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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 53-59

Awareness about donning and doffing of personal protective equipment among doctors working in a fever clinic of West Bengal


1 Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India

Date of Submission25-Aug-2020
Date of Acceptance06-Oct-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Dr. Kuntala Ray
Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_269_20

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  Abstract 

Background: Fever clinics were established across the country for screening of patients suggestive of coronavirus disease-2019 (COVID-19). The doctors posted in these clinics were provided with personal protective equipment (PPE) for their protection. Improper use of these equipment may result in infection.
Objectives: The objective is to assess the awareness of doctors posted at fever clinic regarding donning and doffing of PPE.
Materials and Methods: A cross-sectional descriptive study was carried out from May to June 2020 on doctors posted at the fever clinic of Sambhunath Pandit Hospital, Kolkata by census method using a predesigned, pretested structured questionnaire (Google form). Statistical analysis was done with the help of appropriate statistical software.
Results: None of the doctors working in the fever clinic had adequate knowledge regarding steps of donning and doffing of PPE while 77.4% doctors did not know the correct steps of maintaining hand hygiene. Still the percentage of participants with satisfactory knowledge and satisfactory attitude regarding PPE was 84.9% and 62.3%, respectively.
Conclusions: This study suggests that there is a need for active training of the study population in order to effectively protect them from COVID-19.

Keywords: Coronavirus disease-2019, doffing, donning, fever clinic, personal protective equipment


How to cite this article:
Mishra A, Shukla V, Saha R, Ray K, Misra R, Basu M. Awareness about donning and doffing of personal protective equipment among doctors working in a fever clinic of West Bengal. Indian J Health Sci Biomed Res 2021;14:53-9

How to cite this URL:
Mishra A, Shukla V, Saha R, Ray K, Misra R, Basu M. Awareness about donning and doffing of personal protective equipment among doctors working in a fever clinic of West Bengal. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Mar 2];14:53-9. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/53/308960




  Introduction Top


The year 2020 witnessed a public health emergency of international concern due to outbreak of coronavirus disease-2019 (COVID-19). As there was neither any vaccine to prevent the infection nor was there any specific antiviral treatment, the management of the disease posed the greatest challenge to mankind. Different countries came up with different plans to tackle the problem. One such strategy adopted by the Indian Government to cater to the needs of the people with symptoms suggestive of COVID-19 was establishment of the “FEVER CLINIC” for screening and treatment of influenza like illness or severe respiratory tract infection.

The doctors working in the fever clinic are at an elevated risk of acquiring the infection than doctors posted at other OutPatient Departments as they are involved in screening the COVID suspects. In order to ensure their protection, the government is providing them with personal protective equipment (PPE) which includes protective clothing, masks, goggles, or other garments or equipment designed to protect the wearer's body from infection.

The term PPE has been defined by the Occupational Safety and Health Administration, as the “equipment that protects employees from serious injury or illness resulting from contact with chemical, radiological, physical, electrical, mechanical, or other hazards.”[1] In spite of provision of the best PPE kits, the user may contract the infection if he/she does not follow the guidelines for correct use of these equipment.[2]

Studies conducted in Ohio[3] and Pittsburg,[4] reported self-contamination rates >40% while doffing PPE, especially during the removal of gloves. This means that hand hygiene is also an integral part of the guidelines for use of PPE which helps in reducing the transmission of pathogenic microorganisms to patients and HCWs.[5] Systematic reviews have suggested that hand washing with soap caused a 16% reduction in risk of respiratory infections.[6] Hand hygiene compliance rates of ≤50% have been documented repeatedly, along with considerable difficulties in improving them, for many years.[7],[8],[9],[10],[11]

With this background, a study was conducted with the objectives to measure the knowledge regarding donning and doffing of PPE along with steps of hand washing among doctors posted at the fever clinic of Sambhunath Pandit (SNP) Hospital, Kolkata; to estimate the attitude of the study population towards donning and doffing of PPE and to record the suggestions by the study population to improve adherence to the guidelines for proper use of PPE.


  Materials and Methods Top


Study design, setting, and population

An Institution based descriptive study; cross-sectional in design was carried out among doctors posted at the fever clinic of SNP Hospital, Kolkata, from May 20 to June 26, 2020 over a period of 1 month.

As per the inclusion criteria, doctors who were posted in the fever clinic at SNP Hospital for at least 1 day (9 am to 2 pm) from March 20, 2020, to May 31, 2020, and gave informed electronic consent to participate in the study were included. Those unwilling to participate in the study and those who served both as the participant and the investigator in the study were excluded.

The list of doctors working in the fever clinic at SNP Hospital was obtained from the institute with the permission of The Medical Superintendant cum Vice Principal, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital (IPGME&R and SSKMH). The list included 68 doctors, who served as the study population (Census). No sampling technique was followed.

Data collection was initiated after applying for ethical clearance from the Ethical clearance obtained from IPGMER Research Oversight committee( Institutional Ethics Committee of IPGMER) with memo no. IPGMER/IEC/2020/645 Dated 30.09.20; informed electronic consent was obtained from the study population after explaining the purpose and nature of the study and ensuring their anonymity and confidentiality. An online survey was conducted with the help of the study tool-which was a predesigned, pretested structured questionnaire (Google form) in English. The questionnaire was designed and standardized with the help of a team of 3 experts in the subject. After the questionnaire was designed it was pretested among 10 doctors. Minor corrections were made in the questionnaire. The Google form was designed in a way to avoid multiple entries from the same respondent. Out of the total study population of 68 doctors, 2 were excluded as they were investigators in this study. Rests of the 66 doctors were approached, of which 53 agreed to participate in the study.

Data from the Google forms were then tabulated into Microsoft Office Excel 2010 (Microsoft Corp., Redmond, WA, USA) and analysis was done using Statistical Package for the Social Sciences (SPSS) Version 25.0 (IBM, New York, United States). Chi-square test was used to test the association between the dependent (steps of hand washing, satisfactory knowledge, and positive attitude scores related to PPE) and the independent variables (socio-demographic variables and training). A P < 0.05 was taken as significant.

Total attainable knowledge score ranged from 0 to 14 and it was based on 14 questions which took: (1) knowledge about items to be avoided inside the fever clinic; (2) content of a PPE kit; (3) minimum number of gloves that should be present in the PPE kit; (4) necessity of changing gloves in between patients; (5) use of face shield in place of goggles; (6) use of shoe covers as a substitute for rubber boots; (7) use of disposable apron in place of disposable gown or coverall; (8) steps of donning PPE; (9) steps of doffing PPE; (10) steps of performing hand hygiene; (11) duration of washing hands using soap and water; (12) duration of washing hands using alcohol based hand rub; (13) number of times hand hygiene has to be performed during the process of donning PPE; and (14) ideal frequency of hand hygiene while doffing PPE. A score of “one (1)” was awarded for correct response; while for each incorrect response score “zero (0)” was assigned.

Total attainable attitude score ranged from 0 to 9 and it included 9 questions which enquired about the: (1) views of the participants regarding importance of correct use of PPE; (2) need for training in donning and doffing PPE; (3) significance of institutional training; (4) requirement for provision of facility in the fever clinic to keep away belongings such as mobile phone and purse; (5) necessity for hand washing during donning and doffing; (6) essentiality to have a separate room for donning and doffing PPE; (7) presence of mirror in the area used for donning and doffing; (8) supervision by a trained person to increase adherence to guidelines for donning and doffing; and (9) their wish to know about the correct sequence of steps for donning and doffing PPE. Scoring scheme was similar to that for the calculation of knowledge scores.

The participants were said to have a satisfactory knowledge or a positive attitude, if the scores attained by them were more than or equal to the median. P < 0.05 was considered as statistically significant.

Operational definitions

Personal protective equipment

“The protective equipment consists of garments placed to protect the health care workers or any other persons to get infected. These usually consist of standard precautions: gloves, mask, gown. If it is blood or airborne high infections, will include: Face protection, goggles and mask or faceshield, gloves, gown or coverall, head cover, rubber boots.”[12]

Donning

The act of putting on an item of clothing.

Doffing

The act of removing an item of clothing.


  Results Top


A total of 53 doctors had participated in the study of which 45.3% belonged to the age group of ≥30 years, 83% were males, 28.3% were from the Department of General Medicine and 54.7% were holding the post of Post-Graduate Trainee. About 47% had an experience of 1–5 years' post completion of internship and 77.4% had been working in the fever clinic for the duration of <1 week.

A training session by means of live demonstration (offline) on donning and doffing of PPE was organized by the Department of Microbiology, IPGME&R and SSKMH but 45.3% participants were unaware about it. About 47% of the study population had received institutional training, 11.3% gained knowledge from online sources while 41.5% had not received any training [Figure 1]. About 43% participants had attended live lecture, 15.1% had acquired training through video lectures but no participant had procured hands on training in donning and doffing of PPE.
Figure 1: Pie diagram showing distribution of the study population based on source of training received

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The various components of knowledge and attitude regarding PPE are shown in [Table 1]. About 55% doctors did not feel the need to change gloves in between patients. 77.4% doctors did not know the correct sequence of washing hands. When the knowledge and attitude scores were computed, it was observed that the percentage of participants with satisfactory knowledge (considering a median knowledge score of 4) and positive attitude (considering a median attitude score of 9) regarding PPE were 84.9% and 62.3% respectively [Figure 2] but the knowledge-attitude gap was not statistically significant (P = 0.37). None of the factors studied were found to be associated with satisfactory knowledge and positive attitude regarding PPE [Table 2]. Those from the Department of Pediatrics (P 0.02) and those at the post of Post Graduate Trainee (P 0.02) had better knowledge of the steps of hand washing [Table 3]. Training neither shared a statistically significant association with satisfactory knowledge and attitude regarding PPE nor was it related to correct knowledge of steps of hand washing [Table 2] and [Table 2].
Table 1: Knowledge and attitude of the study population about personal protective equipment (n=53)

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Table 2: Association of knowledge and attitude of personal protective equipment with sociodemographic variables and training (n=53)

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Table 3: The knowledge of steps of hand washing with socio-demographic variables and training among the study subjects (>N=53)

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Figure 2: Bar diagram showing distribution of the study population as per their knowledge and attitude regarding donning and doffing of personal protective equipment

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On enquiring about the facilities provided by the institute, we learnt that the PPE kit provided by the institute consisted of 2 pairs of gloves, surgical cap, shoe cover, cover all, surgical face mask, N95 mask and goggles. Facilities for maintenance of proper hand hygiene were provided. Although there is no separate room for donning and doffing, separate donning and doffing areas have been delineated.

The suggestions of the participants are shown in [Table 4]. The participants stated that arrangement of a separate room for donning and doffing in place of the donning and doffing areas would be more convenient. They also felt that display of a chart showing steps of donning and doffing of PPE in the donning and doffing zone could minimize error in donning and doffing. Donning and doffing under the supervision of a fellow doctor and provision of hands on training would help in increasing adherence to the guidelines for appropriate use of PPE. Some of them also felt the need to improve the quality of contents of the PPE kit provided.
Table 4: Distribution of the study population according to the suggestions given by them to improve adherence to the WHO recommendations for donning and doffing of personal protective equipment (n=53*)

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  Discussion Top


Most of the studies on PPE have been conducted during or after the Ebola outbreak. There is a dearth in studies on use of PPE during COVID-19 outbreak, especially on donning and doffing of PPE as per guidelines among health care workers.

In the present study, no participant was observed to possess the correct knowledge of steps of donning (0%) and doffing (0%) of PPE which is lower than the findings of the study conducted by Archana Lakshmi et al.[13] in tertiary centres of Tamil Nadu and Mitchell et al.[14] in Canada where the order of removal of the PPE was correctly answered by 12.1% and 54% participants, respectively.

The current study revealed that only 32.6% doctors knew the correct sequence of washing hands which was three times less than the findings of Nair et al.[15] where 91.3% medical students possessed the correct knowledge of steps of hand washing. This difference may be because medical students are in the learning phase and understand the need to keep themselves updated. As per this study, those from the Department of Pediatrics and those at the post of Post Graduate Trainee had better knowledge of the steps of hand washing. The reason for better knowledge regarding hand washing among postgraduate trainees (34.5%) and pediatricians (46.2%) may be due to the fact that Post graduate trainees are under constant supervision of their trainers while pediatricians are involved in the care of neonates, infants, and children who are at a greater risk of acquiring infection if not handled properly.

Almost all (99%) doctors in the Tamil Nadu study[13] and 56.3% participants in the study by Asare et al.[16] changed gloves in between two patients, while only 45.3% doctors in our study felt the need to change gloves in between patients. This may be because of lack of availability of sufficient number of gloves in the present settings.

In the present study, 41.5% had not received training in any form which is less than the study by Aguwa et al.[17] where 55.2% were untrained. 45.3% participants in our study were unaware about institutional training which was higher than the Nigerian study[17] where 38.7% were not aware of any hospital policy on PPEs. This may be because the institute did not enforce compulsory institutional training on PPE.

The percentage of participants with satisfactory knowledge and positive attitude regarding PPE in the present study was 84.9% and 62.3%, respectively. These findings are not supported by observations of John et al.[18] and Archana Lakshmi et al.[13] where these parameters were suboptimal. This is because we have considered a score more than or equal to median as satisfactory and the median knowledge score in this study is 4 (total knowledge score = 14). None of the independent variables were found to be statistically associated with satisfactory knowledge or attitude regarding PPE in our study. This may be attributed to the small sample size in our study and the fact that the participants share similar educational qualification and working environment.

The participants of the current study suggested that presence of a fellow doctor as supervisor to observe their steps while donning and doffing PPE could also increase adherence to protocols. According to the study by Aguwa et al.[17] the main reason for noncompliance were nonavailability of PPE, forgetfulness, perception of low risk to infections and ill-fitting PPE.

Like other studies, our study had some limitations: It was a hospital-based study with cross-sectional design. The study was conducted over a shorter period of time and in a single fever clinic and among a smaller population. Besides, the study did not make use of any checklists to observe the practice of donning and doffing of PPE among the participants.


  Conclusions Top


Among the doctors posted in the fever clinic at SNP Hospital, the percentage of participants with satisfactory knowledge and positive attitude regarding variables of donning and doffing of PPE were 84.9% and 62.3%, respectively, though none possessed the correct knowledge about steps of donning and doffing PPE. Near about 80% participants were not accustomed with the correct sequence of washing hands. Training, which should have a positive association, was not found to have an influence on knowledge and attitude regarding PPE. Hence, a second training session may be conducted, especially for the doctors working at the fever clinic ensuring 100% attendance. A fellow doctor could act as a supervisor both during donning and doffing of PPE. Provision of a checklist along with display of a poster showing sequence of donning and doffing of PPE would help in reinforcing present knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
World Health Organization. Emergencies Preparedness, Response. How to put on and how to Remove Personal Protective Equipment – Posters. Geneva, Switzerland: World Health Organization; 2015. Available from: https://www.who.int/csr/resources/publications/ebola/ppe-steps/en/. [Last accessed on 2020 Jun 11].  Back to cited text no. 2
    
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Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerg Infect Dis 2001;7:234-40.  Back to cited text no. 11
    
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World Health Organization. Medical Devices. Personal Protective Equipment. Geneva, Switzerland: World Health Organization; 2014. Available from: https://www.who.int/medical_devices/meddev_ppe/en/. [Last accessed on 2020Jun 10].  Back to cited text no. 12
    
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Archana Lakshmi PA, Gladius Jennifer H, Meriton Stanly A, Paul CM. A study on personal protective equipment use among health care providers, Tamil Nadu. Int J Community Med Public Health 2018;5:1771-4.  Back to cited text no. 13
    
14.
Mitchell R, Roth V, Gravel D, Astrakianakis G, Bryce E, Forgie S, et al. Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals. Am J Infect Control 2013;41:240-4.  Back to cited text no. 14
    
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Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a Tertiary Health Care Centre in Raichur, India. ISRN Prev Med 2014;2014:608927. doi: 10.1155/2014/608927. PMID: 24967144; PMCID: PMC4045463.  Back to cited text no. 15
    
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Asare A, Enweronu-Laryea CC, Newman MJ. Hand hygiene practices in a neonatal intensive care unit in Ghana. J Infect Dev Ctries 2009;3:352-6.  Back to cited text no. 16
    
17.
Aguwa EN, Arinze-Onyia SU, Ndu A. Use of personal protective equipment among health workers in a tertiary health institution, South East Nigeria: Pre-Ebola Period 2016;6:12-8.  Back to cited text no. 17
    
18.
John A, Tomas ME, Cadnum JL, Mana TS, Jencson A, Shaikh A, et al. Are health care personnel trained in correct use of personal protective equipment? Am J Infect Control 2016;44:840-2.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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