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Health workers need quality training on removing PPE: Study

22 Apr 2021

It is important that the relevant authorities take steps to provide quality training on the use and disposal of personal protective equipment (PPE) to all categories of healthcare workers including doctors, before appointing and assigning them to high-risk units, a study has noted. It added that hospital authorities should have plans to make PPE available without a shortage for high-risk units throughout the Covid-19 pandemic period. These recommendations were made in a research paper titled “Knowledge and practices regarding the doffing (taking off) of PPE among frontline healthcare workers during Covid-19” authored by T. Vidanapathirana (attached to the Accident and Emergency Department of the District General Hospital, Matara) and published recently in the Journal of the Ruhunu Clinical Society. As described by the Occupational Safety and Health Administration (OSHA), PPE are specially designed clothing or equipment used to prevent or minimise contact with hazardous substances in a workplace. In healthcare settings, PPE is an essential component to control infections and for the safety of workers. PPE acts as a physical barrier and protects the healthcare worker from getting exposed to hazardous materials such as blood, body fluids, etc. It prevents the transmission of communicable diseases from one person to another. Some of the PPE used in healthcare settings are facemasks, gloves, gowns, and goggles. According to the OSHA, it is the responsibility of the employer to make appropriate PPE available for the employees, to ensure that the employees are trained on the proper handling of PPE and to make sure that the employees are properly using the PPE. The World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) have released guidelines on the rational use of PPE and how to handle the shortage of PPE. In order to get the optimal effectiveness of PPE, donning (putting on) and doffing of PPE should be error free. The doffing process is relatively more important in blocking the transmission of infections than the donning process. As PPE is one of the important strategies in the prevention of the transmission of infectious diseases in healthcare settings, the assessment of the proper usage of PPE and adherence to the standard PPE handling protocols among healthcare workers is an important and timely need. This study by Vidanapathirana was conducted to explore the level of knowledge, practices, and exposure to training related to the proper usage of PPE among healthcare workers and to determine the associations of knowledge and practices regarding the doffing of PPE with the job category and the training exposure of the healthcare worker in a local setting. The study was conducted in the District General Hospital, Matara from September to October 2020, about six months after the WHO declared Covid-19 as a Public Health Emergency of International Concern. The first case of Covid-19 in Sri Lanka was reported on 27 January 2020, of a 44-year-old Chinese woman admitted to the National Institute of Infectious Diseases/Infectious Diseases Hospital (IDH). Since then, the health sector took necessary measures to control the cases by establishing Covid-19 units in certain hospitals. All categories of frontline healthcare workers in the District General Hospital, Matara, were included in the study. A total of 281 healthcare workers were randomly recruited from each category, proportionate to the size of each category. A pre-tested, self-administered questionnaire consisting of socio-demographic data, data on training related to PPE, and knowledge on the doffing of PPE (as per the institutional guidelines used in the District General Hospital, Matara, the WHO guidelines, and the CDC guidelines) was used for data collection. The response rate was 99.3%. All participants were Sinhalese Buddhists. The majority (211 – 75.6%) were females. The age of the participants ranged between 29 to 58 years while the mean age was 40.32 years. The majority of the participants were nurses (154 – 55.2%) followed by medical officers (94 – 33.7%), minor staff (28 – 10%), and matrons and sisters (three – 1.1%). It was noted that 109 (39.1%) had worked for six months or more in Covid-19 units while the rest (170 – 60.9%) had worked for less than six months. Therefore, the majority of the participants had experience of six months, working in Covid-19 wards. Only 190 (68.1%) had received training on how to wear the PPE and the proper use of PPE before being appointed as frontline healthcare workers in Covid-19 wards. This is, Vidanapathirana noted, not a satisfactory figure, as it is evidenced (in “SARS-CoV-2 infection: Advocacy for training and social distancing in healthcare settings” by A. Gagneux-Brunon, C. Pelissier, J. Gagnaire, S. Pillet, B. Pozzetto, E. Botelho-Nevers, and P. Berthelot; and “Barriers and facilitators to healthcare workers adherence with infection prevention and control [IPC] guidelines for respiratory infectious diseases: A rapid qualitative evidence synthesis” by C. Houghton, P. Meskell, H. Delaney, M. Smalle, C. Glenton, A. Booth, X.H.S. Chan, D. Devane, and L.M. Biesty) that proper training on handling PPE reduces the risk of the transmission of Covid-19 to healthcare workers. The number of training sessions the participants had participated in varied from one to 10. Out of these 190 participants, the majority (70 – 36.8%) had participated in only one training session while 64 (33.7%) and 33 (17.4%) had received two and three training sessions, respectively, and the rest of the participants (23 – 12.1%) were exposed to more than three training sessions. The training sessions comprised of demonstrations on handling PPE (147 – 52.7%), lectures (127 – 45.5%), videos (115 – 41.2%), hands-on skill training (79 – 28.3%), workshops (53 – 19%), and the distribution of leaflets (12 – 4.3%) while some training sessions included more than one of the abovementioned methods. Knowledge on PPE used in healthcare settings for Covid-19 (impermeable gowns, gloves, facemasks, face shields, goggles, surgical hoods or caps, covered shoes, and fluid resistant shoe covers or boots) was assessed. More than 80% of healthcare workers knew the types of PPE used in Covid-19 units. The majority (193 – 69%) knew the correct order of the doffing of PPE. Out of this number, 63 (32.6%) were medical officers. There was a significant positive association between participating in a training session on PPE and the knowledge on correct doffing practices. A similar finding was obtained in an intervention study conducted in a tertiary care hospital in Beijing, China (“Whole-Process Emergency Training of PPE Helps Health Care Workers Against Covid-19” by W. Tan, Y. Ye, Y. Yang, Z. Chen, X. Yang, C. Zhu, D. Chen, J. Tan, and C. Zhen) where there was a very significant improvement in the post-test compared to the pre-test after a training programme on PPE. There was no significant association between the job category and satisfactory knowledge on the order of the doffing of PPE. Knowledge on doffing practices was assessed through the answers to the following questions: Hand rub should be used in between each step of doffing PPE; removed boots should be washed with soap and water; removed face shield/goggles should be washed with 1% terephthaloyl chloride (TCL); should have a bath before going home; PPE should be discarded into a closed bin with a yellow colour bag; PPE should be immediately removed after the procedure; and if you are leaving the clinical area, you should not remove the PPE. The majority (more than 70%) gave the correct answer for all the practices assessed and therefore had adequate knowledge on doffing practices. In contrast to these findings, studies conducted outside Sri Lanka (“PPE doffing practices of health care workers” by L.T. Phan, D. Maita, D.C. Mortiz, R. Weber, C. Fritzen-Pedicine, S.C. Bleasdale, R.M. Jones, and the CDC Prevention Epicentres Programme; “Use of PPE among healthcare personnel: Results of clinical observations and simulations” by J.H. Kang, J.M. O'Donnell, B. Colaianne, N. Bircher, D. Ren, and K.J. Smith; and “Assessment of Health Care Worker Protocol Deviations and Self Contamination during PPE Donning and Doffing” by J.H. Kwon, Carey-Ann D. Burnham, K.A. Reske, S.Y. Liang, T. Hink, M.A. Wallace, A. Shupe, S. Seiler, C. Cass, V.J. Fraser, and E.R. Dubberke) revealed poor overall knowledge on the doffing of PPE among healthcare workers. This difference, Vidanapathirana opined, could have been due to the observation component included in most of these studies which revealed more reliable information. A study conducted in West Indies and Jamaica by the CDC on “Using PPE” revealed that 90% nurses, 88% doctors, and 70% medical technicians were very knowledgeable about universal precautions. In the assessment made to describe the source of information the participants had used in order to obtain knowledge regarding the proper usage of PPE, the majority (262 – 93.9%) had stated that they relied on hospital protocols. A reasonable number (231 – 82.8%) referred to the WHO website and the Ministry of Health website (194 – 69.5%). The participants were queried about their practices regarding the wearing of PPE while working as frontline healthcare workers in Covid-19 units. More than 85% were wearing all the required PPE when in contact with Covid-19 patients. The association between the job category and the wearing of PPE when in contact with Covid-19 patients was assessed. Nurses, sisters, matrons, and minor staff were grouped together as “other categories”. It was found that medical officers were wearing impermeable gowns, gloves, face shields, goggles, and boots significantly less than the healthcare workers in other categories. Contrary to the findings of this study, a study conducted in Tamil Nadu (“A study on PPE use among healthcare providers, Tamil Nadu” by P.A.A. Lakshmi, H.J. Gladius, A.S. Meriton, and C.M. Paul) revealed that doctors had significantly good compliance towards using appropriate PPE compared to nurses and technicians. When questioned as to whether they think that they are adequately equipped with PPE, 145 (52%) said that they think that they are wearing PPE adequately “most of the times” while 115 (41.2%) said that they think that they are properly equipped with PPE “all the time”. Only five (1.8%) said that they “never” think that they are adequately equipped with PPE. The reasons given by the participants for not wearing the PPE adequately (namely, I was not knowledgeable enough; I was not trained properly; due to the lack of time; my negligence; I do not consider it as a risk; due to the shortage of PPE and other material; and due to controversial health-related messages) were assessed. A total of 129 (46.2%) stated that they had a shortage of PPE supply at some point in time. The participants were then questioned as to whether there was any shortage of PPE (108/38.7% said sometimes, 73/26.2% said rarely, 50/18% said most of the times; 28/10% said never, and 20/7.2% said always) and the type of PPE which was out of stock (174/62.4% impermeable gowns, 170/60.9% facemasks, 115/41.2% face shields, 102/36.6% goggles, 101/36.2% covered shoes and fluid resistant shoe covers or boots, 77/27.6% surgical hoods or caps, and 7/2.5% gloves). As highlighted by this study, the shortage of the PPE supply was a huge problem in many parts of the world (“Covid-19 and PPE: Some of us will die because of the shortage” by J. Mandrola, and “Global shortage of PPE” by T. Burki) and a high demand for facemasks made facemasks the most scarce PPE as revealed by this study.


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