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ORIGINAL ARTICLE
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 157-160
Awareness of personal protective equipment among frontline postgraduate medical residents who provide care to patients with coronavirus disease-2019
Shital Mahendra Kuttarmare, Sujit Jagannath Kshirsagar, Pradnya Milind Bhalerao
Department of Anaesthesiology, B. J. Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
Correspondence Address:
Sujit Jagannath Kshirsagar
Department of Anaesthesiology, B. J. Government Medical College and Sassoon General Hospitals, Pune - 411 001, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_49_22
Background: To combat the coronavirus disease-2019 (COVID-19) pandemic, which affected the entire world, health-care workers (HCWs) were required to wear personal protective equipment (PPE). PPE offers protection by preventing microorganisms from contaminating hands, eyes, clothing, hair, and shoes. It is mandatory to know about the proper usage of PPE. Objective: The objective of this study was to evaluate the awareness of PPE and its effects on frontline health-care professionals who provide care to patients with COVID-19. Subjects and Methods: This noninterventional cross-sectional questionnaire-based study was conducted in 108 postgraduate (PG) medical residents who have been treated and provided care for COVID-19 in a tertiary care hospital. The Google questionnaire consisted of 25 questions prevalidated through the literature, senior faculty in the department, and ethics. Results: About 87.03% of the 108 PGs were trained in the donning and doffing protocols, whereas 92.59% were aware of the steps. About 62.96% did not follow the two-person protocol for doffing. About 83.33% were aware of the decontamination protocol of PPE. About 64.81% had difficulty intubating and 62.96% had headaches after using PPE. Conclusions: HCWs in a tertiary care center are aware of PPE use and protocols therein. Even though they were adequately trained about protocols, reluctance, and technical difficulties in following them still exist, which can be solved by adequate and repeated training. The problems faced with the use of PPE have appropriate solutions.
Keywords: Coronavirus, health-care workers, personal protective equipment
Coronavirus disease-2019 (COVID-19) is caused by the novel coronavirus SARS-CoV-2 that belongs to the family Ortho Coronaviridae. As it affected the entire world, it was declared a pandemic by the World Health Organization (WHO).[1],[2] COVID-19 is primarily transmitted from person to person by respiratory droplets and the oronasal route. Droplet infection occurs when a person is within 1 m range and is exposed to cough, saliva, and sneeze of the patient. Infection can also occur by indirect contact with surfaces in the environment or using objects used by an infected patient. Many studies also demonstrated that transmission by asymptomatic and presymptomatic patients is also significant.[3] It became an important cause of concern for the health-care profession as they were primarily treating infected patients and were at increased risk due to the multiple routes of transmission of the virus and their close and frequent contact with confirmed or suspected cases. Personal protective equipment (PPE) offers protection against bacterial, viral, and other hazards.[4] PPE consists of gloves, protective eyewear (goggles), N95 or equivalent mask (with triple-layer protection), apron, coverall or gown, boots/shoe cover, hair cover which protects skin, mucous membrane, clothing, and respiratory tract from infections.[5],[6],[7] PPE is used by all health-care providers, support staff, laboratory staff, and family members who provide care to patients in situations where they have contact with blood, body fluids, or secretions.
As postgraduate (PG) medical residents were frontline workers with close and frequent contact with positive and suspected cases, PPE was primarily used by them. We did this study to evaluate and assess the awareness and knowledge of protocols for PPE in PG residents.
Subjects and MethodsThis was a survey for the awareness of PPE among PG medical students working in a COVID care facility. Ethical committee approval was taken for this study (Ref no. BJGMC/IEC/Pharmac/ND-Department 0221068-068 dated February 22, 2021). This study was registered in the clinical trial registry of india (CTRI) trial registry (registration number–CTRI/2021/03/032386). The study was done for 3 months (February 2021 to May 2021).
This was a questionnaire-based cross-sectional study. The participants were medical PGs in the field of general medicine, pulmonary medicine, anesthesia, and pediatric medicine from a tertiary care center. The sample size was determined using the purposive sampling method after discussing with the senior faculty and ethics committee. The calculated sample size was 100. Assuming a 20% dropout rate, we considered the sample size as 120. Online informed consent was taken from them for participation in the study and a questionnaire was sent through WhatsApp and Gmail. A total of 25 questions were set. The first part of the questionnaire elicited information about demographic data such as age, sex, subject, and the year of postgraduation. The second part evaluated the knowledge about PPE. The third part dealt with problems associated with the use of PPE. The identity and survey information of each respondent was kept confidential. A convenient sampling method was used for data collection, and the distribution of responses was presented in the form of descriptive statistics. The data were entered, and descriptive statistics were performed using MS Excel.
ResultsThe questionnaire was sent to 120 PGs, out of which 108 responded indicating a response rate of 90%. The mean age was 28 years (28 ± 4.32). All participants were comparable in age and gender. In our study, 85.2% were working in the intensive care unit (ICU), 5.6% were in the suspect ward, and the remaining 9.2% were working in other wards. Ninety-two percent knew of the WHO-recommended PPE. Ninety-five percent received the complete PPE kit and 5% received a long-sleeve apron with N95 mask.
Among the 108 residents, 87.03% of the residents had received training in the donning and doffing protocols, whereas 92.59% knew the steps of donning and doffing. While doffing, two-person protocol was followed by only 16.66% of residents and 20.37% of residents followed it sometimes. About 62.96% of the residents did not follow the two-person protocol for doffing, which was a serious concern [Figure 1]. In our study, we found that 83.33% of the residents were aware of the PPE decontamination/disposal protocol. About 61.11% of residents believed that PPE is effective in preventing infections. Eight percent of PGs tested positive during the COVID postings [Figure 2]. The majority had done COVID postings for 6-h duration. As this is the duration for which residents wear PPE kits, it is related to the rise in problems associated with the duration of the use of PPE. We evaluated the responses to routine procedures performed in the ICU for ease of comparison in a routine setup where they were performed without PPE [Table 1]. The problems encountered by PGs while and after using PPE were also assessed [Table 2].
Figure 1: Rate of infection among postgraduate students. COVID-19: Coronavirus disease-2019. Discussion COVID-19 is caused by the new coronavirus SARS-CoV-2 which belongs to the Ortho Coronaviridae. COVID-19 is primarily transmitted from person to person by respiratory droplets and oronasal route. Droplet infection occurs when the person is within 1-m range and is exposed to cough, saliva, and sneeze of the patient. Infection can also occur by indirect contact with surfaces in the environment or using objects used by the infected patient. Many studies also demonstrated that transmission by asymptomatic and presymptomatic patients is also significant.[3] PPE offers protection against bacterial, viral, and other hazards. Complete PPE consists of gloves, protective eyewear and face wear (goggles and face shields), N95 or equivalent mask (with triple layer protection), apron, coverall or gown, boots/shoe cover, and hair cover. PPE is used by all health-care providers, supporting staff, laboratory staff, and family members who provide care to patients in situations where they have contact with blood, body fluids, or secretions. Health-care workers (HCWs) data from the WHO and Gholami et al. show that 12.5% of HCWs were infected during this pandemic.[4],[8] To protect against this infection, the WHO advised the use of PPE with a recommendation and guidelines for the donning and discharge of PPE.[9]
The use of PPE is the most important method of protection so there should be awareness about types, donning and doffing protocols, and decontamination protocols of PPE among HCWs. Before posting an HCW for duty, they should be trained about PPE use protocols. In our study, we found that 87.03% of residents had received training of PPE use. This is in contrast to the study by Ojha et al. where they observed that only 44.1% and Pandey et al. observed that only 58% of HCWs received training.[10],[11] The increase in training could be due to increased awareness of PPE with diseases affected over years. Furthermore, the duration of our study was 2021, whereas other studies were conducted in 2020. The difference could also be because in their study they had included nursing staff and other professionals as well. During the initial months of the pandemic, there was less awareness of the protocols to follow. Our results are similar to the study of Sonawane et al. who observed that 88.8% of HCWs were trained.[12] With the increase in the percentage of training, the probability of infected HCW decreases. Although they were adequately trained, many HCWs did not follow donning and doffing protocols. In a study conducted in Bangladesh, Hossain et al. reported that only 51.7% of health-care workers had good practice with respect to the use of PPE, although a majority of them had good knowledge and a positive attitude regarding the use of PPE.[13] A similar study by Ojha et al. reported that only 67.8% of the participants gave the correct response to the questions regarding PPE donning and doffing.[10] In our study, we found that even though the majority of residents were aware of the steps of donning and doffing, but only a minor number of residents followed two-person protocol for doffing. This attitude and ignorance of the protocol lead to increased contamination of the health-care workers.[14],[15],[16] This attitude should be changed by intervention and teaching them the importance of following protocols that can help decrease the infection rate among HCWs. In our study, we found that only a few (8%) residents tested positive during COVID duty. Furthermore, awareness about decontamination or disposal of PPE should be there.
Different institutes follow different protocols for PPE policy. They have different guidelines for donning and doffing along with the duration of duty hours while using PPE. Furthermore, different policies led to different rates of infection for residents of PG and health workers. As PGs were mainly involved in the treatment of COVID-19, their knowledge about PPE use and its policy must be up to date and should follow all the policies and protocol of PPE use to decrease the rate of infection in PG residents. In our study, we found that 59.25% of the PGs responded positively about having a policy for PPE use. By applying strict policies at the institutional level, the infection rate among health-care workers can be reduced.
As COVID-19 spreads by transmission while aerosol-generating procedures such as nebulization and noninvasive ventilation, isolation, and closed environment were maintained in ICU. Sonawane et al. observed that 98.4% of the participants felt exhausted in PPE after 6–8 h of duty and the rest reported some sort of skin problem.[12] Similar situations were reported from various parts of the country.[17] In our study, we found that 62.96% of residents had headache after using PPE, but very few had headache every time they used PPE. The cause of headache would be hypoxia due to the use of a reused N95 mask and surgical mask, dehydration, hypoglycemia, and closed environment. About 53.70% of the residents had myalgia sometimes. About 68.51% of residents always felt dehydrated and thirsty after using PPE. This can be solved by adequate hydration with oral rehydration solutions to replenish electrolytes before starting the duty. Instead of using a reused mask, a new mask should be provided to HCWs. Furthermore, the dehydration was due to sweating. Hence, after discussion with authorities and following all the standard guidelines for the quality of PPE, we switched to 40 GSM quality with breathable fabric that was water repellent. This helped to decrease sweating and its associated discomfort along with dehydration.
As PPEs cover the full body and sometimes cause restriction of movement, it caused some discomfort in doing routine procedures in COVID-19-positive patients. In our study that 64.81% of our PGs were found to have difficulty in intubation. It could be due to the double covering of the eyes by goggles and face shields. In addition, fogging was a major issue observed while using PPE. This can be solved using antifogging spray on the face shields or covering the face shield. Other problems encountered were discomfort with central line placement, positioning, and intravenous cannula insertion. The responses to these problems were subjective since these are also skilled procedures.
The limitations of our study were that this was a questionnaire-based study where responses are often skewed, and there may be a recall bias and social desirability bias as well. In addition, we did not include the noncore, preclinical, and paraclinical PGs.
ConclusionsWe thus conclude that HCWs in a tertiary care center are aware of PPE use and protocols therein. Even though they were adequately trained about protocols, reluctance, and technical difficulties in following it are there, which can be solved by adequate and repeated training of HCW. Problems faced with the use of PPE have their appropriate solutions.
Ethics clearance
The study was approved by the Institutional Ethics Committee (Ref. no. BJGMC/IEC/Pharmac/ND-Dept 0221068-068 dated 22.02.2021).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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