COVID-19 health facility preparedness for protecting healthcare workers: Designing a tool for rapid self- assessment
The novel coronavirus (2019-nCOV), also known as the severe acute respiratory syndrome 2 (SARS-CoV-2), has caused a worldwide COVID-19 pandemic that has afflicted 6,418,078 people and caused 381,064 deaths as of June 3, 2020.[1,2] In India, COVID-19 has spread in all states across the country, with 2,017,615 cases and 5815 deaths reported at the time of writing.
Frontline healthcare workers (HCWs), including doctors, nurses, technicians, ward, and sanitation workers, are experiencing acute challenges in effectively managing patients while also protecting themselves and their families from COVID-19. Globally, tens of thousands of HCWs have been infected with the coronavirus (SARS-CoV-2), and hundreds have died in the line of duty. In India, according to the Indian Council of Medicine Research, 5.2% of the COVID-19 infected patients are healthcare workers.
HCWs comprise a valuable and irreplaceable resource in global efforts to combat the COVID-19 pandemic. Moreover, HCWs are also subject to the code of medical ethics that instruct them to care unconditionally for their patient but remains disencumbered of their self-protection. However, it is the moral and ethical duty of the administration and government to provide HCWs with the required equipment and facilities for effectively safeguarding their health. Failure to address the concerns of HCWs during large scale COVID-19 outbreaks is likely to undermine their morale, diminish their capacity for efficient and effective caregiving for their patients, and increase their risk of contracting the infection. Furthermore, if HCWs perceive their workplace as being unsupportive and nonchalant to their legitimate grievances and concerns, it can augment their stress and anxiety levels and contribute to impaired mental health.
Tools for rapid assessment of health-care facilities for their preparedness in prioritizing the protection of healthcare workers need development and validation in Indian health settings. Analysis based on such a tool would provide instantaneous feedback to hospital administrators regarding their health system deficiencies concerning COVID-19 and identify the necessary interventions required for improvement.
In the present review, a protocol checklist was designed for the rapid survey and assessment of the extent of preparedness of COVID-19 health-care facilities toward the protection of their healthcare workers.
MATERIAL AND METHODS
The checklist was self-designed after reviewing literature from the following sources:
Studies (original research, review articles, and perspectives) available at PubMed/MEDLINE and published from March 1, 2020, to May 31, 2020, using the following keywords:
Healthcare workers AND COVID-19, (b) health- care employees AND COVID-19, (c). doctors AND COVID-19, and (d) nurses AND COVID-19
National guidelines related to health-care facilities preparedness, personal protective equipment, and testing strategies for COVID-19 published by the Ministry of Health and Family Welfare, Government of India, and the Indian Council of Medical Research. International guidelines issued by the World Health Organization were also reviewed.
Media sources by online and hand searching of news reports published in major national newspapers from March 1, 2020, to May 31, 2020.
Preparedness of COVID-19 health-care facilities
The following preparedness domains were identified [Table 1]:
|Characteristic (domain)||Indicators (item)|
|Local (hospital) guidelines for prevention, risk mitigation, and safe management for HCWs||1. Use of PPE in various zones of the hospital (Wards/OPD Clinics/ICUs/etc.)|
|2. Testing guidelines for HCWs|
|3. Quarantine and home isolation for HCWs|
|4. Hospital admission, discharge, and work resumption guidelines for COVID-19 positive HCWs|
|5. Biomedical waste management in the context of COVID-19-related infectious waste.|
|6. Modality to avail health insurance|
|7. Use of air conditioners|
|8. Easy access to the most recent (updated) guidelines preferably on designated web-portal of the health facility|
|9. Frequency of adherence to guidelines and gap assessment surveys by the designated team|
|Designated donning and doffing areas in the wards and laboratories||1. Present|
|Planning for effective social distancing at outpatient (OPD) clinics||1. Online registration facility for patients|
|2. Fixed number of appointments/day|
|Infection prevention and control measures (adherence and implementation)[11,12]||1. COVID-19 IPC Training to all HCWs (employees) including an overview of COVID-19, hand hygiene and respiratory etiquette, hand hygiene compliance, and information sessions for doctors|
|2. Real-time hand sanitizer stock inventory and demand placement|
|3. Handwashing/hand hygiene facilities|
|4. An adequate supply of tissues and appropriate waste disposal|
|5. IEC*Materials throughout the hospital for promoting proper hand hygiene|
|6. IEC materials for visitors telling them to sneeze into the elbow or use a tissue and disposeimmediately into the waste bin|
|PPE stock maintenance (transparency)||1. Real-time PPE stock inventory and demand placement (PPE suit/surgical mask/N-95 mask/face shield/gowns/headcovers) with the availability of the information at the hospital portal.|
|.||2. Quality control specifications and checks|
|Training in the appropriate use of PPE with emphasis on correct donning and doffing techniques||1. Frequency of training sessions planned|
|2. Record of training sessions conducted|
|3. Attendance record of HCWs attending the training sessions|
|4. Schedule of training sessions|
|5. Availability of validated online training resources for on-demand access|
|Testing and positivity status of HCWs|
|Monitoring and evaluation for risk assessment and development of mitigation strategies||1. Records of HCWs tested (date of exposure/date of testing/test result).|
|2. Records of HCWs awaiting testing after coming in contact with COVID-19 case without wearing PPE.|
|3. Designated preventive team for weekly assessment, reporting of reasons, and issuing recommendations to avert future episodes of HCW infection.|
|4. Adherence to the recommendations of the preventive team by the administration.|
|Complaint and grievance redressal mechanism for frontline HCWs|
|(availability of PPE/Quality of PPE/water and food availability/rational duty rosters/quarantine facilities/abuse or violence by COVID-19 suspected or confirmed patients or their relatives/attendants)||1. Existence of online record-based mechanism for lodging complaints/grievances.|
|2. Time to action and grievance redressal with a designated nodal officer for the escalation of the complaints.|
|3. Assessment of satisfaction of HCWs with the grievance redressal process.|
|4. Monthly administrative meetings to assess reasons for the inability to resolve grievances satisfactorily or delayed grievances|
|Mental health care for early recognition of depression/anxiety/stress among HCWs|
|Resources to manage stress, anxiety, and healthy coping||1. Dedicated helplines for consultation with designated psychologists/psychiatrists.|
|2. Webinars/online resources for stress and anxiety management.|
IEC: Information, education, and communication, HCWs: Healthcare workers
Local guidelines (availability and access) are applicable for health facilities and are correctly adapted and compatible with the recommended international and national guidelines on the testing protocols, quarantine, isolation, admission, biomedical waste management, airborne infection control, etc.
Conduct, timeliness, and adherence to recommendations of gap assessments
Effective inventory management and quality control of personal protective equipment (PPE): The shortage of PPE is a pressing public health concern. Governments globally have been handicapped by the original lack of manufacturing of PPE in their home countries. Information about PPE availability and quality checks should be transparently and openly accessible by healthcare workers at their hospital portal to build a culture of trust and understanding. Moreover, it is the responsibility of expert local, national, and international bodies to ensure that guidelines for the rational use of PPE are genuinely data-driven and not an act of compromise due to deficient supply and availability.
Training sessions for HCWs with a focus on content, timeliness, and access: A significant proportion of COVID-19 infections among HCWs are avoidable through practical training to prevent the risk of contamination during donning and doffing.
Good recordkeeping practices: Maintenance of updated records for HCWs undergoing testing and positivity status allows health-care managers and policymakers to understand the effectiveness of IPC measures at health facilities and the current magnitude of the problem.
Monitoring and evaluation for risk assessment and development of mitigation strategies toward risk reduction among HCWs
Mental health-care assessment for early recognition of mental health symptoms suggestive of depression/ anxiety/stress among HCWs. Surveys have reported a high burden of depressive symptoms and anxiety among HCWs involved in COVID-19 management.
Appropriate grievance redressal mechanisms for demonstrating responsiveness and building trust among HCWs. Media reports in India have reported high rates of infection, lack of PPE, and problems with the availability of quarantine facilities for COVID-19 HCWs.[13-15] Responsiveness on the part of the administration to ensure the rapid resolution of such grievances is needed to meet the ethical principle of reciprocity and uphold confidence and trust in the health system for HCWs.
Healthcare worker satisfaction with their place of work at COVID-19 health facilities: Satisfaction of HCWs with their place of work in terms of risk reduction during pandemics has also been overlooked in Indian health settings. A sample questionnaire for identifying HCW satisfaction with their place of work during COVID-19 outbreaks is depicted in Table 2. More “Yes” responses indicate higher satisfaction, more “No” responses indicate lower satisfaction, and more “Not sure” responses indicate possible hesitation due to concerns over confidentiality and lack of trust in the health system.
|Know where to access local hospital guidelines of testing/quarantine/isolation||Yes||No||Not sure|
|Training received for use of PPE||Yes||No||Not sure|
|Training quality and usefulness||Optimal||Suboptimal||Not sure|
|Confident of steps of donning/doffing||Yes||No||Not sure|
|Aware of hospital norms for the use of PPE in different settings (Ward/OPD/ICU)||Yes||No||Not sure|
|Access to PPE during patient care||Adequate||Inadequate||Not sure|
|Usual quality of PPE||Satisfactory||Unsatisfactory||Not sure|
|Facilities for hand hygiene||Adequate||Inadequate||Not sure|
|Availability of food during ward duties||Satisfactory||Unsatisfactory||Not sure|
|Availability of drinking water||Satisfactory||Unsatisfactory||Not sure|
|Grievance redressal available||Yes||No||Not sure|
|Experience of grievance redressal||Satisfactory||Unsatisfactory||Not availed|
|Quality of quarantine facility||Satisfactory||Unsatisfactory||Not availed|
|Have you been assessed for stress/anxiety/depression in the previous 1 month?||Yes||No||-|
|What is your sleep quality in the previous 1 month?||Good||Poor||Average|
COVID-19 cases in India show an accelerating trend with the increasing development of hotspots and clusters. Infection and disease in healthcare workers and their families can undermine efforts in combating and controlling the pandemic in India. There is growing recognition that HCWs perceive the extent of organizational implementation of infection control and patient management strategies as essential risk mitigation strategies. Consequently, there is an urgent need for regular assessment of COVID-19 health facilities to assess their preparedness in preventing infection and promote their health-care employee satisfaction.
Declaration of patient consentPatient’s consent not required as there are no patients in this study.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
- Over 90,000 Health Workers Infected with Covid-19 Worldwide: Nurses Group. 2020. Available from: https://www.thehindubusinessline.com/news/over-90000-health-workers-infected-with-covid-19-worldwide-nurses-group/article31519587.ece [Last accessed on 2020 Jun 03]
- [Google Scholar]
- Indian J Med Res. 2020;151:236-40. Available from: http://www.ijmr.org.in/preprintarticle.asp?id=285361 [Last accessed on 2020 Jun 03]Laboratory surveillance for SARS-CoV-2 in India: Performance of testing and descriptive epidemiology of detected COVID-19.
- [Google Scholar]
- Blog J Med Ethics. Available from: https://www.blogs.bmj.com/medical-ethics/2020/04/01/health-care-professionals-are-under-no-ethical-obligation-to-treat-covid-19-patients [Last accessed on 2020 May 17]Health Care Professionals Are Under No Ethical Obligation to Treat COVID-19 Patients. 2020.
- [Google Scholar]
- Infection Prevention and Control Guidance for Long-term Care Facilities in the Context of COVID-19 Novel Coronavirus Disease 2019 (COVID-19) Geneva: World Health Organization; 2020.
- [Google Scholar]
- Government of India. 2020. Guidelines on Rational Use of Personal Protective Equipment. Available from: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf [Last accessed on 2020 Jun 03]
- [Google Scholar]
- New Indian Express. Available from: https://www.newindianexpress.com/cities/delhi/2020/may/22/no-hotel-quarantine-delhi-doctors-protest-order-to-withdraw-special-quarantine-facility-2146507.html [Last accessed on 2020 Jun 03]No Hotel Quarantine: Delhi Doctors Protest Order to Withdraw Special Quarantine Facility. 2020.
- [Google Scholar]
- The Hindu. Available from: https://www.thehindu.com/news/cities/Hyderabad/dripping-with-sweat-in-ppe-doctors-and-nurses-seek-air-coolers-cool-water/article31603849.ece [Last accessed on 2020 Jun 03]Dripping with Sweat in PPE, Doctors and Nurses Seek Air Coolers, Cool Water. 2020.
- [Google Scholar]
- Hindustan Times. Available from: https://www.economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/how-doctors-nurses-in-india-are-treating-coronavirus-patients-amid-lack-of-protective-gears/slideshow/75042401.cms?from=mdr [Last accessed on 2020 Jun 03]Excruciating hours, bad PPE doctors' key issues. 2020.
- [Google Scholar]