Skin damage due to personal protective equipment among nursing staff in a dedica

Avatarkishan JAISINGHANI, Vikas GUPTA,Amanjot Kaur CHAUHAN

1Department of Dermatology, Government Medical College,Shahdol, Madhya Pradesh, India; 2Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh,India; 3Department of Community Medicine, K D Medical College,Hospital and Research Centre, Mathura, Uttar Pradesh, India

ABSTRACT

Background:Nursing staff are at much greater risk of infection (Ebola virus diseases and severe acute respiratory syndrome) due to their exposure to highly infectious bodily fluids and droplet nuclei and the need for personal protective equipment (PPE) to reduce the transmission risk.

Aim:The present study was conducted to estimate the prevalence of skin injuries and their types due to PPE usage among nursing staff in tribal India.

Materials and Methods:This descriptive cross-sectional study was conducted in the dedicated coronavirus disease-2019 (COVID-19)hospital for a period of 4 months among 144 nursing staff wearing Grade 2 and 3 PPE kits.Study subjects were approached through social networking websites and survey questionnaires (Google forms) according to relevant guides, and research literature was used to collect the details regarding baseline, duty, and skin injury characterization.Chi-square test was used to find the association between skin injury and baseline or duty characteristics, and the association was significant at a P ＜ 0.05.

Results:It was observed that 54.7% of nursing staff were working for 6 or more hours and 16.5% of subjects were wearing the PPE kit for 5 or more hours per day.Skin injury was reported by 86.3% of the subjects after using PPE.Skin injuries among nurses were statistically significant with their current place of stay and daily duty hours (P ＜ 0.05).

Conclusion:In this study, it was found that 86.3% of subjects had suffered from skin injuries by using PPE while caring for COVID-19 patients during duty hours, so an effective preventive measure should be adopted.

Keywords:Coronavirus disease-2019, N-95 mask, nursing staff, personal protective equipment, skin injury

INTRODUCTION

Personal protective equipment (PPE) refers to equipment used to avoid or reduce accidental injuries and occupational hazards at work, and it is meant to protect against the physical, chemical, and biological factors encountered in the work environment.With the emergence of highly infectious epidemics such as Ebola virus diseases and severe acute respiratory syndrome, nursing staff are at a much greater risk of infection than the general population due to their exposure to the highly infectious bodily fluids and droplet nuclei in the immediate patient environment.Hence, treating and caring for such patients needs contact precautions by means of PPE to reduce the transmission risk.[1,2]The use of this protective equipment has again gained attention among health-care workers during the global public health emergency due to the coronavirus disease-2019 (COVID-19)that appeared in December 2019.Nursing staff are highly at risk of contracting COVID-19 while caring for patients, as they have a prolonged duration of exposure while performing many care interventions, including aerosol-generating procedures.[3]Furthermore, there is a common concern about infecting family and friends among nurses.Due to the perceived risk of being infected, the nursing staff generally restrict their social contacts.There is even a feeling of being isolated by their family members and friends because of their hospital work, which in turn pressures them to be absent from work.[4]

Based on the precautionary protocols adopted by various agencies in controlling the infection, adequate use of PPE is reasonable based on the evidence, especially when aerosol-generating medical procedures are being performed.[5]It is shown in the literature that health-care workers who used masks, gowns, and hand washing had a lower likelihood of developing infection than those who did not use them.[6]

Since the mode of transmission of the disease has been established to be respiratory droplets and indirect contact with fomites, the use of PPEs is essential to prevent the cross-transmission of the infection.The PPEs comprise the equipment that protects the mouth, nose, eyes, ears, bare skin, and vulnerable parts, such as the head and hands, from the deadliest infectious secretions of the patients.PPE has been linked to a variety of skin injuries, including pressure injuries, contact dermatitis, pressure urticaria, and exacerbations of preexisting skin diseases such as seborrheic dermatitis and acne.[7,8]

The present institution was started 3 years ago, and the process of recruitment of nursing staff is ongoing.The number of nursing staff ranged from 140 to 150.The college,being in an evolving phase, has no nursing students, so nursing staff alone has to look after the patients in the COVID-19 wards besides doctors.With a limited number of nursing staff, the duties are less rotated, and this means more hours of work for providing nursing care to the patients and more hours of wearing the PPE kit while providing care to the patients.The documented skin injuries due to the PPE kit include device-related pressure injuries,moisture-associated skin damage, and skin tears, mostly for the patients, and no reports of skin injuries among nursing staff wearing PPE have been seen during COVID-19, which needs to be addressed urgently.As a result, we planned to conduct a descriptive study to estimate the prevalence of skin injuries and their types, determine the association of related factors with skin injuries, and analyze the problems in the prevention and treatment of skin injuries among nursing staff during the COVID-19 pandemic, which will serve as a foundation for developing strategies for preventing and treating skin injuries in the upcoming third wave of the pandemic.

MATERIALS AND METHODS

Study setting and design

This descriptive cross-sectional study was conducted in the dedicated COVID-19 hospital (DCH) at Government Medical College, Shahdol, Madhya Pradesh for a period of 4 months (March 2021 to June 2021).On March 27, 2020,GMC Shahdol was recognized as an official site as DCH for managing COVID-19 patients when the disease started to occur in epidemic proportions in India.

Study population and sample size

The study subjects were nursing staff currently working at DCH, Shahdol at the time of the study.The list of the study subjects was obtained from the Medical Superintendent’s office along with their contact details (email and phone),which counted to 144 eligible subjects.

The sample size was calculated (n = 97) considering the proportion of nursing staff having PPE related skin damage as 50% (studies not found in Madhya Pradesh) with a confidence level of 95% and 10% absolute allowable error by applying the following formula:N = (Z1-a/2)2× p (1 - p)/d2; where Z = Standard normal variate for level of significance (at 5% Type I error [P＜ 0.05], Z = 1.96 for 2-sided test), a = Level of significance (0.05),p= Prevalence (proportion-50%),d = Absolute Allowable error (10%),n= Sample Size, so we included all the eligible study participants, which counted to be 144, for the present study.

Study subject inclusion criteria were as follows:(1) nursing staff (age ≥18 years, regardless of gender) who cared for the suspicious and positive COVID-19 cases in intensive care unit, high dependency unit, general wards, isolation wards, and private wards with moderate to severe-risk exposure and were wearing surgical masks with goggles or protective face masks and protective gowns (referred to as Grade 2 PPE) or N95/KN95 respirators with goggles or protective face masks, protective gowns, latex gloves,and shoes (referred to as Grade 3 PPE); (2) Participants who volunteered.

Nursing staff who did not wear PPE or who did not contact suspicious or confirmed COVID-19 patients were excluded from the study.

Study tool and measurements

We designed a survey questionnaire according to relevant guides and research literature[9-11]and reviewed and revised it three times by consulting dermatologists, statistical experts, and nurse-in-charges, and feedback was taken from some medical staff posted in DCH, Shahdol.It gathered baseline data (such as age, gender, marital status, current place of number of household members, years of work); duty characteristics including PPE usage (such as daily working hours, night duties/month data, how many days in a week do you wear your PPE kit, duration of PPE wearing while caring for patients); PPE-induced skin injuries characterization,including preventive and treatment modalities taken for them (such as skin reactions related to masks, goggles/face shields, protective clothing, preventive measures taken to avoid skin injuries due to PPE, and treatment sought for the skin injury that occurred).

Data collection

Participation in this survey was voluntary and was not compensated.After obtaining complete list of the study subjects, they were approached and recruited through social networking websites (Facebook, Twitter, and WhatsApp), and the password-protected survey links containing Google forms were posted on the same, which also included the contact details of the dermatologist (investigator).[12]An introductory paragraph outlining the aims and objectives of the study as well as instructions to complete the questionnaire were explained in the survey link, especially mentioning that if any of the nursing staff have any kind of PPE related skin injuries at present, they should visit the dermatologist in the Outpatient department hours or consult for any queries during suitable hours over the phone.All the questions were mandatory.Informed consent was obtained from each subject before participation.Sufficient time was given to subjects to read, comprehend, and answer all the questions,and the subjects could not change their answers after submission of the questionnaire.The subjects were given a week’s time to voluntarily complete the questionnaire, and those who did not respond back to the questionnaire within the defined time (three or more consecutive reminders)were declared nonrespondents and were excluded from the study.The questionnaire was checked for completeness by the investigator himself, and incomplete questionnaires were excluded from the study.The subjects having skin injuries at present were examined by a dermatologist for the sites, symptoms, signs, and systematic features of skin injury, and treatment was prescribed for them.[7]All information pertaining to the subjects was kept anonymous and confidential.The study was performed following the Checklist for Reporting Results of Internet E-Surveys guidelines.

Statistical analysis

Collected data were entered into the Microsoft (MS) Excel spreadsheet, coded appropriately, and later cleaned.Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp.Armonk, NY, USA).During data cleaning, to facilitate association of variables, more categories among variables (such as year of work) were created.Clear values for various outcomes were determined before running frequency tests.Categorical data were shown as percentages (%), whereas quantitative data were shown as a mean (standard deviation).The baseline and duty-related characteristics were considered the independent variables,and the presence of skin injuries was considered the dependent variable.A Chi-square test was used to find the association between dependent and independent variables.During statistical analysis using the Chi-square test, the cells having values ＜5 for any of the independent variables were not considered for the analysis and were not shown in the results section.All tests (two-tailed) were performed at a 5% level of significance; thus, an association was significant if theP＜ 0.05.

Ethical considerations

All ethical issues were followed during the study.Participation was voluntary and participants were allowed to withdraw from the study at any moment.No personal data was recorded.Participants were assured that all data collected was used only for the current study.The study was initiated after approval from the Institutional Ethics and Review Board of Government Medical College, Shahdol, Madhya Pradesh, India(Project ID:IERC/21/07/001) on August 9th, 2021.In addition,before filling out the questionnaire, participants were asked to give their consent to participate in the study.

RESULTS

Out of a total of 144 study subjects, 139 provided their responses to the questionnaire (response rate 95.6%).The mean age of study subjects was 27.2 ± 4.2 years.More than half of the study subjects had General Nursing and Midwifery as their qualification (53.2%, 74/139).Furthermore, more than half of nursing subjects were unmarried (57.6%, 80/139).Only 5% of nursing staff (7/139) had worked for 5 years or more after graduating from college, and nearly one-quarter of subjects (23.7%, 33/139) were currently residing in a campus hostel [Table 1].

Table 1:Baseline characteristics of study subjects (n=139)

During the peak of the COVID-19 pandemic, the present medical college was established as a DCH, so most of the nursing subjects (95.7%, 133/139) were recruited on a contractual basis.More than half of nurses (54.7%, 76/139) were working for 6 or more hours during their routine shifts in DCH, and more than one-fourth of subjects (28.1%, 39/139) had night shifts for more than 10 days in a month.More than a tenth of nurses (16.5%,23/139) wore the PPE kit for 5 or more hours per day during duty hours, and 11.5% (16/139) reported absenteeism from duty hours due to PPE-induced skin injuries [Table 2].

Table 2:Duty characteristics of study subjects (n=139)

More than four-fifths of subjects (86.3%, 120/139) reported skin injury as a result of PPE use during duty hours [Table 3].Skin injuries among subjects were mainly due to the use of masks and Google/face shields (74.8%, 104/139), followed by the use of latex gloves (70.5%, 98/139) and protective clothing (32.4%, 45/139).Commonly reported symptoms and signs of skin injuries were indentation and pain on the back of ears (61.9%, 86/139); skin itching or rash (39.6%, 55/139); skin soaking in sweat (37.4%, 52/139); and dry skin (36.0%, 50/139).

Table 3:Characterization of personal protective equipment induced skin injuries among study subjects (n=139)

When subjects were asked whether they opted for any preventive measures to avoid skin injury due to the PPE kit, more than half the subjects (60.4%, 84/139) denied such preventive measures were used.Only two-fifths (40%, 48/120)of those who suffered from the skin injury sought treatment for it [Table 4].

Table 4:Characterization of preventive and treatment modalities taken for skin injuries among study subjects (n=139)

To find the association of reported skin injuries with the subject’s various characteristics, the Chi-square test was used, and the cells with a value ＜5 were not shown in Table 5.It was observed that skin injury was more frequent among subjects being married (89.2%, 66/74); staying at home (89.6%, 95/106); and having 2 or more members at their current place of stay (86.6%, 84/97).Furthermore, skin injuries were frequent among subjects who were daily working for 6 or more hours (92.1%, 70/76); wearing PPE kits for 5 or more days in a week during duty hours (89.7%, 61/68); and wearing PPE kits for ＞2 h while on duty at DCH (89.9%, 80/89), but skin injuries were statistically significant with two variables only, i.e., current place of stay and daily duty hours (P＜ 0.05).

Table 5:Association of skin injuries with the baseline and duty characteristics of study subjects (n=139)

DISCUSSION

The present study made an attempt to find if skin injuries occurred after PPE kit usage among nursing staff, and it was found that 86.3% of subjects had suffered from skin injuries after PPE usage during duty hours.In a study by Lanet al.,[13]a similar prevalence of skin injury (97.0%) caused by infection-prevention measures among subjects was observed, whereas the study by Navarro-Triviño and Ruiz-Villaverde,[14]showed a lower prevalence of skin injury (12.7%) among subjects.The differences in the prevalence of the skin injuries probably reflects that series of general recommendations (General Skincare tips during the COVID-19 pandemic) established for all health workers in the present institution was not adopted in a proper manner by them.

While analysis more specifically about which content of the PPE kit caused frequent skin injuries among nursing staff,it was revealed that masks and goggles/face shields caused skin injuries among 74.8% of nurses, followed by latex gloves and preventive clothing, which caused skin injuries among 70.5% and 32.4% of nursing staff, respectively.In a study by Singhet al.,[15]goggles were the most common culprit agent among all PPE causing any one of the dermatoses (51.92%),followed by N95 masks (30.77%) and face shields (17.31%).

Indentation and pain on the back of the ears (61.9%) caused by masks or goggles, followed by skin itching or rash (39.6%), skin soaking in sweat (37.4%), and dry skin (36.0%) caused by latex gloves, whether powdered or nonpowdered, were the most commonly expressed symptoms/signs of the skin injury that occurred, and this was consistent with findings from studies conducted by Agarwalet al.[10]and Soraganviet al.[11]Similarly,a study by Huet al.[16]showed that the most common adverse skin reactions among health-care workers wearing N95 masks were nasal bridge scarring (68.9%) and facial itching (27.9%).

During the COVID-19 pandemic, the present medical college was established as a DCH, and most nurses (95.7%) were recruited on a contractual basis.The rapid rise of cases during the first and second waves of COVID-19 made nursing staff overburdened, which is reflected by the observation that 54.7% of subjects worked for 6 or more hours during their routine shifts and 28.1% of subjects had duties during night shifts for more than 10 days in a month.Due to an overburdened state, 16.5% of nurses were wearing the PPE kit for 5 or more hours per day during duty hours, which was in coherence with the study by Singhet al.,[15]where 25% of nursing staff were wearing PPE for 6 or more hours, whereas the study by Jianget al.,[9]showed that 85.7% of subjects were wearing PPE for more than 4 h.Due to the continuous wearing hours of the PPE kit, it caused skin injuries among 86.3% of nurses, which made 11.5% of subjects absent from duty hours.A review by Cook also approves the present study relevation.[17]A study by Gheisariet al.[8]has shown that skin irritations caused by PPE may cause discouragement of health workers from using it.Similarly, Viduaet al.[18]expressed concern about increasing numbers of health-care workers having discomfort while using PPE.

The data analysis showed that daily duty hours were significantly associated with the skin injury caused (P＜ 0.05).Similarly, the odds of skin injury were significantly associated with the daily wearing time of PPE kits in studies by Jianget al.[9](95% confidence interval [CI] for odds ratio [OR]:1.61-3.21) and Lanet al.[13](95% CI for OR 1.35-3.01).

The mean age of nursing staff was 27.2 ± 4.2 years, which reflects a young working health force in the present evolving institution due to which only 5% of nursing staff had a total working experience of 5 or more years after passing their college.Although the association was not found significant on data analysis, it was observed that skin injuries were quite frequent among subjects who were married (89.2%) and were not staying alone (86.6%), which shows that married and not staying alone nursing staff were more cautious about using the PPE kit to prevent the spread of COVID-19 to others.A study by Kumaret al.[19]showed that 94.2% of subjects working in COVID-19 hospitals were concerned about infecting family members, and a study by Alnazlyet al.[20]showed that fear of infecting family members was significantly higher among married subjects.

According to studies by Bishoppet al.,[21]Yin,[22]and Darlenski and Tsankov,[7]prophylactic measures such as hydrocolloid dressings and benzalkonium chloride patches could be considered to alleviate the PPE-induced skin injuries, but in the present study, a hesitancy was observed among subjects when it came to the application of preventive measures to avoid skin injury due to the PPE kit, as 60.4% of subjects admitted that none of such preventive measures were considered by them.Even among those who had skin injury, 60% of them lagged in seeking treatment, which was a very similar pattern observed in a study by Jianget al.,[9]where 82.7% and 55.0% of subjects did not take any preventive measures or treatment for skin injury, respectively.

Limitations

Although the minimal desired sample size was calculated in the present study, during analysis using the Chi-square test,it was found that there were a few cells where the value was ＜5 but the association was significant for the variables.Therefore, the author suggests taking a larger sample for such studies or doing multicentric studies instead of single-centric studies like the present one, to avoid such issues.Apart from its limitations, the major strength of the study is that it revealed the types of skin injuries and their prevalence among nursing staff in a tribal district of India.Along with that, subjects with skin injuries were treated by dermatologists during and after the study period.Apart from this, the investigators of the present study have planned a prospective study where a subjective examination will be conducted within 24 h of skin injury occurrence.

CONCLUSION

In this study, it was found that 86.3% of subjects had suffered from skin injuries while using the PPE and corresponding care and preventive measures required among health-care workers caring for COVID-19 patients during duty hours.Hence, appropriate monitoring of these adverse effects should be done, and effective preventive measures should be adopted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.