key: cord-323732-7nzjrvla authors: Avo, Cameron; Cawthorne, Katie-Rose; Walters, Joanne; Healy, Brendan title: An Observational Study to Identify Types of Personal Protective Equipment Breaches on Inpatient Wards date: 2020-06-24 journal: J Hosp Infect DOI: 10.1016/j.jhin.2020.06.024 sha: doc_id: 323732 cord_uid: 7nzjrvla nan In response to the COVID-19 pandemic, UK Infection Prevention & Control (IP&C) guidelines have been published on using personal protective equipment (PPE) in various healthcare settings [1] . Improper PPE use can compromise the protection afforded by it [2] . The IP&C guidelines [1] highlight actions which may constitute a PPE 'breach'. In response to a Cochrane review [3] calling for research into barriers to proper PPE use, we investigated the most common types of breaches observed across several inpatient wards. The results highlight areas of practice that could be improved to optimise PPE use and reduce nosocomial transmission of infection [4] . We conducted a behavioural observation study to investigate whether, based on national guidelines [1] , healthcare workers wear correct PPE, what breaches occur, and how frequently. This study was completed in a large acute hospital in May 2020 during the COVID-19 pandemic. National guidelines [1] recommend different PPE requirements according to two different settings, which we have classified as 'all PPE' zones and 'mask only' zones. 'All PPE' zones constitute any room housing COVID-positive patients, or when within 2 metres of any patient. 'All PPE' zones require a fluid-resistant surgical face mask (FRSM), disposable apron, disposable gloves, and, subject to risk assessment, eye protection. 'Mask only' zones represent any area which is not 'all PPE' but where staff are working (e.g. the reception desk), and only FRSMs are required. Examples of PPE 'breaches' can be seen in Figure 1 . The observations were carried out on three medical wards (one designated for COVID-positive patients and two without identified COVID-positive patients). Permission to conduct an observation was obtained from each ward manager but staff were not informed of the purpose of the study. To minimise the Hawthorne effect, observers were unknown to ward staff and the observation period was limited to 30 minutes. For each worker, PPE use was evaluated for the session of work undertaken, and any observed breaches were recorded. If, within the 30-minute period, an individual left and re-entered a zone, they were counted as a separate worker as this represents another working session. Eye protection was not reported as part of the 'required' PPE on non-COVID wards as this could not be objectively measured in the context of individual risk assessments. Across sixteen 30-minute observations, 271 members of staff were observed: 45 in 'all PPE' zones and 226 in 'mask only' zones. A previous study showed that only 34% of healthcare workers donned all recommended PPE for droplet precautions [5] . In our study, we found that workers donned the required PPE on 71.1% of occasions in 'all PPE' zones and 94.2% in 'mask only' zones. 'All PPE' zone compliance was 100% on COVID-designated wards and 48% on non-COVID wards. Though eye protection was discounted in non-COVID 'all PPE' zones, it was noted that visors were not used by any staff in these areas. It is likely that some individual risk assessments would have indicated wearing eye protection. This suggests that further IP&C interventions are likely required to improve compliance with PPE use. Having recorded absolute numbers of PPE breaches, data were normalised to the number of staff observed in each zone across wards so that results were comparable (Figure 1) . Normalisation was necessary as our methodology tracked staff as groups, rather than individual staff members. In the 'mask only' zone, the most common breach was touching the mask, with a normalised frequency of 0.75 occurrences per individual. The data showed that breaches were scattered across staff groups, and it was reported that breaches were common amongst all observed staff rather than specific individuals. As such, these results suggest that around 75% of staff breach their mask by touching it. In the 'all PPE' zone, the most common breaches were failing to remove disposable aprons (0.69) or gloves (0.53) between patients. [1] . These breaches were observed during a number of 30-minute observations across several inpatient wards, covering both 'all PPE' and 'mask only' zones. 'All PPE' zones were defined as bays or cubicles housing COVID-positive patients, or an area within 2 metres of any patient; 'mask only' zones were defined as areas beyond 'all PPE' zones where staff may be working. In 'all PPE' zones, staff are required to don a fluid-resistant surgical mask (FRSM), disposable gloves, a disposable apron, and, subject to risk assessment, an eye protective visor; in 'mask only' zones, only a FRSM is needed. Eye protection was not counted as part of the 'required' PPE on non-COVID wards as this could not be objectively measured in the context of individual risk assessments. Data from the 'all PPE' and 'mask only' zones were normalised to the number of staff observed in the 'all PPE' zone (45) and 'mask only' zone (226), respectively. COVID-19: infection prevention and control guidance Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis Improving the Use of Personal Protective Equipment: Applying Lessons Learned Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals Contact precautions for multidrug-resistant organisms: Current recommendations and actual practice Practical experiences and suggestions for the 'eagle-eyed observer': a novel promising role for controlling nosocomial infection in the COVID-19 outbreak Special thanks are extended to Dr Ian Blyth for his guidance early in the study, Dr Eleri Davies for her review of the manuscript, and Rebekah Velounias for her assistance with the data analysis. We would also like to thank the ward managers and staff for allowing us to carry out our observations. Audits into PPE typically offer a binary view of whether it is used or not [6] . This is problematic as infection transmission risk is not eliminated simply by wearing correct PPE. Workers must also refrain from breaching PPE in a way that might increase the risk of transmission. This study provides an insight into how workers behave whilst wearing PPE. Investigating common breaches identifies possible routes of infection, establishes recommendations for improving PPE design, and enables IP&C teams to educate healthcare workers accordingly. Further work is needed to evaluate methods for reducing PPE breaches.An example might be the "eagle-eyed observer" approach, as suggested by Peng et al. [7] , which could detect PPE breaches and encourage correction. During training, more attention could be given to the use of PPE besides what types are needed and when. Improvements in PPE design with enhanced comfort will also likely increase compliance and reduce the risk and frequency of breaches.