Introduction
Current pandemic, COVID-19, a Coronavirus disease is caused by novel Corona virus, previously known as 2019-nCoV.1 The outbreak of the coronavirus disease (COVID-19) was first reported in Wuhan, China, in December 2019 and disease has since spread rapidly across the globe impacting greatly on health, economics and social life on a global scale.2 On 11th March 2020, COVID-19 was declared a pandemic by World Health Organisation (WHO).3 The rapid spread of COVID-19 has caused challenges world-wide, especially to health-care workers in health care settings. The healthcare workers (HCWs) are at the frontline of COVID- 19 pandemic defence and are exposed to, not only infection with COVID-19 due to their frequent exposure to infected individuals, but also psychological distress, long working hours, fatigue, occupational stigma and physical violence.1 Outbreaks of any newly emerging or remerging infectious diseases present a unique challenge and a threat to healthcare worker and other frontline responders due to limited understanding of the emerging threat and reliance on infection prevention and control (IPC) measures that may not consider all transmission dynamics of the emerging pathogens. Furthermore, HCWs understanding and skills around the use of personal protective equipment (PPE) vary widely. The use of PPEs is important during the early stage of an outbreak or pandemic when drugs, a vaccine and other control measures are not available, or access is limited. Commonly used PPE to protect from respiratory infections like COVID 19 are face masks, respirators, gloves, and goggles or face shields. Face masks (or medical masks) are the most commonly used PPE to protect from influenza and other respiratory infection in healthcare settings whereas N95 mask in most important in airborne infections or COVID 19 aerosol generating procedures. Apart from other infection control and prevention strategies like administrative and environmental control measures, appropriate use of PPE is most commonly used in healthcare settings as standard, droplet and airborne precautions to protect healthcare workers from infections and to prevent further spread to patients around them. It is well documented that transmission of COVID-19 disease among HCWs is associated with overcrowding, absence of isolation room facilities and environmental contamination, but inadequate awareness of hospital infection control & prevention practices , may heightens the risk of infections in HCWs. 4 The correct use of personal protective equipment (PPE) eg. donning, doffing, and other measures are crucial part of COVID 19 infection prevention & control among HCWs.1, 4
Hence, the knowledge, practices, and attitude of healthcare workers (HCW) about use of PPE also determine the transmission and prevention of COVID-19 infection. So, keeping this as front runner, the present study was conducted with the objective of assessing knowledge, attitude and practices among health care workers regarding correct use of personal protective equipment (PPE) in a tertiary care teaching hospital in Navi Mumbai which may be of immense help to the authorities to formulate protocols as well as strengthening hospital infection control practices.
Materials and Methods
Study design
An online cross-sectional descriptive study was conducted from July 2020 to August 2020 at a tertiary care hospital and teaching institute of Maharashtra.
Frontline Health-care workers who were directly involved COVID-19 treatment and prevention and having direct contact with suspected or confirmed COVID-19 patients were enrolled for the study after an informed consent. These included Doctors, Nurses, Post-graduate students and administrators.
The faculties and Staff, above 60 years, with co-morbidities were excluded from the study.
We opted to use WhatsApp Messenger for enrolling the participants as the nationwide lockdown at the time of study. HCWs, who could approach through WhatsApp groups participated in study.
An online data collection for the study was designed and executed by using Google forms (via docs.google.com). The google form link to the self-administered questionnaire consisting of socio-demographic questions (like age , gender, profession & work experience in years) and 20 questions based on knowledge , attitude and practices regarding use of personal protective equipment related to COVID -19 disease in health care setting. The questions were prepared and adapted from standard guideline of WHO, CDC.1, 5 Consent was obtained from all study participants.
Each correct response weight 1 point and 0 point for incorrect responses. Data was tabulated in Microsoft Excel 2016, and descriptive statistics were performed using SPSS 20.0 version.
Results
A total of 250 participants were included the study after taking consent. Most of them were post-graduates 95 (38%) followed by 83 nursing staffs (33.3%), 46 faculty members (18.4%) and 26 administrators (10.4%). Since the study was conducted in a COVID 19 designated hospital and regular training had been conducted by infection control team members one of the most important infection prevention measure ‘appropriate & correct use of personal protective equipment.
Table 1
The participant’s knowledge on use of PPE
Table 2
The participant’s attitude on use of PPE
Table 3
Participants Attitude on use of PPE
Most of the participants attended the regular training program on PPE. 206 participants correctly answered that the most critical part of PPE is mask or N95 mask. (Table 1) It has been observed that who have not attended training most of them were also correctly answered. Among 250 participants, 91 PG students, 67 nursing staffs, 41 faculty members and 15 administrators had answered the correct donning sequence of PPE. While doffing is a crucial part for COVID-19 infection prevention, it has been observed that only 171 participants answered the correct doffing sequence. (Table 1)
Hand hygiene by using alcohol-based hand sanitizer or hand rub another important infection prevention measure for COVID-19. Among 250 participants, only 120 participants knew the correct alcohol percentage of hand-rub and 140 participants knew correct steps of hand hygiene using 70% alcohol-based hand-rub. According to majority of the study participants (133) N95 mask use is mandatory for routine OPD examination. But most of the participants (226) knew the correct method of wearing surgical. 176 participants correctly answered the right etiquettes of using washroom on COVID-19 ICU duty and 196 followed donning-doffing protocol on ICU duty. (Table 1)
Regarding right practices of PPE use, among 250 participants, 237 participants were aware about regularly outer gloves change during COVID-19 duty and all of them (250, 100%) were familiar with removal of personal items eg. Bangles, rings before donning. 226 study participants agreed that they reuse N95 mask at hospital. Majority of them (200) were in favour of wearing double mask i.e. surgical mask beneath N95 mask whereas 215 were familiar with correct method of adjusting surgical mask or N95 mask on duty. According to 246 participants wearing full PPE during 6-8 hours of COVID-19 ICUs/Wards duty was very exhausted inside PPE, few documented skin allergy and breathing problems. (Table 2)
It has been observed that, the practice of using handrub after each doffing steps were followed by 221 participants, whereas 226 were aware with the necessity of fit testing of N95 mask. However, there were poor compliance to biomedical waste segregation as per guideline among the participants after doffing. (Table 3)
Discussion
Among the 250 participants, 222 (88.8%) attended training conducted on indication and appropriate use of PPE. However, 13 postgraduate students, 6 administrator, 7 faculty members, 2 nursing staffs did not attended training. The inability to attend training program probably was due to night shift duty hours or workload. However, despite of vigorous training program 85.6% and 68.4% respondents knew the correct method of donning and doffing PPE respectively. 82% participants were aware about the most critical component of PPE, eg. mask. Similar study conducted in Nigeria showed that despite of training programs were organized, approximately half of the respondents had some form of training on PPE, only 6.6% and 12.5% knew the correct procedure to don and remove PPE, respectively and 46% knows how to correctly select appropriate PPE for use. Another study in the United States assessed the doffing practices of HCWs and found that in 90% of cases, the selection and/or the sequence of doffing PPE was incorrect. Another study in the United States found that 100% and 27% of HCWs at least breached the protocol for Ebola for donning and doffing PPE, respectively. The high levels of breaches of the protocol in wearing and removal of PPE could be attributed to the complexity of the protocols and the need for training and retraining. Following the appropriate steps is important to avoiding self-contamination when utilizing PPE.6 However, in present study the compliance to donning is better, but doffing practices need to improve to avoid cross transmission of infection. There is a strong possibility that post duty doctors are so exhausted in PPE that eager to remove it quickly which leads to incorrect steps of doffing.
Being an essential part of COVID 19 infection prevention, approximately 54% & 56 % participants responded correctly about steps of hand hygiene and percentage of alcohol in hand rub. However, WHO emphasizes maximum adherence to hand hygiene steps as well as the percentage of alcohol before using in COVID 19 set-up.7
Among the study participants, only 53.2% correctly responded that N95 mask is required for routine examination in OPDs. Zhang et al. also mentioned the various type of PPE and their use in their study. In this study Zhang et al mentioned that N95 mask is advisable when the person coughs forcefully or one does not follow cough etiquettes and these both reasons are quite common in OPD areas of our hospital.8
Approximately 90% were aware of correct method of wearing surgical mask. The Nigerian study demonstrated HCWs’ poor knowledge about the indications for and selection of appropriate PPE. Chia et al. in Singapore during the SARS-CoV outbreak in 2003 in which more than half of the nurses and clerical staff agreed that paper face masks serve a similar function to surgical masks.9
Regarding the attitude towards appropriate use of PPE, it was observed that 76.8% HCWs participants knew that they need to follow donning and doffing protocol always when they enter COVID designated ICUs. The finding is similar to Phan et al. as well as WHO and CDC that to avoid maximum risk of self-contamination on HCW’s clothing and skin after providing care for patients having acute respiratory virus infections, HCWs need to follow donning and doffing practices stringently.10
Among the respondents 94.8 % agreed the importance of regularly change the outer gloves during patient care. All of the participants (100%) were aware of mandatory removal of personal items eg. rings, bangles before donning. As per WHO patient Safety guideline, these are mandatory for any contact and droplet infection.11
Approximately 90.4% participants have reused N95 mask at the work set up. 86% participants were familiar with the correct method of adjusting mask while on duty. Re-use policy of N95 was adapted due to shortage of the same in market during COVID 19 pandemic as per CDC and ICMR guidelines.12, 13 Reuse of PPE including N95 mask was also reported in many studies, mainly because of unavailability of PPE.14
98.4% participants documented that they felt exhausted in PPE after 6-8 hours COVID 19 duty and rest reported some sort of skin problem. The same were reported from various parts of country.15
Regarding practices of appropriate use of PPE, it was observed that 88.4% participants were used hand rub after every step of doffing and 90.8% were in opinion of prior fit testing of N95 mask. However, 62.4% correctly segregated the gown post doffing. It takes approx. 30-40 mins for doffing by following all instructions to prevent aerosol generation as well as cross contamination.
