Objective: To evaluate two different types of education and training aids to improve compliance with guidelines related to personal protective equipment in healthcare workers.
Methods: The quasi-experimental study was conducted at the Department of Gynaecology and Obstetrics, Combined Military Hospital, Rawalpindi, from July 1 to December 31, 2020, and comprised healthcare personnel who were divided into two equal groups. Group A received weekly instructor-led training session of donning and doffing for two hours. Group B was assigned to watch 30-min training videos weekly. After one month, an independent instructor evaluated both the groups using validated checklists, with maximum score 8 for donning and 14 for doffing. Data was analysed using SPSS 22.
Results: Of the 60 subjects, 34(56.6%) were females and 26(43.3%) were males. There were 30(50%) subjects in group A with a mean age of 35.35±5.67years, and the remaining 30(50%) were n group B with a mean age of 33.12±4.13 years. There was no significant difference in donning and doffing scores between the groups (p>0.05).
Conclusion: Both types of education and training aids could be used to improve compliance with guidelines related to personal protective equipment in healthcare workers.
Keywords: Covid-19, Donning, Doffing, Personal protective equipment. (JPMA 72: 807; 2022)
Personal protective equipment (PPE) is specialised gear, clothing or equipment worn and used for protection against infectious and hazardous material.1 The world was jolted by the emergence of coronavirus diseases-2019 (COVID-19) pandemic, and the importance and applicability of PPE became known to not only the healthcare workers (HCWs), but to the general public also. This was an unprecedented situation and overwhelmed the healthcare community, too. The availability as well as use of PPE in these taxing times was a challenge. The concept of using personal protection to limit the spread of infections, however, is not new. In 1987, the use of universal precautions was recommended in hospitals to limit the spread of blood-borne infections.2 In 1996, standard precautions were introduced. This now covered prevention of infection to not only HCWs, but patients as well as visitors.3 This led to the concept of safety in healthcare. This required involvement from all stakeholders. Administrators' role is training and controlling isolation policies, ensuring good work-based practices, like proper needle and waste disposal. Administrators and policymakers must ensure control and alignment of infrastructure to cater to isolation and infection control, including creation of negative pressure rooms. With all these in place, finally there comes the use of PPE for the prevention of disease transmission.4
In hospital settings it should be assumed that all patients are a source of spreading infection and protocols are made accordingly. In exceptional circumstances, like the COVID-19 pandemic and Ebola outbreak, expanded precaution strategies, including contact, droplet and airborne infection prevention protocols, need to be implemented. The Centre of Disease Control and Prevention (CDC) regularly issues and updates guidelines for PPE usages according to clinical situation and the potential for spread of infection.5 There is also guidance for donning, doffing, reusing and disposing of PPEs. Although PPE is not a substitute for safe practices of working, the principle of PPE is of risk assessment which is to protect patients and self by assessing risk of exposure and selecting appropriate equipment and clothing. Types of PPE are gloves, aprons, gowns, masks, respirators, goggles, face shields and footwear.6 Guidelines for donning and doffing sequence are available and are intended to limit chances of self-contamination and exposure to others. Adherence to the steps has shown safety in many studies and training sessions improve compliance and safety. Many studies were done in the past to evaluate the effectiveness of training sessions to increase compliance with PPE use. The training methods included courses, practice drills, written information like leaflets, guidelines and posters.7 Some studies measured effectiveness of interventions by using materials to visualise contamination after training sessions, actual number of patients getting infection despite using PPE, or compliance with guidance by comparing against a checklist.8 PPE use and uptake can be improved by personal supervision and directed feedback. Auditing the performance against validated checklists and continuous education, training and evaluation can increase adherence to protocols in short and long terms.9
The current study was planned to compare improvement in personal safety in healthcare environment by regular training sessions and to increase compliance with PPE protocols by using different teaching aides.
Subjects and Methods
The quasi-experimental study was conducted at the Department of Gynaecology and Obstetrics, Combined Military Hospital (CMH), Rawalpindi, from July 1 to December 31, 2020. After approval from the institutional ethics review board, the sample size was calculated by using open Epi calculator.10 The sample was raised using convenience purposive sampling. Those included were HCWs, including doctors, nurses and medical assistants. Those who refused to volunteer were excluded.
Formal training session was organised at the CMH under guidance of National Institute of Health (NIH), and one individual was trained as the master trainer using an oral presentation of 2 hours, followed by practice sessions of 2 hours every day for 5 consecutive days and a post-training assessment. The certified master trainer then led the study groups through the training. After taking informed consent from the participants, they were divided into two equal groups and demographic data, including age, gender, and type of HCW. Group A received weekly instructor-led training session of two hours. Demonstration of donning and doffing by the instructor was followed by observation of the participants with feedback. In between the weekly training sessions, the participants were given 30 minutes daily to self-practise without instructors' observation. Group B was assigned to watch weekly 30-minute training videos 11 demonstrating the procedures. The participants were encouraged to watch videos at home daily and were instructed to note the time they spent watching the videos.
After one month, an independent instructor performed the evaluation of both the groups using validated checklists15 (Table-1) and each participant's score was noted. The participants were assessed for proper selection of the level of PPE according to a situation, as well as donning and doffing techniques. Time spent on training of both groups was noted. Donning and doffing score against the checklists was calculated. Maximum score was 8 for donning and 14 for doffing. Data was analysed using SPSS 22. Independent sample t-test was applied as appropriate. P<0.05 was considered statistically significant.
Of the 60 subjects, 34(56.6%) were females and 26(43.3%) were males. There were 30(50%) subjects in group A with a mean age of 35.35±5.67years, and the remaining 30(50%) were in group B with a mean age of 33.12±4.13 years (Table-2). The average time spent in each group was also noted (Table-3).
In donning, group A score ranged 3-8, while group B score ranged 5-8 (p=0.23). In doffing, scores ranged 10-14 and 12-14, respectively (p-0.16). There was no difference in the ability of the two groups in terms of identification of PPE level (p=0.36).
The current COVID 19 pandemic has highlighted gaps in healthcare systems and a case arose against training on-site considering the highly infectious nature of the virus.12 Virtual training tools and practice sessions seemed to be the safer option keeping physical distancing in mind. Training in a clinical simulation scenario is as close to a real-life situation whereas use of training videos is a valid option in the present situation, but it needs to be tested to ensure accuracy and completeness of actions.13
Adherence to locally agreed infection control protocols is of prime importance to improve PPE usage. This should involve education, training, competency demonstration and ongoing assessment and audits to create an environment that ensures appropriate PPE usage.
In a Spanish study, about 57% HCWs had knowledge about PPE, and 32% had used it previously.14 In a quasi-experimental study in Saudi Arabia assessing clinical skills and simulation centre training for PPE use had a sample composition similar to that of the current study.15
In a local study, only 40.5% HCWs had some awareness regarding PPE use and had received training.16 In a cross-sectional study to assess knowledge of medical students and the training they received for PPE use showed only 41% had received some formal training and only 39% selected the correct PPE.17 In the study in Saudi Arabia, training given to HCWs improved the post-test score from 67% to 85% (p<0.01).13
The overall donning and doffing scores showed no difference in the current study and these results are in line with an earlier study.18 In contrast, a study comparing skills in donning PPE showed that computer simulation led to fewer errors, and that video lecture on donning led to better scores than a traditional lecture.19
In another study, face-to-face instruction improved compliance with donning than providing videos or written material20. Other studies using active training through computer simulation led to fewer errors amongst HCWs compared to passive training.21 Conflicting results from another study showed that participants who watched videos compared to a traditional lecture scored better when tested for donning and doffing.22
The quality of evidence for most of studies cited above is low because of risk of bias, indirectness of evidence and small number of participants. More studies are required on this count.
The limitations of the current study are its small size and the fact that it was conducted at a single centre and while the pandemic was still ongoing.
Adherence to correct PPE use is instrumental for the safety of both the HCW and the patient. No significant difference was noted between the two training methods. Thus, both the methods can be used confidently according to the healthcare setup.
Conflict of Interest: None.
Source of Funding: None.
1. Baloh J, Reisinger HS, Dukes K, da Silva JP, Salehi HP, Ward M, et al. Healthcare Workers' Strategies for Doffing Personal Protective Equipment. Clin Infect Dis 2019; 69: S192-8.
2. Reddy SC, Valderrama AL, Kuhar DT. Improving the Use of Personal Protective Equipment: Applying Lessons Learned. Clin Infect Dis 2019; 69: S165-70.
3. Phan LT, Maita D, Mortiz DC, Weber R, Fritzen-Pedicini C, Bleasdale SC, et al; CDC Prevention Epicenters Program. Personal protective equipment doffing practices of healthcare workers. J Occup Environ Hyg 2019; 16: 575-81.
4. Liu M, Cheng SZ, Xu KW, Yang Y, Zhu QT, Zhang H, et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study. BMJ 2020; 369: m2195.
5. Mumma JM, Durso FT, Ferguson AN, Gipson CL, Casanova L, Erukunuakpor K, et al; Centers for Disease Control and Prevention Epicenters Program, Division of Healthcare Quality Promotion. Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination. Clin Infect Dis 2018; 66: 950-8.
6. Kang J, Kim EJ, Choi JH, Hong HK, Han SH, Choi IS, et al. Difficulties in using personal protective equipment: Training experiences with the 2015 outbreak of Middle East respiratory syndrome in Korea. Am J Infect Control 2018; 46: 235-7.
7. Huh S. How to train health personnel to protect themselves from SARS-CoV-2(novel coronavirus) infection when caring for a patient or suspected case. J Educ Eval Health Prof 2020; 17: 10.
8. Poller B, Hall S, Bailey C, Gregory S, Clark R, Roberts P, et al. 'VIOLET': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment. J Hosp Infect 2018; 99: 229-35.
9. Kwon JH, Burnham CD, Reske KA, Liang SY, Hink T, Wallace MA, et al. Assessment of Healthcare Worker Protocol Deviations and Self-Contamination During Personal Protective Equipment Donning and Doffing. Infect Control Hosp Epidemiol 2017; 38: 1077-83.
10. Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epidemiologic statistics for public health, version; 2013
11. PPE Donning and Doffing: CDC Sequence for COVID 19. [Online] [Cited 202 March 25]. Available from: URL: https://youtu.be/t1lxq2OUy-U
12. Jamieson DJ, Steinberg JP, Martinello RA, Perl TM, Rasmussen SA. Obstetricians on the Coronavirus Disease 2019 (COVID-19) Front Lines and the Confusing World of Personal Protective Equipment. Obstet Gynecol 2020; 135: 1257-63.
13. Christensen L, Rasmussen CS, Benfield T, Franc JM. A randomized trial of instructor-led training versus video lesson in training health care providers in proper donning and doffing of personal protective equipment. Disaster Med Public Health Prep 2020; 14: 514-20.
14. Díaz-Guio DA, Ricardo-Zapata A, Ospina-Velez J, Gómez-Candamil G, Mora-Martinez S, Rodriguez-Morales AJ. Cognitive load and performance of health care professionals in donning and doffing PPE before and after a simulation-based educational intervention and its implications during the COVID-19 pandemic for biosafety. Infez Med 2020; 28: 111-7.
15. Abualenain JT, Al-Alawi MM. Simulation-based training in Ebola Personal Protective Equipment for healthcare workers: Experience from King Abdulaziz University Hospital in Saudi Arabia. J Infect Public Health 2018; 11: 796-800.
16. Kashif S, Pervaiz E, Azam F, Waqar T, Babar A, Gul A. Awareness Regarding personal protective equipment use among health care providers in various tertiary hospitals across Pakistan during COVID-19 Pandemic. Pak Armed Forces Med J 2020; 70: S518-22.
17. John A, Tomas ME, Hari A, Wilson BM, Donskey CJ. Do medical students receive training in correct use of personal protective equipment? Med Educ Online 2017; 22: 1264125.
18. Curtis_HA, Trang_K, Chason_KW, Biddinger_PD. Video-based learning vs traditional lecture for instructing emergency medicine residents in disaster medicine principles of mass triage, decontamination, and personal protective equipment. Prehosp Disaster Med 2018; 33: 7-12.
19. Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 4: CD011621.
20. Andonian J, Kazi S, Therkorn J, Benishek L, Billman C, Schiffhauer M, et al. Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing. Clin Infect Dis 2019; 69: S248-55.
21. Hung_PP, Choi_KS, Chiang_VC. Using interactive computer simulation for teaching the proper use of personal protective equipment. Comput Inform Nurs 2015; 33: 49-57.
22. Barratt R, Shaban RZ, Gilbert GL. Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey. Infect Dis Health 2020; 25: 253-61.