key: cord-0952211-7ar8sra4
authors: Kadoya, Yoshito; Zen, Kan; Wakana, Noriyuki; Yanishi, Kenji; Senoo, Keitaro; Nakanishi, Naohiko; Yamano, Tetsuhiro; Nakamura, Takeshi; Matoba, Satoaki
title: Knowledge, perception, and level of confidence regarding COVID-19 care among healthcare workers involved in cardiovascular medicine: a web-based cross-sectional survey in Japan
date: 2020-08-08
journal: J Cardiol
DOI: 10.1016/j.jjcc.2020.07.029
sha: 8f3b9d63ee222390489d2e868678242f60985b63
doc_id: 952211
cord_uid: 7ar8sra4

BACKGROUND: The pandemic of coronavirus disease 2019 (COVID-19) has a significant impact on daily practice in cardiovascular medicine. The preparedness of healthcare workers (HCWs) can affect the spread of infection and the maintenance of the healthcare system. This study aimed to investigate the knowledge, perception, and level of confidence regarding COVID-19 care among HCWs involved in cardiovascular medicine. METHODS: A cross-sectional, web-based study about COVID-19 was performed between April 22 and May 7, 2020, among 311 HCWs in cardiovascular departments. The demographic information, COVID-19-related knowledge, and perception and level of confidence toward COVID-19 care were assessed. RESULTS: The median age of the participants was 38 years, and 215 (69.8%) were male. There were 134 (43.1%) physicians and 177 (56.9%) non-physician HCWs. The HCWs, especially non-physician HCWs, had insufficient knowledge about infection-prevention measures for COVID-19, such as how to isolate patients with COVID-19, how to use personal protective equipment, and how to prevent infection during aerosol-generating procedures. Most HCWs showed a low level of confidence toward COVID-19 care, and such poor confidence was associated with the lack of knowledge on optimal infection-prevention measures. CONCLUSIONS: This survey revealed the lack of knowledge about adequate infection-prevention measures for COVID-19. More attention should be paid to the preparedness of HCWs, and educating and supporting HCWs involved in cardiovascular medicine is an urgent need.

Coronavirus disease 2019 (COVID-19), which originated from Wuhan, China, in December 2019, has been spreading worldwide [1, 2] . The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020 . In Japan, the first confirmed COVID-19 case was reported on January 16, 2020 [3] . The Japanese government proclaimed a state of emergency for Tokyo and the prefectures of Chiba, Saitama, Kanagawa, Osaka, Hyogo, and Fukuoka on April 7, and the declaration was extended nationwide on April 16, 2020. A total of 11,919 cases and 287 deaths have been confirmed in Japan as of April 23, 2020 [4] . Exhaustion of healthcare resources, including medical personnel, medical equipment, and personal protective equipment (PPE), is occurring in many regions while dealing with patients with Recent studies showed that cardiovascular comorbidities are common in patients with COVID-19 and such patients are at a higher risk of morbidity and mortality [5, 6] . In addition, various cardiac manifestations, such as myocarditis, venous thrombosis, arrhythmia, and heart failure were reported in patients with COVID-19 [7] . Therefore, the importance of cardiovascular care in dealing with the COVID-19 pandemic has become pronounced. To ensure and maintain the efficiency of the cardiovascular healthcare system, it is essential to take appropriate infection-prevention measures among healthcare workers (HCWs) and to protect both HCWs and patients from infection. However, the preparedness for COVID-19 pandemic among HCWs involved in the cardiovascular healthcare system has been poorly investigated. Accordingly, the aim of this study was to evaluate the knowledge, perception, and level of confidence toward COVID-19 care among HCWs involved in cardiovascular medicine.

This was a cross-sectional study conducted through a web-based survey between April 22 and May 7, 2020. The participants were recruited from the cardiovascular departments of 35 hospitals, including three university hospitals. All hospitals had multiple departments, including cardiovascular department, and were general hospitals that played a central role in the healthcare system of each region. Most of the hospitals were located in the Kansai region, the southern-central region of Japan's main island Honshu. A member of the research team of each hospital explained the survey purpose and recruited the participants. At the time of the survey, sporadic clusters were occurring in hospitals and nursing homes across Japan, leading to the collapse of healthcare systems in some areas [8] .

The study complied with the Declaration of Helsinki and was approved by the ethics committee of the Kyoto Prefectural University of Medicine (reference number: ERB-C-1718). Electronic informed consent was obtained from each participant prior to starting the investigation.

Participants could withdraw from the survey at any moment without providing any justification.

All authors read and agreed to the article as written.

An online questionnaire using Google Forms was used to collect the data to prevent the spread of COVID-19 by human contact. The survey was conducted using a multiple-choice questionnaire comprising 41 questions divided into the following sections: HCWs' demographic characteristics; HCWs' knowledge regarding COVID-19 (i.e. symptoms and diagnostic tools, aspects that should be considered to identify high-risk patients for COVID-19, and sources of knowledge about COVID-19); HCWs' perception and level of confidence toward COVID-19 care; HCWs' satisfaction level regarding the supply of medical equipment for COVID-19 care; and HCWs' feeling of anxiety and stress. This survey did not include Questions on infection-prevention measures for COVID-19 were answered on a Yes/No scale. The participants were also asked to report their experience of caring for patients with COVID-19 and relevant training programs they had received.

Descriptive analysis was used to describe items included in the survey. Continuous variables were presented as medians and interquartile ranges (quartiles 1-3) and categorical variables as counts and percentages. Differences in each item regarding the knowledge, perception, and level of confidence regarding COVID-19 care between physician and non-physician HCWs were analyzed using the Wilcoxon signed-rank test considering parity. We conducted a multiple regression analysis to identify the independent determinants of the low level of confidence toward COVID-19 care (i.e. answering "Not at all confident" or "Slightly confident" in the survey). The following variables were included as possible confounders: age, gender (male), Table 1 . A total of 311 HCWs completed the survey (100% response rate). The median age of the participants was 38 years, and 215 (69.8%) were male. There were 134 (43.1%) physicians and 177 (56.9%) nonphysician HCWs, consisting of 73 (23.5%) nurses, 36 (11.6%) clinical engineers, 56 (18.0%) radiology technologists, and 12 (3.9%) other HCWs. The majority of participants (60.5%) had over 10 years of work experience. Twenty-seven participants (9.8%) reported having experience caring for patients with suspected or confirmed COVID-19 infection, and 24 (7.8%) had completed a COVID-19 training program. There were no missing data regarding variables that were related to knowledge, perception, and level of confidence toward COVID-19 care.

The knowledge about COVID-19 among the participants is summarized in Table 2 . Most HCWs reported fever, cough, and taste and smell disorders as symptoms of COVID-19, while only a few HCWs recognized skin and eye manifestations. There were some knowledge gaps between physicians and non-physician HCWs regarding the relatively uncommon symptoms of COVID-19, such as vomiting, diarrhea, red eyes, skin rash, and joint or muscle pain.

Regarding the diagnostic examination for COVID-19, most HCWs correctly recognized the polymerase chain reaction testing on respiratory samples as the mainstay of diagnosis, whereas the computed tomographic examination was also considered a diagnostic tool for COVID-19.

Almost all HCWs knew the aspects that should be considered to identify patients at risk of having COVID-19. With respect to the sources of knowledge, approximately 90% of the participants reported using conventional news media (e.g. newspapers, television, and radio), and 106 participants (34.2%) used social networking services, such as Twitter and Facebook.

Physicians were more likely to obtain information via scientific journals and the internet as J o u r n a l P r e -p r o o f sources of information compared to non-physician HCWs. Overall, there was a lack of knowledge about the infection-prevention measures for COVID-19, such as how to isolate patients with COVID-19, how to use PPE, and how to prevent infection during aerosolgenerating procedures. This trend was more evident among non-physician HCWs than physicians. Nearly half of the HCWs were aware of the guidelines or online resources of COVID-19 published by cardiovascular societies; however, most of them were physicians, and awareness among non-physician HCWs was low. The knowledge about how to use PPE and how to prevent infection during aerosol-generating procedures was significantly lower among non-physician HCWs than physicians.

The perception and level of confidence regarding COVID-19 care are shown in Table 3 . Only 13.8% of HCWs responded that they kept themselves up to date with the information on COVID-19. Approximately 60% of the HCWs stated "No" when asked "Do you think you have received enough training for COVID-19 care?" The majority of HCWs were not satisfied with the supply of PPE for COVID-19 care. Notably, only two HCWs answered "confident" and 50 HCWs answered "somewhat confident" when asked about the confidence toward COVID-19 care. Most of the HCWs had a low level of confidence and answered "Slightly confident" or "Not at all confident" (54.7% and 28.6%, respectively). Moreover, non-physician HCWs tended to have significantly lower levels of confidence compared to physicians. The multivariate logistic regression analysis revealed that the low level of confidence was associated with the lack of knowledge about appropriate infection-prevention measures, such as how to use PPE, how to prevent infection during aerosol-generating procedures, and how to isolate patients with suspected or confirmed COVID-19 infection (Table 4 ).

In this study, we investigated the knowledge, perception, and level of confidence regarding COVID-19 care among HCWs involved in cardiovascular medicine. There was a lack of knowledge about optimal infection-prevention measures for COVID-19, such as how to use PPE, how to isolate patients with COVID-19, and how to prevent infection during aerosolgenerating procedures. Most of the HCWs, especially non-physician HCWs, showed a low level of confidence toward COVID-19 care. Poor confidence was associated with the lack of knowledge about infection-prevention measures. Because this is the first survey to evaluate HCWs' preparedness for COVID-19 care in Japan, our study provides physicians with new insights into the field.

We demonstrated the lack of knowledge about appropriate infection-prevention measures for COVID-19, such as how to use PPE, how to isolate patients with COVID-19, and how to prevent infection during aerosol-generating procedures.

Wu et al. reported that a total of 1,716 (3.8%) of 44,672 patients with COVID-19 were HCWs, indicating that HCWs are at an increased risk for COVID-19 transmission [9] . Wang et al. showed that among 138 confirmed patients with COVID-19, 41.3% were considered to have acquired infection from the hospital, and more than 70% of these were HCWs [10] . In Japan, cluster infections in hospitals have become a problem, and there are fears that this could lead to the collapse of the healthcare system. Therefore, the need for minimizing the risk of COVID-19 transmission to HCWs is becoming increasingly pronounced. To protect HCWs and patients from infection, the recommendations from the Japanese Circulation Society emphasize the importance of standard precautions while using PPE and optimal prevention when performing aerosol-generating procedures [11] . However, HCWs, especially training program [12] . Considering that our survey was conducted after COVID-19 infection was already widespread in Japan, the percentage of HCWs who received COVID-19 training was thought to be very low. We speculate that the absence of practical and effective training programs for HCWs has led to a lack of knowledge of basic infection-prevention measures and to the low level of confidence toward COVID-19 care. Previous studies suggested that training by hospitals and related organizations played an important role in the prevention of infectious diseases [13, 14] . Our study revealed the clear need for training programs to there is a concern that non-physician HCWs are not well informed about current guidelines of J o u r n a l P r e -p r o o f COVID-19. Guidelines should be delivered to all HCWs, including non-physician HCWs, to make them aware of the best practices for COVID-19 care and optimal infection-prevention strategies.

At the time of this survey, cluster outbreaks in hospitals and the spread of infection among HCWs had become a major problem in Japan. Further expansion of this situation would result in the disruption of the healthcare system and have a negative impact on not only COVID-19 care but also cardiovascular emergency care, including primary percutaneous coronary intervention for patients with acute myocardial infarction. Hence, strengthening the training for HCWs on optimal preventive and protective measures for infection is an urgent need to maintain the efficiency of cardiovascular care during the COVID-19 pandemic. We hope our data will contribute to revealing problems associated with infection-prevention and control measures during COVID-19 care and protecting HCWs from infection to maintain healthcare systems. We believe that we have a social responsibility of achieving these goals.

Despite its strengths, this study has some limitations. First, because participants were recruited from institutions in a specific area, the results may have been affected by selection bias. Second, as this is a cross-sectional study, evaluating causal relationships is impossible.

Third, because the results of this study are based on a self-reported survey, they might not represent actual practices. Finally, this study included only Japanese participants, and the results cannot be generalized to other populations with different ethnic and geographical backgrounds. Therefore, further research is needed for confirmation and generalizability of the present findings. 

None IRB information: The study protocol was approved by the ethics committee of the Kyoto Prefectural University of Medicine (reference number: ERB-C-1718). All patients provided written informed consent prior to study participation.

We thank all HCWs for their contribution to the survey. The authors recognize all the principal investigators and institutions that enrolled in the study as collaborators in gathering this data.

J o u r n a l P r e -p r o o f Table 1 Demographic characteristics of study participants.

Categorical and continuous variables are presented as number (percentage) and as median Table 4 Relevant factors of low level of confidence (i.e. answering "Not at all confident" or "Slightly confident" to the question "Are you confident toward COVID-19 care?" in the survey).

In the multivariate model, the adjusted HR for low level of confidence (i.e. answering "Not at all confident" or "Slightly confident") compared with that for high level of confidence (i.e.

answering "Very confident," "Confident," or "Somewhat confident") was calculated by 

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