the pandemic and lessons can be taken to adopt effective measures to deal with COVID-19 outbreaks in LTCF. We aimed to systematically review the available evidence on the effect of measures to minimize the risk of transmission of COVID-19 in LTCs during outbreaks since 2021.

METHODS

The search method was guided by the preferred reporting items for systematic reviews (PRISMA) and the reporting guideline synthesis without meta-analysis (SWiM) in systematic reviews. The search was performed in April 2023. Observational and interventional studies from the databases of PubMed, Web of Science, Scopus, Cochrane Systematic Reviews, CINAHL, and Academic Search were systematically reviewed. We included studies conducted in the LTCF with outbreaks that quantitatively assess the effect of non-pharmacological measures on cases of COVID-19. Two review authors independently reviewed titles for inclusion, extracted data, and undertook the risk of bias according to pre-specified criteria. The quality of studies was analyzed using the Joanna Briggs Institute Critical Appraisal.

RESULTS

Thirteen studies were included, with 8442 LTCF experiencing COVID-19 outbreaks and 598 thousand participants (residents and staff members). Prevention and control of COVID-19 infection interventions were grouped into three themes: strategic, tactical, and operational measures. The strategic measures reveal the importance of COVID-19 prevention and control as LTCF structural characteristics, namely the LTCF size, new admissions, infection control surveillance, and architectural structure. At the tactical level, the lack of personal and long staff shifts is related to COVID-19's spread. Operational measures with a favorable effect on preventing COVID-19 transmission are sufficient. Personal protective equipment stock, correct mask use, signaling, social distancing, and resident cohorting.

CONCLUSIONS

Operational, tactical, and strategic approaches may have a favorable effect on preventing the spread of COVID-19 in LTCFs experiencing outbreaks. Given the heterogeneous nature of the measures, performing a meta-analysis was not possible. Future research should use more robust study designs to explore similar infection control measures in LTCFs during endemic situations with comparable outbreaks.

TRIAL REGISTRATION

The protocol of this systematic review was registered in PROSPERO (CRD42020214566).

[Practical Application of Body Mechanics Principles in the Process of Health Workers Doffing Personal Protective Equipment]

Objective

To examine the application effect of body mechanics principles in the process of health workers doffing personal protective equipment (PPE).

Methods

A total of 360 health workers from a Fangcang shelter hospital, also known as alternate care site, in Shanghai were involved in a centralized 1-day training concerning essential skills for taking off PPE. The training was focused on integrating body mechanics principles, including expanding the support surface, lowering the center of gravity, reducing the shift in the the center of gravity, using the principle of leverage, and creating the appropriate operating space, in the PPE doffing process. Through remote video monitoring and recording, observations were made of the physical stability, pollution risks, and operational smoothness of the health workers when they applied body mechanics principles in their actions.

Results

The results of binary logistic regression showed that, compared with the actions taken without applying body mechanics principles, performing the operation of the body leaning forward and then slightly leaning backward was positively correlated with stability in the doffing process (odds ratio [O R]=3.291, 95% confidence interval [ CI]: 1.627-6.656), negatively correlated with pollution risks ( OR=0.203, 95% CI: 0.100-0.412), and positively correlated with operational smoothness ( OR=20.847, 95% CI: 8.061-53.916); performing the operation of taking off the boot sleeve in a horse-riding stance, with one foot standing ahead of the other, was positively correlated with stability ( OR=5.299, 95% CI: 1.041-26.957), negatively correlated with pollution risks ( OR=0.079, 95% CI: 0.009-0.692), and positive correlated with operational smoothness ( OR=16.729, 95% CI: 1.238-226.077); performing the operation of taking off the boot sleeve by lifting the heel and then the toes was positively correlated with stability ( OR=19.361, 95% CI: 8.391-44.671), negatively correlated with pollution risks ( OR=0.181, 95% CI: 0.084-0.393), and positively correlated with operational smoothness ( OR=10.977, 95% CI: 3.764-32.008); performing the operation of the leaning forward and keeping the face looking forward when taking off the mask was positively correlated with stability ( OR=2.935, 95% CI: 1.412-6.101), negatively correlated with pollution risks ( OR=0.123, 95% CI: 0.059-0.258), and positively correlated with operational smoothness ( OR=18.126, 95% CI: 6.665-49.297).

Conclusion

In the process of medical staffs doffing PPE, correct and proper mechanical postures and actions can effectively assist medical staffs to maintain balance and stability and reduce the risks of infection, which has major significance and should be widely incorporated in personal protection skills training and applied in clinical practice.

A Blockchain-Based Life-Cycle Environmental Management Framework for Hospitals in the COVID-19 Context

During the coronavirus disease 2019 (COVID-19) emergency, many hospitals were built or renovated around the world to meet the challenges posed by the rising number of infected cases. Environmental management in the hospital life cycle is vital in preventing nosocomial infection and includes many infection control procedures. In certain urgent situations, a hospital must be completed quickly, and work process approval and supervision must therefore be accelerated. Thus, many works cannot be checked in detail. This results in a lack of work liability control and increases the difficulty of ensuring the fulfillment of key infection prevention measures. This study investigates how blockchain technology can transform the work quality inspection workflow to assist in nosocomial infection control under a fast delivery requirement. A blockchain-based life-cycle environmental management framework is proposed to track the fulfillment of crucial infection control measures in the design, construction, and operation stages of hospitals. The proposed framework allows for work quality checking after the work is completed, when some work cannot be checked on time. Illustrative use cases are selected to demonstrate the capabilities of the developed solution. This study provides new insights into applying blockchain technology to address the challenge of environmental management brought by rapid delivery requirements.

Compliance to donning and doffing of personal protective equipment among dental healthcare practitioners during the coronavirus pandemic: a quality improvement plan, do, study and act (PDSA) Initiative

Introduction

With the emergence of SARS-Cov-2, the Centers for Disease Control and Prevention (CDC) defined mandatory guidelines for donning and doffing personal protective equipment (PPE) among dental healthcare professionals. The study’s objective was to improve the compliance of the donning and doffing protocols for PPE among dental practitioners by the Plan, Do, Study, and Act (PDSA) cycle.

Materials and methods

A quasi-experimental study was conducted on a sample of dental healthcare professionals using the non-probability purposive technique. In the first planning stage, compliance with CDC-approved donning and doffing was assessed on the clinical premises. In the second stage, an educational session was arranged with all the healthcare professionals to explain stepwise guidelines of donning and doffing to improve the quality of donning and doffing compliance. In the third stage, improvement in the quality outcome was then assessed after the session. Data were normally distributed. Qualitative variables for all the steps of donning and doffing are reported as frequency and percentages. Pareto charts were made to assess the non-compliance rate for donning and doffing protocols among dental healthcare professionals.

Results

There was an improvement of 44.55% in the hand hygiene practices before wearing the PPE after the second step of the PDSA cycle. A percentage improvement of 7.4% was recorded for removing jewellery, wearing the gown and wearing a surgical cap. No improvement was seen in securing the mask/ respirator ties, washing hands after wearing the respirator, placing the goggles or face shield practices.

Conclusions

PDSA cycle improved the overall compliance to PPE donning and doffing practices. Most of the protocols were followed by the dental healthcare professionals; however, some of them remained the same or worsened due to ease in SARS-CoV 2 restrictions.