Early Doffing among Frontline Healthcare Workers Working in the COVID Areas in Resource-Limited Settings: Lessons Learned and Interventions Taken

Abstract

Background:

In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings.

Methods:

This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables.

Findings:

Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each).

Conclusion:

Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE.

BACKGROUND

COVID-19 pandemic is still here and we are battling it with all energy and resources. Despite the fear of being infected, the healthcare workers (HCWs) have been leading the battle as the warriors. In their fight, personal protective equipment has played a vital role. Personal protective equipment (PPE) acts as a last layer of defense for HCWs and has been proved to be highly effective in preventing infection.[1] However, the mere use of the PPE does not serve the purpose, but correct and consistent use of the PPE is important. The factors contributing to the efficacious use of the PPE include the availability of appropriate size of the PPE and proper training in donning, doffing, and disposing PPE.[2]

Proper donning and doffing of the PPE are two extremely important procedures which allay the infection. As compared to donning, there is an increased risk of contamination during doffing.[3] Moreover, doffing hastily in emergency situations or in panic can further increase the risk of contamination. Such urgency can arise due to various reasons like breach in PPE, feeling of uneasiness in PPE, problems due to prolonged use like fogging leading to decreased visibility, etc.[4]

The aim of our study was to find out the reasons of early doffing, that is, doffing in emergency situations among healthcare workers (HCWs) while working in PPE in the COVID areas. This study served as an insight to the problems faced by the HCWs while working in PPE. Pertaining to this, certain interventions were done in our center to reduce this problem of early doffing which are also mentioned here.

METHODS

This cross-sectional, survey-based study was carried out in the Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, a dedicated COVID center of Northern India. The healthcare workers involved in direct care of patients with COVID-19 disease were included in the study. The HCWs included doctors, nursing staff, operation theater assistant (OTA), and supporting staff like health assistants. A self-designed semi-structured standard questionnaire was sent as a Google form to HCWs who were posted for COVID duties through email and social media platforms like WhatsApp and Facebook and through a link [https://docs.google.com/forms/d/e/1FAIpQLSd06GtV0T0cnFdPvDb0F_mLxetfhukizTmroScoV8C6tOiTjA/viewform?usp=sf_link]. Doffing early was defined as doffing before the end of the shift. The breach in PPE was divided according to the component of the PPE involved as breach in mask; coverall/gown; shoe cover; goggles; and gloves. The participants were asked to contact the investigators if they could not understand any question.

Answered forms were considered as implied consent for participation in the study. All answered Google forms received within one month were included for the analysis. Data collected included demographic characteristics of the HCWs, the number of times each HCW doffed early, and the reasons for doffing.

The data was summarized and analyzed using STATA (version 14.0) software. The data was reported as the mean ± SD for continuous variables, and as the proportion for categorical variables.

Ethical Committee

Ethical approval for this study (Ethical Committee IEC-428/22.05.2020, RP-19/2020) was provided by the Ethical Committee All India Institute of Medical Sciences, New Delhi, on 27^th May 2020.

RESULTS

At the time of the study, there were 458 HCWs working at the COVID facility. Because the contact information for 16 HCWs could not be found, 442 HCWs were approached to participate in the study. Out of 442, 252 HCWs responded and were included in the study. The demographic characteristics and the category of HCWs are depicted in Table 1. Of the total 252 participants, 175 (69.44%) were males and 77 (30.55%) were females. The mean age of the participants was 30.10 ± 4.83 years. The majority of the participants (57.53%) were less than 30 years old and less than 10% had comorbidities. The comorbidities included diabetes mellitus, hypertension, hypothyroidism, asthma, and migraine. Seven (2.7%) HCWs reported history of latex allergy and similar number reported skin disorders.

Table 1:

Demographics of the participants and the category of participant HCWs (n=252)

Variable	n (%); mean±SD
Total participants	252
Male	175/252 (69.44)
Female	77/252 (30.55)
Mean age (years)	30.10±4.83
Age <30 years	145/252 (57.53)
Age 31-40 years	100/252 (39.68)
Age >40 years	7/252 (2.7)
	Number of HCW who participated in the survey n (%)
Category of HCW
Doctors	145/252 (57.5)
Nursing staff	61/252 (24.2)
OTA	25/252 (9.9)
Supporting staff	21/252 (8.3)
Comorbidities
Without comorbidities	227/252 (90.07)
With comorbidities	25/252 (9.92)
Latex allergy
Present	7/252 (2.7)
Absent	245/252 (97.22)
Skin disorder
Present	7/252 (2.7)
Absent	245/252 (97.22)

HCW - Healthcare worker; OTA - Operation theater assistant

Out of these 252 participants, 145 (57.5%) reported incidences of early doffing. The percentage of specific category of HCWs who reported early doffing is mentioned in Table 2. The total number of reported incidents of early doffing was 300 by 145 participants. About half of the participants (50.34%) doffed early only once, 44% doffed early between 2and 5 times and 5.5% doffed early more than five times. About 70% of the participants doffed within 4 hours of their shift and had to don again. The majority of incidents of early doffing occurred in the months of June and July (56 and 54, respectively).

Table 2:

Percentages of HCWs in each category who reported early doffing (n=145) and the frequency of early doffing by one HCW

	Number of HCW who reported early doffing n (%)
Category of HCW
Doctors	81/145 (55.86)
Nursing staff	38/61 (62.29)
OTA	16/25 (64)
Supporting staff	10/21 (47.61)
Frequency of early doffing by one HCW
Only 1 time	73/145 (50.34)
2-5 times	64/145 (44.1)
>5 times	8/145 (5.5)

OTA - Operation theater assistant; HCW - Healthcare worker

The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%) [Table 3]. A total of forty-six incidents of early doffing were due to the breach in PPE and the most common breach was in mask and coverall/gown (32.6% each) followed by shoe cover (19.5%), goggles (13.04%), and gloves (2.17%). The incidents of early doffing due to fogging were 42, which were the most common in the month of June and July. Other reasons of doffing included needlestick injury, pain over nasal bridge, chest pain, and family emergency.

Table 3:

Reasons of early doffing n=300 (total incidents)

Reasons of doffing	n (%)
Breach in PPE	46 (15.33)
Fogging	42 (14)
Headache	36 (12)
Full bladder	29 (9.6)
Breathlessness	25 (8.33)
Nausea	23 (7.6)
Dizziness	23 (7,6)
Excessive sweating	20 (6.66)
Thirst	12 (4)
Vomiting	12 (4)
Palpitation	12 (4)
Menstrual issue	6 (2)
Itching	5 (1.66)
Others	9 (3)

*Multiple incidents of early doffing were reported by some HCWs

DISCUSSION

Owing to the high infectivity rate of COVID-19, the healthcare workers possess an increased risk of infection.[5] In this critical situation, proper hygienic practices and workplace controls like usage of appropriate PPE are recommended to protect HCWs.[6] However, working with the PPE is not without discomfort. There have been instances when HCWs had to doff out earlier than expected. Doffing in urgency hastily increases the chances of getting infection especially in frontline workers who already have increased fear of infection, anxiety, and depression.[7] Here, we describe the reasons for early doffing among HCWs. We also mention the initiatives that were taken to resolve the problems faced by the HCWs while working in PPE.

This was a survey-based study and the majority of the participants were resident doctors followed by nurses and OTAs. The participants were young with the mean age of 30.1 years and mostly without comorbidities as young HCWs without significant comorbidities were posted inside the COVID areas. The incidence of early doffing was higher in the OTAs (64%) and nurses (62.3%) than among doctors (55.8%). Better donning practices among doctors could be one of the reasons for this difference. Half of the HCWs doffed only once defying a persistent problem, whereas nearly 44% doffed 2–5 times. However, the reasons for early doffing were not the same every time in each individual.

The most common reason for doffing in our study was breach of PPE and the commonly breached components were masks and coverall/gowns. This breach in mask and coverall/gown was mostly due to inappropriate size. This study was conducted during the early phase of the pandemic when all the sizes of mask and coverall were not available in our institution. Although various societies recommend formal fit test to be done for the mask before usage, it was not carried out in our institute due to lack of availability of all sizes. Similar problems have been encountered by the staff elsewhere. The female healthcare workers in the UK in their interview quoted that “Even the small-sized masks are designed for small men rather than women”.[8] Training sessions held during and after the 2015 Middle East respiratory syndrome outbreak in Korea also showed that the major problem encountered by the female healthcare professionals was ill-fitting sizes.[9]

Other reasons reported for the breach in mask were slippage of the mask and the failure of the exhalation valve. It is already reported that the prolonged use of N-95 masks is associated with rashes, acne, and facial itching.[10] In a survey conducted by Atay et al.[11] on nurses, the most commonly reported physical problems while wearing N95 masks were sweating (64.2%), redness of cheeks (61.5%), and dry mouth (55.6%). In our institution, HCWs practiced applying oil on face or cotton under the mask to prevent rashes which led to accidental slippage. Sometimes, HCWs loosened their tight-fitting masks to avoid discomfort, thus leading to slippage. Similar findings were reported by Avoa et al.[12] where 75% of the staff breached their mask by touching in order to adjust it. Besides slippage, the failure of the exhalation valve, leading to the inhalation of the ambient air, was also one of the reasons for early doffing.

Fogging of the goggles was the second commonest cause of early doffing in our HCWs. Working with the fogged goggles results in difficulty in reading instructions, reading drug names, and also in performing different procedures. Fogging was mainly observed during the summer months of June and July owing to the hot and humid climatic conditions of our country. Although the temperature of the wards was maintained in the recommended range, humidity levels were not recorded. Similar results were observed in a study conducted by Agarwal et al.[4] who reported fogging as the second most common difficulty encountered while using PPE kits. Madan et al.[13] suggested various methods to prevent fogging including use of anti-fog markers, sterillium, soap solutions, etc.

Headache was identified as the third major reason of early doffing. Çağlar et al.[14] also reported headache as the most common symptom related to PPE in their study. In another study, Jyong et al.[15] reported an increase of 81% in the incidence of headache in frontline HCWs which was related to wearing PPE for more than 4 h and CO₂ retention. In our study besides CO₂ retention, the tight strapping of goggles, simultaneous use of goggles, and face shield causing pressure on the forehead were found to be the factors resulting in the headache.

About 8% of the participants reported breathlessness as the reason for early doffing. In a study by Farronato et al.,[16] the authors reported surprisingly high rate of breathing difficulties (66%) in the participants. The reason cited for the same was use of non-valved masks. In another study by Çağlar et al.,[14] the breathing/palpitation ratio reported was 25.1% in the participants using the masks without the valves. However, in our institute both valved and non-valved masks were available which could be the reason for lower percentage of breathlessness in the participants.

The disruption of routine activities such as drinking, eating, or using washroom during the duty hours further add to the complications of working with PPE. A study reported the concern of HCWs to take breaks in duty due to feeling of guilt of wasting PPE on breaks.[17] As a result, it became difficult to follow guidance to remain “appropriately hydrated during prolonged use”.[18] In our study, 14% of HCWs doffed early due to excessive sweating, thirst, nausea, and vomiting. The healthcare workers in the UK also tweeted about dehydration and the challenges of the PPE use when fasting during Ramadan.[8]

In addition, it is cumbersome for the female professionals to work with the PPE during their menstrual days. Menorrhagia and dysmenorrhea were also noted as the reasons of early doffing in our study, but in small percentages.

The increased risk of self-contamination during doffing has been observed in various studies.[3] The virus gets transferred from PPE to HCWs hands and clothes[19] during doffing. As COVID virus can survive on surface for hours,[20] further spread can occur by surface-to-hand[21] and hand-to-hand contact.[22] There is a high probability of transmission of virus if one has to doff early, in emergency situations. Hence, it is necessary to reduce the frequency of such incidents.

In our institution, different measures were taken to reduce these incidents of early doffing. These are mentioned in Table 4.

Table 4:

Interventions taken to decrease the incidents of early doffing

Different sized PPEs [coverall, shoe cover] were made available

Tyvek gowns which were more comfortable and durable were procured

Masks of two different sizes were made available in the donning area

The valved masks were replaced by the non-valved masks

Better quality goggles were procured

Anti-fog markers were kept in the donning area for the use by HCWs

Face shields with a cushion were issued

The HCWs were given option to choose either face shield or goggles or both as per their choice

Staggering of duty hours was allowed for HCWs

The temperature of the ICUs was maintained around 22 degrees Celsius

Water coolers were made available in the donning area

HCWs with any sickness were refrained from the duty

Duty rosters were revised so that the female HCWs were given off during their menstruation period

This pandemic has come with the new set of standards with respect to the working conditions. Although the PPE is important to decrease the risk of infection, it is a challenge for the healthcare workers to work with them. Hence, continuous interventions are needed to minimize the difficulties associated with their use. Through this study, we tried to look into the major problems faced by the healthcare workers while working in PPE and tried to intervene to overcome the issues.

The first limitation of the study was small sample size due to the low response rate. Since the questionnaire was in the English language which is not the native language and the Google forms were sent through social media, the participation from the supporting staff was less. Secondly, the questionnaire was not validated. The symptoms mentioned in the Google form like headache, breathlessness, nausea, etc., were not graded. We just enquired whether the HCW had particular symptom or not. Thirdly, we could not assess the effectiveness of our interventions as the HCWs were rotated between the COVID and non-COVID areas.

The battle with this virus is not over yet. We hope that the study helps to improve the working condition of the healthcare workers while donned in PPE and enable them to provide better care to the patients. Moreover, we recommend further studies to determine the effect of suggested interventions on the working conditions of the healthcare workers.

CONCLUSION

To conclude, working with the PPE is a challenging task and continuous interventions are needed to improve the working conditions of the healthcare workers without compromising their safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.