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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 29-33

Evaluation of appropriate usage of PPE among healthcare providers during COVID-19 pandemic


1 Apollo Institute of Hospital Administration, Telangana, India
2 Dr N.T.R. University of Health Sciences, Andhra Pradesh, India

Date of Submission24-Feb-2021
Date of Acceptance07-May-2021
Date of Web Publication09-Aug-2021

Correspondence Address:
Mr. Tarun Kumar Suvvari
Dr N.T.R. University of Health Sciences, Andhra Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_8_21

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  Abstract 

Background: Shortage of personal protective equipment (PPE), inadequate staff training regarding PPE usage, and confused PPE guidance led to infections and deaths among healthcare workers in many countries. Protection of healthcare workers is needed as they are delivering essential services during the pandemic time. So, the main aim of our study is to evaluate the appropriate use of PPE among healthcare providers (HCPs) during COVID-19 pandemic. Materials and Methods: An observational cross-sectional study was conducted among the HCPs of India during September and October. A 15-item self-administered questionnaire was used, and Excel 2019 and SPPS 24 were used for statistical analysis. A χ2 test was performed to determine the role of sociodemographic characteristics on appropriate usage of PPE. Results: One hundred and eighteen HCPs have participated in our study. About 44.9% of the study participants know the proper way of donning the PPE, and 38.9% of the study participants know the proper way of doffing the PPE. About 40.6% of the study participants were aware of place for PPE removal and how to dispose a PPE; 69.49% of the study participants were aware of guidelines of donning and doffing of PPE recommended by the Centers for Disease Control and Prevention and World Health Organization. Conclusion: The prevalence of breathing difficulty, headaches, suffocation, dehydration, hair problems, and skin irritation/maceration among frontline healthcare personnel using PPE during pandemic was seen. Appropriate usage of PPE is vital in safeguarding the HCPs and restriction of the spread of viral infection in the hospital setting.

Keywords: COVID-19, healthcare workers, personal protective equipment, SARS-CoV-2


How to cite this article:
Sabbella SR, Suvvari TK, Naraayan P. Evaluation of appropriate usage of PPE among healthcare providers during COVID-19 pandemic. Amrita J Med 2021;17:29-33

How to cite this URL:
Sabbella SR, Suvvari TK, Naraayan P. Evaluation of appropriate usage of PPE among healthcare providers during COVID-19 pandemic. Amrita J Med [serial online] 2021 [cited 2021 Dec 9];17:29-33. Available from: https://www.ajmonline.org.in/text.asp?2021/17/2/29/323555




  Introduction Top


Corona virus disease 2019 (COVID-19), caused by the pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared as pandemic on March 11, 2020. Clinical symptoms of COVID-19 include fever, cough, shortness of breath, breathing difficulties, fatigue, sore throat, etc. Severe form of COVID-19 can lead to acute respiratory distress syndrome (ARDS), septic shock, and organ failure, finally causing death.[1]

Physical and psychological impact on healthcare workers was vulnerable than general population during this COVID-19 pandemic. Healthcare workers worked under stressful conditions without proper facilities.[2] Shortage of personal protective equipment (PPE) has been reported across several countries. During this global pandemic of COVID-19, severe shortage of PPE had occurred due to sudden increase in demand, usage, panic-buying, and irrational use. Similar global shortage of PPE was observed during the past outbreaks like Ebola in West Africa.[3] So, concerned governments have taken necessary steps to ensure adequate PPE kits. Commonly, PPE includes items such as full body suits, vests, masks or respirators, face cover, gloves, safety glasses, shoe covers, and earplugs or muffs. Mandatory usage of PPE kits (gloves, N95 masks, gowns, shoe cover, googles, facemask) was issued by Ministry of Health and Family Welfare of India (MoHFW).[2],[3]

All healthcare workers are forced to use PPE during their entire duty, despite difficulty of breathing, sweat, and work stress. Shortage of PPEs, inadequate staff training, reduced understanding of PPE use, and confused PPE guidance led to infections and deaths among healthcare workers in many countries. Protection of healthcare workers is needed as they are delivering essential services during the pandemic time. All healthcare workers must be given proper training on usage of PPE, hand hygiene, and waste management of potentially harmful materials.[3]

Inefficient or lack of proper training/knowledge among healthcare providers (HCPs) on efficient and rational usage of PPE was reported at many places, and it may lead to exposure to COVID-19 patients. Also, due to the inappropriate/long-term use of PPE, there were many problems faced by the HCPs. This study helps in identifying the problems that most of the HCPs are facing in the usage of PPE.

The main aim of this study is to evaluate the appropriate use of PPE among HCPs during the COVID-19 pandemic. The objectives of this study are to identify the problems faced by healthcare workers using PPE and to assess the need of training and education required in HCPs.


  Materials and Methods Top


An observational cross-sectional study was conducted among the HCPs of India during the period from September 3, 2020 to October 15, 2020 (43 days). Due to lockdown and risk of COVID-19 infection for face-to-face interview, the study was conducted online using Google Forms questionnaire. Random sampling method was used, and convenient sample of 118 was taken. Inclusion criteria were all HCPs (doctors, nurses, technicians) aged 20 years and above, people who are working in COVID wards, hospitals, and clinics, PG students working as frontline warriors using PPE, residents of India, and willing to participate in the study. Exclusion criteria were HCPs who are not using PPE and not willing to participate in this study. Ethical approval was waived off as it is a survey-based study and necessary permissions were obtained from Apollo Institute of Hospital Administration to perform this study. Informed consent was obtained from all study participants.

Brief information including the title, objectives, voluntary participation, and declaration of confidentiality about their information was attached to the survey form. The questionnaire starts with the consent of participation, followed by sociodemographic and background information including age, gender, occupation, and healthcare facility they work pertaining to COVID-19.

  • The questionnaire was a pre-tested, self-administered questionnaire developed according to the information and guidelines on usage of PPE during COVID-19 given by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC).


  • The questionnaire had a total of 15 questions, in which few questions have subquestions. The knowledge questions were based on the proper usage of PPE, according to the guidelines, type of PPE used, and the problems faced using PPE during this period. The practice questions were based on the practice of preventive measures against COVID-19, followed by implementing them according to the CDC/WHO guidelines.


  • Statistical analysis

    Responses from Google Forms were converted into excel spreadsheets, and percentages were calculated and tabulated. Statistical Package for Social Sciences (SPSS) version 24.0 (SPSS, Inc., Chicago, IL, USA) was used for descriptive statistics. Responses were represented by using mean and standard deviation. A χ2 test was used to determine the role of sociodemographic characteristics on appropriate usage of PPE. The statistical significance level was set at P < 0.05 (two-sided).


      Results Top


    A total of 118 healthcare workers participated in this study. Among them, the majority were doctors, 102 (86.44%). Most of the study participants belong to the age group less than 30% (93.2%). About 46.61% of the study participants work in government or private clinics. The sociodemographic profile of the study participants was described in [Table 1].
    Table 1: Sociodemographic profile of the study participants (n = 118)

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    Nose and mouth protection

    About 98.3% of the participants have reported the usage of mouth mask, and N-95 mask was used by 44% of the study participants followed by surgical mask (43.1%). For the question, “Do you have problems/difficulties wearing a mouth mask?” (multi-answer question), 66.1% responded as sweating and 50.9% have responded as breathing difficulty. For the question on duration of wearing a mouth mask, 33.05% of the study participants responded as 4–6 h, followed by 27.11% for 6–8 h.

    Eye and face protection

    About 87.28% (103) of the participants were using eye and face protection and 12.7% (15) were not using. The reasons for not using were as follows: non-availability, 8 (53.33%); not aware of its importance, 4 (28.57%); and uncomfortableness, 3 (21.42%). About 72.81% of the study participants used face shields. For the question on problems faced during eye/face protection (multi-answer question), 91.9% of the study participants responded for fog covering the eye wear and face shields.

    Head protection

    Among the participants, 91 (77.11%) were using head protection and 27 (22.88%) were not. The reasons for not using the head protection were due to non-availability, 13 (48.14%), and uncomfortableness, 10 (37.03%). Bonnet type of headcaps [48 (52.74%)] was mostly used by the study participants, followed by full hood [14 (31.86%)]. For the question on problems faced while using the head protection (multi-answer question), 75.8% responded for sweating, 33.7% responded for hair problems, and 32.6% responded for irritation.

    Body protection

    Ninety-three study participants (78.81%) were using the body protection and 71 (60.16%) prefer to use coverall, followed by 28 (23.72%) who prefer to use gown. The reasons for not using head protection were non-availability by 12 (10.16%) and uncomfortableness by 10 (8.4%). The coverall type of body protection [50 (53.76%)] was mostly used by the study participants, followed by gown type, which is 28 (30.12%).

    Hand protection

    Study participants using gloves were 109 (92.37%) and not using gloves were 9 (7.62%). Among the participants using gloves, single pair was used by 35 (29.66%), double pair was used by 37 (31.35%), and 46 (38.98%) have responded for depending on the availability. Ninety-five (80.5%) of the study participants have changed gloves from patient to patient and 23 (19.5%) have not changed. General examination gloves were used by 52.29% of the study participants, followed by surgical gloves (44.95%). For the question on problems faced while using the gloves (multi-answer question), 55.4% responded for sweating and 39.6% responded for the skin irritation.

    Donning and doffing

    About 44.9% of the study participants know the proper way of donning the PPE and 38.9% of the study participants know the proper way of doffing the PPE; 40.6% of the study participants were aware of place for PPE removal and how to dispose a PPE. About 69.49% of the study participants were aware of guidelines of donning and doffing of PPE recommended by the CDC and WHO.

    The knowledge about CDC/WHO guidelines among the doctors and nurses was 66.67% and 87.5%, respectively, but the correct donning and doffing procedures were followed by only few study participants. Appropriate usage of PPE by doctors and nurses was described in [Figure 1]. For the question on do you know the CDC/WHO guidelines of donning and doffing of PPE and gender, the χ2 test was performed and the P-value of 0.0016 was obtained which is statistically significant. For the question “What do you think is the proper way to take off PPE (doffing)?” and gender, the χ2 test was performed, and P-value of 0.001 was obtained which is statistically significant. The detailed analysis of the above two questions is described in [Table 2].
    Figure 1: Appropriate usage of PPE by doctors and nurses (n = 118)

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    Table 2: Distribution of study population in relation to PPE usage and gender (n = 118)

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      Discussion Top


    In our study, we have analyzed about the usage of the PPE and various procedures related to PPE among the HCPs. In our research study, appropriate donning method was followed by 49% of doctors and 18.75% of nurses. Appropriate doffing method was followed by 40.19% of doctors and 31.25% of nurses. The disposal of the PPE kits into the plastic bag provided along with the PPE kit according to the guidelines was highly followed by 71.56% of doctors and 75% of nurses. Whereas the removal of PPE at the doorway, before leaving patient room or appropriate place, was followed by only 42.15% of doctors and 31.25% of nurses.

    In a study conducted in north-east India by Kotian et al.[4] among allied healthcare workers regarding the efficacy of use of PPE, 400 participated. About 39% responded for not using PPE, 90.6% responded for usage of surgical mask, 47.6% wore the face-shield/googles, and 97% have used hand sanitizer and maintained proper hand hygiene. The absence of proper removal/discard of PPE for physical discomfort or due to negligence can lead to easy contamination of virus from patient to HCPs. A multicenter study by Jiang et al.[5] was on the prevalence, characteristics, and prevention status of skin injury caused by PPE in China among medical staff fighting COVID-19. Grade of PPE and daily wearing time, skin injury types, anatomical sites, and preventive measures were asked, and a total of 4308 participated in the study from 161 hospitals. Study participants (42.8%) were found to have skin injuries, i.e., moist-associated skin damage, skin tear, and device-related pressure injuries. Multiple location injuries and co-skin injuries were 76.8% and 27.4%, respectively. Sweating, daily wearing time, and grade 3 PPE were associated with skin injuries. Only 17.7% of the study participants have taken preventive measures and 45.0% of the skin injuries were treated.

    In a study conducted in Singapore by Ong et al.[6] among frontline workers regarding the headaches associated with PPE, out of the 158 respondents, 128 (81.0%) respondents developed de novo PPE-associated headaches, in which pre-existing primary headache diagnosis was present in about a third [46/158 (29.1%)] of respondents and the study concludes that most healthcare workers develop de novo PPE-associated headaches or exacerbation of their pre-existing headache disorders. A multinational study by Rajamani et al.[7] assessed the PPE-preparedness across intensive care units (ICUs) in six Asia-Pacific countries (Australia, New Zealand (NZ), Singapore, Hong Kong (HK), India, and the Philippines) during the initial phase of the COVID-19 pandemic in 633 level II/III ICUs. Response rates were 68–100% in all countries except India, where it was 24%. About 97% either conformed to or exceeded WHO recommendations for PPE-practice; 59% employed airborne precautions irrespective of aerosol generation procedures. There were variations in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE stock-awareness (best in HK/Singapore/NZ). High flow-nasal-oxygenation and non-invasive ventilation were not options in most HK (66.7% and 83.3%, respectively) and Singapore ICUs (50% and 80%, respectively), but were considered in other countries to a greater extent. About 38% reported not having specialized airway teams.

    Research studies on PPE during past outbreaks showed lesser appropriate usage of PPE than present COVID-19 studies on PPE appropriate usage. A study on common behavior and faults when doffing PPE for patients with serious communicable diseases during the outbreak of EBOLA virus at Ebola treatment centers in Georgia was found. Across hospitals, they identified 256 failure modes (FMs) during the common doffing steps, 61 of which comprised 19 common FMs. They identified that doffing protocols for high-level PPE may fail to protect healthcare workers. Hand hygiene, removing the outermost garment, boot covers, and respirator hood harbored the greatest risk and failed in similar ways across different hospitals.[8]

    Recommendations

    Periodic reinforcement and training programs are needed for all levels of healthcare workers for adherence with appropriate use of personal care equipment. Online training modes can be adopted because physically gathering in a training area is not appropriate during this pandemic. Relevant lectures by experts on standard procedures along with onsite special training program are recommended for better training of HCPs. Strong knowledge and perfect skills regarding PPE usage are basic needs for self-protection during this COVID-19 global health crisis.

    The emergency response plan if exposed to contaminated PPE should be educated among the HCPs. Infection control team should monitor the HCPs’ knowledge on PPE usage and educate them for prevention of contamination of virus. Maintaining the proper coordination between the supply and demand of PPE was needed as shortage of PPEs was observed in many places across the country. Proper measures should be taken to reduce the problems/difficulties faced by HCPs using PPE kits. The temperature of the work environment should be maintained at 22°C to have no negative impacts such as heat stress and dehydration on the HCPs. The long working hours for the HCPs in PPEs must be reduced in order to decrease the fatigue and susceptibility to mistakes due to fatigue, causing themselves to become more prone to infection.


      Conclusion Top


    The prevalence of breathing difficulty, headaches, suffocation, dehydration, hair problems, and skin irritation/maceration among front-line healthcare personnel using PPE during the pandemic was seen. The reason for inappropriate use of PPE was non-availability and uncomfortability, and the shortage of PPE was observed in certain areas during the initial time of COVID-19 pandemic.

    Appropriate usage of PPE is vital in safeguarding the HCPs and restriction of spread of viral infection in the hospital setting. The correct donning and doffing techniques should be followed, and proper steps should be taken to ensure that strict infection control guidelines should be followed to improve the same.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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    Ong JJY, Bharatendu C, Goh Y, Tang JZY, Sooi KWX, Tan YL, et al. Headaches associated with personal protective equipment—A cross-sectional study among frontline healthcare workers during COVID-19. Headache 2020;60:864-77.  Back to cited text no. 6
        
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    Rajamani A, Subramaniam A, Shekar K, Haji J, Luo J, Bihari S, et al. Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: A multinational survey. Aust Crit Care2021;34:135-41. doi: 10.1016/j.aucc.2020.09.006  Back to cited text no. 7
        
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    Mumma JM, Durso FT, Casanova LM, Erukunuakpor K, Kraft CS, Ray SM, et al. Common behaviors and faults when doffing personal protective equipment for patients with serious communicable diseases. Clin Infect Dis 2019;69(Suppl 3):S214-220. doi: 10.1093/cid/ciz614.  Back to cited text no. 8
        


        Figures

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        Tables

      [Table 1], [Table 2]



     

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