key: cord-1034597-x4iaj2rl authors: Reidy, Jennifer; Brown-Johnson, Cati; McCool, Nancy; Steadman, Shawna; Heffernan, Mary Beth; Nagpal, Vandana title: Provider perceptions of a humanizing intervention for healthcare workers – a survey study of PPE Portraits date: 2020-09-07 journal: J Pain Symptom Manage DOI: 10.1016/j.jpainsymman.2020.08.038 sha: ea4b3affecbc4bb8ba9e14e55b63b8ee408e74e7 doc_id: 1034597 cord_uid: x4iaj2rl INTRODUCTION: Reports from patients and healthcare workers dealing with COVID-19 underscore experiences of isolation and fear. Some of this experience results from the distancing effect of masks, gloves, and gowns known as Personal Protective Equipment (PPE). One approach to bridging the divide created by PPE is the use of PPE Portraits, postcard-sized pictures affixed to PPE. OBJECTIVE: Our confidential, email-based survey aimed to quantify provider attitudes towards PPE Portraits. METHODS: PPE Portraits were piloted at an academic, safety-net health system experiencing a COVID-19 patient surge in April-May 2020, necessitating use of full PPE for COVID-positive patients and surgical masks in all hospital settings. Our survey assessed staff exposure to PPE Portraits, attitudes towards PPE Portraits, and potential program expansion. For staff wearing PPE Portraits, we also assessed perceptions of interactions with other staff and patients/families and impact on personal wellbeing. The University of Massachusetts Medical School’s IRB designated this a quality improvement project (#H00020279). RESULTS: Over half of survey respondents (n=111/173, 64%) reported exposure to PPE Portraits. Attitudes towards PPE Portraits were positive overall, with agreement that PPE Portraits were a good idea (89%), improved provider mood (79%), enhanced perception of team connection (72%) and more positive among those who reported exposure. Open-ended responses (n=41) reinforced positive survey data, and also raised concerns about infection control (n=6), cost/logistics (n=5), and provider vulnerability (n=3). CONCLUSIONS: Providers report that PPE Portraits may represent a positive, patient-centered idea that helps reassure patients, is well-received by interdisciplinary staff, and may enhance patient and team interactions. Potential adaptations to address concerns include “photo pins,” and donor/ patient and family experience department support for costs. KEY MESSAGE: This article describes a cross-sectional study that investigated provider perceptions on the use of PPE Portraits, an intervention that addresses the barrier to patient-provider connection presented by the use of PPE. The results suggest that implementation of the PPE Portrait Project is feasible, acceptable, and effective. Reports from patients and healthcare workers during the COVID-19 pandemic underscore experiences of isolation and fear, with extreme cases even resulting in self-harm. 1 Some of this experience may result from the necessary distancing effect of masks, gloves, and gowns known as Personal Protective Equipment, or PPE. PPE is a necessary response to highly infectious diseases, 2 but may also create emotional and physical barriers between clinicians and patients. These and other barriers to communication, including the fast-paced, high-acuity hospital environment during the COVID crisis, can negatively impact clinicians' ability to connect with patients, especially in high-touch, relationship-based specialties such as palliative care. . 3 Visitor restrictions during pandemic also prevent family and loved ones from being at a patient's bedside, and mask-wearing hospital caregivers and palliative care teams avoid touching patients for contact unrelated to clinical care such as holding a person's hand or giving a hug. The global pandemic has been described as a "powerful amplifier of suffering," 4 and the field of palliative care has mobilized onto the frontlines in emergency rooms, hospital wards, and intensive care units during COVID crisis. Palliative care teams are facing historic numbers of hospital consults in COVID surge areas and witnessing seriously ill patients dying without family present; in response to abovementioned barriers, there is an urgent need for creative solutions to maintain and enhance human connection in hospitals besieged by COVID. 8 At UMass Memorial Medical Center (UMMMC), a 781-bed academic, safety-net health system in central Massachusetts, the inpatient palliative care service saw its daily new consult volume J o u r n a l P r e -p r o o f significantly increase (85/month to 108/month) and experienced an unprecedented number of patient deaths (19/month to 43/month) during a patient surge in April-May 2020. In virtual "town hall" meetings during this time, hospital providers expressed severe levels of stress related to deployment in areas outside their discipline with unfamiliar colleagues, caring for very sick and dying patients in a depersonalized hospital environment, and long hours of donning/doffing PPE, with fears of contracting COVID and/or transmitting the virus to loved ones leading to their self-isolation at home to prevent potential infection spread 5 . As a result, the UMMMC palliative care team implemented an art intervention, "PPE Portraits," with the goal of improving connection between the team, patients and hospital colleagues. implemented PPE Portraits based on current best practices -including use of a large, full-face portrait (4"x5") of the palliative care team member smiling directly at the camera. 6 We innovated on Ebola PPE Portrait pilot stickers, utilizing a combination of stickers for full PPE and laminated portraits affixed with pins for team members' clothing, clearly visible below their surgical masks at other times. At UMMMC, the palliative care team worked directly with the artist (MBH) who created disposable labels (at $8-15 for 100 4x5 labels) with existing institutional photos of each team member via a color laser printer (price range $300-600); as next step, one team member (SS) used a laminator machine (~$150) to laminate a label for each colleague which could be pinned to their clothing. The total start-up cost for the team was $800 at maximum. In addition to positive signals with respect to provider wellbeing, team functioning, and even potentially patient care, our results also highlight areas for improvement for PPE Portraits. Infection control concerns must be addressed, and further investigation and protocols are needed to ensure decontamination and cleaning of laminated PPE Portraits reused by staff. Wearing a PPE portrait is also not for everyone and can make some providers feel more exposed and vulnerable. Lastly, the logistics and cost of creating PPE Portraits locally, as well as competing priorities -especially in COVID surge situations -may be deterrents to the intervention, though overall startup costs for a single unit may be manageable. Finally, this study did not measure the perspectives of patient and families; further investigation of the intervention's impact on patient and family experience in health care is needed. In general, PPE Portraits were acceptable and ready for exploration to systemwide rollout at our institution. Based on the positive response and high visibility of the PPE Portrait project, senior leadership at UMMMC and the dean of the University of Massachusetts Medical School committed to creating "photo pins" for hospital staff and medical students to wear on their white coats and scrubs (launched June 2020). This effort was coordinated by the Office of J o u r n a l P r e -p r o o f Patient and Family Experience and funded by a private donor. Toggling between stickers, laminated badges, and more permanent photo pins may give providers the tools to address infection control concerns by setting; in addition, support through patient and family experience departments and private donors may be one way to address cost concerns. Functional next steps include documenting and sharing best practices for this simple and promising intervention, while continuing to monitor and report on its impact on providers, patients, and families. The authors declare no conflicts of interest Self-harm and COVID-19 Pandemic: An emerging concern -A report of 2 cases from India A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of the HCID programme Perspectives of Vancouver Island Hospice Palliative Care Team Members on Barriers to Communication at the End of Life: A Preliminary Study The Lancet. Palliative care and the COVID-19 pandemic. The Lancet Grief During the COVID-19 Pandemic: Considerations for Palliative Care Providers PPE Portraits-a Way to Humanize Personal Protective Equipment Continuity, Coordination, and Transitions of Care for Patients with Serious and Advanced Illness: A Systematic Review of Interventions The Role and Response of Palliative Care and Hospice Services in Epidemics and Pandemics: A Rapid Review to Inform Practice During the COVID-19 Pandemic Acknowledgements: Thanks to Alexis Amano for support on this work.