Assessing the confidence, knowledge and learning preferences of healthcare workers regarding personal protective equipment use during the coronavirus disease 2019 (COVID-19) pandemic

We surveyed healthcare workers at an urban academic hospital in the United States about their confidence in and knowledge of appropriate personal protective equipment use during the coronavirus disease 2019 (COVID-19) pandemic. Among 461 respondents, most were confident and knowledgeable about use. Prescribers or nurses and those extremely confident about use were also the most knowledgeable.

Appropriate use of personal protective equipment (PPE) by healthcare workers (HCWs) is critical to preventing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). [1][2][3] Although studies have examined HCW knowledge of appropriate PPE practices in the context of the coronavirus disease 2019 (COVID-19) pandemic outside the United States, to our knowledge no evaluation of HCWs in the United States has been published. 4,5 In this study, we examined the confidence, knowledge and learning preferences of HCWs with regard to PPE practices during the COVID-19 pandemic in an urban academic hospital in the United States.

Methods
A 22-item survey (provided in the Appendix online) was distributed between July 14 and July 31, 2020, to emergency department and inpatient medical center HCWs at the University of Chicago Medical Center, which includes an adult and free-standing children's hospital with 811 beds and >35,000 inpatient admissions and 100,000 emergency department visits annually. Surveyed HCWs included physician and nurse providers, social workers and care coordinators, nutritionists, chaplains, pharmacists, phlebotomists, therapists, patient transporters, and dialysis and environmental cleaning technicians. The survey was e-mailed to HCWs by their local leadership, and the responses were used to assess demographics, confidence in and knowledge of PPE best practices, and preferences for learning about PPE practices. Responses were captured anonymously using Research Electronic Data Capture (REDCap). 6 Those who had not worked in the emergency department or on an inpatient hospital unit during the pandemic (between March 15, 2020, and the survey distribution dates) were excluded.
Responses were reported using absolute counts and proportions. Logistic regression examined the association between staff role (ie, prescriber [physician, advanced practice provider], nurse, other), being "high risk" for severe disease (ie, yes, no, prefer not to answer), and confidence in PPE practices (ie, extremely, somewhat, other) with answering all 4 core-knowledge-based questions correctly. "High risk" was defined as those high risk for severe illness from COVID-19, or living with someone who is "high risk," and included older adults, those with chronic lung disease or moderateto-severe asthma, diabetes, severe obesity, serious heart conditions, an immunocompromised state, chronic kidney disease, and/or chronic liver disease. [7][8][9] Knowledge-based questions were informed by published guidance from relevant organizations locally and globally, 7-9 and they assessed the following: donning practices prior to entering a room of a patient with COVID-19 or persons under investigation (PUI) for COVID-19 infection (including the need to perform hand hygiene prior to donning, and use of the appropriate mask/respirator, gowns, gloves and eye protection); doffing practices (including doffing gown and gloves prior to leaving a COVID-19 or PUI patient room); appropriate extended use of one's N95 respirator; and use of an appropriate respirator prior to entering a COVID-19 or PUI room during an aerosol-generating procedures. Analyses were conducted using Stata software (College Station, TX). This project was deemed a formal quality improvement study, and as such it was not reviewed by the institutional review board, which is consistent with institutional policy.

Results
Of the 531 respondents, 461 (87%) were eligible for inclusion. Most eligible respondents were female; most reported their race as white; >80% worked in adult settings; and up to 30% worked in pediatric settings (Table 1). Most provided direct care to patients with COVID-19 or PUIs, but <20% of respondents provided direct care to patients in the COVID-19 cohort units that were established during the peak of the pandemic, from March 20 to June 24, 2020. Also, >25% of respondents considered themselves or those they lived with "high risk" for severe illness from COVID-19 infection, but few reported being diagnosed with COVID-19. Most were extremely or somewhat confident about PPE use. They correctly answered questions examining core knowledge of PPE best practices; they always or often used isolation signage to facilitate PPE use; and they found PPE isolation signage helpful in facilitating appropriate PPE practices ( Table 2).

Discussion
In a convenience sample of emergency department and inpatient HCWs in an urban academic hospital in the United States, most were confident and knowledgeable about PPE use in the context of COVID-19, and they found PPE signage helpful in facilitating appropriate PPE use. Those who were prescribers or nurses, and those who were extremely confident about PPE use were most knowledgeable about PPE practices.
Confidence about and core knowledge of appropriate PPE practices appeared to be greater in our study than in studies of HCWs outside the United States. For example, ∼50% of respondents in a study of HCWs in an academic pediatric hospital in Canada correctly identified the appropriate sequence of donning PPE compared to 77% of respondents in our evaluation, 4 despite assessing knowledge at similar time points in the global pandemic (ie, mid-2020) and including a similar distribution of prescribers and nurses and respondents providing care in the emergency and intensive care settings. Confidence and core knowledge were also higher in our study compared to estimates reported in a nationwide survey of nurses in the United Kingdom. 5 The higher estimates reported in our study could be due to remaining differences between our respondents and those in the other studies referenced, such as the inclusion in our study of more providers specializing in the care of adults and exclusively providing care in an academic setting. Differences in approaches to training may also have resulted in greater confidence and knowledge. For example, our institution used a multimodal approach to educating HCWs about PPE practices, including e-mail communications, instructional videos, town halls, team huddles, in-person observers, and isolation precaution signage developed using principles of human-centered design. 10 Our study had several limitations. Our estimates were from a single site, and responses were self-reported. In addition, our statistical analyses were unadjusted. However, our study did include a Prefer not to answer/Other 22 (4.8) Note. APP, advanced practice provider; COVID-19, coronavirus disease; PUI, person under investigation. "High risk" denotes those who are at high risk for severe illness from COVID-19, or live with someone who is at high risk, and includes older adults, those with chronic lung disease or moderate to severe asthma, diabetes, severe obesity, serious heart conditions, an immunocompromised state, chronic kidney disease, and/or chronic liver disease.