Highlights•

PPE donning and doffing was performed poorly by medical staff.

•

Mid-level (registrar) staff performed the highest.

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Further PPE training was required.

AbstractBackground

Personal protective equipment (PPE) compliance is important to reduce the rate of transmission of virulent pathogens to health care workers. Medical officer compliance with PPE protocol for COVID-19 was audited in a regional hospital in Australia early in the pandemic response.

Method

Compliance was assessed based on the order and technique of donning and doffing PPE, with medical officers from multiple departments and levels of seniority audited.

Results

Average compliance from all participants was 58.61% with donning and 68.84% with doffing.

Conclusions

Medical Officer compliance with PPE donning and doffing was poor and additional training was required.

KeywordsIntroductionPersonal protective equipment (PPE) compliance is important to reduce the transmission rate of virulent pathogens to health care workers (1Gamage B. Moore D. Copes R. Yassi A. Bryce E. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.). Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and its clinical syndrome Coronavirus Disease 19 (COVID-19) were first reported to the World Health Organisation by China on December 31st, 2019 with subsequent international spread. The first case in Queensland, Australia was recorded on January 29th, 2020. An audit was undertaken in March 2020 to assess the compliance of medical staff with the Queensland Health PPE guideline for the management of patients with suspected or confirmed COVID-19 (COVID-19 PPE guideline). This guideline was published approximately one month prior to conducting the audit. Posters were in the work environment prior to this audit being undertaken, with all staff members having access to these, but no face-to-face training or compliance evaluation had occurred previously. There was no online module available prior to 2020.Methods

This study audited the PPE donning and doffing practices of medical officers in a large regional teaching hospital in southern Queensland, Australia. 30 medical officers, consisting of: 9 interns, 6 residents, 10 registrars and 5 specialists were assessed. Staff from the emergency department (ED), intensive care unit (ICU), general medicine, and surgical specialities (surgery, obstetrics and gynaecology and orthopaedic) were recruited. Clinicians were approached in person at unplanned times by the primary data collector. Data was collected in the standard work environment separate from patient care areas during working hours from March 9-12, 2020. A standardised script was used when recruiting participants. Written consent for digital recording was obtained. This included both participation in the audit and filming of this, and reassurance that data would be de-identified. Medical officers were video recorded performing donning and doffing PPE by the primary data collector (a medical officer) using a mobile phone for the duration of don and doffing only. This did not occur as part of a clinical or patient care episode but was performed solely for audit purposes and was not covert. Following data collection, each participant was offered written and verbal education in the correct procedure. Data collected was de-identified with only the level of seniority recorded, not names. All recordings were watched and audited independently using the instructions in the current Queensland Health PPE Guideline by two medical officers involved in PPE education, and the data was then averaged to create a percentage of compliance. Clinicians were marked according to their compliance with COVID-19 PPE instructions in this Guideline. This involved donning and doffing non-sterile gloves, gown, protective eyewear, and a surgical mask. N95 masks were only marked as being correct if they were donned by a member of ICU staff, as this was consistent with their workspace at the time of auditing. Hand hygiene was expected to be completed before don and doffing and between each step in doffing. At the time of this audit, both removing gown and gloves in one motion, and removing gloves then gown, with hand hygiene being performed between tasks, were acceptable options in the audited facility and were marked accordingly. Compliance data was stored electronically in a deidentified manner with data only in groups of medical seniority and no names recorded, with all digital recordings deleted. Generalised information around individual don and doffing was made available to participants.

Results30 medical officers were observed donning and doffing PPE. Of these doctors, 13 (43.33%), were women. Only three doctors completed all steps in the correct order following a PPE guideline. Average compliance from all participants was 58.61% with donning and 68.84% with doffing, as seen in table 1. Combined (donning and doffing) average compliance was 63.73%. The best performing level of seniority were registrars, with a combined average compliance of 72.79%. However, consultant medical officers were the most compliant with donning PPE with 68% compliance. ED was the most compliant department, with a combined average compliance of 72.3%. The lowest performing units were the surgical specialties and medicine, averaging 51.9% and 47.83% combined compliance respectively. 14 doctors (46.67%) chose to remove their gown and gloves in one motion. This resulted in 106 occasions of hand hygiene being required during this audit, as seen in table 2. The most common PPE item donned and doffed incorrectly, or omitted, was protective eyewear. A 33.3% donning and 60% doffing compliance rate was noted. Gloves were consistently applied and removed appropriately, with 90% and 93% compliance respectively.

Table 1Medical officer PPE compliance by seniority and specialty.

Note: PPE = Personal Protective Equipment.

Table 2Medical officer PPE compliance by PPE item.

Note: PPE = Personal Protective Equipment.

DiscussionDespite the limitation of the small sample size, the data obtained through our audit was concerning as evidence from the SARS-CoV-1 epidemic emphasised the importance of PPE in preventing nosocomial transmission (1Gamage B. Moore D. Copes R. Yassi A. Bryce E. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.). Ninety percent of participants in this audit made at least one error in donning or doffing their PPE, increasing their risk of self-contamination and subsequent infection. This is similar to previous findings, with only 13% of participants correctly doffing all PPE during an audit by Zellmer et.al. (2Zellmer C. Van Hoof S. Safdar N. Variation in health care worker removal of personal protective equipment.) and Mulvey et al (3Mulvey D. Mayer J. Visnovsky L. Samore M. Drews F. Frequent and unexpected deviations from personal protective equipment guidelines increase contamination risks.). Errors in doffing are particularly concerning as these could result in health care worker contamination as found in previous studies (4Koh Okamoto Rhee Y. Shoeny M. Lolans K. Cheng J. Reddy S. Weinstein R. Hayden M. Popovich K. Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions., 5Phan L. Maita D. Mortiz D. Weber R. Fritzen-Pedicini C. Bleasdale S. Jones R. ) as well as the potential for cross contamination to other patients found by Okamoto et al. (4Koh Okamoto Rhee Y. Shoeny M. Lolans K. Cheng J. Reddy S. Weinstein R. Hayden M. Popovich K. Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions.) The registrar cohort was found to have the highest overall average compliance within our audit, however the group with highest donning compliance were the consultant group. This compliance from the more senior staff in our audit is encouraging when compared with a study by Van Haren et.al. from 2015 (6Fv Haren Cohen J. McKee A. Mitchell I. Pinder M. Seppelt I. Infection control in times of Ebola: how well are we training the next generation of intensivists in Australia and New Zealand?.). This study found that 66.67% of senior ICU registrars sitting their fellowship examination scored 50% or less on an interactive station assessing understanding and compliance with PPE for the care of patients with a respiratory virus. Phan et al proposed that PPE training especially including practical experience that improves not just knowledge and skills but also acts to change attitudes was found to be helpful (5Phan L. Maita D. Mortiz D. Weber R. Fritzen-Pedicini C. Bleasdale S. Jones R. ).

In response to the data obtained through this audit and the worsening pandemic, face-to-face and online COVID-19 PPE and hand hygiene training was provided to medical staff within the health service. This had the aim of preventing both healthcare worker contamination as well as cross-contamination to other patients. Due to a lack of PPE availability, a follow up audit to assess the impact of this education was unable to be performed. Further research would be beneficial in monitoring the long-term outcomes of similar education programs following this pandemic.

Funding

No external sources of funding were required.

Ethical considerations

This project was submitted to the Darling Downs Health Human Research Ethics Committee who deemed it not requiring ethical review.

Authorship statement

SW was responsible for Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing - original draft; Writing - review & editing. SC was responsible for Conceptualization; Methodology; Supervision; Validation; Writing - review & editing.

Declaration of Competing Interest

There are no conflicts of interest to be declared.

ReferencesGamage B. Moore D. Copes R. Yassi A. Bryce E.

Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.

American journal of infection control. 33: 114-121Zellmer C. Van Hoof S. Safdar N.

Variation in health care worker removal of personal protective equipment.

American journal of infection control. 43: 750-751Mulvey D. Mayer J. Visnovsky L. Samore M. Drews F.

Frequent and unexpected deviations from personal protective equipment guidelines increase contamination risks.

American Journal of Infection Control. 47: 1146-1147Koh Okamoto Rhee Y. Shoeny M. Lolans K. Cheng J. Reddy S. Weinstein R. Hayden M. Popovich K.

Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions.

Infection Control & Hospital Epidemiology. 40: 559-565Phan L. Maita D. Mortiz D. Weber R. Fritzen-Pedicini C. Bleasdale S. Jones R. Journal of Occupational and Environmental Hygiene. 16: 575-581Fv Haren Cohen J. McKee A. Mitchell I. Pinder M. Seppelt I.

Infection control in times of Ebola: how well are we training the next generation of intensivists in Australia and New Zealand?.

Critical care and resuscitation. 17: 65-66Article InfoPublication History

Accepted: June 14, 2021

Received in revised form: June 13, 2021

Received: December 3, 2020

Publication stageIn Press Accepted ManuscriptIdentification

DOI: https://doi.org/10.1016/j.idh.2021.06.002

Copyright

Crown Copyright © 2021 Published by Elsevier B.V. on behalf of Australasian College for Infection Prevention and Control. All rights reserved.

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