Healthcare Workers' Strategies for Doffing Personal Protective Equipment

Self-Contamination Risk and Failure Modes During High-Level PPE Doffing: A Comparison of Two Powered Air Purifying Respirator (PAPR) Hoods: A Pilot Study

BACKGROUND

Personal protective equipment (PPE) doffing protocols can reduce risks of pathogen self-contamination. Powered air purifying respirators (PAPRs) may increase these risks. This study compares viral contamination and errors during simulated doffing of single layer vs double layer hood PAPRs.

METHODS

Eight participants performed two simulations (video recorded for failure modes and effects analysis): one single-layer hood (laid over Tyvek suit), and one double-layer hood (top laid over and bottom tucked into suit). Hoods were contaminated with viruses. After doffing, inner gloves, face, hands, and scrubs were sampled.

RESULTS

Virus contaminated least one site in 6/8 single and 5/8 double layer simulations. Virus contaminated inner gloves in single (six participants, median 5.42×104 PFU) and double-layer (two participants, median 7.23×102 PFU) simulations, and hands of two participants in single-layer simulations. Single layer doffing had 13 failure modes; double had 31.

DISCUSSION

Double-layer doffing reduced inner glove contamination. The double-layer protocol may reduce glove-face shield contact but allow more opportunities for error. Double-layer doffing errors may less frequently lead to contamination than single-layer.

CONCLUSIONS

Contamination and failure modes may differ between double and single-layer doffing. Although inner glove contamination was reduced, double-layer doffing may need redesign to reduce failure modes and contamination.

Does doffing the FEES Box generate a significant cloud of particles after aerosol-generating procedures? A proof-of-concept study

PURPOSE

The spread of airborne diseases, including coronaviruses, remains a widespread public health concern. Published studies outline the use of protective barriers to limit the spread of pathogenic particles and droplets resulting from coughing, sneezing, and talking. The findings suggest a role for these barriers during aerosol-generating procedures, such as flexible endoscopic evaluation of swallowing (FEES). However, the question remains of whether doffing a protective barrier will create a concentrated cloud of particles that will increase health professionals' exposure.

METHOD

We simulated four clinical scenarios of coughing and sneezing, talking, eating and drinking, and delivering supplemental oxygen to test whether doffing the FEES Box protective barrier would result in a particle cloud.

RESULT

For all scenarios simulated, doffing the FEES Box did not result in a significant increase in mean particle count. Further, the manner of FEES Box removal did not significantly influence mean particle counts on a consistent basis.

CONCLUSION

These results suggest that doffing the FEES Box does not increase exposure to airborne particles. Although more research is needed to confirm these findings, FEES Box usage should be considered during aerosol-generating procedures, to protect and reassure healthcare professionals who work with patients with COVID-19 or other airborne diseases.

Effectiveness of donning and doffing personal protective equipment education using video debriefing among Korean undergraduate nursing students

BACKGROUND

The use of appropriate personal protective equipment (PPE) in healthcare settings is a very important factor of infection control activities to prevent transmission of infection. In this study, we aimed to develop a non-face-to-face method that can reduce transmission of infection and an educational method that allows self-learning and self-training, and verify the effectiveness of a donning and doffing PPE education using video debriefing on third-year nursing students in clinical train.

METHODS

The researcher assigned groups through random sampling using a random number table from the list of research subjects who agreed to participate. Therefore, 35 subjects in the experimental group with an education on donning and doffing PPE using video debriefing and 34 subjects in the control group with video-based training (VBT) were participated in April 2023 at a university in Incheon, South Korea. The evaluation phase involved verifying effects of the education on observer evaluation donningand doffing PPE performance and self-evaluation donningand doffing PPE performance. Satisfaction with the education also assessed immediately after intervention by the experimental group.

RESULTS

The experimental group had significantly higher scores for observer evaluationdonning (t = 7.84, p < .001) and observer evaluation doffing (t = 6.52, p < .001) PPE performances than the control group. However, there was no significant difference in self-evaluation donning (t = 0.98, p < .330) or doffing PPE performance (t = 0.17, p < .869) between the two groups. In the experimental group that applied video debriefing, learning satisfaction was 4.33 ± 0.82 points out of 5 points.

CONCLUSIONS

The education on donning and doffing PPE applying video debriefing was effective. If the education developed in this study is used as a self-learning method to improve the infection control capacity necessary to respond to a disaster crisis caused by infectious diseases, it is considered to be useful for preventing the transmission of infectious diseases in the future.

Study on Knowledge of Infection Control Practice of Healthcare Workers

Background

Healthcare-associated infections (HAIs), also known as nosocomial infections, are a significant risk in hospitals, leading to increased morbidity and mortality among patients due to poor hygiene practices.

Materials and Methods

This descriptive study involved 350 participants from Wuhan's private hospitals. Respondents answered a questionnaire distributed in person or via email, and data were analyzed using SPSS version 25.0.

Results

Analysis revealed a knowledge gap among healthcare workers in infection control, affecting their ability to maintain hospital cleanliness. Education levels were assessed, showing that 60% of participants held diplomas or higher qualifications.

Conclusion

The study highlights the urgent need for enhanced training and information dissemination on infection control practices among healthcare staff. Identifying this knowledge and practice gap is crucial for improving hospital hygiene and reducing HAI incidence.

Use, failure, and non-compliance of respiratory personal protective equipment and risk of upper respiratory tract infections-A longitudinal repeated measurement study during the COVID-19 pandemic among healthcare workers in Denmark

INTRODUCTION

Upper respiratory tract infections (URTI) are common and a common cause of sick-leave for healthcare workers, and furthermore pose a threat especially for patients susceptible to other diseases. Sufficient use of respiratory protective equipment (RPE) may protect both the workers and the patients. The COVID-19 pandemic provided a unique opportunity to study the association between use of RPE and URTI in a real-life setting. The aim of this study was to examine if failure of RPE or non-compliance with RPE guidelines increases the risk of non-COVID-19 URTI symptoms among healthcare workers.

METHODS

In a longitudinal cohort study, we collected self-reported data daily on work tasks, use of RPE, and URTI symptoms among healthcare workers with patient contact in 2 Danish Regions in 2 time periods during the COVID-19 pandemic. The association between failure of RPE or non-compliance with RPE guidelines and URTI symptoms was analyzed separately by generalized linear models. Persons tested positive for severe acute respiratory syndrome coronavirus 2 were censored from the analyses. The 2 waves of data collection were analyzed separately, as there were differences in recommendations of RPE during the 2 waves.

RESULTS

We found that for healthcare workers performing work tasks with a risk of transmission of viruses or bacteria, failure of RPE was associated with an increased risk of URTI symptoms, RR: 1.65[0.53-5.14] in wave 1 and RR: 1.30[0.56-3.03] in wave 2. Also non-compliance with RPE guidelines was associated with an increased risk of URTI symptoms compared to the use of RPE in wave 1, RR: 1.28[0.87-1.87] and wave 2, RR: 1.39[1.01-1.91]. Stratifying on high- versus low-risk tasks showed that the risk related to failure and non-compliance was primarily associated with high-risk tasks, although not statistically significant.

DISCUSSION

The study was conducted during the COVID-19 pandemic and thus may be affected by other preventive measures in society. However, this gave the opportunity to study the use of RPE in a real-life setting, also in departments that did not previously use RPE. The circumstances in the 2 time periods of data collection differed and were analyzed separately and thus the sample size was limited and affected the precision of the estimates.

CONCLUSION

Failures of RPE and non-compliance with RPE guidelines may increase the risk of URTI, compared to those who reported use of RPE as recommended. The implications of these findings are that the use of RPE to prevent URTI could be considered, especially while performing high-risk tasks where other prevention strategies are not achievable.

Efficacy of remote audio-visual system versus standard onsite buddy system to monitor the doffing of personal protective equipment during COVID-19 pandemic: An observational study

OBJECTIVES

Literature states a higher self-contamination rate among healthcare workers (HCWs) while doffing personal protective equipment (PPE). During the Covid-19 pandemic, onsite trained observers were not always available to monitor PPE compliance. The remote audio-visual doffing surveillance (RADS) system has the potential to overcome this limitation. We aimed to compare the efficacy of this real-time RADS system against the onsite buddy system for monitoring the doffing of PPE.

METHODS

This prospective, observational study was carried out at our tertiary care centre in northern India. 200 HCWs who cared for Covid-19 patients in the intensive care units/operation theatres were included. Group A included HCWs who performed doffing with the help of an onsite trained observer and group B included HCWs who performed doffing with the RADS system. An independent observer noted the error at any step using the CDC doffing checklist, in both groups. An online questionnaire to analyse the level of satisfaction post-doffing was also surveyed.

RESULTS

The proportion of errors committed during doffing was significantly lower in group B compared to group A with a low relative risk of 0.34 (95% CI 0.22-0.51) (p < 0.001) (Figure 1A,B). In both groups, there was no difference in HCWs feedback regarding the ease of the system and fear of committing an error. Though the perceived quality of monitoring was felt better with onsite buddy, the overall confidence rating of being safe after doffing was better with the RADS system.

CONCLUSION

Real-time RADS system may be more effective than the onsite buddy system for ensuring the safety of HCWs during doffing PPE. HCWs level of satisfaction related to the ease and anxiety with the monitoring systems were comparable. RADS system can reduce reliance on HCW resources and can integrate well into existing healthcare systems.

Contributing Risk Factors to Self-Contamination During the Process of Donning and Doffing Personal Protective Equipment

OBJECTIVE

The goal of this study is to explore the risk factors associated with self-contamination points during personal protective equipment (PPE) donning and doffing among health care workers (HCWs).

METHODS

In total, 116 HCWs were randomly sampled and trained to don and doff the whole PPE set. We smeared the whole PPE set with the fluorescent powder. After each participant finished PPE doffing, the whole body was irradiated with ultraviolet light in order to detect contamination points and record the position and quantity. Sociodemographic characteristics and previous infection prevention control (IPC) training experience, among others, were collected by using electronic questionnaires. Poisson regression was used in identifying risk factors that are associated with the number of contamination points, and the relative risk (RR) and its 95% confidence interval (CI) were calculated.

RESULTS

About 78.5% of participants were contaminated. Ever training experience (RR = 0.37; 0.26, 0.52), clinical departments (RR = 0.67; 0.49, 0.93), body mass index (BMI) (RR = 1.09; 1.01, 1.18), and shoulder width (RR = 1.07; 1.01, 1.13) were associated with the number of contamination points.

CONCLUSIONS

Previous IPC training experience, department types, BMI, and shoulder width were associated with self-contamination points after the PPE was removed.

Donning and doffing of personal protective equipment for health care workers in a tertiary hospital in China: A simulation study

The application and removal of personal protective equipment (PPE) by health care workers (HCWs) is pivotal to their health and safety and the comprehensive efficacy of hospital infection control measures. This investigation was orchestrated to elucidate the challenges that HCWs may encounter during the donning and doffing of PPE. A total of 110 participants from a tertiary hospital in China were engaged. The study employed fluorescent markers to mimic the exposure of HCWs to tainted body fluids, quantified the contamination outcomes, and evaluated adherence to procedures for donning and doffing. Factors including gender, educational background, and the timing of the most recent instruction on PPE donning and doffing were found to influence the occurrence of contamination points (p < 0.05). No significant differences were identified in contamination frequency when assessing age, body mass index (BMI), occupation, educational background, positional title, working tenure, and experience in managing respiratory infectious diseases (p > 0.05). Predominant contamination sites for fluorescent marker residue included the shoulder (32.73%), neck (21.82%), forearm (16.36%), chest (12.73%), and abdomen (11.82%), with the shoulder being the most contaminated body part. A majority of HCWs exhibited susceptibility to errors during the removal of protective clothing, boot covers, and gloves. The contamination frequency was observed to be correlated with the timing of the last PPE training, educational background, and gender. In acknowledging the intricacy of PPE removal and the deficiencies in HCWs' removal techniques, there emerges a perpetual necessity to refine training methodologies and perpetuate regular PPE instruction.

Unfamiliar personal protective equipment: The role of routine practice and other factors affecting healthcare personnel doffing strategies

BACKGROUND

Healthcare personnel (HCP) may encounter unfamiliar personal protective equipment (PPE) during clinical duties, yet we know little about their doffing strategies in such situations.

OBJECTIVE

To better understand how HCP navigate encounters with unfamiliar PPE and the factors that influence their doffing strategies.

SETTING

The study was conducted at 2 Midwestern academic hospitals.

PARTICIPANTS

The study included 70 HCP: 24 physicians and resident physicians, 31 nurses, 5 medical or nursing students, and 10 other staff. Among them, 20 had special isolation unit training.

METHODS

Participants completed 1 of 4 doffing simulation scenarios involving 3 mask designs, 2 gown designs, 2 glove designs, and a full PPE ensemble. Doffing simulations were video-recorded and reviewed with participants during think-aloud interviews. Interviews were audio-recorded and analyzed using thematic analysis.

RESULTS

Participants identified familiarity with PPE items and designs as an important factor in doffing. When encountering unfamiliar PPE, participants cited aspects of their routine practices such as designs typically used, donning and doffing frequency, and design cues, and their training as impacting their doffing strategies. Furthermore, they identified nonintuitive design and lack of training as barriers to doffing unfamiliar PPE appropriately.

CONCLUSION

PPE designs may not be interchangeable, and their use may not be intuitive. HCP drew on routine practices, experiences with familiar PPE, and training to adapt doffing strategies for unfamiliar PPE. In doing so, HCP sometimes deviated from best practices meant to prevent self-contamination. Hospital policies and procedures should include ongoing and/or just-in-time training to ensure HCP are equipped to doff different PPE designs encountered during clinical care.

Assessment of potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients admitted to tertiary care hospitals

Meningitis is an important cause of morbidity and mortality in children and adults. Its treatment strategy varies with age and gender. To assess potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients, a multicenter, clinical, descriptive, cross-sectional prospective observational study in 120 patients admitted to different tertiary care hospitals in Karachi was conducted. It includes both males 48% and females 52% belonging from all age groups i.e. peadiatrics (01 to 12 years), adults (18 to 65 years), and geriatrics (66 to 75 years). Out of these 72 patients were admitted in the public sector and 48 patients were admitted in private sector hospitals. Nosocomial infections were developed in 41% of patients during their stay at the hospital. Potentially nephrotoxic drugs were administered to all BM patients, these drugs should be administered carefully. Majorly Ceftriaxone was administered to 86% of patients, Vancomycin 71%, and meropenem 73% whereas 68% of patients were administered piperacillin-tazobactam. Organisms involved as causative agents in the majority of patients are Neisseria meningitides, Pseudomonas aeruginosa and, Streptococcus pneumoniae. DRPs impacted patient clinical outcomes in presence of many other factors like comorbidities, DDIs, Nis, administration of potentially nephrotoxic drugs, and administration of watch group and reserve group antibiotics without having culture sensitivity test, even after having CST no principles of de-escalation for antibiotics were done, which is a very important factor for hospitalized patients having IV antibiotics. The mortality rate among BM patients was 66%. The majority of patients (87%) stay at the hospital was 1-10 days. The present study helped in the identification of DRPs along with some other factors affecting the clinical outcomes in patients suffering from bacterial meningitis. Healthcare professionals should receive awareness and education on the importance of CST before initiating antibiotic therapy. Pharmacist-led medication review is necessary and should be followed to avoid negative outcomes and serious consequences related to DRPs.

Contamination of SARS-CoV-2 RNA on personal protective equipment and environmental surfaces in nonpatient entry area of a Fangcang shelter hospital

OBJECTIVES

To determine the extent of contamination of personal protective equipment (PPE) and surfaces by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nonpatient entry area of a Fangcang shelter hospital, the medical staff accommodation area, and the staff transport bus.

METHODS

We collected 816 samples from the nonpatient entry area and floors in a Fangcang shelter hospital, medical staff accommodation area, and scheduled bus, and the five major types of PPE used from April 13 to May 18, 2022. SARS-CoV-2 ribonucleic acid (RNA) was detected by reverse transcription-polymerase chain reaction.

RESULTS

Overall, 22.2% of PPE samples were positive for SARS-CoV-2 RNA. Boot covers and gowns were the most contaminated types of PPE. The positive PPE contamination rate of staff collecting respiratory specimens was significantly higher than that of the general-treatment staff group (35.8% vs. 12.2%) and cleaner group (35.8% vs. 26.4%), p < 0.01. In total, 27 of 265 (10.2%) environmental surface samples were positive for SARS-CoV-2 RNA. The contamination-positive rates were 26.8% (22/82), 5.4% (4/74), and 0.9% (1/109) for contaminated, potentially contaminated, and clean zones, respectively. SARS-CoV-2 RNA was frequently detected on objects such as mobile phones, tables, computer keyboards and mice, and door handles.

CONCLUSIONS

SARS-CoV-2 RNA was widely distributed on high-touch surfaces and on PPE in the contaminated zone of the Fangcang shelter hospital, implying a potentially high infection risk for healthcare workers. Our findings emphasize the need to ensure adequate environmental cleaning, improve hand hygiene, and reduce the risk of infection. Additionally, prevention of self-contamination during PPE donning and doffing is complex and needs more research.

Barriers and Facilitators to the Use of Personal Protective Equipment in Long-Term Care: A Scoping Review

OBJECTIVE

To review existing literature evaluating barriers and facilitators to the use of personal protective equipment (PPE) by health care workers in long-term care (LTC).

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Health care workers in LTC settings.

METHODS

Several online databases were searched and a gray literature search was conducted. Study inclusion criteria were (1) conducted in nursing homes or LTC settings, (2) focused on LTC health care workers as the study population, and (3) identified barriers and/or facilitators to PPE use. The Theoretical Domains Framework (TDF), which assesses barriers to implementation across 14 behavioral change domains, was used to extract and organize data about barriers and facilitators to appropriate use of PPE from the included studies.

RESULTS

A total of 5216 references were screened for eligibility and 10 studies were included in this review. Eight of the 10 studies were conducted during the COVID-19 pandemic. Several barriers and facilitators to PPE use were identified. The most common TDF domain identified was environmental context and resources, which was observed in 9 of the 10 studies. Common barriers to PPE use included supply issues (n = 7 studies), the cost of acquisition (n = 3 studies), unclear guidelines on appropriate use of PPE (n = 2 studies), difficulty providing care (n = 2 studies), and anxiety about frightening patients (n = 2 studies). Having PPE readily available facilitated the use of PPE (n = 2 studies).

CONCLUSIONS AND IMPLICATIONS

Further research is necessary to identify barriers and facilitators more extensively across behavior change domains to develop effective strategies to improve PPE use and prevent infection transmission within LTC.

Perceived Workload Using Separate (Filtering Facepiece Respirator and Face Shield) and Powered Air-Purifying Respirator and Integrated Lightweight Protective Air-Purifying Respirator: Protocol for an International Multisite Human Factors Randomized Crossover Feasibility Study

BACKGROUND

The design of personal protective equipment (PPE) may affect well-being and clinical work. PPE as an integrated item may improve usability and increase adherence by healthcare professionals. Human factors design and safety may reduce occupational-acquired diseases. As an integrated PPE, a lightweight protective air-purifying respirator (L-PAPR) could be used during health procedures where healthcare professionals are exposed to airborne pathogens. The human factors affecting the implementation of alternative PPE such as L-PAPR have not been thoroughly studied. The population of interest is health care professionals, the intervention is the performance by PPE during tasks across the three PPE types 1.) N95 respirators and face shields, 2.)traditional powered air-purifying respirator(PAPR), and 3.) L-PAPR. The outcomes are user error, communications, safety, and end-user preferences.

OBJECTIVE

This study will assess whether the L-PAPR improves health care professionals' comfort in terms of perceived workload and physical and psychological burden during direct patient care when compared with the traditional PAPR or N95 and face shield. This study also aims to evaluate human factors during the comparison of the use of L-PAPR with a combination of N95 respirators plus face shields or the traditional PAPRs.

METHODS

This is an interventional randomized crossover quality improvement feasibility study consisting of a 3-site simulation phase with 10 participants per site and subsequent field testing in 2 sites with 30 participants at each site. The 3 types of respiratory PPE will be compared across medical tasks and while donning and doffing. We will evaluate the user's perceived workload, usability, usage errors, and heart rate. We will conduct semistructured interviews to identify barriers and enablers to implementation across each PPE type over a single continuous wear episode and observe interpersonal communications across conditions and PPE types.

RESULTS

We expect the research may highlight communication challenges and differences in usability and convenience across PPE types along with error frequency during PPE use across PPE types, tasks, and time.

CONCLUSIONS

The design of PPE may affect overall well-being and hinder or facilitate clinical work. Combining 2 pieces of PPE into a single integrated item may improve usability and reduce occupational-acquired diseases. The human factors affecting the implementation of an alternative PPE such as L-PAPR or PAPR have not been thoroughly studied.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/36549.

Electronic monitoring of doffing using video surveillance to minimise error rate and increase safety at Howard Springs International Quarantine Facility

Background

Safe donning and doffing of personal protective equipment (PPE) are critical to prevent transmission of infectious diseases. Novel strategies to improve infection prevention and control (IPC) adherence can optimise safety. We describe and quantify video surveillance of doffing at an outdoor hotel quarantine facility led by the Australian Medical Assistance Team in the Northern Territory, Australia.

Methods

Motion-activated video cameras were installed in seven areas where personnel doffed PPE upon exit from an area dedicated to quarantined residents. Video footage was reviewed daily and compliance issues were identified using a standardised checklist and risk graded to initiate feedback. We collated audit data from 1 February to 18 April 2021 to describe trends by month, staff group, doffing component and risk.

Results

In 235 h of video footage, 364 compliance issues were identified, of which none were considered high-risk compromising to PPE integrity. Compliance issues were low risk (55/364, 15%) or moderate risk (309/364, 85%) and the most common issue was missed or inadequate hand hygiene (156/364, 43%). Compliance issues per minute of video footage reviewed decreased following introduction of the activity, from 24 per 1000 in February to 7 per 1000 in March and April.

Conclusion

Video surveillance with feedback supported rapid response to improve IPC adherence in a challenging ambient environment. The activity focused on perfection to identify compliance issues that would go unreported in most healthcare settings and contributed to a suit of activities that prevented any high-risk PPE breaches or compromises to safety.

An outdoor hotel quarantine facility model in Australia: best practice with optimal outcomes

Objective: To describe the operationalisation of a novel outdoor quarantine facility managed by the Australian Medical Assistance Team, the Howard Springs International Quarantine Facility (HSIQF) at the Centre for National Resilience in the Northern Territory, Australia.

Methods: We collated documentation and data from HSIQF to describe policies and procedures implemented and performed a descriptive analysis of key procedures and outcomes.

Results: From 23 October 2020 to 31 March 2021, 2.2% (129/5,987) of residents were confirmed COVD‐19 cases. On average per day, 82 [Interquartile Range (IQR): 29‐95] staff completed personal protective equipment (PPE) training, 94 [IQR: 90‐104] staff completed antigen testing and 51 [IQR: 32‐136] staff completed polymerase chain reaction testing. The operation focused on building a safe environment with infection prevention and control adherence and workforce sustainability. There was no leakage of SARS‐CoV‐2 to staff or the community and no PPE compromises requiring staff to quarantine for 14 days.

Conclusion: HSIQF demonstrates the operationalisation of an effective, safe and replicable quarantine system.

Implications for public health: Quarantine is a critical public health tool for pandemic control. The HSIQF operations may be useful to inform the establishment and management of quarantine facilities for future and current disease outbreaks.

Effect of the Personal Protective Equipment Donning and Doffing Program for Nurses in Military Hospitals

This study aimed to develop and verify the effect of a new personal protective equipment donning and doffing program for nurses in military hospitals. A total of 40 nurses (20 experimental group, 20 control group) participated in this non-equivalent control group experimental study. The new program consisted of the description of the design modification of the inner and outer boundary marks of coveralls and a video with verbal instructions and footswitch that the participants could watch at their own pace. Data collection was carried out before, immediately after, and two weeks after the intervention. The effects of the program on accuracy, self-efficacy, and time were analyzed using a generalized estimating equation. PPE donning and doffing accuracy, self-efficacy, and time were significantly increased in the experimental group compared to those in the control group, both immediately after and two weeks after intervention. As this program has been confirmed to be effective in improving PPE donning and doffing accuracy and self-efficacy, we recommend to use this program for training nurses on donning and doffing of PPE.

Attitude and Perception of Nursing Personnel Involved in Real Time Remote Audio-Visual Aided (RT-RAVA) Monitoring of Doffing for the Prevention of Covid-19 Infection among the Health Care Workers

The study was carried out to explore the attitude and perception of observers involved in monitoring of doffing through Real Time Remote Audio-Visual aided (RT-RAVA), the first well-sophisticated surveillance system. A 21-item online-survey proforma was used to collect the data amongst 150 nursing personnel. 3/4th of the participants strongly agreed that they helped in reducing the doffing errors through RT-RAVA doffing. 97.3% perceived that the system is highly effective in reducing the infection during doffing. There was significant correlation between attitude and perception of the observers. The system was perceived as highly effective and was recommended for doffing.

Modeling fomite-mediated SARS-CoV-2 exposure through personal protective equipment doffing in a hospital environment

Self-contamination during doffing of personal protective equipment (PPE) is a concern for healthcare workers (HCW) following SARS-CoV-2-positive patient care. Staff may subconsciously become contaminated through improper glove removal; so, quantifying this exposure is critical for safe working procedures. HCW surface contact sequences on a respiratory ward were modeled using a discrete-time Markov chain for: IV-drip care, blood pressure monitoring, and doctors' rounds. Accretion of viral RNA on gloves during care was modeled using a stochastic recurrence relation. In the simulation, the HCW then doffed PPE and contaminated themselves in a fraction of cases based on increasing caseload. A parametric study was conducted to analyze the effect of: (1a) increasing patient numbers on the ward, (1b) the proportion of COVID-19 cases, (2) the length of a shift, and (3) the probability of touching contaminated PPE. The driving factors for the exposure were surface contamination and the number of surface contacts. The results simulate generally low viral exposures in most of the scenarios considered including on 100% COVID-19 positive wards, although this is where the highest self-inoculated dose is likely to occur with median 0.0305 viruses (95% CI =0-0.6 viruses). Dose correlates highly with surface contamination showing that this can be a determining factor for the exposure. The infection risk resulting from the exposure is challenging to estimate, as it will be influenced by the factors such as virus variant and vaccination rates.

Knowledge and practice of Protective Personal Equipment (PPE) among healthcare providers in Saudi Arabia during the early stages of COVID-19 pandemic in 2020

Introduction

Healthcare providers are at high risk of becoming infected when taking care of patients who have COVID-19, especially while attending aerosol generating procedures. Protective personal equipment must be used in the correct manner to prevent transmission of the disease. Published protocols on protective personal equipment (PPE) donning and doffing have been issued by disease control agencies.

Methods

A questionnaire-based cross-sectional study was designed. An online anonymous questionnaire, which was validated and tested for reliability, focused on PPE related knowledge, donning and doffing practices of healthcare providers across the eastern region of Saudi Arabia.

Results

A total of 312 healthcare providers across the eastern region of Saudi Arabia participated in the study, 208 physicians (66.7%) and 104 non-physicians (33.3%). Results indicate poor practice regarding PPE donning (13.8% reported the correct sequence) and PPE doffing (3.5% reported the correct sequence) among participants. In addition, practice and confidence scores regarding other issues with PPE were analyzed. Based on questionnaire responses, being male (T = 2.825; p = 0.008), being a non-physician (T = -2.120; p = 0.014) and being an allied medical professional (F = 5.379; p = 0.003) were significantly associated with higher confidence levels. Also, being a consultant was significantly associated with higher practice scores (F = 4.774; p = 0.008).

Conclusion

The study demonstrates deficiencies among healthcare providers in following the recommended practices for correctly using PPE during the pandemic. Poor practice in PPE donning and doffing necessitates additional educational and training programs focused on infection control practices.

Self-contamination following removal of two personal protective equipment suits: a randomized, controlled, crossover simulation trial

BACKGROUND

Healthcare personnel are often at high risk of contamination when participating in airway management and other aerosol-generating procedures.

AIM

To explore the differences in self-contamination after removal of gown and coverall personal protective equipment (PPE) using an ultraviolet-fluorescent solution.

METHODS

This prospective, randomized, controlled crossover trial was set in a third-level university health centre in Buenos Aires, Argentina between August and October 2020. The study included 60 anaesthesia personnel volunteers, and no participants were excluded from the study. A two-period/two-intervention design was chosen; each intervention comprised audio-guided placement of PPE, full-body spraying of fluorescent solution, audio-guided removal of PPE, and self-contamination assessment through ultraviolet light scanning. The primary outcome was the mean within-participant difference (any traces) between PPE suits. Statistical significance was tested using t-tests for paired data. The allocation ratio was 25/35 (gown followed by coverall/coverall followed by gown).

FINDINGS

Self-contamination after removal of coveralls was greater than that after removal of gowns, with a mean within-participant difference of 11.45 traces (95% confidence interval 8.26-14.635; P<0.001). Significant differences were found for the number of self-contaminated body zones, small fluorescent traces and large fluorescent traces. Removal of a gown was associated with a markedly lower risk of self-contamination.

CONCLUSIONS

Quick one-step removal of a gown and gloves may reduce self-contamination in the arm/hand area. Fluorescent solutions can help to identify self-contamination and compare outcomes between available PPE suits. Repeated training sessions and enhanced knowledge on self-contamination following removal of PPE are paramount.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04763304 (on ClinicalTrials.gov).

Performance of Health Care Workers in Doffing of Personal Protective Equipment Using Real-Time Remote Audio-Visual Doffing Surveillance System: Its Implications for Bio-Safety Amid COVID-19 Pandemic

Background Very little has been reported about health care workers' (HCWs) adherence to the Centers for Disease Control and Prevention (CDC) guidelines of doffing personal protective equipment (PPE) amid the COVID-19 pandemic. Real-time remote audio-visual doffing surveillance (RADS) system for assisting doffing might reduce the risk of self-contamination. We used this system to determine the incidence of the breach in biosafety during doffing of PPE among HCWs involved in the care of Covid-19 patients. Methods A total of 100 HCWs were enrolled in this observational study who performed duties in the COVID intensive care unit (ICU) of our tertiary care centre. With a real-time RADS system, trained observers from remote locations assisted HCWs during doffing of PPE and noted breach at any step using the CDC doffing checklist. The breach was considered major if committed during removal of gloves/gown/N-95 or if ≥3 errors occurred in any other steps. Results Overall, 40% of the HCWs committed a breach during doffing at least one step. The majority of the errors were observed during hand hygiene (34%), followed by glove removal (12%) and N-95 removal (8%). Nineteen percent of HCWs committed the major breach, out of which 37.5% were done by house-keeping sanitation staff (p = 0.008 and RR 2.85; 95% CI of 1.313-6.19), followed by technicians (22.5%), nursing staff (16.7%) and resident doctors (6.5%). Conclusions Performing doffing using a real-time RADS system is associated with a relatively low incidence of a breach in biosafety compared with earlier studies using an onsite standard observer. Overall adherence of HCWs to the CDC guidelines of doffing PPE was satisfactory. This study highlights the importance of the RADS system during doffing of PPE in a health care setting amid the COVID-19 pandemic.

Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation

BACKGROUND

The use of personal protective equipment (PPE) by emergency medical services (EMS) providers requires specific attention, as it takes place in out-of-hospital unsecured settings. The aim of this study was to evaluate which PPE gown was less contaminating during doffing procedures in an EMS setting. Six well-trained healthcare worker (HCW) subjects tested 4 different gowns: (1) surgical gowns (SG), (2) full body coveralls (FBC), (3) self-made alternative PPEs (SMP), and (4) non-surgical isolation gowns (NSIG). An invisible tracer was sprayed on the gown after donning each subject. After doffing, each HCW was photographed under UV lights to show areas of fluorescent "contamination" on their clothes. The number, size, and intensity level of contaminated areas were noted, as well as observational deviation from the procedure and doffing time. In addition, the subjects were asked to take a questionnaire about their perception of the level of comfort, ease of doffing, and overall safety for each gown.

RESULTS

Despite a well-trained team of HCW subjects, contamination while doffing was observed with every type of PPE gown, and with each HCW subject. All body areas were contaminated at least once, except the face. Contamination was more frequent while doffing FBCs. On the other hand, the removal of SG was found to be the least contaminating. The mean doffing time was significantly shorter with SG 1:29 and longer with FBC 2:26 (p=0.005).

CONCLUSION

Results of this study converge towards the selection of surgical gowns over other types of PPE gowns, which met both contamination criteria as well as staff appreciation in this context. Specific attention should be paid to the legs and abdomino-pelvic areas. Additional protection such as protective trousers or aprons could be added.

The Error-Prone Operational Steps and Key Sites of Self-Contamination During Donning and Doffing of Personal Protective Equipment by Health Care Workers

OBJECTIVE

This study aims to identify error-prone operational steps and key sites of self-contamination during donning and doffing of personal protective equipment (PPE).

METHODS

A total of 56 health care workers, including 37 nurses and 19 physicians, were recruited to don and doff the PPE recommended by the Chinese Center for Disease Control and Prevention. Operational errors and sites of self-contamination were recorded using UV-fluorescent labeling and video surveillance.

RESULTS

Three main errors during donning were identified: choosing a loose-fitting coverall that was difficult to handle; ignoring to inspect the seal of N95 respirator or gloves; and forgetting to pull up the zipper completely. Four main errors during doffing were identified: removing the N95 respirator in a wrong way; touching the scrubs with contaminated hands and elbows; touching contaminated external surfaces of the goggles; and performing insufficient hand hygiene. Key sites that were easily contaminated during the doffing of PPE included left hand and wrist, left lower leg, chest, and left abdomen.

CONCLUSION

Identifying the steps prone to errors and key sites of self-contamination in the process of PPE donning and doffing can facilitate the training of PPE use and provide detailed evidence for optimizing standardized protocols to reduce contamination.

European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients

BACKGROUND

The 2020 novel coronavirus (SARS-Cov-2) pandemic necessitates tailored recommendations addressing specific procedures for neonatal and paediatric transport of suspected or positive COVID-19 patients. The aim of this consensus statement is to define guidelines for safe clinical care for children needing inter-facility transport while making sure that the clinical teams involved are sufficiently protected from SARS-CoV-2.

METHODS

A taskforce, composed of members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Transport section and the European Society for Paediatric Research (ESPR), reviewed the published literature and used a rapid, two-step modified Delphi process to formulate recommendations regarding safety and clinical management during transport of COVID-19 patients.

RESULTS

The joint taskforce consisted of a panel of 12 experts who reached an agreement on a set of 17 recommendations specifying pertinent aspects on neonatal and paediatric COVID-19 patient transport. These included: case definition, personal protective equipment, airway management, equipment and strategies for invasive and non-invasive ventilation, special considerations for incubator and open stretcher transports, parents on transport and decontamination of transport vehicles.

CONCLUSIONS

Our consensus recommendations aim to define current best-practice and should help guide transport teams dealing with infants and children with COVID-19 to work safely and effectively.

IMPACT

We present European consensus recommendations on pertinent measures for transporting infants and children in times of the coronavirus (SARS-Cov-2 /COVID-19) pandemic. A panel of experts reviewed the evidence around transporting infants and children with proven or suspected COVID-19. Specific guidance on aspects of personal protective equipment, airway management and considerations for incubator and open stretcher transports is presented. Based on scant evidence, best-practice recommendations for neonatal and paediatric transport teams are presented, aiming for the protection of teams and patients. We highlight gaps in knowledge and areas of future research.

An Emphasis on Engineering Controls and Administrative Controls in the Prevention and Control of COVID-19 in an Orthodontic Setting: Thinking Beyond Tomorrow

Introduction: Most of the initial focus in handling COVID-19 had been based on avoiding exposure by refraining from rendering most treatments other than those considered an emergency or urgent. Post-lockdown, with the resumption of most activities, there has been concern over the possibility of transmission scenarios if sufficient care is not taken. The control and prevention of the spread of infections when elimination of exposure is not possible is chiefly achieved through the judicious use of engineering controls and administrative controls in a clinical setting in addition to the standard protocols and transmission-based protocols. True safety lies in being one step ahead. There have been mentions of the possibility that COVID-19 could be opportunistic airborne in its spread, in addition to being spread via saliva, droplets, and contaminated surfaces or objects.

Method: A literature search of PubMed, Google Scholar, Cochrane Library, and advisories released by such organizations as the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Ministry of Health and Family Welfare (MOFHW), European Centre for Disease Prevention and Control (ECDC), Chinese Center for Disease Control and Prevention (China CDC), American Dental Association (ADA), Canadian Dental Association (CDA), French National Dentists Association, Dental Council of Belgium, National Health Service, England (NHS UK), National Health Service Scotland (NHS Scotland), and International Society for Infectious Diseases (ISID) was performed, with search parameters aimed at gathering information pertaining to infection control and cross infection control in dental settings as related to orthodontics.

Result: There have been numerous articles and advisories published over the last 20 years, but the main focus has been on safe practices and to an extent on personal protective equipment, with relatively less emphasis on the need for respiratory protection by way of engineering controls and administrative controls. This review highlights the engineering and administrative controls that can be put into effect to make infection control and prevention much more effective.

Conclusion: Any health care facility must be able to prevent, contain, and control infections with no risk of nosocomial infections. For this, an assumption has to be made that every individual in a health care setting is either at risk or a risk, depending on whether the person is infected or not. Meticulous attention to stringent policies of hygiene and infection control and prevention, coupled with suitable supporting engineering and administrative controls, is to be made a standard way of life in such facilities.

Global vascular surgeons' experience, stressors, and coping during the coronavirus disease 2019 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available.

METHODS

The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multivariable analyses of the factors associated with the anxiety levels and qualitative analysis were performed.

RESULTS

A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (∼60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multivariable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95).

CONCLUSIONS

Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.

Containing SARS-CoV-2 in hospitals facing finite PPE, limited testing, and physical space variability: Navigating resource constrained enhanced traffic control bundling

The COVID-19 outbreak has led to a focus by public health practitioners and scholars on ways to limit spread while facing unprecedented challenges and resource constraints. Recent COVID-19-specific enhanced Traffic Control Bundling (eTCB) recommendations provide a cogent framework for managing patient care pathways and reducing health care worker (HCW) and patient exposure to SARS-CoV-2. eTCB has been applied broadly and has proven to be effective in limiting fomite and droplet transmissions in hospitals and between hospitals and the surrounding community. At the same time, resource constrained conditions involving limited personal protective equipment (PPE), low testing availability, and variability in physical space can require modifications in the way hospitals implement eTCB. While eTCB has come to be viewed as a standard of practice, COVID-19 related resource constraints often require hospital implementation teams to customize eTCB solutions. We provide and describe a cross-functional, collaborative on-the-ground adaptive application of eTCB initially piloted at two hospitals and subsequently reproduced at 16 additional hospitals and health systems in the US to date. By effectively facilitating eTCB deployment, hospital leaders and practitioners can establish clearer 'zones of risk' and related protective practices that prevent transmission to HCWs and patients. We outline key insights and recommendations gained from recent implementation under the aforementioned constraints and a cross-functional team process that can be utilized by hospitals to most effectively adapt eTCB under resource constraints.

Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China

The spread of coronavirus disease 2019 (COVID-19) around the world has put a heavy burden on human society and is also a great challenge facing medical staff. This study aimed to assess the difficulties faced by health care personnel (HCP) in using personal protective equipment (PPE) in clinical practice during the COVID-19 outbreak in Wuhan, China. One hundred twenty medical staff from the First Affiliated Hospital of Chongqing Medical University presented to the Wuhan First Hospital to provide medical assistance, from whom 20 HCP volunteered to participate in a focus group discussion attended by infection control nurse leaders. Participants' responses and discussions were recorded, and the content was analyzed for themes. Observed difficulties included inappropriate PPE sizes, the design of the PPE and its complexity of use, doubts related to the quality and effectiveness of PPE, potential risks during doffing, space layout between clean and contaminated area, and poor comfort with PPE use. Other factors, such as the support environment, management, processes, preparedness, HCP, and equipment can also have a positive or negative impact on the use of PPE. Future efforts to optimize PPE use should focus on strengthening training for HCP using real items for increasing compliance with standardized protocols, improving PPE design, and performing further research on the risks, benefits, and best practices of PPE use.

Comparison of Repeated Video Display vs Combined Video Display and Live Demonstration as Training Methods to Healthcare Providers for Donning and Doffing Personal Protective Equipment: A Randomized Controlled Trial

Purpose

The lack of training in personal protective equipment (PPE) donning and doffing is hindering the current fight against the COVID-19 worldwide. In order to enable medical staff to learn how to don and doff PPE faster and more effectively, we compared two training methods of PPE donning and doffing.

Methods

Participants in this study were 48 health care workers randomly divided into two groups. Group A watched a 10-minute demonstration (demo) video four times, while Group B watched the same 10-minute demo video twice and then watched a 10-minute live demo twice. The 40-minute learning time was the same for both groups. A 29-step examination was held after the training was completed. The examination scores of Groups A and B were recorded according to a checklist containing PPE donning and doffing steps . The time spent by the participants on PPE donning and doffing, their satisfaction with the training, and their confidence in donning and doffing PPE accurately were analyzed.

Results

The average score of Group B was higher than that Group A, with a mean (SD) of 94.92 (1.72) vs 86.63 (6.34), respectively (P<0.001). The average time spent by Group B was shorter than that spent by Group A, with a mean (SD) of 17.67 (1.01) vs 21.75 (1.82), respectively (P<0.001). The satisfaction and confidence of Group B were higher than those of Group A (P<0.001).

Conclusion

Compared with repeated video display, combined video display and live demonstration are more suitable training methods for donning and doffing PPE.

Identifying and Implementing Strategies to Reduce the Risk of Self-Contamination of Health Care Workers Caused by Doffing of Personal Protective Equipment During the COVID-19 Pandemic

During the current coronavirus disease (COVID-19) pandemic, it is estimated that tens of thousands of health care workers have been infected. The doffing of personal protective equipment (PPE) has been identified an important place and procedure that might influence the self-contamination of health care workers. More recent evidence suggests that, in addition to existing infection control standards, there is an urgent need for the incorporation of various recent information and advancements pertaining to structure and process to reduce the self-contamination of health care workers during the doffing of PPE.

How to rapidly design and operationalise PPE donning and doffing areas for a COVID-19 care facility: quality improvement initiative

Introduction

Effective implementation of standard precautions specific to COVID-19 is a challenge for hospitals within the existing constraints of time and resources.

Aim

To rapidly design and operationalise personal protective equipment (PPE) donning and doffing areas required for a COVID-19 care facility.

Methods

Literature review was done to identify all issues pertaining to donning and doffing in terms of Donabedian’s structure, process and outcome. Training on donning and doffing was given to hospital staff. Donning and doffing mock drills were held. 5S was used as a tool to set up donning and doffing areas. Instances of donning and doffing were observed for protocol deviations and errors. Plan–do–study–act cycles were conducted every alternate day for 4 weeks. The initiative was reported using Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Results

Best practices in donning and doffing were described. Our study recommends a minimum area of 16 m² each for donning and doffing rooms. Verbally assisted doffing was found most useful than visual prompts.

Discussion

Challenges included sustaining the structure and process of donning and doffing, varied supplies of PPE which altered sequencing of donning and/or doffing, and training non-healthcare workers such as plumbers, electricians and drivers who were required during emergencies in the facility.

Conclusion

Our study used evidence-based literature and quality improvement (QI) tools to design and operationalise donning and doffing areas with focus on people, task and environment. Our QI will enable healthcare facilities to rapidly prototype donning and doffing areas in a systematic way.

Improving the Use of Personal Protective Equipment: Applying Lessons Learned

Unrecognized transmission of pathogens in healthcare settings can lead to colonization and infection of both patients and healthcare personnel. The use of personal protective equipment (PPE) is an important strategy to protect healthcare personnel from contamination and to prevent the spread of pathogens to subsequent patients. However, optimal PPE use is difficult, and healthcare personnel may alter delivery of care because of the PPE. Here, we summarize recent research from the Prevention Epicenters Program on healthcare personnel contamination and improvement of the routine use of PPE as well as Ebola-specific PPE. Future efforts to optimize the use of PPE should include increasing adherence to protocols for PPE use, improving PPE design, and further research into the risks, benefits, and best practices of PPE use.