key: cord-0754903-s9qmti2b authors: Kea, Bory; Johnson, Alicia; Lin, Amber; Lapidus, Jodi; Cook, Jennifer N.; Choi, Calvin; Chang, Bernard P.; Probst, Marc A.; Park, Joel; Atzema, Clare; Coll‐Vinent, Blanca; Constantino, Giorgio; Pozhidayeva, Dar'ya; Wilson, Amy; Zell, Adrienne; Hansen, Matt title: An international survey of healthcare workers use of personal protective equipment during the early stages of the COVID‐19 pandemic date: 2021-03-26 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12392 sha: 6ec0cb76294b57c5b9a804775d3de4dcf597e442 doc_id: 754903 cord_uid: s9qmti2b OBJECTIVE: Little is known regarding the specific ways personal protective equipment (PPE) has been used and reused during the coronavirus disease 2019 (COVID‐19) pandemic. The objective of this study was to evaluate the patterns of PPE use and the impact of PPE availability on the attitudes and well‐being of an international population of healthcare workers. METHODS: This was an online, cross‐sectional survey of healthcare workers. The survey was disseminated internationally using social media, specialty society list‐serves, and email augmented by snowball sampling to healthcare workers who provided direct care to patients with suspected or confirmed COVID‐19. The survey was conducted between April 13 and May 1, 2020. The primary outcome was self‐reported PPE use during aerosol‐generating medical procedures. Other outcomes included PPE use during care for respiratory patients in general, PPE reuse, PPE decontamination, and healthcare worker impressions related to their work and the pandemic. RESULTS: A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol‐generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol‐generating medical procedure, 756 (72%) reported re‐using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay. CONCLUSIONS: This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol‐generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single‐use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID‐19 infection and harmed mental health. Results: A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol-generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol-generating medical procedure, 756 (72%) reported re-using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay. Conclusions: This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol-generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single-use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID-19 infection and harmed mental health. The novel coronavirus disease 2019 (COVID- 19) global pandemic has had a remarkable impact on healthcare practice worldwide. A critical element of the global pandemic response is protecting healthcare workers from contracting the virus. This is important both on an individual level for healthcare workers who wish to avoid infection in themselves and to their families, and collectively for healthcare systems to reduce disruptions in care caused by an ill workforce. Several studies have documented increased risk of COVID-19 infections among healthcare workers, with healthcare workers accounting for 4%-11% of total infections with a hazard ratio of over 11 for COVID-19 infection compared to the general community. [1] [2] [3] One report indicated that 10% of cases in Italy could be in healthcare workers. 4 Limited personal protective equipment (PPE) availability has been an ever-present concern among healthcare workers and is associated with increased risk of COVID-19 infection. 2 Due to severe shortages, healthcare organizations rapidly developed PPE use and reuse protocols. Previous studies have reported increased stress, anxiety, and depression among healthcare workers associated with the pandemic, with some reporting inadequate PPE as a contributor. [5] [6] [7] [8] However, the patterns of PPE use, reuse, and the specific personal impact of PPE scarcity on healthcare workers are poorly described. The objective of this study is to evaluate the patterns of PPE use during the COVID-19 pandemic and the impact of PPE availability on the attitudes and wellbeing of an international population of healthcare workers. This was an international survey conducted between April 13 and May 1, 2020, using snowball sampling to reach as many healthcare workers as possible. The study was approved by the university's Institutional Review Board. Informed consent was obtained within the survey before completing the questions. The Our analysis included the following demographic variables: age, race, We used primarily social media and email distribution lists to disseminate the survey. We selected snowball sampling to efficiently reach as many healthcare workers as quickly as possible over a wide geographic area. Snowball sampling is a method of non-probability sampling where participants are invited to share the survey with additional individuals. 9 We used Twitter, Facebook groups (ie, Essential Workers, COVID-19, Physicians Mom's Group), specialty listservs (Pediatric Emergency Medicine, Critical Care Medicine), specialty societies, and personal contacts to share the survey. We specifically asked that the survey be forwarded to healthcare workers who had tested positive for COVID-19. The snowball sampling approach precludes the calculation of a response rate. The survey was conducted using the Qualtrics (Provo, UT) platform. Respondents were included if they indicated they were healthcare workers with direct patient contact since January 2020. We excluded respondents who had not "completed the survey" in Qualtrics, which means they had clicked through each page of the survey. The only We first evaluated demographic variables using descriptive statistics. We then described PPE used by participants stratified by region and PPE use-cases. We then analyzed PPE reuse and cleaning and stratified this analysis by region. Data management was conducted in R (ver- To complement the thematic analysis, text mining was applied to the responses for both open-ended questions. 11, 12 All words were initially singularized, and common stop words such as "the" were removed. Words referring to survey prompt or location (such as states and countries) were also removed. Text responses were then tokenized into bigrams (patterns of 2 consecutive words that occur within the text). The bigrams were then analyzed by the prioritized themes, using a ratio of bigram frequency by thematic code over the frequency of thematic codes present. Results were then stratified by specialty and placed into subgroups by qualitative themes that emerged from the qualitative analysis. If a specialty did not contain any bigrams for a given thematic code, the result was recorded as "no response." Textual cleaning and analysis were conducted in R using the tidytext and textclean packages to clean the text and the SamNetCleaner package to singularize the text. [13] [14] [15] 3 RESULTS There was a wide range of PPE use among the 1451 providers who reported performing aerosol-generating medical procedures. Table 2 summarizes PPE use among all survey respondents divided by geographic areas. The N95 was the most common respirator reported for aerosol-generating medical procedures (n = 1050, 72.4%). Few providers reported using foot booties or head-to-toe coverings, although foot coverings and head coverings were more common in Italy. Generally, there was little regional variability in PPE use within the United States; internationally, there was some limited variability. Providers in Italy were using the powered air-purifying respirator (PAPR) less frequently (1 of 39 Italian respondents, 2.6%) than other areas (20%). The N95 respirator was reported to be used by 965 (55.9%) respondents when caring for a patient with respiratory symptoms without an aerosol-generating medical procedure being performed and by 582 (28.3%) respondents when providing care for patients without any respiratory symptoms. Overall, 1783 (80.1%) of providers reported reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain ( In total, 634 comments were analyzed for the scope question, and 477 were analyzed for the additional thoughts question. Analysis of the scope Mental and physical health/illness were also noteworthy themes. For example, respondents described mental health effects such as stress/anxiety, emotional exhaustion, frustration, concern, or fear. pay raises, or other benefits for healthcare workers during the pandemic. Some noted decreases in pay, or deferral of normal pay raises. A few respondents noted inequity in workload and compensation with nurses "getting paid to be sent home" while paramedics were "asked to use vacation to compensate for low volume." We evaluated these respirator was the most commonly reused item in our study. This is concerning given the correlation with N95 extended-use, reuse, and fit failure, increasing risk of user contamination. 19, 20 In this study, 72% of individuals who wore an N95 respirator for an aerosol-generating medical procedure reused the respirator, with 45.5% of those reusing reporting >3 days of reuse. One previous study found the risk of fit failure of the N95 respirator after 4 days of use was alarmingly high F I G U R E 2 Results of the bigram ratio frequency analysis at 46%, while another found that fit tests failed after a median of 2 use-sterilization cycles. 21, 22 In our study, nearly half of the respondents indicated they reused the N95 respirator for >3 days, likely resulting in loss of adequate protection for many users. Further, most respirators were not decontaminated, and COVID-19 is reported to be stable on a surgical mask for 1 week although there is limited data on the N95. 23 The PPE was reused during high-risk procedures, such as endotracheal intubation, and may contribute to the high rate of COVID-19 infections among healthcare workers. We noted the highest rate of N95 respirator reuse in the Eastern US, which also corresponds to the US area at highest risk for COVID-19 among healthcare workers. 2 The free-text responses indicate that healthcare workers experienced fear and anxiety as they reused PPE that was designed to be disposable. Other responses indicated that people were worried about reductions in pay and spreading infection to their family members at home. This study highlights the multifaceted nature of healthcare worker occupational risk during the pandemic includes infectious exposure risk, fear, anxiety, family risk, and reductions in pay. In addition to increasing the risk of COVID-19 infection, the scarcity of PPE may have a considerable impact on healthcare workers' mental health and wellbeing. This burden continues, and has not been adequately addressed. We recommend that health systems and gov-ernments consider all aspects of healthcare provider wellness during the pandemic to minimize the negative impacts on our healthcare workforce. Our large, international survey of healthcare workers indicates that the worldwide supply of PPE was not adequate for a global pandemic. We identified extensive reuse of PPE, specifically the N95 respirator (that is intended to be disposable), with highly variable approaches to disinfection between uses. This underscores the ongoing urgent need to improve the availability of PPE that meets the highest standards of protection for our healthcare workforce. As COVID-19 cases continue to rise in various communities around the world and others enter a second wave, protecting healthcare workers will be essential to protect the community. Finally, efforts to prepare for future pandemics must ensure an adequate supply of N95-equivalent respirators will be available when needed. 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