Introduction
Personal protection equipment (PPE) is assigned a critical role in healthcare interventions, and its effectiveness is rarely questioned. With COVID-19 case numbers exploding, not a single day passes away without news about healthcare facilities lacking personal protection equipment. While these concerns are not entirely ungrounded, they overshadow the often ignored aspect of the problem: how PPE itself is exploited by healthcare workers. Formally, full-body PPE sets for medical workers treating COVID-19 patients have been found to protect from 99.99% of particles (Holland, Zaloga & Friderici, 2020). The reasonable question arises as to whether doctors, nurses, and the rest of the medical staff can use PPE – including taking it on and off – without contaminating themselves. There is a possibility of existing gaps in PPE use that should be eliminated to turn this tool from almost symbolic to working. This article provides evidence that the efficiency of PPE decreases without proper safety strategies and in-service education.
Search Strategy
To achieve the goal of writing this literature review, the researchers sought to locate recent (less than five years old), peer-reviewed articles from reputable journals on three topics: (1) efficiency of PPE use; (2) difficulties in using personal protective equipment; (3) interventions for improving the efficiency of PPE use. Limiting the search strategy to these domains allowed us to understand the actual empirical usefulness of PPE and gain insights into difficulties encountered by medical staff when using PPE. Apart from that, researchers were able to get a grasp on what intervention techniques were effective in improving the outcomes of PPE use.
For this search strategy, the researchers used Google and Google Scholar. The latter has a feature of filtering articles by the time of publications, which allowed for only displaying recent articles on the topic. The keyword search for “use of personal protective equipment” returned 63,610 results, but many of them were irrelevant. From then on, the researchers used more specific keywords such as: “efficiency”, “efficiency healthcare”, “difficulties”, “barriers”, “mers”, “sars”, and “covid.” After further filtering sources by relevance and contents, the researchers were able to locate eight articles to be used in the present literature review.
Literature Review
The Efficiency of PPE Use
At the moment, very little is known about how medical workers use personal protective equipment and what actions lead to contamination. Kang et al. (2017) videotaped healthcare personnel at the University of Pittsburgh Medical Center (UPMC) and ran simulations using fluorescent powder. The results have shown that the vast majority of medical workers were contaminated during either donning or doffing of PPE. Kang et al. (2017) report that out of the totality of 130 observed simulations, the overall contamination rate was 80% or 103 simulations. Out of 60 simple set PPE contaminations, 40% were categorized as minor and the rest as obvious. The full-body set results were a bit better: two-thirds of PPE contaminations were minor. The study demonstrated the ubiquitousness of PPE contaminations with a significant share of them being potentially dangerous. However, the scope of the study was limited to one medical facility, which compromises the chances of the results being inferred on broader populations.
The concerns regarding the efficiency of PPE have become especially acute during the global COVID-2019 outbreak. Today, it is known that COVID-19 is spread by four means: contact, droplet infection, airborne, and faeco-oral (World Health Organization, 2020). Greenhalgh et al. (2020) reported that the official UK guidance published in February 2020 stated that both standard and respirator masks showed 80% protection against SARS-CoV-2. Greenhalgh et al. (2020) express doubts regarding the claimed efficiency rate as it is based on a 2017 systematic review that was conducted before the COVID-19 pandemic and included trials that revolved around seasonal influenza. Based on this information, Greenhalgh et al. (2020) suppose that the actual protection rate may be much lower, especially given that COVID-19 is significantly more contagious than seasonal influenza. To conclude, the efficiency of PPE itself is questionable and is further compromised by inappropriate use in clinical settings.
Difficulties in Using Personal Protective Equipment
Even if a hospital is properly funded and has PPE available in adequate numbers, its efficiency might still be compromised. Kang et al. (2018) investigated the difficulties experienced by nurses when using personal protective equipment during the 2015 outbreak of Middle East respiratory syndrome in Korea. The researchers conducted focus group interviews in one of the Korean hospitals with themes discovered in the interviews further ranked by frequency, specificity, emotion, and extensiveness. Participants complained about the ill-fitting PPE sizes: smaller females were frustrated by the baggy fits while bigger males disliked the tightness of the overalls (Kang et al., 2018). They interviewed medical staff who experienced anxiety and confusion over ambiguous, unstandardized protocols and the questionable quality and effectiveness of PPE. Lastly, the study participants reported the complexity of using different PPE types at the same time (Kang et al., 2018). The study’s findings are worthwhile because they show that the problem of using PPE is both personal, organizational, and systemic.
Rozenbojm, Nichol, Spielmann, and Holness (2015) highlight the importance of organizational factors in nurses’ adherence to PPE guidelines. Rozenbojm et al. (2015) state that despite the existence of protocols, nurses’ commitment to following them in clinical settings remains suboptimal. The researchers challenge the commonly held belief that safety behaviors are mainly contingent on individual knowledge and beliefs. For their study, Rozenbojm et al. (2015) investigated the safety climate of hospital units. They operated on the premise that “units [differed] by type of patients, acuity, pace of clinical care activities, workload, as well as by staff composition, local leadership, and organizational structure.” The inner climate of discrete units was operationalized through measuring factors such as availability of PPE, job barriers, cleanliness, and communication. Apart from that, Rozenbojm et al. (2015) gauged the level of organizational support for health and safety, the availability of safety-related training, and fit testing. The study discovered that the quality of the safety climate at a unit predicted the proper use of PPE.
The research conducted by Rozenbojm et al. (2015), however, does not diminish the importance of individual knowledge of safety guidelines. Chughtai et al. (2015) carried out a qualitative study that engaged 20 focus groups of healthcare workers from seven hospitals. The purpose of the study was to learn about the perceived barriers to the proper use of PPE and gauge participants’ knowledge of safety guidelines. Chughtai et al. (2015) discovered that healthcare workers often experienced shortages in PPE even during non-emergency situations. For this reason, some workers routinely resorted to reusing face masks. Their beliefs about such a practice varied: some medical workers were against reusing while others thought that it did not pose any threat to the caregiver. In summation, poor use of PPE is a complex issue that has roots in both individual issues such as lack of knowledge as well as organizational problems.
Interventions for Improving the Efficiency of PPE Use
The question arises as to how individual and organizational shortcomings could be addressed to improve the efficiency of personal protection equipment. Radonovich et al. (2016) write that healthcare personnel (HCP) are subject to routine exposure to respiratory pathogens such as COVID-19. Because of the risks of contracting the disease and being a transmitter, Radonovich et al. (2016) highlight the importance of choosing an appropriate method of personal protection. Medical masks may seem like a suboptimal option as compared to respirators. However, in their randomized trial, Radonovich et al. (2016) discovered that respirators were not any more efficient than medical masks. Besides, as it turned out, healthcare workers were more prone to removing respirators and having adverse side effects from prolonged wear, which defeated their purpose. Therefore, the practical implication is to test the efficiency of PPE before its use and avoid enforcing wearing cumbersome sets with unproven advantages.
Addressing the lack of knowledge about the proper use of PPE should also be one of the key priorities when devising a strategy to improve the efficiency of PPE. Al-Tawfiq, Rothwell, Mcgregor, and Khouri (2018) conducted an intervention study in which they applied a multi-faceted approach of nursing-led education in response to MERS-CoV infection. Before the start of the training, nurses studied Mosby’s Nursing Skills, took up an online skill module, and revised materials about donning and doffing of PPE and the process for obtaining a nasopharyngeal swab. After that, Al-Tawfiq (2018) conducted a four-day training that relied on engaging teaching methods such as group discussions and simulation on a mannequin. As a result, nurses reported a better understanding of the proper use of PPE. For all its advantages, Al-Tawfiq et al. (2018) did not provide any follow-up data on whether the training had brought about any sustainable changes.
The study by Al-Tawfiq et al. (2018) has many important implications for healthcare facilities and how they should address outbreaks of respiratory diseases. Firstly, the researchers demonstrated that an organizational response to emerging infectious diseases requires an interdisciplinary approach and a united effort of experts in various fields. Secondly, healthcare workers need to adhere to recommendations from national and international health authorities, which should make part of the training. Lastly, some measures cannot be incidental: practices such as fit testing should become mandatory.
Conclusion
The global public health catastrophe that is the COVID-19 outbreak raised concerns about the effectiveness of personal protection equipment. This literature review demonstrated that face masks and respirators themselves do not guarantee full protection from particles. However, what aggravates the situation is healthcare workers’ improper use of PPE that leads to a contamination rate of as high as 80%. Recent studies show that the problem with poor use of PPE that endangers the lives of primary caregivers stems from both individual and systemic shortcomings. On the one hand, healthcare workers might hold erroneous beliefs about the proper use of PPE. On the other hand, healthcare facilities do not help to uphold a safety culture by failing to do fit testing, issuing comprehensive protocols, and providing enough PPE. The problem of poor use of PPE should be addressed by assessing the efficiency of different options available. Facilities should not enforce the use of specific equipment, especially if it is considered inconvenient if there is no solid evidence of its advantages. Apart from that, handling the problem requires an interdisciplinary approach, adherence to national and global guidelines, and continuing education.
References
- Al-Tawfiq, J. A., Rothwell, S., Mcgregor, H. A., & Khouri, Z. A. (2018). A multi-faceted approach of a nursing led education in response to MERS-CoV infection. Journal of Infection and Public Health, 11(2), 260-264.
- Chughtai, A. A., Seale, H., Chi Dung, T., Maher, L., Nga, P. T., & MacIntyre, C. R. (2015). Current practices and barriers to the use of face masks and respirators among hospital-based health care workers in Vietnam. American Journal of Infection Control, 43(1), 72–77.
- Greenhalgh, T., Chan, X. H., Khunti, K., Durand-Moreau, Q., Straube, S., Devane, D.,… & Ireland, C. (2020). What is the efficacy of standard face masks compared to respirator masks in preventing COVID-type respiratory illnesses in primary care staff? CEBM Research, 1-8.
- Holland, M., Zaloga, D. J., & Friderici, C. S. (2020). COVID-19 Personal Protective Equipment (PPE) for the emergency physician. Visual Journal of Emergency Medicine, 19, 100740.
- Kang, J., Kim, E. J., Choi, J. H., Hong, H. K., Han, S. H., Choi, I. S.,… & Park, E. S. (2018). Difficulties in using personal protective equipment: Training experiences with the 2015 outbreak of Middle East respiratory syndrome in Korea. American Journal of Infection Control, 46(2), 235-237.
- Kang, J., O’Donnell, J. M., Colaianne, B., Bircher, N., Ren, D., & Smith, K. J. (2017). Use of personal protective equipment among health care personnel: results of clinical observations and simulations. American Journal of Infection Control, 45(1), 17-23.
- Radonovich, L. J., Bessesen, M. T., Cummings, D. A., Eagan, A., Gaydos, C., Gibert, C.,… & Savor-Price, C. (2016). The Respiratory Protection Effectiveness Clinical Trial (ResPECT): A cluster-randomized comparison of respirator and medical mask effectiveness against respiratory infections in healthcare personnel. BMC Infectious Diseases, 16(1), 243.
- Rozenbojm, M. D., Nichol, K., Spielmann, S., & Holness, D. L. (2015). Hospital unit safety climate: relationship with nurses’ adherence to recommended use of facial protective equipment. American Journal of Infection Control, 43(2), 115-120.
- World Health Organization. (2020). Coronavirus disease 2019 (COVID-19) – Situation report –73. Web.