key: cord-0962981-fhqghx7t
authors: Alberto, Emily C.; McCarthy, Kathleen H.; Hamilton, Colleen A.; Shalkevich, Jacob; Milestone, Zachary P.; Izem, Rima; Fritzeen, Jennifer L.; Marsic, Ivan; Sarcevic, Aleksandra; O’Connell, Karen J.; Burd, Randall S.
title: Personal Protective Equipment Adherence of Pediatric Resuscitation Team Members during the COVID-19 Pandemic
date: 2021-05-29
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2021.05.022
sha: 7881b3149af196fd7d5dcd69c53e0b9edb7f71d2
doc_id: 962981
cord_uid: fhqghx7t

Objective During the COVID-19 pandemic, healthcare workers (HCWs) have had the highest risk of infection among essential workers. Although personal protective equipment (PPE) use is associated with lower infection rates, appropriate use of PPE has been variable among HCWs, even in settings with COVID-19 patients. We aimed to evaluate the patterns of PPE adherence during emergency department resuscitations that included an aerosol generating procedure (AGP). Methods We conducted a retrospective, video-based review of pediatric resuscitations involving one or more AGPs during the first three months of the COVID-19 pandemic in the United States (March-June 2020). Recommended adherence (complete, inadequate, absent) with five PPE items (headwear, eyewear, masks, gowns, gloves) and the duration of potential exposure were evaluated for individuals in the room after AGP initiation. Results Among the 345 HCWs observed during 19 resuscitations, 306 (88.7%) were nonadherent (inadequate or absent) with recommended use of at least one PPE type at some time during the resuscitation, 23 (6.7%) of whom had no PPE. One hundred and forty HCWs (40.6%) altered or removed at least one type of PPE during the event. The aggregate time in the resuscitation room for HCWs across all events was 118.7 hours. During this time, providers had either absent or inadequate eyewear for 46.4 hours (39.1%) and masks for 35.2 hours (29.7%). Conclusions Full adherence with recommended PPE use was limited in a setting at increased risk for SARS-CoV-2 virus aerosolization. In addition to ensuring appropriate donning, approaches are needed for ensuring ongoing adherence with PPE during exposure.

As of February 2021, the COVID-19 pandemic has led to more than 26 million infections and more than 460,000 deaths in the United States. 1 Healthcare workers (HCWs) have a more than 10-fold higher risk of contracting the virus compared to the general population. 2, 3 The Centers for Disease Control (CDC) has published several guidelines to reduce the risk of viral spread from patients to HCWs, including recommendations for universal personal protective equipment (PPE) standards (N-95 mask, eye protection, gloves, and a gown), monitoring of PPE donning and doffing by trained observers, avoiding aerosol generating procedures (AGPs), and minimizing the number of providers with potential exposure. 4 Although these recommendations have been widely adopted, variable adherence with PPE use has been observed even in settings at high risk for SARS-CoV-2 transmission. 5 Several factors have been associated with PPE nonadherence, including the perceived likelihood of transmissible infection, workplace stress and fatigue, availability of adequate PPE, and prioritization of urgent patient need over appropriate PPE use. 3, [5] [6] [7] [8] These factors are especially relevant in an emergency department (ED) setting where patients with unknown COVID-19 status often require time-sensitive management by multidisciplinary teams. Even before the pandemic, variable adherence with recommended PPE use was observed in the settings with a high-risk for infection transmission, including pediatric and adult trauma resuscitations, and intensive care units. [9] [10] [11] Goals of this Investigation

The goal of this investigation was to evaluate the patterns of PPE use and identify factors associated with adherent and nonadherent PPE use among HCWs during AGPs performed in an emergency department setting. We focused on pediatric resuscitations occurring at the beginning of the US pandemic (March-June 2020) to evaluate evolving changes in PPE adherence.

Using video review, we conducted a retrospective, observational study of PPE adherence among participants in pediatric resuscitations in the ED between mid-March and mid-June of 2020. To focus on periods with the highest risk for potential SARS-CoV-2 virus transmission to HCWs, we selected resuscitations that included one or more AGP. 12 Resuscitations are video recorded with three views from overhead, the head, and the foot of the bed. Consent is required for video use for research purposes. Parental or guardian consent is attempted at the time of patient presentation. Consent may also be obtained at any time during the hospital stay. The Children's National Hospital Institutional Review Board approved this study.

Children's National Hospital is a tertiary care hospital and accredited level 1 pediatric trauma center serving the greater Washington DC area. The hospital has two resuscitation bays in the ED, where about 275 children are managed as medical resuscitations and about 600 injured children are managed as trauma resuscitations each year.

A multidisciplinary team evaluates patients who are treated in the resuscitation bays.

Leadership for these resuscitations includes an emergency medicine attending and a documenting nurse for all events and a critical care physician for medical resuscitations and a surgical coordinator (pediatric surgery fellow or senior surgical resident) for trauma resuscitations. Other team members include a bedside surveyor (emergency medicine resident, J o u r n a l P r e -p r o o f surgical resident, or nurse practitioner) responsible for the physical assessment, two or more bedside nurses or technicians, and an airway team comprised of an anesthesiologist and a respiratory therapist. A surgical attending and a critical care attending are present for children triaged to the highest-level of trauma or medical resuscitations.

PPE requirements for HCWs participating in ED resuscitations at our hospital before the COVID-19 pandemic included only gloves and a water-resistant gown. 9 After the start of the pandemic, hospital guidelines for PPE use in this area were changed to also include a recommendation for headwear (e.g., scrub cap), and required eyewear (e.g., goggles, surgical glasses, face shield), and a facemask (N-95 required) or powered air purifying respirator (PAPR). 4 N-95 masks and eye protection were distributed to staff at the start of the study period.

N-95 mask supply early in the study period was limited, and individuals only received one mask.

At the study midpoint (end of April 2020), an individual was stationed outside the resuscitation bay to help monitor PPE usage. Throughout the study period, the hospital conducted weekly or twice weekly town halls for dissemination of information about issues related to the pandemic, including updates on appropriate PPE usage and PPE availability.

Among the cases that were available for review, we assessed the time of each HCW in the room ("individual room time") and the time spent in each category of adherence (complete, inadequate, absent). To identify the lapses in PPE adherence during the highest risk periods, we evaluated PPE use by providers from the beginning of the first AGP to the time of patient departure from the resuscitation area. When a provider left the room and returned, the time spent outside of the room was not included. We defined aggregate exposure time as the sum of the time of individuals in the room after the AGP, regardless of the duration of individual exposure J o u r n a l P r e -p r o o f or whether individual exposure time was continuous or not. The approach using aggregate time is supported by the observation of viral transmission after multiple brief exposures. 13 Analysis of indoor spreader events suggests that transmission risk is linearly related to exposure time. 14 PPE items were identified and assigned an adherence level for each team member. If a team member changed their PPE use during the observation period, the separate durations of adherence and nonadherence (inadequate or absent) were recorded.

We developed a data dictionary to define AGP type and PPE adherence level (complete, inadequate, or absent) for the five recommended or mandatory PPE items (headwear, eyewear, facemasks, gowns, and gloves) (Appendix). Three observers were trained to use this data dictionary to assess the PPE adherence of each resuscitation participant independently using three resuscitations not included in the final dataset. These raters achieved a multi-rater reliability of 0.72 (Fleiss' Kappa, indicating good agreement). 15 Adherence with the PPE item was documented if the participant was properly wearing each item. The definitions of full adherence to PPE items followed CDC guidelines, including a secured isolation gown, an N-95 respirator, a face shield or goggles that covered the eyes, and gloves covering the wrists. 16 Nonadherence was categorized as inadequate protection (e.g., wearing a regular facemask instead of an N-95, not fully covering hands with gloves) or complete absence of the PPE item.

HCWs who properly wore a PAPR were recorded as wearing complete head covering, eye protection, and facemasks.

We summarized the data of adherence time for each PPE item and examined associations with resuscitation type ("medical" or "trauma") and across PPE types. We summarized J o u r n a l P r e -p r o o f categorical characteristics using count and frequencies and examined associations with resuscitation type using Chi-square tests. We summarized count or continuous variables with medians and interquartile ranges (IQR) and tested for association with resuscitation type using the Wilcoxon rank sum test. To examine association between PPE items among HCWs, we used scatter plots and calculated Pearson's correlation coefficients. We performed a mixed effect logistic regression analysis to determine factors associated with nonadherence (inadequate or absent) of each PPE item. This regression adjusted for the fixed effects of duration of room time of the provider, the chronological order of the resuscitation during the study period, and the random effects of subject. For interpretability of coefficients in this multivariable regression, we rescaled the order and time variables by subtracting the mean and dividing by the standard deviation. This rescaling transforms the regression coefficients to a similar scale. The random effect adjusted for correlation of repeated measures within the same subject (multiple PPEs) and within the same resuscitation (multiple HCWs). We calculated 95% confidence intervals (CI) and the Wald test for model-based significance testing. To compare adherence between different types of PPE usage, we varied the PPE type used as the reference group in the multivariable model. We then constructed a matrix representing the odds ratios using different reference and comparison PPE types. All statistical analyses used R. 17

Thirty-four resuscitations ("medical" n=21, "trauma" n=13) involving AGPs occurred during the three-month study period. Four resuscitations ("medical" n=4) were excluded due to absent or poor-video quality and eleven ("medical" n=3, "trauma" n=8) because consent was not obtained for video review. The final dataset included 19 resuscitations containing 45 AGPs J o u r n a l P r e -p r o o f -7events (median 2, IQR 2-3 AGP events per case). Among the included resuscitations, most were in the "medical" group (n=14, 77.8%). Intubation was the most frequent task requiring one or more AGP events (n=12, 63.1%, Table 1 ) followed by tracheostomy changes (n=5, 26.3%) and cardiopulmonary resuscitation (CPR) (n=2, 10.5%). The identified AGPs included bag valve mask ventilation in every resuscitation (n=19, 42.2%), endotracheal tube insertion in 12 resuscitations (26.7%), suctioning in 12 resuscitations (26.7%), and cardiopulmonary resuscitation in two resuscitations (4.4%). Daytime resuscitations were most common (n=15, 78.9%). The distribution of the main AGP type was similar between cases included and excluded from the study. Compared to excluded cases, included cases more often occurred during the daytime and earlier in the study period.

The observation period between AGP and patient departure had a median length of 44 minutes (IQR 31.7-48.9) and were similar for both "medical" and "trauma" resuscitations ("medical" median duration 42.9 minutes, IQR 30.5-52.8, "trauma" median duration 44 minutes, IQR 40.4-45.8). Among the 19 patients included in the study, 17 patients (89.5%) were tested for SARS-CoV-2, one (5.3%) of whom was positive. A median of 17 providers (IQR 16-20.5) participated in each event. Team size was similar for "medical" and "trauma" resuscitations ("medical"-median 17 providers, IQR 16-20.8, "trauma"-median 18 providers, . The cumulative duration of potential viral exposure for team members present in the room following the start of the AGP was also similar between event types ("medical" -median 350 minutes, IQR 262.7-471.5, "trauma" -median 396 minutes, IQR 392.4-415.2). The duration of nonadherent (inadequate or absent) use of each PPE item was similar between "medical" and "trauma" resuscitations (Table 1) In a multivariable analysis, nonadherent (either inadequate or absent) PPE use decreased over the study period (odds ratio 0.54, 95% confidence interval, 0.37, 0.77, Table 2 ).

Nonadherence occurred less often when providers were in the room for a longer period of time after the start of the AGP. Pairwise comparisons of individual types of PPE use showed a twolevel hierarchy of adherence: mask and glove use were equivalent, and providers had greater compliance with these items compared to eyewear and gown use, which were also equivalent (Table 3) .

This study has several limitations. First, this study was performed at a single institution.

Our analysis was limited by the video coverage of the room. Although the video views include most of the room, providers may have been in other areas of the room not covered by our video recording system. Second, our analyses were limited to the resuscitations that were available for review. We observed differences between included and excluded cases based on the time of day and based on distribution over the study period. These factors may have also contributed to differences in PPE adherence. Third, a large number of providers were present at each resuscitation. It is not known if this feature is unique to resuscitations at our hospital that may limit the generalizability of our findings. One study outside our institution counted team size J o u r n a l P r e -p r o o f -10during adult trauma resuscitations using video review. Although a maximum of 10 providers were observed, individuals in all roles or providers without a designated role who were briefly in the room were not counted. 18 In our study, we included every person coming into the room, if only briefly. Validation of our findings will require replication at other sites using video review.

Additional limitations of a single center design include workplace culture, PPE availability, or institutional policies. 8 Additionally, our analyses were limited to the resuscitations that were available for review. We observed differences between included and excluded cases based on the time of day and based on distribution over the study period. These factors may have also contributed to differences in PPE adherence. We were not able to identify whether differences in PPE use were related to provider role, a factor previously associated with PPE use. 19, 20 Although we were able to track individuals in the video by their appearance, it was more difficult to identify roles when most individuals were wearing PPE covering their head and face. We were also not able to identify the reasons for PPE nonadherence using video review. Tracking the pattern of PPE use and the impact of any intervention on these patterns is needed for enhancing adherence and promoting provider safety. We did not evaluate the distance of providers from the patients as an assessment of relative risk of contact with aerosolized virus. Although some providers were consistently either near or at a distance from the patient, most moved throughout the room.

Advanced tracking methods using optical particle sizers to assess air concentration may address the impact of distance on the patterns of PPE use. 21, 22 Finally, this study evaluated PPE use during what is widely accepted as the first three months of the US COVID-19 pandemic (March-

June 2020). Our findings during this period show improvements in PPE adherence as we adjusted to the pandemic.

Aerosol-generating procedures are often required during medical and trauma resuscitation for critically ill and injured children. Although the need for an AGP can sometimes be anticipated before a resuscitation begins, the need for an AGP may only be identified after a resuscitation starts. To reduce the risk of infection to HCWs and avoid delays in performing potentially lifesaving interventions, our hospital adopted a policy at the start of the pandemic that requires specific types of PPE before entering the resuscitation room. The zone of detectable aerosolized virus extends to as much as four meters and aerosolized virus may remain in the air for as long as three hours after an AGP. [23] [24] [25] Providers also may increase their risk of infection even if their exposure time is brief. 13 These factors support our hospital policy of requiring continued PPE use throughout the duration of each resuscitation regardless of the need for an AGP.

Despite the implementation of a hospital PPE policy to promote provider safety, we observed frequent nonadherence with required PPE use. We identified several factors associated with the frequency, duration, and type of nonadherence (inadequate or absent), including the type of PPE being evaluated and the length of provider time in the room. Most providers had less than recommended PPE adherence and changed their PPE adherence throughout the resuscitation.

Although nonadherence by individuals was often brief, viral transmission may occur with multiple brief exposures. 13 Aggregation of the time of nonadherence across providers established a metric for evaluating the potential exposure of all individuals providing care.

J o u r n a l P r e -p r o o f -12-Several explanations may account for variability in use based on PPE type. Before the pandemic, our hospital guidelines required only gowns and gloves for providers participating in medical and trauma resuscitations. 9 After the start of the pandemic, these two types of PPE continued to be used with high frequency and were correlated in use among individuals. These findings suggest the influence of established practices, even after extension to other types of PPE. Although based only on findings from qualitative studies, a recent Cochrane review identified workplace culture as a facilitator of infection control practices in settings at risk for respiratory infection transmission. 8 Improvements in adherence with all types of PPE during the study period may reflect a similar impact of workplace culture during the study period.

In March 2020, our hospital instituted a mandatory mask policy (surgical mask) for staff working in all locations. This requirement was supported by making surgical masks easily available to all employees. Despite a hospital-wide surgical mask policy, providers were observed without masks in the time period after AGPs in the resuscitation area. The aggregate length of time of providers without masks was small, showing that most without masks were in the room for a short time. Although we did not determine the reasons for nonadherence, this finding may have been attributable to the perceived low risk of exposure during a short exposure time or the need to provide urgent patient care before donning appropriate PPE. 5, 8 The resuscitation area included an additional requirement for either N-95 masks or PAPRs to ensure that providers were prepared for the risks associated with potential AGPs. Switching from a paper surgical mask to an N-95 or a PAPR involves a change in PPE before entering the room.

For PAPRs, this exchange can be time consuming. Early in the pandemic, N-95 masks were in short supply at our hospital, with distribution prioritized to those at highest risk of exposure.

These factors partially account for the observation that the use of only paper surgical masks was J o u r n a l P r e -p r o o f the most frequent type of partial mask adherence. As with all types of PPE use, adherence with mask protection increased during the study period, likely related to the availability of N95 masks and PAPRs and the development of a workplace culture expecting this type of protection.

Because this study was retrospective, we were not able to determine whether nonadherence with recommended usage was related to PPE availability or personal choice. This distinction is needed for implementing the most effective interventions for promoting adherence.

Inadequate and full adherence with headwear was the lowest among the types of PPE evaluated. More complete body coverage has been associated with a lower risk of exposure to contaminated body materials. Head coverings reduce contamination of the hair and other head areas, mainly resulting from hand to head contact. Despite this evidence, the CDC has not included headwear as a recommendation for preventing SARS-CoV-2 transmission. 4 Although recommended in the ED and other high-risk clinical areas, headwear was not required in most areas in our hospital. Because many providers only work in the ED for resuscitations, work in this area requires donning headwear in addition to other types of PPE before entering the room.

The lack of a national mandate and variability in local head covering practices likely contributed to high nonadherence with headwear.

Previous studies evaluating PPE use have focused on the periods of donning and doffing, with the assumption that period between these two procedures has static PPE use. In our study, we observed that providers frequently changed their PPE use while in the room by either modifying or removing equipment. Although we did not determine the reasons for premature doffing or modification of PPE, several factors may have contributed to these changes, including the comfort of the PPE items and the perceived risk of infection based on patient factors or proximity to the patient. 3, 8, 26 The CDC has recommended the use of trained observers to promote J o u r n a l P r e -p r o o f -14adherence with PPE donning and doffing during previous disease outbreaks. 27 Although widely adopted, these practices do not address variable PPE adherence that may occur after donning. In addition, these recommended observation practices are difficult to implement in a resuscitation setting where providers need to rapidly assemble for a time-sensitive event, often arriving from other areas of the hospital with different PPE practices. These findings support the need for new approaches for monitoring the continuous use of PPE, particularly in settings requiring the participation of multidisciplinary providers.

To reduce potential viral transmission to HCWs, our ED leadership implemented several interventions. To reduce incorrect use or premature doffing of PPE, a PPE monitor was positioned outside of the resuscitation area, observing providers entering the room and ongoing PPE use through a window. This PPE monitor may also help reduce the number of providers present in the room, a CDC recommendation for reducing risk of viral transmission to the medical team. 28 To increase awareness and promote understanding of recommended PPE use, hospital-wide guidelines based on CDC recommendations were disseminated in written form and presented at unit-and hospital-level conferences and twice weekly "town halls." Educational videos showing the proper use of PPE, including donning and doffing, were developed and made available to providers. Although the relative contribution of these interventions is not known, these types of interventions have been identified as facilitators of adherence with infection control guidelines. 19, 20, 29 These interventions occurred at different times during the study period, likely accounting for the contribution of resuscitation order as a predictor of adherence.

A final contributor to the variability in PPE use that we observed was our limited knowledge of the virus at the start of the pandemic. 3, 4, 30 In March 2020, our understanding of the risks of and modes of SARS-CoV-2 transmission was rapidly increasing, particularly in J o u r n a l P r e -p r o o f healthcare settings. The evolution of our understanding of viral transmission has been accompanied by the rapid implementation of new PPE practices that protect frontline HCWs.

The large contribution of viral transmission from asymptomatic children has also been recognized and supports the adoption of broad PPE protection among frontline HCWs providing pediatric care. 31 This information has been disseminated in the non-medical press and likely contributed to increased PPE use in the resuscitation area of our hospital.

In conclusion, we observed variability in patterns of PPE nonadherence in a high acuity pediatric resuscitation setting in the early months of the US COVID-19 pandemic. PPE adherence improved over time, but partial and full nonadherence remained even at the end of the observation period. We have shown the value of considering the aggregate exposure risk at the population level of providers rather than of individual providers. This measure may be more suitable for assessing risk in settings where frequent but short duration of PPE nonadherence occurs. Although PPE adherence was higher when individuals spent a longer time in an at-risk setting, many providers modified their PPE while working, supporting the need for continuous PPE monitoring during the entire period of required PPE use. Type of main aerosol generating procedure (no., %) 

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