key: cord-0986606-smc52z6c authors: Prakash, Gagan; Shetty, Preethi; Thiagarajan, Shivakumar; Gulia, Ashish; Pandrowala, Saneya; Singh, Lovedeep; Thorat, Veena; Patil, Vijaya; Divatia, Jigeeshu V.; Puri, Ajay; Pramesh, C. S. title: Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID‐19 negative cancer patients during the pandemic date: 2020-08-03 journal: J Surg Oncol DOI: 10.1002/jso.26151 sha: 100c4b5f3e953be63cfc6b184854df0052e36ad1 doc_id: 986606 cord_uid: smc52z6c BACKGROUND: Health care workers (HCWs) are at risk of getting infected while at work, for example, operating room (OR), hence it is pertinent that they don all the appropriate personal protective equipment (PPE) to minimize the chance of getting infected. METHODS: A COVID‐19 specific briefing and debriefing form was created and used in the OR along with the World Health Organization surgical safety checklist to reinforce the use of appropriate PPE. An audit was subsequently done to understand the compliance to PPE use, followed by a survey based on the findings of the audit to understand the issues related to noncompliance. RESULTS: The form was used in 183 out of the 238 (77%) surgeries performed during a months' time. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for eye protection (45/567) (P = .01). The survey revealed that this was mostly among surgeons mainly due to discomfort, poor visibility, and frequent fogging. CONCLUSIONS: Our HCW were adapting well to the new normal of donning appropriate PPE in the OR, except for the eye protection due to discomfort and visibility related issues. This is important to know so that necessary changes could be introduced to better the compliance. The year 2020 began with news about a novel coronavirus originating from the city of Wuhan in China and spreading progressively to different continents across the globe. 1 The World Health Organization (WHO) declared this rapidly evolving event as a pandemic in March 2020, and the causative organism was termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 2 Health care centers around the world had various challenges to face at the same time. At one end, there was a multiplication of symptomatic patients and health care workers (HCW) infected by this virus. 3, 4 On the other hand, there was a concern about patients with non-COVID-19 ailments, such as cancer, risking a delay in treatment. The judicious use of hospitals and human resources became critical. The selection of surgeries that should be performed during this pandemic was based on recommendations from various international guidelines. 5 Cancer surgery being categorized as semiemergency had to continue. With no effective treatment or vaccines available for the COVID-19 till date, the best way to minimize the risk of getting infected is by taking adequate protection. WHO had issued guidelines for personal protective equipment (PPE) use in February 2020 which includes gloves, medical masks, goggles or a face shield, and gown, as well as N95/FFP2 or equivalent respirators, for those performing aerosol-generating procedures. 6 The level of exposure varies among HCW depending on their specific role in inpatient care. The HCW in the operating room (OR) is at higher risk because of the close contact with the patients while intubation or during surgery with the inherent danger of contact with the patient's body fluids and during aerosol-generating procedures. 7 During the SARS epidemic studies showed that HCW who wore adequate personal protection had a lesser chance of getting infected. 8, 9 Despite the proven benefits, compliance with the usage of PPE is fraught with issues like availability, discomfort, and individual perception. The model of the WHO surgical safety checklist (SSC) in ensuring patient safety is well established and has been in use at our center. 10 Similar to the concept of SSC, the surgical briefing and debriefings are essentially communication and teamwork tools, that help to identify issues at the start and the end of an operating session and involves all members of the team. 11 It helps to identify errors (such as not donning appropriate PPE in our case), excessive OR traffic and also aims at improving communication among the staff members. 12 We adopted this established concept of team briefing and debriefing to reinforce among our HCWs the use of appropriate PPE at the beginning of the case itself and confirm the same at the end of the case so that we could identify multiple recurring errors to avoid them. We created a COVID-19 specific briefing and debriefing form and used it in addition to the SSC at the beginning and the end of the case (Supporting Information Appendix-I). The forms were used for a month and subsequently audited. Based on the findings of the audit, a survey was done to understand the perception among HCW about various components of PPE and reasons for noncompliance if any. We also looked at common reasons for poor compliance to take suitable actions. The COVID-19 specific briefing and debriefing forms were created and finalized after consensus among participating colleagues from the Department of Surgery and Anaesthesiology of our institute. The authors confirm that all the procedures contributing to this study complied with ethical standards. The COVID-19 briefing and debriefing form has three parts (Supporting Information Appendix-I). Part-I captured the patient details including the COVID-19 status. Part-II is the briefing section which has two steps within. Step-1 captures the details regarding the different PPE's (surgical cap, N95 mask, three-ply mask, double gloves, plastic apron, face shield or goggles, and disposable gowns) being used by the HCW in the OR as the patient is wheeled into the OR and affirming the same at the time of incision. Step-2 specifically identifies if an aerosol-generating procedure was anticipated during surgery (surgeries involving the use of saw for cutting bone, eg, marginal mandibulectomy). Part-III is the debriefing section to be done at the end of the surgery before the patient is wheeled out of the OR A total of 238 routine (elective) surgeries were performed between 4th May 2020, and 3rd June 2020. The COVID-19 briefing and debriefing forms were used in 183 surgeries (77%). All of these patients were COVID-19 negative. The utilization of OR among the various oncosurgical specialties is shown in Table 1 . In general, for one surgery three surgeons, two anesthetists, one scrub nurse, and one technician would be involved at a given time. Typically, at our institute (and many others) scrub nurses and technicians would have an 8-hour shift. Occasionally due to human resource logistics, a technician would be shared between adjoining OTs. In these 183 surgeries, 567 surgeons (including consultants and residents), 413 anesthesiologists (including consultants and residents), 291 scrub nurses, and 164 OT technicians were involved. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for face shields and this was largely among surgeons (45/567) (P < .001). Surgical cap, N95/3-ply mask, and double gloves were worn by all as part of PPE (Table 2) . Nearly 10% of the OT technicians were not wearing the gowns. This could be attributed to the fact that the OT technicians do not routinely use gowns and probably are yet to get accustomed to using gowns in the COVID-19 era on a regular basis. The scrub nurses were the most compliant to donning all the prescribed PPE (99.5%). As noted in the audit, surgeons were not using the face shields provided most often. The circulated survey questionnaire was an Among the PPE, that is, N95, 3-ply mask, double gloves, eye protection (face shield, and/or goggles; Figure 1 ), only 43 of the 122 (35%) wore all of the above at the times that it was considered mandatory in the OR among the respondents. Thirty-six out of the 122 (29.5%) people surveyed wore neither goggles nor face shields. Only 40% of the respondents felt either goggles or face shields or both needed to be worn in the OT in the current situation. Among the surgeons, uro-oncologists (100%) followed by head and neck surgeons (81%) perceived that face shields and goggles are not required once the patient has been tested negative for SARS-CoV-2. Since face shields had been repeatedly found to be least worn in the OR, the questionnaire specifically included further questions directed towards finding the usage pattern, preference, and reasons for nonusage. One of the questions in the survey had pictorial options of the different varieties of face shields available for usage. Among the four commonly used face shield types (Figure 2 ), that is, hard visor shield, the M foam shield, OHP face shield, and shield mask, the M foam shield was the most commonly used (70% usage). The reasons for poor compliance with the usage of face shield included discomfort (33%), poor visibility due to thickness (36%), and repeated fogging (33%). A total of 42 of the 122 (34%) did not have any issues with using face shields (Figure 3 ). Based on the survey, the hard visor shield was the most preferred and the shielding mask was the least preferred one among the four face shields currently available. The audit showed that the overall compliance with the use of PPE in the OR by HCWs was high at 96.3%. Face shield was one of the components among the PPE that was not always donned while in the OR, especially by the surgeons, citing poor visibility, fogging, and discomfort as the common reasons. we could not capture these details we would concur with these findings of the problem faced by many of us in the OR. These factors would be contributing to surgical fatigue and exhaustion. Our next effort would be directed towards identifying issues that cause discomfort while donning these PPE and attempt to reduce their influence on surgeon fatigue. We believe that the checklist was probably instrumental in ensuring the compliance of PPE usage among the HCW in the OR. Improvement in compliance for all components of PPE would depend on two factors. One, the perceived necessity for wearing a particular protective equipment and second the comfort of HCW while using these PPE. These two factors are likely to be interrelated as also reflected in our results. Hospitals should be receptive to the fact that discomfort is known and options of different types of PPE, especially like face protection equipment, should be made available. We have made an initial effort towards this by connecting with a reputed national manufacturer of motorcycle helmet visors with the feedback from our surgeons. 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