Personal protective equipment during the COVID-19 crisis: a snapshot and recommendations from the frontline of a university teaching hospital

Key points

• This evaluation provides an insight into staff awareness of PPE guidance, perceptions of PPE measures, and anxiety regarding PPE use whilst caring for patients during the COVID-19 pandemic.

• These timely and relevant recommendations may help hospitals improve the PPE situation and decrease anxiety amongst clinical staff, helping them care for patients safely at this challenging time.

Introduction

The COVID-19 pandemic has necessitated unprecedented change within our hospitals across the world. As health care professionals, we are working at a very challenging time to ensure that we are still able to provide safe and effective care to patients. Personal protective equipment (PPE) is important to protect both patients and staff, while caring for those with suspected or confirmed COVID-19 infection.¹ High numbers of healthcare workers infected with COVID-19 have been reported in China (3,300) and Italy (20%).² Devastatingly, NHS healthcare workers have sadly died after contracting COVID-19.³ With the ongoing increase in case numbers of COVID-19, issuing clear PPE guidance and ensuring adequate supply of appropriate PPE for healthcare workers has been an enormous task for our government and healthcare organisations. Criticism has been rampant in the mainstream media, focusing on shortages of PPE for frontline healthcare workers with some staff describing that their lives are at risk due to PPE failings.⁴ The British Medical Association and the Royal College of Surgeons have issued press releases after conducting their own surveys demonstrating shortfalls in the supply of PPE to those caring for patients with COVID-19.^5,6 Clinicians within our orthopaedic department observed, first-hand, high levels of staff anxiety both on the wards and in the emergency department relating to the PPE use while caring for COVID-19 patients. We planned to formally evaluate this to gain an insight into the wider perception of PPE among staff within our health board. To our knowledge, no studies have been published to date that evaluate, among all healthcare professionals in the clinical setting, the awareness of PPE guidance, perceptions of PPE measures and attitudes and anxiety relating to PPE use while caring for COVID-19 patients. Our objective was to provide this insight by conducting a snapshot evaluation of clinical staff using PPE within our university teaching hospital. We aimed to compare the responses of doctors, nurses, and other healthcare professionals (OHCPs).

The three aims of the study were:

1. To evaluate the awareness of PPE guidance among staff;

2. To explore the staff perception of the PPE measures; and

3. To evaluate attitudes and concerns of staff using PPE while caring for patients with confirmed or suspected COVID-19.

The objective was to use the information gained from the clinical workforce of our hospital, to develop recommendations relevant to the workforce caring for patients with COVID-19 in all hospitals to help improve PPE awareness, staff perceptions, and decrease anxiety levels among the hospital workforce at this challenging time.

Methods

This service evaluation was performed among clinical staff at a university teaching hospital by our orthopaedic research team. An online questionnaire was designed and hosted using the online site Survey Monkey (San Mateo, California, USA). The questionnaire was composed of a series of statements relating to PPE and COVID-19. Participants indicated their response using a five-point Likert scale graded from 5 for strongly agree to 1 for strongly disagree. Questions were grouped into the three key themes, based on the three aims of the study. The study was approved and registered by the hospital research team and following discussion at the hospital executive board meeting. The questionnaire was first trialled with 15 members of staff comprising of doctors, nurses and OHCPs. Open questions relating to questionnaire content, wording, and relevance to clinical practice were asked. Participants were also asked if they believed the study was worthwhile and if any questions should be changed. The overall feedback was that the study was relevant, content was appropriate, and questions were worded clearly. Face validity and relevance of the questionnaire was therefore ensured. As the questionnaire related to the measurement of specific facts rather than underlying trait measurements, no other forms of validity testing were required. Trial participants agreed that the study would provide worthwhile information about PPE awareness, perceptions, and staff anxiety within the health board.

The study was launched online and staff were invited to take part by clicking a hyperlink or scanning a matrix barcode (QR code) shared by email, social media, and posters displayed in clinical areas. An information sheet at the beginning of the questionnaire outlined the background and study aims and included statements about confidentiality, consent, and data use. The inclusion criteria were all staff working in clinical areas of the hospital including doctors, nurses and OHCPs (such as physiotherapists, radiographers, occupational therapists, dieticians, and healthcare assistants). Clear guidance has been issued for clinical staff in secondary care regardless of their role or level of training.⁷ Therefore, no further information such as sub-specialized staff role or level of training was collected. Data was collected over the course of six days in order to present findings at the next executive health board meeting. Data was extracted from the Survey Monkey hosting site and analyzed using the statistic package SPSS V25 (IBM, Armonk, New York, USA). For each question, descriptive statistics were used to analyze the answers. In order to demonstrate subtle shifts in responses, results for both the median and the mean were presented, as well as a measure of spread, namely, the standard deviation (SD). Non-parametric statistical tests were used here because the data was ordinal and so it was not normally distributed. The Kruskal-Wallis test (i.e. non-parametric one-way analysis of variance (ANOVA)) was used to compare results across all three groups for each question. In order to test results for each subject group further (and individually) against the mid-range value for the five-point Likert scale (i.e. 3 = “neither agree nor disagree”), the Wilcoxon signed-rank test was carried out for each question. Each subject group (doctors, nurses, and OHCPs) were compared separately against this “test value” of 3.

Results

Overall, 315 staff participated in the study comprising of 110 doctors (34.9%), 114 nurses (36.2%), and 91 OHCPs (28.9%).

Discussion

The orthopaedic clinicians within our research team had all observed first-hand, the concerns of clinical staff members across the hospital surrounding PPE during the COVID-19 pandemic. Our evaluation provided live feedback to the executive board to allow recommendations to be rapidly implemented to improve the clarity of guidance and PPE measures and decrease staff anxiety levels. We think it is a testament to the strength of character and strong work ethic of the hospital workforce that despite the challenges and adversity we face in the current health climate, 67.9% of clinical staff are still keen to work in the hospital to help win the battle against the biggest healthcare challenge of our generation. We work with highly educated colleagues with a strong commitment to continued professional education as evidenced by the high level of knowledge staff reported about COVID-19 and a high level of awareness of both the government and local PPE guidelines. It is of concern, however, that only 52.4% of staff felt adequate PPE was provided in their clinical area. Additionally, a low percentage of the workforce felt supported by the health board with their concerns or requirements. We believe this represents the current level the anxiety and vulnerability experienced by our healthcare workers caring for the sickest patients on the clinical frontline in the fight against coronavirus. With reports from China outlining the more drastic PPE measures they implemented, staff may simply believe that some of the recommended measures in the UK, provide inadequate levels of protection.^7,8 It is a recognized part of human nature that inadequate education combined with uncertainty can lead to fear which in turn can manifest in anxiety.⁹ Based on the insights of our study exploring the responses of all groups of clinical staff, we make four recommendations applicable to all hospitals. We believe these measures can heighten PPE awareness, improve staff perceptions of PPE measures taken in the hospital, and lower anxiety levels among the clinical workforce.

Conclusion

During the COVID-19 pandemic, our hospitals have made huge adaptations in order to care for patients with coronavirus while maintaining a service for patients with other healthcare emergencies. Day-to-day and week-to-week, we have been faced with new challenges within our different departments, specialities, and healthcare disciplines. PPE arguably represents one of the most significant challenges that has faced our healthcare system during the coronavirus pandemic. It has presented challenges both with supply and implementation of safe PPE measures in order to protect the health of our staff caring for COVID-19 patients. We aimed to provide a snapshot insight of the live PPE situation for our clinical staff to enable us to make recommendations to improve the PPE situation for staff within our hospital and across the NHS. During a period of huge change within the hospital system, particularly with dynamic rota changes for all staff, fluctuating levels of staff illness and significant departmental restructuring, we acknowledge that this study does not represent a comprehensive evaluation of PPE across all staff in the hospital. However, we aimed to adopt a pragmatic approach to data collection during this unprecedented time, in order to provide an insight and make timely, relevant recommendations regarding PPE. We hope these recommendations can benefit clinical staff working in NHS hospitals by increasing the clarity and consistency of PPE guidance, hospital PPE measures and most importantly, decrease staff anxiety levels surrounding PPE use. We believe that these measures have an important role in helping staff to care for patients safely and effectively for the remainder of the COVID-19 pandemic.