Timing and Type of Personal Protective Equipment Adherence Lapses in Pediatric Trauma Resuscitation: A Retrospective Video Study

Abstract

Background

Although personal protective equipment (PPE) reduces the transmission of infectious diseases, adherence among healthcare providers remains inconsistent. Developing strategies to improve PPE use requires understanding the factors associated with adherence lapses, defined as the partial undoing or removal of PPE, leading to nonadherence.

Methods

We performed a retrospective video review of ten pediatric trauma resuscitations from March 2023 to July 2024. We recorded the number of lapses, the time from adherence to lapse (time-to-lapse), and the timing of lapses during resuscitation. We observed provider actions before and after a lapse to understand situational factors.

Results

We observed 292 lapses among 120 providers. The median time-to-lapse was 7.7 minutes (IQR 3.8 to 15.1) for gloves, 1.5 minutes (IQR 0.3 to 6.8) for masks, and 13.4 minutes (IQR, 6.6 to 26.6) for gowns. Lapses in masks (estimate −0.4, 95% CI −0.6 to −0.3, p<0.001) occurred earlier in the resuscitations. Of 292 lapses, 105 (36.0%) were corrected. The most common provider action before a lapse included “observing” (n=109/292, 37.3%).

Conclusion

PPE lapses were frequent in the post-pandemic setting. The time-to-lapse and lapse timing varied by PPE type. Aligning PPE monitoring with lapse patterns may optimize nonadherence detection and correction.

INTRODUCTION

Infection control is needed to protect patients and staff from hospital-acquired infections.¹ Despite the benefits of wearing personal protective equipment (PPE), healthcare provider adherence to PPE has remained low, even at the height of the COVID-19 pandemic.² Although many hospitals have relaxed universal masking policies after the pandemic, PPE precautions remain in place based on specific potential pathogens or procedural risks.³ Continued evaluation of PPE practices is necessary to strengthen current safety measures and prepare for future public health emergencies.³ Examining current adherence practices may provide insights for developing strategies for improving PPE adherence.

Common errors in PPE behaviors include failure to don before entering the patient room and adjusting or removing PPE during clinical care.^4,5 Addressing these errors requires strategies that prevent and correct nonadherence. In a prior study, we examined individual and environmental factors associated with nonadherence corrections among providers responding to pediatric resuscitations in the emergency department during the COVID-19 pandemic.⁶ We observed that direct (e.g., verbal prompting) and indirect (e.g., accessible PPE) reminders facilitated timely corrections.⁶ While correcting nonadherence helps reduce exposure, preventing errors in adherence (adherence lapse) after initial donning can provide optimal safety.⁷

Implementing strategies for sustained adherence requires understanding the factors that contribute to PPE removal during patient care. Prior surveys and interviews with healthcare providers identified barriers to PPE adherence, but these studies did not distinguish between challenges in donning and maintaining PPE during patient care.^8,9 These prior findings also reflect perceived barriers, rather than observed practices.⁹ Most studies on PPE adherence were also conducted during the COVID-19 pandemic, a unique period with PPE shortages, social pressure, mental fatigue, and evolving PPE guidelines.^8,9 Evaluating provider behaviors in the post-pandemic period may identify practices in a setting without these confounding factors.

To address these knowledge gaps, we conducted a post-COVID-19 pandemic (March 2023 – July 2024) retrospective video review of pediatric trauma resuscitations at a tertiary pediatric hospital and a level 1 trauma center in a metropolitan area. Video review captures clinical context and provides objective evaluation free from recall bias inherent in surveys.⁴ The objective of this study was to evaluate factors associated with lapses in PPE adherence, defined as the partial removal or undoing of gloves, masks, or gowns at any point during the event. We hypothesized that the duration from adherence to lapse (time-to-lapse) and the timing of lapses would vary by PPE type, given differences in the physical design, ease of removal, and comfort of individual PPE.¹⁰ In addition to these quantitative measures, we also evaluated provider actions before and after lapses to identify contextual and behavioral triggers for lapses.

METHODS

Study Design

The study site is a tertiary hospital and level 1 pediatric trauma center in a metropolitan area, serving about 600 injured children annually in the two resuscitation rooms within the emergency department. Patient care events in the resuscitation rooms are video recorded for performance improvement. The videos may be used for research after obtaining parent or guardian consent as appropriate. The (name blinded) Hospital Institutional Review Board (Organization Number IORG0000245) approved this study (STUDY00000360).

We performed a retrospective video review of PPE adherence and adherence lapses among providers involved in pediatric trauma resuscitations from March 2023 to July 2024, a post-COVID-19 pandemic period. Resuscitation events were included if (1) consent was obtained for research use, (2) video recordings were available, and (3) an aerosol-generating procedure (AGP) was performed during the event. We selected cases involving AGPs to assess provider PPE practices during procedures that increase the risk of infection transmission.^11,12 AGPs were identified based on Centers for Disease Control and Prevention (CDC) guidelines, including open suctioning of airways, endotracheal intubation and extubation, and manual ventilation.¹

Before the COVID-19 pandemic, the required PPE for emergency department resuscitations were gowns and gloves. In response to the outbreak in the Spring of 2020, the hospital updated the PPE guidelines to mandate surgical masks in all patient care areas and N95 masks or powered air-purifying respirators during AGPs. PPE requirements were gradually relaxed in 2022, returning to pre-pandemic standards by 2023. Although the universal masking mandate was lifted, masks were still required for portions of the resuscitation for which they are standard practice (e.g., sterile procedures). We defined PPE adherence as wearing a gown tied at the neck, gloves covering both hands, and a surgical or N95 mask covering the nose and mouth. Any deviation from this standard (e.g., wearing a mask under the nose) was classified as nonadherent. Adherence, nonadherence, lapse, and correction were assessed independently for each PPE type (Table 1). A lapse in one PPE type did not imply a lapse in another.

Table 1.

Data Dictionary of Personal Protective Equipment Types and Adherence Status

PPE type	Adherence	Definition
Glove	Adherent	Both gloves are worn.
	Nonadherent	One or no gloves are worn.
	Lapse	One or both gloves are removed while remaining in the resuscitation room with the patient.
	Correction	One or both missing gloves are put on.
Mask	Adherent	A surgical or N95 mask covers both the nose and mouth.
	Nonadherent	No mask is worn, or the mask is worn below the nose.
	Lapse	Mask is pulled down below the nose or removed while remaining in the resuscitation room with the patient.
	Correction	Mask is worn and adjusted to cover both the nose and mouth.
Gown	Adherent	Gown is worn with the neck strings tied.
	Nonadherent	Gown is worn without tied neck strings, or no gown is worn.
	Lapse	Gown is untied or removed while remaining in the resuscitation room with the patient.
	Correction	Gown is put on and neck strings tied.

Data Collection

We reviewed ten consecutive trauma resuscitation videos from the start of an AGP until patient departure using a video analytic program (Mangold Interact, Arnstorf, Bavaria, Germany).¹³ Observation began at the start of the AGP because this period represented the highest risk for respiratory infection transmission. We documented the type and timing of AGPs, the number of providers adherent and nonadherent to each PPE type (gloves, masks, and gowns), and the instances of PPE adherence lapse. For each lapse, we recorded the PPE type, the time of lapse from the start of the AGP, the duration from adherence to lapse (time-to-lapse), and the duration from lapse to correction (time-to-correction), if corrected. If a provider removed a PPE, then corrected it, but then removed it again, a lapse was counted as a separate event.

We evaluated potential triggers and deterrents of PPE adherence lapses, including the presence of patient body fluids (blood, vomitus, urine, or stool) at the time of arrival. We also documented provider actions immediately before and after each lapse to identify activities that may be associated with adherence lapses. We considered all instances of PPE removal during patient care as lapses, including the events followed by “exiting” and “hand hygiene.” This method is consistent with the CDC recommendation to maintain a decontamination zone separate from both the patient care (hot) zone and the non–patient care (cold) zone.¹⁴ Activities were grouped into seven categories. “Enter” and “exit” indicated providers entering and leaving the resuscitation room after AGP had started. “Observe” described providers watching the resuscitation without directly participating in patient care. “Care” included both direct (e.g., measuring blood pressure) and indirect (e.g., setting up a patient monitor) patient care. Because the use of the medication dispenser required glove removal for fingerprint scanning, the activity was assigned a separate designation, “Pyxis.” Communication with another provider in the room or by phone was labeled “talk,” and hand hygiene with soap and water or hand sanitizer was labeled “hand hygiene.”

Statistical Analyses

We summarized resuscitation characteristics, provider PPE practices, and activities using counts and percentages for categorical variables and medians with interquartile ranges (IQR) for continuous variables. Factors associated with time to adherence lapse were assessed using Cox regression analysis. We included PPE type, time of day, day of the week, presence of body fluids, and the percentage of nonadherent providers in each resuscitation as variables. Covariates were selected based on results from prior surveys of perceived barriers to adherence, such as discomfort with PPE, staff shortages, transmission risks, and peer pressure.^8,9,15

We analyzed the timing of adherence lapses from the start of AGP using a Weibull survival model. Variables included PPE type, time of day, and day of the week. We included random effects to account for clustering within resuscitations and providers that may affect the timing of adherence lapses. Providers were censored if they did not have adherence lapses (e.g., left the room adherent or remained adherent until patient departure). Statistical significance was defined as p<0.05, and analyses were performed using SAS 9.4 (SAS Institute, Cary, NC).

RESULTS

Resuscitation Characteristics

Three of the ten resuscitations occurred at night and four on the weekend. Twenty-one AGP events (median 2; IQR 1 to 3 AGP events per case) were observed across these ten cases. Bag-valve-mask ventilation (n=9/21, 42.9%) was the most frequent AGP, followed by intubation (n=7/21, 33.3%) and suction (n=3/21, 14.3%). The median duration from the start of an AGP to patient departure was 29.7 minutes (IQR 17.5 to 35.8 minutes) (Table 2).

Table 2.

Resuscitation Characteristics

Number of cases, n	10
Night, n (%)	3 (30.0)
Weekend, n (%)	4 (40.0)
AGP type, n (%)
Bag-valve-mask ventilation	9 (90.0)
Intubation	7 (70.0)
Suction	3 (30.0)
Extubation	2 (20.0)
Provider per case, median (IQR)	24 (21, 29.3)
AGP duration (minute), median (IQR)	29.7 (17.5, 35.8)

AGP, aerosol-generating procedures; IQR, interquartile ranges.

Of the 242 providers observed, 120 (49.6%) experienced one or more PPE lapses during the evaluated resuscitations. These providers included those who began with all three PPE items, and those who wore only one or two and removed at least one PPE item while in the room. The remaining 122 providers (50.4%) had no observed lapses: 20 (8.3%) wore all three PPE items throughout their time in the room, 71 (29.3%) wore one or two PPE items without removal, and 31 (12.8%) wore no PPE at any time during the resuscitation.

We observed 292 PPE adherence lapses among 120 providers. The median number of lapses per provider was 2 (IQR 1 to 3). Gloves accounted for most lapses (n=142/292, 48.6%), followed by masks (n=84/292, 28.8%) and gowns (n=65/292, 22.3%). The median time until lapse was 7.7 minutes (IQR 3.8 to 15.1) for gloves, 1.5 minutes (IQR 0.3 to 6.8) for masks, and 13.4 minutes (IQR, 6.6 to 26.6) for gowns.

Factors Influencing PPE Adherence Lapse and Correction

Time of day, day of the week, presence of body fluids, and percentage of nonadherent providers in each resuscitation were not associated with time to adherence lapse (Table 3). Compared to gloves, gowns were associated with a longer time until adherence lapse (hazard ratio [HR] 0.6, 95% confidence interval [CI] 0.5 to 0.7, p<0.001). No difference in time-to-lapse was observed between gloves and masks. Changing the reference category for PPE type did not show an association in the time-to-lapse between masks and gowns.

Table 3.

Cox Regression Analysis of Factors Influencing Time to PPE Adherence Lapse

Variable	Hazard ratio (95% confidence interval)	p-value
PPE type
Gloves	reference	-
Mask	0.5 (0.3 to 1.0)	0.06
Gown	0.6 (0.5 to 0.7)	<0.001
Night	0.7 (0.4 to 1.1)	0.29
Weekend	1.1 (0.7 to 1.8)	0.68
Body fluids	0.8 (0.6 to 1.1)	0.19
Percentage nonadherent	1.0 (1.0 to 1.0)	0.49

PPE, personal protective equipment.

Adherence lapses in masks (estimate −0.4, 95% CI −0.6 to −0.3, p<0.001) occurred earlier in resuscitations, while lapses in gown adherence had no difference in timing compared to glove adherence lapses (Table 4). When masks were used as the reference type, gown adherence lapses occurred later in resuscitations (estimate 0.1, 95% CI 0.1 to 0.5, p=0.002).

Table 4.

Weibull Survival Analysis of Factors Associated with Timing of PPE Adherence Lapse

Variable	Estimate	95% Confidence interval	p-value
PPE type
Gloves	-	reference	-
Mask	−0.4	−0.6 to −0.3	<0.001
Gown	−0.1	−2.5 to 0.0	0.07
Weekend	2.4	2.2 to 2.7	<0.001

PPE, personal protective equipment.

Among the 292 lapses, 105 (36.0%) were corrected. The most corrected PPE type was gloves (n=58/84, 69.1%), followed by masks (n=46/143, 32.2%) and gowns (n=1/65, 1.5%). The median time-to-correction was 43.5 seconds (IQR, 26 to 105 seconds) for gloves, 7 seconds (IQR, 4 to 33 seconds) for masks, and 222 seconds for the gown. Compared to gloves, masks were associated with a faster time-to-correction (HR 1.96, 95% CI 1.15 to 3.33, p=0.01).

Provider Behaviors at Time of Adherence Lapses

The most common activities preceding glove adherence lapses were “patient care” (n=73/143, 51.1%) and “observing” (n=39/143, 27.3%), while mask adherence lapses were most preceded by “observing” (n=45/84, 53.6%) and “talking” (n=17/84, 20.2%). Similar to mask adherence lapses, gown adherence lapses were most often preceded by “observing” (n=25/65, 38.5%), followed by “talking” (n=19/65, 29.2%) and “patient care” (n=19/65, 29.2%) (Table 5).

Table 5.

Provider Activities Before and After PPE Adherence Lapses

Activity	Glove lapses (n=143)	Mask lapses (n=84)	Gown lapses (n=65)
Before lapse, n (%)
Providing care	73 (51.1)	16 (19.1)	19 (29.2)
Observing	39 (27.3)	45 (53.6)	25 (38.5)
Talking	24 (16.8)	17 (20.2)	19 (19.2)
Using the Pyxis	—	1 (1.2)	—
Entering	7 (4.9)	5 (6.0)	2 (3.1)
Exiting	—	—	—
Hand hygiene	—	—	—
After lapse, n (%)
Providing care	25 (17.5)	6 (7.1)	1 (1.5)
Observing	30 (21.0)	21 (25.0)	16 (24.6)
Talking	29 (20.3)	50 (59.5)	12 (18.5)
Using the Pyxis	17 (11.9)	2 (2.4)	—
Entering	—	—	—
Exiting	35 (24.5)	5 (6.0)	31 (47.7)
Hand hygiene	7 (4.9)	—	5 (7.7)

PPE, personal protective equipment.

After removing gloves, providers most often “exited” the room (n=35/143, 24.5%), “observed” the resuscitation (n=30/143, 21.0%), or “talked” to another provider (n=29/143, 20.3%). Other activities following glove adherence lapses included providing “patient care” (n=25/143, 17.5%), fingerprinting on the “Pyxis” machine (n=17/143, 11.9%), and performing “hand hygiene” (n=7/143, 4.9%). After a mask adherence lapse, providers often “talked” to another provider (n=50/84, 59.5%) or “observed” (n=21/84, 25.0%). After doffing gowns, providers “exited” the room (n=31/65, 47.7%), “observed” in the room (n=16/65, 24.6%), or “talked” to another provider (n=12/65, 18.5%) (Table 5).

DISCUSSION

Studies of PPE practices among healthcare providers surged during the COVID-19 pandemic, identifying barriers and facilitators of safe practices during this highly infectious period. As the general population gained immunity, PPE adherence in the post-pandemic era has been less examined despite the continued prevalence of infection risk. Recent public surveys show decreased risk vigilance and increased complacency among the public, raising questions about current PPE practices among healthcare providers.¹⁶ To address this knowledge gap, we conducted a retrospective video review of PPE behaviors among providers involved in pediatric trauma resuscitation. Healthcare providers are required to wear appropriate PPE while performing resuscitation due to the absence of a complete medical history defining infection risk and the potential need for invasive procedures. In a prior study, we examined factors associated with the correction of nonadherence. In the current study, we focused on adherence lapses to identify factors that may lead adherent providers to deviate from the standard of care.

PPE nonadherence remains an ongoing concern, with a lower percentage of adherent providers being observed after compared to before the pandemic.⁶ We found that fewer than a tenth of providers adhered to PPE guidelines despite relaxed requirements (e.g., eyewear was not required). Other institutions and clinical settings have observed similar declines in PPE use, highlighting a shift in infection prevention practices over time.¹⁷ One possible explanation for this decline is the lack of enforcement measures. Many institutions implemented routine monitoring during the pandemic, with auditors overseeing and instructing proper PPE donning and doffing.¹⁸

Although effective in increasing provider compliance, this measure was costly and often discontinued post-pandemic for this reason. When the intervention was stopped, providers returned to previous routines of nonadherence.¹⁷ Given their tendency to revert to baseline behavior, providers may benefit from continued surveillance to reinforce adherence.¹⁷

A third of providers present during pediatric trauma resuscitation had one or more adherence lapses, with only a third of these lapses being corrected. Masks were associated with shorter time-to-lapse and occurred earlier in resuscitation compared to other PPE types. This finding has public health implications for future respiratory outbreaks, when masks serve as primary protection. About half of lapses in mask adherence were followed by speech, supporting prior findings that masks may impede communication among providers and with patients.¹⁹ Whether mask removal was intentional or habitual, increasing awareness through direct feedback (e.g., self-video review) may encourage more deliberate behavior.

We found frequent adherence lapses among providers who were observing the resuscitation and did not have an active role in patient management. A possible explanation for this conduct is perceived self-immunity due to physical distance from the patient. Human behavior research has shown that self-vulnerability and the vulnerability of loved ones are strong motivators for personal protective behaviors.¹⁵ As most healthcare providers are vaccinated, their perceived risk of infection and disease severity may be lower. Providers also perceive children as having low communicable disease risk.²⁰ This perception of low self-risk may explain the lack of association between the presence of patient body fluids (blood, vomitus, urine, or stool) and time to adherence lapse.

The study also highlights a potential risk of having excess personnel in the resuscitation room—increased infection exposure. Emergency departments often experience an influx of providers during high-acuity cases, many of whom are observers.²¹ Although blood-borne diseases may be avoided without direct patient contact, nonadherent observers may still contribute to the spread of respiratory infections.^21,22 Using mathematical modeling, a population risk of airborne diseases correlates with the cumulative nonadherence time of all individuals in proximity.²³ Both patient and staff safety may be at risk due to treatment delays and infection exposure secondary to congestion by excess personnel.

We propose several strategies for hospital infection control based on our findings. Because providers often remove their PPE while in the patient care area, monitoring beyond the point of entry may promote sustained adherence. For respiratory or airborne precautions, monitoring should begin at the start of care, as mask lapses occur early in resuscitation. For contact or enteric precautions, monitoring should continue throughout care, as gown and glove lapses tend to occur later. Aligning monitoring with the typical timing of lapses by PPE type can optimize resource use and improve detection and response. Surveillance may be achieved using computer-vision-assisted monitoring with existing cameras and microphones in resuscitation rooms.²⁴ Given the adverse effects of congestion on workflow and infection risk, limiting access to patient care areas to only the essential providers may also improve efficiency and infection control.²¹ Although the consequences of PPE nonadherence may be less life-threatening after the pandemic, continued surveillance is necessary to reinforce safe practices. Our finding that the time to adherence lapse varies by PPE type suggests a need for future research and innovation focused on designs that balance breathability with reduced removability. For example, evaluations of PPE designs have shown that a modified glove-gown combination results in less contamination than standard gowns.¹⁰

This study has several limitations. First, the study focused on providers involved in pediatric trauma resuscitation at a single institution, a study requirement given the limited access available for video-recorded patient care. The findings may not generalize to other clinical settings with different patient populations, requiring additional study to confirm our observations. Second, due to protected health information, we were unable to evaluate the association between adherence lapse and communicable disease transmission. Despite a low likelihood of transmitted infections, the study contributes to future risk reduction by highlighting factors associated with lapses. Third, the retrospective study design precluded an evaluation of individual motivations for protective behaviors. Future qualitative research incorporating interviews or focus groups with healthcare providers may help validate the study findings.

CONCLUSION

PPE adherence among healthcare providers remained low in the post-pandemic period, with frequent lapses and few corrections observed during pediatric resuscitation. Both the time-to-lapse and the timing of lapses differed by PPE type: mask lapses occurred early in resuscitation, while gowns and gloves occurred later. These patterns suggest that PPE monitoring protocols should be tailored to patient risks and the type of precaution required. Many lapses involved providers without an active role, highlighting their potential contribution to both overcrowding and infection transmission. Our findings call for infection control efforts that extend beyond the entrance to the patient care area to ensure continued adherence throughout clinical care until doffing.

Highlights.

• PPE adherence among providers remained low in the post-COVID-19 pandemic period.

• Only a third of adherence lapses were corrected.

• Adherence lapses were common among observers without an active clinical role.

• A policy is needed to address PPE adherence and limit access to patient care areas.