Initial evidence that skin health deteriorates for younger age groups and with increased daily use of face masks for healthcare professionals at a dental hospital in the United Kingdom

OBJECTIVE

To determine the incidence and site of any adverse effects of wearing face masks via an online questionnaire.

METHODS

Healthcare workers in a dental hospital who wear Respiratory Protective Equipment (RPE) were invited to participate. An online questionnaire was used to identify adverse effects as a result of wearing face masks and possible remedies.

RESULTS

Red marks (72.1 %) and indentations (66.7 %) were the most frequently reported issues with increased use of the RPE. The bridge of the nose and cheeks were the most frequently reported sites of facial skin problems, such as blanching (54.1 % and 42.2 %, respectively) and pressure damage (42.3 % and 24.3 %, respectively). Overall perceived facial skin health deteriorated strongly and significantly (P < 0.001) following the use of RPE, where the mean skin health score (0 = best possible skin health and 10 = worst possible skin health) increased from 2.68 to 4.76. Broadly, there was increased discomfort with increased hours of use of RPE per day (P = 0.049). 71 % of participants said that they generally felt safe or very safe using RPE.

CONCLUSION

The facial skin health of respondents deteriorated strongly after the use of RPE. Guidelines for using RPE should be made clearer. A greater range of face mask sizes or bespoke masks should be made available to improve the fit and wearability, as well as to reduce the frequency and incidence of surface skin problems.

CLINICAL SIGNIFICANCE

This study has identified the factors influencing adverse skin reactions from face mask use, which can be used to inform face mask designers and manufacturers to improve the fit and wearability of face masks.

A systematic review of passing fit testing of the masks and respirators used during the COVID-19 pandemic: Part 1-quantitative fit test procedures

BACKGROUND

During respiratory infection pandemics, masks and respirators are highly sought after, especially for frontline healthcare workers and patients carrying respiratory viruses. The objective of this study was to systematically review fit test pass rates and identify factors influencing the fitting characteristics.

METHODS

Potentially relevant studies were identified using PubMed, Scopus, Web of Science, and Science Direct during the COVID-19 pandemic from February 5, 2020, to March 21, 2023. The search strategy using the following keywords was conducted: Quantitative Fit Test, Condensation Nuclei Counter, Controlled Negative Pressure, PortaCount, Sibata, Accufit, Fit, Seal, Mask, Respirator, Respiratory Protective Device, Respiratory Protective Equipment, Protective Device, Personal Protective Equipment, COVID-19, Coronavirus, and SARS-CoV-2. The quality of the included studies was also assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 137 articles met the eligibility criteria. Fifty articles had a quality score of less than 7 (good quality). A total of 21 studies had a fit test pass rate of less than 50%. 26 studies on disposable respirators and 11 studies on reusable respirators had an FF of less than 50 and less than 200, respectively. The most influential factors include respirator brand/model, style, gender, ethnicity, facial dimensions, facial hair, age, reuse, extensive movement, seal check, comfort and usability assessment, and training.

CONCLUSION

37.36% of the disposable respirator studies and 43% of the reusable respirator studies did not report fit test results. 67.86% of the disposable respirator studies had a fit test pass rate greater than 50%, and 35.84% of these studies had an FF greater than 100. Also, 85.71% of the reusable respirator studies had a fit test pass rate greater than 50%, and 52.77% of these studies had an FF greater than 1000. Overall, the fit test pass rate was relatively acceptable. Newly developed or modified respirators must undergo reliable testing to ensure the protection of HCWs. Subject and respirator characteristics should be considered when implementing fit testing protocols. An optimal fit test panel should be developed prior to respirator design, certification, procurement decisions, and selection procedures.

Effectiveness of fit testing versus fit checking for healthcare workers respiratory protective equipment: A systematic review

Objectives

Respiratory protection is critical in healthcare to minimise the risk of airborne infections for healthcare workers (HCWs). It emphasizes the use of proper fitting of particulate filter respirators and equivalent respiratory protective equipment (RPE) to ensure a good facial seal. The systematic review aimed to compare the effectiveness of fit testing and fit checking for HCWs' respiratory protective equipment.

Methods

A systematic review of the literature exploring RPE for HCWs to determine the effectiveness of fit-testing versus fit-checking from January 2003 to April 2022 was identified using CINAHL Complete via EBSCO Host, Cochrane Library, EMBASE, PubMed, and MEDLINE via Ovid electronic databases, and grey literature. The study protocol was registered with PROSPERO (registration number: CRD42020213968).

Results

Of the 561 articles identified in the search, 25 articles (22 quantitative studies and three guidelines) were included in this review. Overall, these studies suggest fit-testing as a method that is more effective, widely adopted, and reliable in assessing the effectiveness of RPE; however, a respiratory program should include both fit-testing and fit-checking to maximise effectiveness of the RPE. The COVID-19 epidemic highlighted a lack of knowledge among HCWs regarding fit-checking and fit-testing, and relevant education increased the effectiveness of respiratory equipment protection.

Conclusion

It is imperative that both fit-testing and fit-checking is implemented in order to ensure HCW safety. It is recommended to integrate education, fit-testing and fit-checking into a comprehensive respiratory protective program run by trained fit-testers. There is also a need for practical testing methods that incorporate the clinical environment.

Public health infection prevention: An analysis of existing training during the COVID-19 pandemic

OBJECTIVES

In response to the COVID-19 pandemic, agencies and organizations required trainings to support the needs of the public health workforce. To better understand the training resources available, this study identified, organized, and classified infection prevention and control (IPC) training and educational opportunities.

STUDY DESIGN

Environmental scan.

METHODS

A total of 306 IPC training resources were compiled between January and April 2021. Key themes and topics were identified and compared to the Healthcare Infection Control Practices Advisory Committee's (HICPAC) core IPC practices.

RESULTS

Three hundred and six training resources, including webinars, fact sheets, module-based learning activities, infographics, and professional practice guidance materials, were identified. Common themes included proper use of personal protective equipment (e.g., masks, gloves), community reopening guidance, and mass vaccination resources. A large proportion (74.9%) of trainings were under 60 min. Using the HICPAC framework, the most frequently addressed content included standard precautions (40%), leadership support (31.6%), and transmission-based precautions (25.8%). Few trainings addressed performance monitoring and feedback (17.1%).

CONCLUSIONS

A wide range of organizations developed IPC-specific content during the pandemic. However, these resources did not address the breadth of knowledge required to implement IPC concepts effectively. The creation of universally applicable IPC core competencies and the development of high-quality IPC education and trainings for public health and the overall responder workforces should be prioritized. Accessible high-quality online and just-in-time trainings are critical for future pandemic and disaster preparedness.

Respiratory Protection: Lessons Learned from a Global Pandemic

The COVID-19 pandemic exposed the limitations of global health systems' abilities to manage the rapid spread of a novel infectious disease, which was exacerbated by shortages of respiratory protective devices and other critical personal protective equipment (PPE). An advisory panel of experienced health-care professionals with backgrounds in Occupational and Environmental Health and Safety (OEHS), Infection Prevention, Nursing, and Clinical Application Specialists convened to discuss challenges and strategies associated with the selection and use of respiratory protective devices as experienced during the first year of the COVID-19 pandemic. This discussion led to the following recommendations: 1) the need for clear communication of alternative respiratory protection selection and use recommendations in accordance with US regulatory and agency guidance; 2) the need for collaboration between Infection Prevention, OEHS, clinical staff, supply chain/materials management, emergency preparedness, executive leadership, and finance; 3) the need for adequate stockpiling, inventory rotation, and diverse respiratory protection options to accommodate the majority of health-care workers; 4) the need for efficient and innovative strategies to communicate evolving regulatory, agency, and facility recommendations and to deliver appropriate training on respiratory protection; and 5) the need for additional research on respiratory protection use - involving filtering facepiece respirators (FFRs) as well as other respirator types designed to be reused - to balance infection prevention best practices with a sustainable process. In conclusion, these considerations may offer guidance and identify areas for research on preparedness, communication, education, and training to enhance the preparation of health-care facilities including community-based health-care organizations for unexpected public health events.

COVID-19 Infection Among Healthcare Workers at a Tertiary Healthcare Hospital

PURPOSE

SARS-CoV-2 or COVID-19 virus was the culprit of the global pandemic that began in 2019. With alarming mortality rates reaching sky-high worldwide, the virus prompted the masses to switch to online working. However, this was not feasible for healthcare workers (HCWs) exposed to a higher-than-normal risk of acquiring COVID-19 infection. This study aims to observe the prevalence of COVID-19 positivity among the various areas of a healthcare facility in Saudi Arabia.

METHODS

A cross-sectional study of positive employees among all departments at a tertiary care hospital in Riyadh, Saudi Arabia, such as administration, capital projects/facilities, and healthcare. The study included all hospital employees-permanent staff, rotating physicians, and trainees-who tested positive for COVID-19 between March 20, 2020 and December 30, 2020.

RESULTS

It was found that HCWs had the most significant number of infected individuals with nursing staff being the predominant demographic. This was followed by the capital projects/facilities departments, of which the environmental services staff were the most infected.

CONCLUSION

It is pertinent that strict protocols be taken by hospital management to limit the spread of future infectious diseases within hospital settings. This includes the provision of personal protective equipment (PPE) and adequate education on its proper usage, alongside regular surveillance of staff with regard to adherence and early detection of symptoms.

HALO CleanSpace PAPR evaluation: Communication, respiratory protection, and usability

OBJECTIVE

To evaluate a relatively new half-face-piece powered air-purifying respirator (PAPR) device called the HALO (CleanSpace). We assessed its communication performance, its degree of respiratory protection, and its usability and comfort level.

DESIGN AND SETTING

This simulation study was conducted at the simulation center of the Royal Melbourne Hospital.

PARTICIPANTS

In total, 8 voluntary healthcare workers participated in the study: 4 women and 4 men comprising 3 nursing staff and 5 medical staff.

METHODS

We performed the modified rhyme test, outlined by the National Institute for Occupational Safety and Health (NIOSH), for the communication assessment. We conducted quantitative fit test and simulated workplace protection factor studies to assess the degree of respiratory protection for participants at rest, during, and immediately after performing chest compression. We also invited the participants to complete a usability and comfort survey.

RESULTS

The HALO PAPR met the NIOSH minimum standard for speech intelligibility, which was significantly improved with the addition of wireless communication headsets. The HALO provided consistent and adequate level of respiratory protection at rest, during and after chest compression regardless of the device power mode. It was rated favorably for its usability and comfort. However, participants criticized doffing difficulty and perceived communication interference.

CONCLUSIONS

The HALO device can be considered as an alternative to a filtering face-piece respirator. Thorough doffing training and mitigation planning to improve the device communication performance are recommended. Further research is required to examine its clinical outcomes and barriers that may potentially affect patient or healthcare worker safety.

Laboratory assessment of bacterial contamination of a sterile environment when using respirators not traditionally used in a sterile field environment

OBJECTIVE

During infectious disease outbreaks or pandemics, an increased demand for surgical N95s that create shortages and necessitate the use of alternative National Institute for Occupational Safety and Health (NIOSH)-approved respirators that do not meet the Food and Drug Administration (FDA) additional requirements. The objective of this research was to quantify the level of bacterial contamination resulting from wearing NIOSH-approved respirators lacking the additional protections afforded by surgical N95s.

METHODS

Participants performed simulated healthcare tasks while wearing 5 different respirators approved by the NIOSH. Sterile field contamination resulting from use of a surgical mask cleared by the FDA served as a baseline for comparison with the NIOSH-approved respirators.

RESULTS

The bacterial contamination produced by participants wearing the N95 filtering facepiece respirators (FFRs) without an exhalation valve, the powered air-purifying respirators (PAPRs) with an assigned protection factor of 25 or 1,000 was not significantly different compared to the contamination resulting from wearing the surgical mask. The bacterial contamination resulting from wearing the N95 FFR with an exhalation valve and elastomeric half-mask respirator (EHMR) with an exhalation valve was found to be statistically significantly higher than the bacterial contamination resulting from wearing the surgical mask.

CONCLUSIONS

Overall, NIOSH-approved respirators without exhalation valves maintain a sterile field as well as a surgical mask. These findings inform respiratory guidance on the selection of respirators where sterile fields are needed during shortages of surgical N95 FFRs.

Tolerability, User Acceptance and Preference for a Novel Reusable Respirator Among Healthcare Workers

BACKGROUND

The CleanSpace Technology Halo respirator combines a clear face mask and a powered air supply, without belts or hoses. Although providing higher protection than other respirators used in healthcare, user acceptance of this device has not been assessed with validated tools.

METHODS

We surveyed healthcare workers (HCWs) within a US medical system using Halo respirators in 2021. Subjects completed three surveys over eight weeks, which included the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), a validated tool to assess respirator tolerability. The survey included additional questions about user acceptability and respirator preference. Responses were evaluated for change over time and for significant predictors.

RESULTS

Of 113 HCWs who completed the initial survey (29% response rate), mean ± SD R-COMFI score was 9.1± 5.1, (scale 0-47, lower = more tolerable) and did not change over time (p = 0.42). Fewer years in healthcare significantly predicted better R-COMFI score (p=0.01). Many users preferred Halo in both usual care (45-52%) and care of patients with COVID-19 (60-64%).

DISCUSSION

Halo respirators received favorable tolerability scores by HCWs, who often preferred them, especially during care of patients with COVID-19.

CONCLUSIONS

Given demand for respirator use in healthcare, the innovative design provides higher protection than other respirators with a favorable user experience.

Impact of biosecurity measures, social pressure and bullying on attitudes, perceptions, and job satisfaction levels among healthcare workers during the COVID-19 pandemic: a cross-sectional survey

INTRODUCTION

The extent and nature of social pressure and bullying towards healthcare workers (HCWs) during the COVID-19 remains unclear. The following study identifies the effect of social pressure and bullying directed towards HCWs when using biosecurity measures during the COVID-19 pandemic; further, the impact on perceptions, attitudes and job satisfaction level is also explored.

METHODOLOGY

We conducted a cross-sectional survey-based study among 684 Ecuadorian HCWs. The survey consisted of 38 questions related to the frequency, attitudes, and perceptions of biosecurity measures during the COVID-19 pandemic. Exploratory factor analysis was performed to assess the validity of the questionnaire. Associations between variables were analysed using χ² and Fisher's exact test. Using SPSS V.25, qualitative and quantitative data were analysed.

RESULTS

Of the 684 participants, 175 (25.59%) experienced or felt bullying or social pressure during the COVID-19 pandemic associated with the use of biosecurity measures. Of these, 40.6% believed it was due to an imbalance of power in the workplace. The perception that HCWs wearing personal protective equipment resulting in bullying was noted in 12% of the respondents. Job satisfaction was positive among 73% of the respondents. Gender (female) and type of institution (public) were noted to contribute towards job satisfaction and bullying experiences.

CONCLUSION

Exposure to social bullying and pressure due to the use of biosecurity measures during the COVID-19 pandemic may result in reduced job satisfaction and thoughts about quitting work.

Determinants of nurse's and personal support worker's adherence to facial protective equipment in a community setting during the COVID-19 pandemic in Ontario, Canada: A pilot study

Background

Appropriate and consistent facial protective equipment (FPE) use is critical for preventing respiratory illness transmission. Little is known about FPE adherence by home care providers. The purpose of this study is to adapt an existing facial protection questionnaire and use it to develop an initial understanding of factors influencing home care providers’ adherence to FPE during the COVID-19 pandemic.

Methods

A survey was shared with home care providers during Wave 2 of the COVID-19 pandemic in Ontario. Descriptive statistics and logistic regression by FPE adherence were conducted across individual, organizational, and environmental factors.

Results

Of the 199 respondents (140 personal support workers; 59 nurses), 71% reported that they always used FPE as required, with greater adherence to masks (89%) than eye protection (73%). The always-adherent reported greater perceived FPE efficacy, knowledge of recommended use and perceived occupational risk, lower education, and not experiencing personal barriers (including difficulty seeing, discomfort, communication challenges).

Discussion

Adherence rates were relatively high. In this context, with participants reporting high levels of organizational support, individual-level factors were the significant predictors of adherence.

Conclusions

Initiatives addressing perceived FPE efficacy, knowledge of recommended use, perception of at-work risk, and personal barriers to use may improve FPE adherence.

Supporting the Delivery of Infection Prevention and Control Training to Healthcare Workers: Insights from the Sector

Infection prevention and control (IPC) cannot be implemented without healthcare workers (HCWs) being properly trained and competent. The provision of training is essential, yet there is a gap in our understanding of the factors impacting the implementation of IPC training. This paper reports the results from in-depth interviews that explored the current landscape around IPC training delivered across low-, middle-, and high-income countries. Semi-structured interviews were conducted with the key stakeholders involved in policymaking or IPC implementation in Saudi Arabia, Pakistan, India, Indonesia, the Philippines, and Australia. Although the training was mandated for many HCWs, participants indicated that only some training elements were mandatory. Participants spoke about covering various topics, but those in low-resource settings spoke about the challenges of delivering training. Classroom-based training dominated, but online delivery modes were also used in some locations. Whilst HCW’s training was postulated to have improved during the COVID-19 pandemic, the capacity to deliver training did not improve in some settings. More research is needed to establish the essential elements that could underpin the development of training packages.

Nursing Infection Control Practice Adherence, Related Barriers, and Methods of Intervention

OBJECTIVE

This study aims to evaluate the level of infection control (IC) practice adherence and related barriers among nursing staff at a US academic medical center. Furthermore, it surveys staff to identify interventions to improve adherence with IC practices.

BACKGROUND

Infectious disease emergencies have exposed healthcare workers to increased infection risk. This study aims to explore IC practice adherence in the tertiary hospital setting and further investigate the personal protective equipment (PPE) champion role as a method to boost adherence.

METHODS

This descriptive quality improvement study includes 2 parts: 1) A PPE champion role was piloted to support healthcare worker adherence to IC practices; and 2) a survey was disseminated to nursing staff to identify the perceptions of their own and coworkers' adherence to IC practices as well as suggestions for improvement.

RESULTS

Twenty-six percent of PPE champion observations found nursing staff nonadherent with IC practices and policies. Barriers included knowledge deficit (38%), lack of motivation (38%), time constraints (21%), and lack of supplies (3%). Two hundred sixty-four RNs and nurse technicians responded to the IC survey. Nursing staff rated their IC adherence higher than observed by their peers. Perceived barriers to adherence included the lack of supplies (53%), knowledge of proper technique (41%), time constraints (35%), and motivation (5%). Staff recommended using PPE champions (52%) and mandating supervised practice of essential skills (48%) to increase adherence.

CONCLUSIONS

Nursing staff reported barriers related to their knowledge of proper technique and suggested interventions including supervised practice of critical skills. It seems that the PPE champion role is a popular method to boost IC practice adherence that can be implemented during pandemic and nonpandemic environments at minimal cost.

What We Are Learning from COVID-19 for Respiratory Protection: Contemporary and Emerging Issues

Infectious respiratory diseases such as the current COVID-19 have caused public health crises and interfered with social activity. Given the complexity of these novel infectious diseases, their dynamic nature, along with rapid changes in social and occupational environments, technology, and means of interpersonal interaction, respiratory protective devices (RPDs) play a crucial role in controlling infection, particularly for viruses like SARS-CoV-2 that have a high transmission rate, strong viability, multiple infection routes and mechanisms, and emerging new variants that could reduce the efficacy of existing vaccines. Evidence of asymptomatic and pre-symptomatic transmissions further highlights the importance of a universal adoption of RPDs. RPDs have substantially improved over the past 100 years due to advances in technology, materials, and medical knowledge. However, several issues still need to be addressed such as engineering performance, comfort, testing standards, compliance monitoring, and regulations, especially considering the recent emergence of pathogens with novel transmission characteristics. In this review, we summarize existing knowledge and understanding on respiratory infectious diseases and their protection, discuss the emerging issues that influence the resulting protective and comfort performance of the RPDs, and provide insights in the identified knowledge gaps and future directions with diverse perspectives.

Management of pediatric facial fractures during COVID-19 pandemic

Objective

The coronavirus disease 2019 (COVID-19) pandemic caused delays in medical and surgical interventions in most health care systems worldwide. Oral and maxillofacial surgeons (OMSs) delayed operations to protect themselves, patients, and staff. This article (1) presents one institution's experience in the management of pediatric craniomaxillofacial trauma during the COVID-19 pandemic and (2) suggests recommendations to decrease transmission.

Methods

This was a retrospective review of children aged 18 years or younger who underwent surgery at Children's Healthcare of Atlanta in Atlanta, GA, between March and August 2020. Patients (1) were aged 18 years old or younger, (2) had one or more maxillofacial fractures, and (3) underwent surgery performed by an OMS, otolaryngologist, or plastic surgeon. Medical records were reviewed regarding (1) fracture location, (2) COVID-19 status, (3) timing, (4) personal protective equipment, and (5) infection status. Descriptive statistics were computed.

Results

Fifty-eight children met the inclusion criteria. The most commonly injured maxillofacial location was the nose. Operations were performed 50.9 hours after admission. Specific prevention perioperative guidelines were used with all patients, with no transmission occurring from a patient to a health care worker.

Conclusions

With application of our recommendations, there was no transmission to health care workers. We hope that these guidelines will assist OMSs during the COVID-19 pandemic.

Personal respiratory protection and resiliency in a pandemic, the evolving disposable versus reusable debate and its effect on waste generation

The COVID-19 pandemic sweeping much of the globe is not anticipated to be short in duration, with contingency plans suggesting that it may last at least eighteen months. In the United States, one of the critical issues in coping with the pandemic has been a lack of essential personal protective equipment (PPE), at the local, state, and national level. As COVID-19 is primarily transferred through respiratory routes, adequate respiratory protection is a dire necessity. The shift from durable and reusable medical supplies in recent years to their single use counterparts has reduced the resiliency of the medical system with respect to PPE and other critical supplies in the current pandemic. This work explores the role of reusable compared to single use respiratory protection in the current pandemic, including reprocessing of single use options, from the perspective of number of equivalent protection devices needed. The current state of literature is also reviewed to provide context to this work, with respect to resource procurement. The economic cost of PPE throughout a pandemic is explored, and it is found that utilizing reusable PPE options depending on filter cycling may be less costly. Increased waste production is another issue with the current pandemic, and this is explored utilizing a mass basis, finding that reusable respiratory PPE would generate less waste than using single use PPE in a business as usual scenario. As future outbreaks of COVID-19 are likely along with other future pandemics, this work provides insights at how to prepare from the standpoint of PPE, and in particular respiratory protection.

Use of powered air-purifying respirator(PAPR) as part of protective equipment against SARS-CoV-2-a narrative review and critical appraisal of evidence

BACKGROUND

The last 2 decades have seen an increasing frequency of zoonotic origin viral diseases leaping from animal to human hosts including Severe Acute Respiratory Syndrome Coronaviruses (SARS-CoV-2). Respiratory component of the infectious disease program against SARS-CoV-2 incorporates use of protective airborne respiratory equipment.

METHODS

In this narrative review, we explore the features of Powered Air Purifying Respirators (PAPR) as well as logistical and evidence-based advantages and disadvantages.

RESULTS

Simulation study findings support increased heat tolerance and wearer comfort with a PAPR, versus decreased communication ability, mobility, and dexterity. Although PAPRs have been recommended for high-risk procedures on suspected or confirmed COVID-19 patients, this recommendation remains controversial due to lack of evidence. Guidelines for appropriate use of PAPR during the current pandemic are sparse. International regulatory bodies do not mandate the use of PAPR for high-risk aerosol generating procedures in patients with SARS-CoV-2. Current reports of the choice of protective respiratory technology during the SARS-CoV-2 pandemic are disparate. Patterns of use appear to be related to geographical locations.

DISCUSSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment in healthcare workers performing AGPs in patients with SARS-CoV-2. Whether a higher PAPR filtration factor translates to decreased infection rates of HCWs remains to be elucidated. Utilization of PAPR with high filtration efficiency may represent an example of "precautionary principle" wherein action taken to reduce risk is guided by logistical advantages of PAPR system.

Airborne Infections and Emergency Surgery: The COVID-19 Pandemic Perspective

COVID-19 which emerged in Wuhan, China has rapidly spread all over the globe and the World Health Organisation has declared it a pandemic. COVID-19 disease severity shows variation depending on demographic characteristics like age, history of chronic illnesses such as cardio-vascular/renal/respiratory disease; pregnancy; immune-suppression; angiotensin converting enzyme inhibitor medication use; NSAID use etc but the pattern of disease spread is uniform - human to human through contact, droplets and fomites. Up to 3.5% of health care workers treating COVID-19 contact an infection themselves with 14.8% of these infections severe and 0.3% fatal. The situation has spread panic even among health care professionals and the cry for safe patient care practices are resonated world-wide. Surgeons, anesthesiologists and intensivists who very frequently perform endotracheal intubation, tracheostomy, non-invasive ventilation and manual ventilation before intubation are at a higher odds ratio of 6.6, 4.2, 3.1 and 2.8 respectively of contacting an infection themselves. Elective surgery is almost always deferred in fever/infection scenarios. A surgeon and an anesthesiologist can anytime encounter a situation where in a COVID-19 patient requires an emergency surgery. COVID-19 cases requiring surgery predispose anesthesiologists and surgeons to cross-infection threats. This paper discusses, the COVID-19 precautionary outlines which has to be followed in the operating room; personal protective strategies available at present; methods to raise psychological preparedness of medical professionals during a pandemic; conduct of anesthesia in COVID-19 cases/suspect cases; methods of decontamination after conducting a surgery for COVID-19 case in the operating room; and post-exposure prophylaxis for medical professionals.

Knowledge and practices: Risk perceptions of COVID-19 and satisfaction with preventive measures at workplace among maternity care providers in Pakistan

INTRODUCTION

While all healthcare services across the globe deferred non-urgent surgeries, labor wards provided maternity care during the COVID-19 pandemic continuously. This study assesses the knowledge and practices of obstetricians and midwives about personal protective equipment (PPE); their risk perception of COVID-19 and satisfaction with the preventive measures adopted at their workplace.

METHODS

A questionnaire designed according to the World Health Organization’s advice on rational use of personal protective equipment for COVID-19 was administered to 452 Pakistani maternity care providers between 1 July and 30 July 2020.

RESULTS

Most (85%) had adequate knowledge and 78.8% had good practices regarding PPE use. The perceived risk of contracting COVID-19 was lower than for influenza and tuberculosis. Perceived risk of contracting COVID-19 was highest for outpatient clinics. Fewer midwives compared to obstetricians (23.3% vs 32.9 %, p=0.001) were satisfied with the job security provided. Only 19.5% were satisfied with the social distancing measures at their setups. Less than one-third (31%) were satisfied with the PPE available to them.

CONCLUSIONS

The participants had good knowledge and practices regarding PPE. The perceived risk of contracting COVID-19 was lower than for contracting influenza; however, they were concerned about contracting COVID-19 in outpatient clinics and emergency rooms. They had poor satisfaction with the measures adopted by hospital managements regarding job security and social distancing.

"I'm smiling back at you": Exploring the impact of mask wearing on communication in healthcare

BACKGROUND

Surgical and respirator masks are worn to reduce the risk of droplet and airborne transmission of viral respiratory disease. As a result of the novel coronavirus (COVID-19) pandemic, mask wearing has been designated mandatory for healthcare professionals working in UK hospitals for the foreseeable future. It is thus timely to consider the long-term implications of mask wearing on communication within healthcare settings, from both a patient and a clinician perspective.

AIMS

The primary objective is to identify research evidence that corresponds to the mask-wearing experiences of healthcare professionals working on the ground. By drawing together a summary of the literature illustrating the potential challenges associated with mask wearing, it is possible to make an application to various clinical cohorts and to formulate a set of preliminary, evidence-based support strategies. The paper additionally explores the role for the Speech and Language Therapist (SLT) in supporting communication in the context of mask wearing.

METHODS & PROCEDURES

Through a scoping review of the relevant literature, this paper reflects holistically on the prospective challenges associated with mask wearing across a variety of healthcare settings and patient populations. The subsequent conclusions have been used to inform the proposed clinical guidelines for safe and effective practice.

OUTCOMES & RESULTS

There is a current research gap with regards to mask wearing in non-medical and non-clinical healthcare workers, and the impact this may have on both a professional and a personal basis. In the absence of preliminary data, the development of associated communication support strategies is hindered. This paper draws upon a variety of clinically conceivable issues faced by healthcare professionals, outlines important practical and ethical considerations, and proposes evidence-based solutions to some of the challenges identified. Future research is required to gather evidence with regards to actual clinical experiences of mask wearing to substantiate hypotheses.

CONCLUSIONS & IMPLICATIONS

Although undoubtedly essential in protecting the health of staff and patients, there are numerous logistical, physiological, psychological, social and economic complications associated with the wearing of masks. The ability of healthcare staff to successfully communicate with patients and with colleagues is jeopardized, which may adversely affect the efficiency, effectiveness, equitability and, most notably, safety of therapeutic intervention. The SLT has a distinct role in facilitating communication in order to safeguard the provision, accessibility and efficacy of services. What this paper adds What is already known on the subject Existing research explores the impact of mask wearing on medical doctors, surgeons and dentists, and upon the corresponding patient cohorts. Little is known about how mask wearing may affect Allied Health Professionals and their ability to deliver therapeutic interventions safely and effectively. With mandatory face covering potentially a long-term requirement for UK healthcare staff, it is both timely and relevant to consider the consequences of mask wearing on communication across acute and community settings. What this paper adds to existing knowledge This paper identifies a range of prospective key issues associated with mask wearing across a variety of clinical and non-clinical populations, with application specifically to vulnerable patient cohorts. Through evidence synthesis, this paper provides a summary of fundamental issues supported by relevant literature, and draws upon these in order to propose a preliminary set of evidence-based clinical guidelines setting out potential solutions to the challenges faced. This review additionally assists in quantifying the role of the SLT within these extraordinary circumstances, with the aim of prompting unified practice, building upon professional guidance and increasing skill recognition. What are the potential or actual clinical implications of this work? In addition to their role in facilitating the development of individualised communication strategies for patients, SLTs should actively seek to provide widely accessible multidisciplinary education opportunities focusing on supporting communication; with specific reference to mask wearing and the associated communicative challenges. At a commissioning and managerial level, leaders within healthcare should acknowledge mask wearing as just one of the complexities associated with frontline working in the context of the COVID-19 pandemic, and aim to support their workforce by delivering resources and protocols which maximize and promote staff safety, efficiency, resilience and well-being in concurrence with positive patient outcomes.

Personal protective equipment availability and usage amongst pediatric otorhinolaryngologists during the COVID-19 pandemic: An international survey

OBJECTIVES

To survey a group of global pediatric otolaryngology specialists to assess their usage and access to personal protective equipment during the COVID-19 pandemic.

METHODS

A survey of 13 questions was created collecting information on: basic demographics of practice, types of PPE used for procedures of varying aerosolization risk, access to positive air-purifying respirator (PAPR) and patient testing for SARS-CoV-2. Pediatric otolaryngologists were invited to complete the survey via Whatsapp™.

RESULTS

96 responses were collected from 17 different countries. N95 was the most commonly utilized PPE when dealing with COVID-19 patients (64.2%-81.9% depending on aerosolization risk of the procedure). Significantly higher use of PAPR was noted in high-risk aerosolization generating medical procedures, when compared to other risks. Face covering was used consistently (91.6%). Most respondents (78.1%, n = 75) had access to PAPR or had at least requested it. The majority of patients (56.2%, n = 54) was being tested for SARS-CoV-2 prior to procedures performed in operating rooms (OR); whereas, only 1.1% (n = 1) of clinic patients were tested for SARS-CoV-2 irrespective of the history or symptomatology.

CONCLUSIONS

Most pediatric otolaryngologists used N95 and some form of face covering (eg. goggles, face shields) when dealing with patients with COVID-19 positive status. PAPR was used in situations of high aerosolization risk. Majority of respondents were screening all patients prior to procedures in the operating room.

The role of fit testing N95/FFP2/FFP3 masks: a narrative review

For healthcare workers performing aerosol-generating procedures during the COVID-19 pandemic, well fitted filtering facepiece respirators, for example, N95/FFP2 or N99/FFP3 masks, are recommended as part of personal protective equipment. In this review, we evaluate the role of fit checking and fit testing of respirators, in addition to airborne protection provided by respirators. Filtering facepiece respirators are made of material with sufficient high filter capacity to protect against airborne respiratory viruses. Adequate viral protection can only be provided by respirators that properly fit the wearer's facial characteristics. Initial fit pass rates vary between 40% and 90% and are especially low in female and in Asian healthcare workers. Fit testing is recommended to ensure a proper fit of respirators for the individual healthcare worker so that alternative respirators can be selected if required. Although fit testing is required to comply with respirator standards, it is not performed consistently within all healthcare settings. Fit checking (a self-test) is recommended every time a healthcare worker dons a respirator, but is unreliable in detecting proper fit or leak. Additionally, fit testing has a high educational value and as such is best performed as part of a hospital respiratory protection programme. Whether fit checking alone, as opposed to fit tested and fit checked respirators, provides adequate airborne protection against aerosols containing the SARS-CoV-2 virus and other respiratory viruses remains unknown. While fit testing undoubtedly incurs additional costs, it is still recommended, not only to protect healthcare workers but also as it may reduce overall healthcare cost when considering the potential costs of sickness leave and the associated legal costs of compensation.

COVID-19 and a novel initiative to improve safety by 3D printing personal protective equipment parts from computed tomography

BACKGROUND

Powered air-purifying respirators are in short supply and can break down with extended use. Replacement parts can become hard to acquire. The aim of this study was to create an innovative quality improvement proof of concept using rapid prototyping.

METHODS

Here we report three cases of 3D printed powered air-purifying respirator parts. 3D printing was performed on all parts using fused deposition modeling with standard polylactic acid, in the same way that presurgical models would be created. Measurements using an electronic caliper as well as CT scans were used to compare an original part to its corresponding 3D printed parts for accuracy.

RESULTS

Electronic caliper and computed tomography measurements both showed accuracy consistant with current published norms.

CONCLUSIONS

Ultimately, there will be questions surrounding intellectual property, effectiveness and potential long-term safety for these types of 3D printed parts. Future research should look into the addition of specific nanoparticles from the position of cost, efficacy, safety and improved accuracy.

Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases-a systematic review of evidence

BACKGROUND

Healthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include severe acute respiratory syndrome coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS), and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of powered air-purifying respirators (PAPRs) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination.

METHODS

Our primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola, or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed evidence profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system.

RESULTS

We identified 689 studies during literature searches. We included 10 full-text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during the care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend towards greater self-reported wearer comfort with PAPR technology in low-quality observational simulation studies.

CONCLUSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR was identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42020184724 .

Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey

Background

Using personal protective equipment (PPE) is one of several fundamental measures to prevent the transmission of infection and infectious diseases and is particularly pertinent in the current COVID-19 pandemic. Appropriate use of PPE by healthcare workers is, however, often suboptimal. Training and monitoring of PPE competency are essential components of an infection prevention and control program but there is a paucity of research and data on the content of such training programs across Australasia. This paper reports the results of a survey that characterised the nature of PPE training in Australian and New Zealand hospitals.

Methods

A population-based online survey was distributed to members of three major Australasian colleges representing infection prevention and control.

Results

Results indicate that, although training is frequently provided at orientation, many healthcare workers do not receive regular updates. Training programmes combine online and classroom sessions, but over a third do not include a practical component. The frequency of monitoring PPE competency is variable with one third of respondents indicating that no auditing occurs. PPE items used for high-level training are variable, with use of powered air purifying respirators (PAPRs) uncommon.

Conclusion

The results of this study suggest that HCWs’ confidence, competence and familiarity with PPE are a concern, which in the context of the current global COVID-19 pandemic is problematic. More research is needed into how PPE training programs could be better designed, to prepare HCWs for practice using PPE safely and confidently.

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Most HCW orientation programmes include PPE training but fewer than half are updated annually.

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One third of PPE programmes do not include a practical component.

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Only two thirds of PPE training programmes monitor PPE compliance.

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Future research should consider the design of PPE training programs to optimise HCW PPE practice.

Implementation of an Elastomeric Mask Program as a Strategy to Eliminate Disposable N95 Mask Use and Resterilization: Results from a Large Academic Medical Center

Background

The COVD-19 global pandemic has placed a large demand on personal protective equipment for healthcare workers. N-95 respirators, required to perform aerosolizing procedures, are in short supply and have increased significantly in cost. The lack of a clear end to the pandemic requires hospitals to create a long-term, cost effective solution to the N95 shortage. We initially used previously described methods to reuse and resterilize N95 masks; however, we found they did not solve the issues related to just-in-time fit-testing and cost.

Study design

We initiated a program with the aim to reduce our dependence on N95 masks by initiating a phased program to acquire industrial style elastomeric P100 masks as a substitute for reuse and resterilization of disposable N95s. We created an allocation strategy based on availability of the masks, as well as an operational plan to fit test, educate, and disinfect the masks.

Results

Within 1 month, we were able to reduce the number of N95s needed by our network by 95%. We also found that the cost was, conservatively, 10 times less per month than purchasing disposable N95s, and the cost benefit increases the longer they are needed.

Conclusions

Establishment of an elastomeric mask program is feasible and less expensive than programs focused on reusing and disinfecting disposable N95 masks. A well thought out elastomeric distribution and disinfection program does not pose greater operational challenges than an N95 reuse and resterilization program. In addition, elastomeric masks can be stored for future surges and should be considered an essential part of all healthcare facilities’ supply of personal protective equipment. Implementation of the program has eliminated our dependence on disposable N95s to maintain normal operations during the global pandemic.

Role of respirators in controlling the spread of novel coronavirus (COVID-19) amongst dental healthcare providers: a review

During the ongoing COVID‐19 pandemic, healthcare professionals are at the forefront of managing the highly infectious coronavirus. As the most common route of transmission is via aerosols and droplet inhalation, it is critical for healthcare workers to have the correct personal protective equipment (PPE) including gowns, masks and goggles. Surgical masks are not effective in preventing the influenza and SARS, so they are unlikely to be able to resist contaminated aerosols from entering the respiratory system. Therefore, it is vital to use respirators which have been proven to offer better protection against droplets, aerosols and fluid penetration and which form a tight seal around the mouth and nose. Various types of respirators are used in healthcare settings, such as half‐mask filtering facepiece respirators (FFRs) and powered air‐purifying respirators (PAPRs). The most commonly used FFR is the N95 disposable respirator, which is tight fitting and has a 95% or above particle filtering efficiency for a median particle size of 0.3 µm. This review discusses respirators, their purpose, types, clinical efficiency and proper donning and doffing techniques.

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study

The current international COVID‐19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air‐purifying respirators and powered air‐purifying respirators during simulated difficult airway scenarios. Twenty‐five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.

COVID-19 and endoscopy services in intermediately affected countries: a position statement from the saudi gastroenterology association

With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.

Addressing the corona virus pandemic: will a novel filtered eye mask help?

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The CDC recommends not touching the eyes to prevent 2019-nCoV

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Non-hermetically sealed eye protection does not protect the eyes against airborne particulates

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Hermetically sealed goggles protect the eyes, but tend to fog up, which is a barrier to use

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A filtered eye mask (FEM) is a design to both protect the eyes from particulates and prevent fog

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An FEM may help to mitigate the spread of 2019-nCoV and should be researched further

Objective

Non-hermetically sealed eye protection does not fully protect the eyes from airborne particles. Hermetically sealed eye protection fully protects the eyes from particles, but tends to fog up, rendering it unusable. This study aimed to build and test a filtered eye mask (FEM) to protect the eyes from airborne particles, while being usable without excessive fog build up.

Methods

The steps performed to build the FEM were described. A hermetically-sealed standard eye mask (SEM) and an FEM were examined at 1-minute, 5-minute and 60-minute periods for performance metrics relating to fog.

Results

The SEM showed minimal fog at 1 minute, lots of fog at 5 minutes and was dripping with condensation at 60 minutes. The FEM was clear at 1 minute, 5 minutes and showed minimal fog at 60 minutes.

Conclusion

An FEM may play an important role in preventing novel coronavirus (COVID-19) exposure by protecting the eyes from airborne particles and preventing fog, rendering it usable. Further research is strongly recommended.

Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis

BACKGROUND

This review is one of a series of rapid reviews that Cochrane contributors have prepared to inform the 2020 COVID-19 pandemic. When new respiratory infectious diseases become widespread, such as during the COVID-19 pandemic, healthcare workers' adherence to infection prevention and control (IPC) guidelines becomes even more important. Strategies in these guidelines include the use of personal protective equipment (PPE) such as masks, face shields, gloves and gowns; the separation of patients with respiratory infections from others; and stricter cleaning routines. These strategies can be difficult and time-consuming to adhere to in practice. Authorities and healthcare facilities therefore need to consider how best to support healthcare workers to implement them.

OBJECTIVES

To identify barriers and facilitators to healthcare workers' adherence to IPC guidelines for respiratory infectious diseases.

SEARCH METHODS

We searched OVID MEDLINE on 26 March 2020. As we searched only one database due to time constraints, we also undertook a rigorous and comprehensive scoping exercise and search of the reference lists of key papers. We did not apply any date limit or language limits.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with a distinct qualitative component) that focused on the experiences and perceptions of healthcare workers towards factors that impact on their ability to adhere to IPC guidelines for respiratory infectious diseases. We included studies of any type of healthcare worker with responsibility for patient care. We included studies that focused on IPC guidelines (local, national or international) for respiratory infectious diseases in any healthcare setting. These selection criteria were framed by an understanding of the needs of health workers during the COVID-19 pandemic.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed the titles, abstracts and full texts identified by our search. We used a prespecified sampling frame to sample from the eligible studies, aiming to capture a range of respiratory infectious disease types, geographical spread and data-rich studies. We extracted data using a data extraction form designed for this synthesis. We assessed methodological limitations using an adapted version of the Critical Skills Appraisal Programme (CASP) tool. We used a 'best fit framework approach' to analyse and synthesise the evidence. This provided upfront analytical categories, with scope for further thematic analysis. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and developed implications for practice.

MAIN RESULTS

We found 36 relevant studies and sampled 20 of these studies for our analysis. Ten of these studies were from Asia, four from Africa, four from Central and North America and two from Australia. The studies explored the views and experiences of nurses, doctors and other healthcare workers when dealing with severe acute respiratory syndrome (SARS), H1N1, MERS (Middle East respiratory syndrome), tuberculosis (TB), or seasonal influenza. Most of these healthcare workers worked in hospitals; others worked in primary and community care settings. Our review points to several barriers and facilitators that influenced healthcare workers' ability to adhere to IPC guidelines. The following factors are based on findings assessed as of moderate to high confidence. Healthcare workers felt unsure as to how to adhere to local guidelines when they were long and ambiguous or did not reflect national or international guidelines. They could feel overwhelmed because local guidelines were constantly changing. They also described how IPC strategies led to increased workloads and fatigue, for instance because they had to use PPE and take on additional cleaning. Healthcare workers described how their responses to IPC guidelines were influenced by the level of support they felt that they received from their management team. Clear communication about IPC guidelines was seen as vital. But healthcare workers pointed to a lack of training about the infection itself and about how to use PPE. They also thought it was a problem when training was not mandatory. Sufficient space to isolate patients was also seen as vital. A lack of isolation rooms, anterooms and shower facilities was a problem. Other important practical measures described by healthcare workers included minimising overcrowding, fast-tracking infected patients, restricting visitors, and providing easy access to handwashing facilities. A lack of PPE, and equipment that was of poor quality, was a serious concern for healthcare workers and managers. They also pointed to the need to adjust the volume of supplies as infection outbreaks continued. Healthcare workers believed that they followed IPC guidance more closely when they saw the value of it. Some healthcare workers felt motivated to follow the guidance because of fear of infecting themselves or their families, or because they felt responsible for their patients. Some healthcare workers found it difficult to use masks and other equipment when it made patients feel isolated, frightened or stigmatised. Healthcare workers also found masks and other equipment uncomfortable to use. The workplace culture could also influence whether healthcare workers followed IPC guidelines or not. Across many of the findings, healthcare workers pointed to the importance of including all staff, including cleaning staff, porters, kitchen staff and other support staff when implementing IPC guidelines.

AUTHORS' CONCLUSIONS

Healthcare workers point to several factors that influence their ability and willingness to follow IPC guidelines when managing respiratory infectious diseases. These include factors tied to the guideline itself and how it is communicated, support from managers, workplace culture, training, physical space, access to and trust in personal protective equipment, and a desire to deliver good patient care. The review also highlights the importance of including all facility staff, including support staff, when implementing IPC guidelines.