Impact of personal protective equipment on patient safety and health care workers

Abstract

Background

The study aims to assess the effect of personal protective equipment (PPE) on the physical and psychological well-being of health care workers (HCWs) and its impact on patient safety.

Methods

After ethical approval, a 14-point questionnaire was circulated offline and online among the HCWs of ours institute, who were involved in performing invasive procedures while wearing a PPE. The responses were analysed using the SPSS software version 26.

Results

Of 198 responses, the mean duration of PPE use was 4.6 ± 1.52 h. Seventy percent of respondents suggested <4 h of continuous use of PPE. Seventy-seven percent found difficulties during the procedures while wearing PPE and agreed to errors while performing a procedure. Poor visibility (95.5%), fogging (84.9%), communication difficulty (75.3%), sweating (74.2%), posture-related discomfort (56.1%) and poor concentration (51%) were major causes. Anxiety (39.9%) and fear of spreading an infection to the family (42.9%) were major psychological effects. Eighty percent of HCWs raised concern over the quality of PPE, N95 mask and eye protector. The HCWs felt the need to improve the quality of PPEs, use extra padding around the ears, sealing the N95 mask with adhesive tape, besides using sign language for communication for more safety. Fifty percent graded the procedure-related difficulty level >6 on a Likert scale of 1–10.

Conclusion

PPE-related discomfort is common among the HCWs and could contribute to errors during an invasive procedure. Efforts to alleviate the physical and psychological well-being of the HCWs will be essential for reducing procedural error while wearing a PPE.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has forced health care workers (HCWs) to use personal protective equipment (PPE) while providing care to infected patients. PPE plays an essential role in avoiding the transmission of viruses between patients and HCWs. HCWs perform many minor and major invasive procedures, including surgeries while wearing the PPE for a variable duration. However, few researchers have studied the impact of PPEs on the psychological and physical well-being of the HCWs.¹ Stress, depression, fatigue, poor performance, impaired decision-making, and impairment of technical and nontechnical skills are some of the limitations reported using current generation PPEs for long durations.^2,3 Poor decision-making due to physical hindrances and psychological stress can be a potential source of error during patient care delivery. Most of the current literature regarding PPE focus on donning and doffing techniques.^4,5 Few studies have tried to find out how the use of PPE impacts the performance of the HCWs physical and mental well-being, for example, the influence of PPE on decision-making while performing an invasive procedure.^3,6 The present study aimed to assess the perceptions of the HCWs on the impact of wearing PPE in patient care and on themselves. The study also tried to identify the possible solutions to the factors responsible for the discomfort while wearing PPE and procedural errors.

Materials and methods

Study design

A cross-sectional study was performed in December 2020 among the HCWs of our institute. The institutional ethical committee approved the study (IEC approval No-T/IM-NF/Gen. Surg/20/144).

Study participants

HCWs involved in the care of the COVID-positive patients, who have performed invasive procedures such as intravenous cannulation, nasogastric tube placement, catheterisation, sampling, lumbar puncture, drain insertion and surgical procedures were requested to participate in this study. The HCWs, who did not perform any invasive procedures, were excluded. The HCWs include the nursing staff, residents and the faculty. Written consent was obtained from all participants. The HCWs, who had submitted their response through a Google form, were asked to sign the consent form and mail it to us.

Sample size

An exponential snowball sampling was used to recruit the participants in an unbiased sampling environment for the study. Then, the questionnaire were distributed to 500 HCWs keeping the error margin as 10% and an estimated response rate of 20%.

Study variables and instruments

The 14-point questionnaire based on the current literature and personal experience of PPE use during the COVID-19 pandemic by the investigator was circulated online (https://docs.google.com/forms/d/e/1FAIpQLSe8sbAlQKJOrGFtfEPYcMJLY7QLsUBf_3pnfu0lpbYIpU46Cw/viewform?vc=0andc=0andw=1andflr=0andgxids=7628) and in hard copy (Table 1). The basic characteristics, including age, gender, place, family details, experience and nature of work, were retrieved from the response sheet. The experience of HCWs, including the sense of protection, fear associated with PPE, overall comfort, fatigue, visual impairment, communication with the patient and team members, awareness of the situation and decision-making process while wearing the PPE were also recorded. Multiple attempts were made to collect as many responses as possible. We also sought suggestions from the participants regarding the possible ways to improve the PPE's working condition. The identification of the respondents was masked during the data analysis.

Table 1.

Fourteen-point questionnaire.

S No	Items	Response
1.	Age
2.	Sex
3.	Designation
4.	Comorbidities
5.	Approximate duration of PPE use per day/hours of shift
6.	What should be the maximum duration of continuous use of PPE? (Circle one option)	<2 h	2–4 h	4–8 h
7.	Which of the following factors prohibits the use of PPE for longer duration?	Yes	No	NA
	Thirst
	Sweating
	Pressure area
	Headache
	Inability to use washroom
	Exhaustion/fatigue
	Inability to use mobile phones/social cutoff
	Fear of getting infected with longer duration of use
	Cumbersome donning and doffing
	Restricted movement
	Insomnia
	Inability to take regular medicines
	Inability to maintain personal hygiene
	Any other reasons? Please specify
8.	Choose the procedures you have attempted, wearing PPE
	Intubation
	Sampling – swab/blood
	Ryle tube
	Urinary catheter
	Central line
	IV line
	Lumber puncture
	Pigtail drainage
	Minor surgical procedures
	Major surgical procedures
	Others (please specify)
9.	Did you find any difficulty in performing these procedures?
10.	Kindly grade the difficulty level in a scale of 1–10
11.	Do you agree that incidence of surgical/medical errors increases due to the use of the PPE?
12.	Which of the following factors contributes to these errors?
	Poor visibility
	Frequent fogging
	Posture-related discomfort
	Discomfort related to sweating
	Overall comfort
	Poor reflexes
	Poor concentration
	Impaired decision-making capacity
	Deterioration of skill
	Unavailability of assistant
	Hearing and communication difficulties
	Feeling of being unprotected/unsafe
	Others (Please specify)
13.	Do you think use of PPE has psychological impact on you?
	Fear of acquiring infection
	Fear of spreading infection to family
	Fear of social stigma
	Anxiety
	Depression
14.	What can be done to reduce the errors related to use of PPE?
	Better quality of PPE
	Reducing the duration of PPE use
	Better quality of eye protector
	Any other suggestion

Statistical methods

Descriptive statistics were used in the study, and the analysis was done using SPSS software version 26. Categorical variables were expressed as frequency and percentage.

Results

A total of 210 (40.2%) HCWs from our hospital responded to the survey. Therefore, after removing the missing data and incomplete responses, 198 responses were considered for data analysis.

Participants characteristics

The participant's mean age was 28 ± 7 years with almost equal gender distribution. Most respondents were nursing staff (n = 108, 54.5%), followed by the doctors (n = 90, 45.5%). Most (83.3%) had no associated comorbidities, whereas a few had one (16.7%). Twenty responders had more than one comorbidity (10%; Table 2).

Table 2.

Demographics of the responders and responses.

S no	Items		Number	Percentage
1	Age group	21–25	61	30.8
		26–30	95	48.0
		31–35	31	15.7
		36–40	7	3.5
		41–45	3	1.5
		46–50	1	0.5
2	Sex	Male	98	49.5
		Female	100	50.5
3	Designation	Nursing officer	101	51
		Nursing trainee	7	3.5
		Resident doctor	70	35.4
		Faculty	7	3.5
		Intern	13	6.6
4	Comorbidities	None	165	83.3
		Asthma	6	3
		Diabetes	2	1
		Hypertension	2	1
		Migraine	1	0.5
		Myopia	17	8.6
		others	4	2.0
5	Duration of hours of use of PPE	<2	13	6.6
		2–4	40	20.2
		4–6	118	59.6
		6–8	26	13.1
		8–10	1	0.5
6	What should be the maximum duration of continuous use of PPE?	<2	17	8.6
		2–4	130	65.7
		4–8	51	25.8
7	Did you find any difficulty in performing these procedures?	Yes	153	77.3
		No	32	16.2
		NA	13	6.6
8	Do you agree that incidence of surgical/medical errors increases due to the use of the PPE?	Yes	153	77.7
		No	43	21.8
		Cannot say	2	1
9	Do you think use of PPE has psychological impact on you?	Fear of acquiring infection	65	32.8
		Fear of spreading infection to family	85	42.9
		Fear of social stigma	38	19.2
		Anxiety	79	39.9
		Depression	38	19.2
10	What can be done to reduce the errors related to use of PPE?	Better quality of PPE	159	80.3
		Reducing the duration of PPE use	159	80.3
		Better quality of eye protector	161	81.3
		Any other suggestion	6	3

NA, not applicable, PPE, personal protective equipment.

PPE usage hours and procedure

The majority (60%) of the responders worked 6 h shift duty in COVID wards and intensive care units. The mean duration of continuous use of PPE was 4.61 ± 1.52 h. Faculty members had less PPE time in comparison to nursing staff and residents (1.48 h vs. 4.6 h). The majority (63.1%) of the HCWs favoured a 2- to 4-h continuous wearing of PPE for optimal output (Table 2). Seventy-seven percent of HCWs reported some discomfort with prolonged use of PPE. Sweating (83.8%) and fatigue (80.8%) were the most common cause of discomfort. Other common discomforts were thirst, inability to use the washroom, headache, restricted movement, pressure area, cumbersome donning and doffing. Social cutoff or inability to use the mobile phone was reported by 62 responders (31.3%). The least common reasons were the inability to maintain personal hygiene (visit to the washroom), fear of getting infected, insomnia and failure to take regular medicine (Fig. 1). The most common procedure performed was the sampling (including throat swab/blood collection) followed by intravenous cannulation (IV line), nasogastric tube insertion, urinary catheterisation, intubation and minor/major surgical procedures, including central line insertion and chest tube placement (Fig. 2). A major surgical procedure (>1 h) was performed by 50 respondents (25.2%).

Fig. 1.

Personal protective equipment (PPE)-related discomfort.

Fig. 2.

Invasive procedure.

Procedure-related difficulties

Approximately 77% of the responders faced difficulties in performing their tasks. Poor visibility (95.5%) and fogging (94.9%) were common complaints apart from discomfort because of sweating (74.2%), hearing/communication issues (75.3%), posture-related discomfort (56.1%) and poor concentration (51%). Few (28.3%) also found impaired reflexes, hampering decision-making and deterioration of skills. Because of these difficulties, 77% of HCWs agreed that errors are more while wearing PPE than without PPE (Fig. 3). The feeling of being unprotected was reported by only 22% of responders. Approximately 50% of responders graded the procedure-related difficulty level as more than six on a Likert scale (1–10; Fig. 4). The difficulty level reported by the HCWs involved in surgery for more than 1 h had a mean difficulty level of 6.7 ± 1.2. HCWs with a short duration of procedures had experienced a difficulty level of 6.1 ± 0.7.

Fig. 3.

Procedure-related difficulties.

Fig. 4.

Difficulties levels during a procedure.

Impact of PPE and improvising safety measures

The psychological impact of PPE on HCWs is tabulated (Table 2). Fear of spreading the infection to the family was reported by 42% of responders. Seventy-seven percent of HCWs suggested limiting the continuous use of PPE to 4 h, extra padding around the ears, sealing of N95 mask with adhesive tape and sign language for communication as possible methods to reduce errors (Table 3).

Table 3.

Suggestions for improvement in working condition while wearing PPE.

Limitations	Modifications
Headache and ear pain	Self-massage, directly under the scalp16 Use of next-generation respirators17 Use of ear protector18
Fogging/poor visibility	Use of antifogging material in the goggles and face shields11
Hearing/communication related difficulties	Use of more sign language8
Sweating, fatigue, and thirst	Proper hydration before wearing PPE19
Poor concentration	Meditation20
The feeling of being unprotected Deterioration of skill Overall comfort	Use of synthetic antimicrobial textures for PPE production, especially in high virus load area such as ICU.14,15

ICU, intensive care unit; PPE, personal protective equipment.

Discussion

Most HCWs in our study agreed that PPEs had a detrimental effect on the quality of their procedural skills, contributing to medical errors. The PPEs limited their comfort in multiple ways. Fatigue, exhaustion, thirst, lack of personal hygiene (inability to visit washroom), and restricted movement were a few factors that adversely affected their quality of patient care. Frountzas et al. had suggested that PPE may provide some safety to HCWs but at the cost of comfort, fatigue and anxiety that could ultimately culminate in periprocedural adverse outcomes.²

Previous reports have suggested that long work hours and weariness can result in an increased incidence of medical errors.⁷ The long duration of work during the COVID-19 pandemic, added with the HCW's anxiety, depression, fear of getting contaminated and sleep deprivation, can affect patient care. Most HCWs in this study had 6-h shift duties at a stretch. The time taken for their safe donning and doffing was an addendum to their shift duration.

More than 80% of HCWs in this study were young (aged <35 years) with their family commitments. As a result, there was a fear of spreading the disease to their family among 43% of these workers.

HCWs are expected to provide error-free care even during highly stressful conditions. Adverse events could fill a sense of guilt to the service providers who risk their lives to save the sick patients. Many participants in this study reported that PPE could slow the reaction time and adversely affect decision-making. PPE also affects surgical and nontechnical skills, such as verbal communication and situational awareness. These effects are more pronounced when the HCWs are fatigued. McCormick found that medical errors increased by 22% with the fatigued resident than well-rested historical control subjects.⁷ Benitez et al. found that the respirators and face shields were the primary hurdle to effective communication in their study subjects.³ They noted in their survey that N95 muffled the user's voices and the face shields disrupted the voice projection, forcing the HCWs to speak louder to colleagues while performing any task, including surgery.³ It is suggested to use sign language for communication. Leyva-Moraga et al. have published a list of sign language during the surgical procedure.⁸ Another common problem was fogging of the spectacles or goggles used by HCWs, obstructing visibility which can be overcome by sealing the N95 mask with tape. However, it can cause dermatitis in some individuals and is painful during removal. Using an emollient before wearing the mask and moistening the adhesive tape during removal can circumvent the problem. Thirty percent of our responders believed that their decision-making capacity was hampered; this is in contrast to 48% of the subjects in the study by Benitez et al.³ This is primarily because of the kind of procedure the HCWs are involved in. Although we have taken the routine procedures, that is, insertion of IV line, NG tube, catheter, and blood/swab sampling, the other authors surveyed surgeons involved in acute surgical care. Benitez et al. also found that surgical performance was affected with the use of PPE. Reduced comfort, impaired communications and poor visibility added to the slower reaction time during the surgical procedure.³ In an experimental setting, Loibner et al, did not find an impact on performance.⁶ We believe that working in a simulation is more comfortable than performing in a real-time situation. Ong et al, in their study, noted that 81% of the HCWs had PPE-associated headaches, and another 91% had worsening of their previous headaches because of wearing PPE for >4 h.⁹ Wearing the current N95 mask and protective eyewear with elastic head straps often causes headaches, facial pain and ear lobe discomfort.^9,10 The discomfort is more if the elastic tapes are tight to ensure a close fit. Twenty-three percent of the subjects in the study by Ong et al. also developed associated symptoms such as nausea and photophobia.^9,10 Sixty-two percent of HCWs experienced a headache in our study. However, our study could not identify if headache among these HCWs was because of tight protective eyewear or the N95 face masks. Few simple modifications were suggested by the HCWs to make the PPE and the eye protectors more comfortable. These include putting a layer of soft paddings such as cotton behind the ear, a face shield instead of tight-fit goggles, a spectacle-like eyewear in place of goggles with strap and adhesive tape to seal the N95 mask to avoid fogging. These simple modifications may mitigate the problem of headaches.

The snugly fitting mask may also decrease the incidence of fogging. The use of antifogging material can also be tried. Simple measures such as wiping the goggles evenly using gauze or cotton swab or washing up soap-liquid and sanitiser or iodophor are also reported to reduce fogging.¹¹

Singh et al. have reported dermatitis cases related to wearing PPE, N95 and goggles.¹² Only two HCWs reported dermatitis in our study. The primary reason behind dermatitis is the hyperhydration effect of the PPE and friction. The exact reason behind the low incidence of dermatitis in our study could not be ascertained. However, the frequent use of emollients and moisturisers along with different climatic conditions may have some protective effect. Therefore, we suggest applying emollient and moisturiser, which can restore the integrity of the skin barrier, at least 30 min before donning of PPE/mask. Besides sufficient water intake before donning, properly fitting masks and air-conditioning can reduce the incidence of dermatitis.

Sixty percent of our responders suggest that the ideal time to wear the PPE should be 2–4 h for optimal work performance. A similar suggestion was made by Janssen, who suggests the maximum duration of the continuous use of the respirator should be 4 h.¹³ Till the availability of the better quality of the PPEs, we suggest that the duty hour with PPE should not last more than 4 h.

Researchers are trying to develop facemasks and PPE with antiviral effects.¹⁴ One such study by Aydemir et al. suggests using angiotensin-converting enzyme 2 (ACE2) coated/embedded nanoflowers, or quantum dots to produce the masks, gloves and clothes.¹⁵ The principle behind using ACE2 nanoflower or quantum dots–coated mask or PPE is the affinity of coronavirus towards the ACE2 receptor. ACE2 is a membrane protein exposed on the host cell's surface. Thus, ACE2-coated masks and PPEs can catch the coronavirus before it enters the host body. The ongoing research on this and reusable masks with antiviral filters seems to be promising. Some of the suggestions for improvements are incorporated in Table 3.

In contrast to the published article focusing on the safety of the PPE, we tried to identify problems felt by the end user, that is, the HCWs. Unlike other studies, which have mainly focused on surgical safety, this study has attempted to identify patient safety at every step during their hospital stay. Feedback was taken from all categories of the HCWs involved in the invasive procedures and not just limited to operation theatre procedures.

Discomfort and difficulty related to PPE use during procedures were studied across skill levels in this study. Some procedures require more physical and mental efforts and hence can cause more discomfort. This brings heterogeneity to this study. In the subgroup analysis, we found an almost similar difficulty level among surgeons and nurses. The study highlights the adverse effects of PPE on patient safety and possible causes of errors. HCWs were also asked for potential solutions to these problems.

There were some limitations of this study. First, it was a single-institution study with a subjective assessment of problems with the use of PPE. Although the endeavour included HCWs of all skill levels, only 17 faculties responded to the questionaries. The inadequate response could be because of the shorter duration or less frequent use of PPE among the faculty members, as the residents performed most emergency procedures. The study did not separately highlight the difficulties faced by HCWs during elective surgeries wearing PPE. The study also failed to highlight the errors during noninvasive procedures and interactions such as history taking, physical examination, and two-way communication. Finally, the study could not highlight the importance of adherence to the guidelines while donning. It is a possibility that the HCWs not adhering to the proper guidelines may have experienced more discomforts. In our institute, the administration appointed one observer during the donning of the PPE. Hence, we believe the HCWs adhered to the guidelines, and problems experienced by the HCWs were a true reflection of the PPE-related complications. Besides the protective gowns, N95 masks and the eyewear were of different qualities, supplied by different manufactures. As this was a recall-based study, we could not assess the quality of the PPE and the discomfort. A larger multicentric study with participants in a controlled condition can probably take care of these biases.

The glass/plastic industry needs further research in this field. The textile industry can take feedback from the end user, and other modifications can be made. Reusable, antiviral PPE is a need of the hour. Researchers should collaborate with HCWs to develop temperature-controlled PPE, which should also be easy to wear. In addition, proper fitting, which interferes minimally with the movement of HCWs, will undoubtedly aid the comfort of the HCWs and enhance the safety of the patients.

Conclusion

PPE-related discomfort to HCWs is common. PPE affects both the psychological and physical well-being of HCW, indirectly contributing to surgical and medical errors. The current generation of the PPEs is not comfortable with the HCWs and plays a significant role in patient safety. With the second wave of COVID-19 pandemic continuing around in many countries and the possibility of another pandemic, it is prudent to manufacture better PPEs for the future. Restricting the continuous PPE use for up to 4 h, besides some simple methods to improvise the current PPEs, could benefit in improving patient safety as well as the well-being of the HCWs. Research to develop a better quality of PPEs and strategise using the current one is the need of the hour.

Institutional Ethical Committee Approval

T/IM-NF/Gen.Surg/20/144.

Disclosure of competing interest

The authors have none to declare.