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Personal protective equipment implementation in healthcare: A scoping review

      Highlights

      • Protective personal equipment adherence is related to organizational policy and individual engagement.
      • Protective personal equipment implementation is a complex cycle of elements all of which are required to achieve optimal use.
      • Innovative and participatory interventions enhance infection and prevention control.
      • Implementation as a political practice impacts equity and promotes health.

      Abstract

      Background

      Adherence to infection prevention and control (IPC) measures, including the proper use of protective personal equipment (PPE), in health care is complex and is influenced by many factors. Isolated interventions do not have the potential to achieve optimal PPE adherence and appropriate provision, leading to incomplete PPE implementation.

      Objective

      To map PPE implementation in health care with a focus on its barriers and facilitators.

      Methods

      A scoping review was conducted across 14 electronic databases using the Joanna Briggs Institute methodology.

      Results

      Seventy-four papers were included in the review. Findings were analyzed and synthesized into categories to match the Consolidated Framework for Implementation Research domains. The content was then synthesized into barriers for PPE implementation and interventions to address them. The main barriers were discomfort in clinical work; shortage, supply and logistics problems; inadequacies in facilities infrastructure, weakness in policies and communication procedures; and health workers’ (HW) psychological issues and lack of preparedness. Implementation interventions reported were related to HW wellbeing assurance; work reorganization; IPC protocols; adoption of strategies to improve communication and HW training; and adoption of structural and organizational changes to improve PPE adherence.

      Conclusions

      PPE implementation, which is critical IPC programs, involves multilevel transdisciplinary complexity. It relies on the development of context-driven implementation strategies to inform and harmonize IPC policy in collaboration with local and international health bodies.

      Key words

      Health care-associated infections (HCAIs) continue to cause morbidity and mortality in most countries,
      • Haque M
      • Sartelli M
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      Health care-associated infections – an overview.
      despite increases in control.
      • Moralejo D
      • El Dib R
      • Prata RA
      • Barretti P
      • Corrêa I
      Improving adherence to Standard Precautions for the control of health care-associated infections.
      In low- and middle-income countries (LMICs) HCAI may be 20-fold higher than in high-income countries.
      • Allegranzi B
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      • Graafmans W
      • et al.
      Articles Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.
      ,
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      • Flynn E
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      Interventions to improve water supply and quality, sanitation and handwashing facilities in health care facilities, and their effect on healthcare associated infections in low-income and middle-income countries: a systematic review and supplementary scoping.
      The current situation has raised awareness about the need for preventive measures for patients and health workers (HWs).
      • Padoveze MC
      • Nogueira-Jr C
      • Tanner J TS
      What are the main drivers for public policies to prevent healthcare-associated infections?.
      • Kim H
      • Hegde S
      • LaFiura C
      • et al.
      Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries.
      • Poletti P
      • Tirani M
      • Cereda D
      • et al.
      Seroprevalence of and risk factors associated with SARS-CoV-2 infection in health CareWorkers during the early COVID-19 pandemic in Italy.
      Coronavirus disease 2019 (COVID-19) represents the greatest global pandemic health challenge of the 21st century and has so far exposed structural and systemic health care problems of access, equity, quality and affordability worldwide.
      • Brito SBP
      • Braga IO
      • Cunha CC
      • Palácio MAV
      • Takenami I
      COVID-19 pandemic: the biggest challenge for the 21st century.
      Published data suggests that 7%-8.7% of HWs were infected with COVID-19 which, if acquired due to health work activities, is considered HCAI. However, high variability across countries has been reported. COVID-19 infection risks–including inadequate access to or use of personal protective equipment (PPE)–are associated with health facilities’ (HF) organization and preparedness.
      • Poletti P
      • Tirani M
      • Cereda D
      • et al.
      Seroprevalence of and risk factors associated with SARS-CoV-2 infection in health CareWorkers during the early COVID-19 pandemic in Italy.
      Restriction or reuse due to limited availability of PPE compared with unrestricted access to fresh PPE for each patient encounter was associated with a 2.2-fold to 22-fold increased risk of reporting COVID-19 symptoms.
      • Kim H
      • Hegde S
      • LaFiura C
      • et al.
      Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries.
      Appropriate provision of PPE and adherence to infection prevention and control (IPC) protocols represent valuable strategies for protecting HWs.
      • Poletti P
      • Tirani M
      • Cereda D
      • et al.
      Seroprevalence of and risk factors associated with SARS-CoV-2 infection in health CareWorkers during the early COVID-19 pandemic in Italy.
      Nonetheless, the literature reports that PPE adherence in health care remains low.
      • Agarwal A
      • Ranjan P
      • Saraswat S
      • et al.
      Are health care workers following preventive practices in the COVID-19 pandemic properly? - A cross-sectional survey from India.
      • Harrod M
      • Weston LE
      • Gregory L
      • Mayer J
      • Drews FA KSL
      A qualitative study of factors affecting personal protective equipment use among health care personnel.
      • Larkin J
      • Lee D
      • Kruedelback G
      • et al.
      Target-improving personal protective equipment (PPE) compliance: a three year study.
      The COVID-19 pandemic and outbreaks of Ebola virus disease (EVD) represent an opportunity to reinforce standard precautions
      • Padoveze MC
      • Nogueira-Jr C
      • Tanner J TS
      What are the main drivers for public policies to prevent healthcare-associated infections?.
      and collect evidence on additional transmission-related measures.
      Published research studies have found that isolated interventions such as education and training and other behavioral interventions do not have a considerable effect on IPC measures adherence.
      • Moralejo D
      • El Dib R
      • Prata RA
      • Barretti P
      • Corrêa I
      Improving adherence to Standard Precautions for the control of health care-associated infections.
      ,
      • Luong Thanh BY
      • Laopaiboon M
      • Koh D
      • Sakunkoo P
      • Moe H
      Behavioural interventions to promote workers’ use of respiratory protective equipment.
      Furthermore, multiple factors influence HW ability and willingness to adhere to IPC guidelines,
      • Houghton C
      • Meskell P
      • Delaney H
      • et al.
      Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis.
      an issue that should be recognized as an organizational responsibility.
      • Harrod M
      • Weston LE
      • Gregory L
      • Mayer J
      • Drews FA KSL
      A qualitative study of factors affecting personal protective equipment use among health care personnel.
      Therefore, PPE adherence is not a matter of individual HW decision. Integrated implementation strategies should be planned to ensure uptake of evidence-based practices and technologies in health care.
      Considering that effective PPE implementation is a complex practice, the objective of this scoping review is to map how PPE is implemented in health care, focusing on barriers and facilitators.

      Methods

      Study design

      A scoping review following the Joanna Briggs Institute methodology

      Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping Reviews. In: Aromataris E, Munn Z, eds. JBI Manual for Evidence Synthesis. JBI; 2020. Accessed February 17, 2022. https://synthesismanual.jbi.global.

      was performed. PRISMA-ScR recommendations
      • Tricco AC
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      • Zarin W
      • et al.
      PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
      were used. ​​A scoping review protocol was registered at OSF Registries.

      Cordeiro L, Padoveze MC. Personal protective equipment implementation in the healthcare: a scoping protocal. Accessed February 25, 2022. https://osf.io/m6qe5/.

      The guiding questions of the present scoping review were: (1) How is PPE implemented in health care? (2) What does the process of PPE selection, acquisition, training, maintenance, acceptance, adherence, and assessment entail in health care? (3) What are the barriers and facilitators to the implementation process for PPE in health care settings?

      Data sources and search strategy

      Searches were conducted in the following 14 databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Epistemonikos, Eric, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Review, Excerpta Medica Database (EMBASE), Health System Evidence, Health Evidence, Joanna Briggs Institute, PsychInfo, PubMed/Medline, Web of Science, Scopus, from their conception until May 11th, 2021. Controlled descriptors and keywords from each database were delimited and combined (Supplementary file 1) for the search. The query expression was a combination of at least 2 terms: one comprising PPE (“personal protective equipment” or “respiratory protective devices”) and another related to processes (“implementation,” “assessment,” “maintenance,” “hospital engineering,” “education” and “training”) Data search was carried out by two independent investigators (JRG and LC).

      Study inclusion and exclusion criteria

      Primary studies in English, French, Italian, Spanish, or Portuguese containing PPE implementation description were included. Excluded studies were those that focused on ​​clinical procedures used in respiratory diseases and did not mention PPE in the abstract; descriptions of unit plan to control infection due to COVID-19 that do not mention PPE; occupational needlestick injuries; PPE compliance/attitude/adherence or risk assessment/prevalence/incidence; and studies with paramedics, students, and individuals that work in labs, dental care or with dead bodies. Effectiveness studies, research protocols, reviews, letters to the editor, comments and texts of opinion were also excluded.
      Methodological appraisal was not performed as it is not a mandatory step in scoping reviews.

      Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping Reviews. In: Aromataris E, Munn Z, eds. JBI Manual for Evidence Synthesis. JBI; 2020. Accessed February 17, 2022. https://synthesismanual.jbi.global.

      Data extraction

      Data extraction was carried out by two independent investigators. The first author, LC, was also the first reviewer and others (AP; CLCS; GMM.; NAO; RMAA; SS; WC; YLL) were the second reviewers. Data extracted from included publications were title, year of publication, country, specific disease, objective, setting, characteristics of individuals, study design, PPE type, selection, supply, training or simulation, strategies for implementation, maintenance/disinfection/sterilization/reuse and disposal, acceptance, adherence/compliance and workers' experience, implementation assessment and policies, barriers, facilitators and conclusions. ​​In case of disagreements during data extraction, a third author was consulted to achieve consensus.

      Data synthesis

      Studies were grouped in eight barriers and implementation intervention categories and matched to the Consolidated Framework for Implementation Research (CFIR) domains.
      • Damschroder LJ
      • Aron DC
      • Keith RE
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      Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
      Results were mapped to the domains “Intervention Characteristics,” “Outer Setting,” “Inner Setting,” and “Individuals Characteristics,” except for “Process” domain, which could not be matched. The findings were further described in a narrative overview and supplemented with figures.

      Results

      Included studies

      Search and study selection is presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram (Fig 1). Seventy-four studies were included in the review. Study characteristics and summarized findings can be found in Supplementary file 2. A graph of study targeted diseases and years of publication is shown in Figure 2.
      Fig 1
      Fig 1PRISMA diagram search and study selection based on Moher et al
      • Moher D
      • Liberati A
      • Tetzlaff J AD
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      .
      Fig 2
      Fig 2Published articles per targeted disease by year.
      Studies from LMIC,
      • Adejumo OA
      • Adejumo OA
      • Egbi OG
      • Abolarin OS
      • Alli OE
      Level of implementation of WHO COVID-19 document on rights, roles and responsibilities of health care workers in a tertiary hospital in Southwest Nigeria.
      • Autrán-Gómez AM
      • Tobia I
      • Molina RC
      • et al.
      Exploring urological experience in the COVID-19 outbreak: American Confederation of Urology (CAU) Survey.

      Carvalho JF de S, Chaves LDP. Nursing supervision of the use of protective equipment in a general hospital. Cogitare enferm. 5:513-20.

      Castro-Sánchez E, Alexander CMM, Atchison C, et al. Evaluation of a personal protective equipment support programme for staff during the COVID-19 pandemic in London. J Hosp Infect. 202:68–77.

      • Chalikonda S
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      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      • Fierro JL
      • Middleton M
      • Smallwood AN
      • et al.
      Barriers to the use of PPE to prevent pertussis exposures in a pediatric primary care network.
      • Hung PP
      • Choi K-S
      • Chiang VC-LC
      Using interactive computer simulation for teaching the proper use of personal protective equipment.
      • Kumar P
      • Rajamani A
      • Haji JY
      • et al.
      State of personal protective equipment practice in indian intensive care units amidst COVID-19 pandemic: a nationwide survey.
      • Levy B
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      Ebola infection control in Sierra Leonean health clinics: a large cross-agency cooperative project.
      • Li Y
      • Wang Y
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      Comparison of repeated video display vs combined video display and live demonstration as training methods to healthcare providers for donning and doffing personal protective equipment: a randomized controlled trial.
      • Li S
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      Practice and exploration of 24h “sCI” model in personal protection supervision in COVID-19 isolation ward.
      • Madziatera D
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      • Phiri TV
      • et al.
      Availability, accessibility and proper use of personal protective equipment in wards at Queen Elizabeth Central Hospital (QECH) blantyre, malawi: an observational study.
      • Malotle MM
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      Occupational tuberculosis in South Africa: are health care workers adequately protected?.
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      Perceived barriers to the practice of preventive measures for COVID-19 pandemic among health professionals in public health facilities of the Gamo zone, southern Ethiopia: a phenomenological study.
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      Improving Ebola infection prevention and control in primary healthcare facilities in Sierra Leone: a single-group pretest post-test, mixed-methods study.
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      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
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      Whole-process emergency training of personal protective equipment helps healthcare workers against COVID-19: design and effect.
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      Remote nursing training model combined with proceduralization in the intensive care unit dealing with patients with COVID-19.
      from high income countries,
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      Emergency medical service personnel awareness and training about personal protective equipment during the COVID-19 pandemic.
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      Facing the coronavirus pandemic: an integrated continuing education program in Taiwan.
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      A randomized trial of instructor-led training versus video lesson in training health care providers in proper donning and doffing of personal protective equipment.
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      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
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      The use of personal protective equipment during the COVID-19 pandemic in a tertiary pediatric hospital.
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      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
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      Training non-intensivist doctors to work with COVID-19 patients in intensive care units.
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      Rapid conversion of an in-patient hospital unit to accommodate COVID-19: an interdisciplinary human factors, ethnography, and infection prevention and control approach.
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      Personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use?.
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      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
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      Difficulties in using personal protective equipment: training experiences with the 2015 outbreak of Middle East respiratory syndrome in Korea.
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      A developing nation's experience in using simulation-based training as a preparation tool for the coronavirus disease 2019 outbreak.
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      Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.
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      Hospital preparedness and SARS.
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      • Pompeii L
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      • Quah LJJ
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      Reorganising the emergency department to manage the COVID-19 outbreak.
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      Comparing training techniques in personal protective equipment use.
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      Preparing an academic medical center to manage patients infected with ebola: experiences of a university hospital.
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      Teaching adequate prehospital use of personal protective equipment during the COVID-19 pandemic: development of a Gamified e-Learning module.
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      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
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      Simulated pediatric resuscitation use for personal protective equipment adherence measurement and training during the 2009 influenza (H1N1) pandemic.
      and studies conducted in several income economies
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      Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: Experience from mobile SARS containment teams, 2003.
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      Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: a multinational survey.
      were integrated into the synthesis. Study settings were mainly hospitals.
      • Adejumo OA
      • Adejumo OA
      • Egbi OG
      • Abolarin OS
      • Alli OE
      Level of implementation of WHO COVID-19 document on rights, roles and responsibilities of health care workers in a tertiary hospital in Southwest Nigeria.
      ,

      Carvalho JF de S, Chaves LDP. Nursing supervision of the use of protective equipment in a general hospital. Cogitare enferm. 5:513-20.

      Castro-Sánchez E, Alexander CMM, Atchison C, et al. Evaluation of a personal protective equipment support programme for staff during the COVID-19 pandemic in London. J Hosp Infect. 202:68–77.

      • Chalikonda S
      • Waltenbaugh H
      • Angelilli S
      • et al.
      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      • Fierro JL
      • Middleton M
      • Smallwood AN
      • et al.
      Barriers to the use of PPE to prevent pertussis exposures in a pediatric primary care network.
      • Hung PP
      • Choi K-S
      • Chiang VC-LC
      Using interactive computer simulation for teaching the proper use of personal protective equipment.
      • Kumar P
      • Rajamani A
      • Haji JY
      • et al.
      State of personal protective equipment practice in indian intensive care units amidst COVID-19 pandemic: a nationwide survey.
      ,
      • Li Y
      • Wang Y
      • Li Y
      • et al.
      Comparison of repeated video display vs combined video display and live demonstration as training methods to healthcare providers for donning and doffing personal protective equipment: a randomized controlled trial.
      ,
      • Madziatera D
      • Msofi KSKS
      • Phiri TV
      • et al.
      Availability, accessibility and proper use of personal protective equipment in wards at Queen Elizabeth Central Hospital (QECH) blantyre, malawi: an observational study.
      ,
      • Malotle MM
      • Spiegel JM
      • Yassi A
      • et al.
      Occupational tuberculosis in South Africa: are health care workers adequately protected?.
      ,
      • Parbhoo AN
      • Numanoglu A
      • Argent AC
      • Franken M
      • Mukosi M
      • McCulloch I M
      COVID-19: Experience of a tertiary children's hospital in Western Cape Province, South Africa.
      ,
      • Tan W
      • Ye Y
      • Yang Y
      • et al.
      Whole-process emergency training of personal protective equipment helps healthcare workers against COVID-19: design and effect.
      • Tanaka AKS da R
      • Lunardi LS
      • Silva FG da
      • Gil LMCR
      The multidisciplinary surgical center team's response to the COVID-19 pandemic.
      • Wang H
      • Kang K
      • Gao Y
      • et al.
      Remote nursing training model combined with proceduralization in the intensive care unit dealing with patients with COVID-19.
      ,
      • Bleasdale SC
      • Sikka MK
      • Moritz DC
      • Fritzen-Pedicini C
      • Stiehl E
      Brosseaulm. Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015.
      ,
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      ,
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      among others.
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      ,
      • Sarfraz A
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      ,
      • Bessesen MT
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      ,
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      The categorized barriers and associated implementation interventions (Fig 3) were extracted from the studies’ findings and allocated into CFIR Domains.
      Fig 3
      Fig 3Personal Protective Equipment (PPE) implementation barriers identified in the literature, according to the country income.

      PPE
      The studies mentioned all types of PPE such as medical/surgical masks, filtering facepiece respirators (N95 mask, FFP2, FFP3, powered air purifying respirator, reusable elastomeric respirator and Sundström SR 100), face shield, glasses/goggle/eye protection, hospital scrub, apron, gown, head covering/cap, hood, gloves and long gloves, (fluid-impermeable) coverall/ bunny suit, shoe cover, and boots.
      1The studies mentioned all types of PPE such as medical/surgical masks, filtering facepiece respirators (N95 mask, FFP2, FFP3, powered air purifying respirator, reusable elastomeric respirator and Sundström SR 100), face shield, glasses/goggle/eye protection, hospital scrub, apron, gown, head covering/cap, hood, gloves and long gloves, (fluid-impermeable) coverall/ bunny suit, shoe cover, and boots.
      barriers and implementation interventions

      Intervention characteristics domain

      PPE impact on clinical work

      HW experience discomfort while using PPEs. Reported PPE issues were: (1) overheating,
      • Ratnayake R
      • Ho LS
      • Ansumana R
      • et al.
      Improving Ebola infection prevention and control in primary healthcare facilities in Sierra Leone: a single-group pretest post-test, mixed-methods study.
      ,
      • Bleasdale SC
      • Sikka MK
      • Moritz DC
      • Fritzen-Pedicini C
      • Stiehl E
      Brosseaulm. Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015.
      ,
      • Brosseau LM
      • Conroy LM
      • Sietsema M
      • Cline K
      • Durski K
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      ,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
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      ,
      • Messeri A
      • Bonafede M
      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
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      ,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      (2) communication issues while speaking or listening,
      • Brosseau LM
      • Conroy LM
      • Sietsema M
      • Cline K
      • Durski K
      Evaluation of minnesota and illinois hospital respiratory protection programs and health care worker respirator use.
      ,
      • Corley A
      • Hammond NE
      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
      • LoSavio PS
      • Eggerstedt M
      • Tajudeen BA
      • et al.
      Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.
      ,
      • Phin NFF
      • Rylands AJJ
      • Allan J
      • Edwards C
      • Enstone JEE
      • Nguyen-Van-Tam JSS
      Personal protective equipment in an influenza pandemic: a UK simulation exercise.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      (3) inability to use the bathroom and thirst because of difficulties drinking water,
      • Corley A
      • Hammond NE
      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
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      ,
      • Messeri A
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      • Pietrafesa E
      • et al.
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      ,
      • Phin NFF
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      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      (4) the demanding and time-consuming nature of donning and doffing,
      • Corley A
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      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
      • Kang JH
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      Use of personal protective equipment among health care personnel: results of clinical observations and simulations.
      (5) breathing difficulties,
      • Corley A
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      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      (6) poor visibility when performing medical tasks,
      • LoSavio PS
      • Eggerstedt M
      • Tajudeen BA
      • et al.
      Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.
      ,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      (7) topical allergies and skin reactions to PPE, especially with extended wear,
      • Kang JH
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      • Bircher N
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      • Smith KJKJ
      Use of personal protective equipment among health care personnel: results of clinical observations and simulations.
      ,
      • Messeri A
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      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      ,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      (8) pressure areas,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      (
      • Agarwal A
      • Ranjan P
      • Saraswat S
      • et al.
      Are health care workers following preventive practices in the COVID-19 pandemic properly? - A cross-sectional survey from India.
      ) exhaustion,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ,
      • Messeri A
      • Bonafede M
      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      (10) headaches, (11) increase of clinical breaches,
      • Corley A
      • Hammond NE
      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
      • LoSavio PS
      • Eggerstedt M
      • Tajudeen BA
      • et al.
      Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.
      and (12) productivity loss.
      • Messeri A
      • Bonafede M
      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.
      ,
      • Phin NFF
      • Rylands AJJ
      • Allan J
      • Edwards C
      • Enstone JEE
      • Nguyen-Van-Tam JSS
      Personal protective equipment in an influenza pandemic: a UK simulation exercise.
      Implementation interventions: To improve personal well-being and minimize adverse effects of PPE both HF and HW should co-design and co-produce implementation and sustainability strategies. Adjustments in the duty area like temperature control,
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      improvement ventilation in the building,
      • Messeri A
      • Bonafede M
      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.
      and limiting time spent in the clinical zone
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      ,
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      are recommended. In addition, comfort should be taken into consideration when PPE is selected and purchased. HWs should be provided with PPE design that allows them to drink water and take breaks as needed.
      • Messeri A
      • Bonafede M
      • Pietrafesa E
      • et al.
      A web survey to evaluate the thermal stress associated with personal protective equipment among healthcare workers during the covid-19 pandemic in Italy.

      Outer and inner setting domains

      PPE shortage/unavailability

      PPE shortage or unavailability including the filtering face piece respirators and gowns used as additional transmission-based precautions as required for human safety and to reduce transmission in EVD and COVID-19 cases were reported
      • Madziatera D
      • Msofi KSKS
      • Phiri TV
      • et al.
      Availability, accessibility and proper use of personal protective equipment in wards at Queen Elizabeth Central Hospital (QECH) blantyre, malawi: an observational study.
      • Malotle MM
      • Spiegel JM
      • Yassi A
      • et al.
      Occupational tuberculosis in South Africa: are health care workers adequately protected?.
      • Mersha A
      • Shibiru S
      • Girma M
      • et al.
      Perceived barriers to the practice of preventive measures for COVID-19 pandemic among health professionals in public health facilities of the Gamo zone, southern Ethiopia: a phenomenological study.
      ,
      • Kay MB
      • Braun A
      • Fox C
      • et al.
      A California Hospital's response to COVID-19: from a ripple to a Tsunami warning.
      ,
      • Mantelakis A
      • Spiers HVM
      • Lee CW
      • Chambers A
      • Joshi A
      Availability of personal protective equipment in NHS hospitals during COVID-19: a national survey.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      ,
      • Lee NE
      • Siriarayapon P
      • Tappero J
      • et al.
      Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: Experience from mobile SARS containment teams, 2003.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      These shortages were found in public and private HFs.
      • Sarfraz A
      • Sarfraz Z
      • Anwer A
      • Sarfraz M
      • Siddiq J
      Availability, use, and satisfaction of personal protective equipment among healthcare workers: a cross-sectional assessment of low- and middle-income countries.
      Specific sizes needed for adequate protection were unavailable, which led to the use of poorly fitted PPE.
      • Corley A
      • Hammond NE
      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
      • Cummings KJ
      • Choi MJ
      • Esswein EJ
      • et al.
      Addressing infection prevention and control in the first US community hospital to care for patients with ebola virus disease: context for national recommendations and future strategies.
      ,
      • Lee NE
      • Siriarayapon P
      • Tappero J
      • et al.
      Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: Experience from mobile SARS containment teams, 2003.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      These situations resulted in inadequate adaptations, including the adoption of non-evidence-based reuse, extended use, and decontamination and reprocessing practices.
      • Brosseau LM
      • Conroy LM
      • Sietsema M
      • Cline K
      • Durski K
      Evaluation of minnesota and illinois hospital respiratory protection programs and health care worker respirator use.
      ,
      • Kay MB
      • Braun A
      • Fox C
      • et al.
      A California Hospital's response to COVID-19: from a ripple to a Tsunami warning.
      Two authors reported that HW had no other options but to purchase their own PPE in retail settings.
      • Adejumo OA
      • Adejumo OA
      • Egbi OG
      • Abolarin OS
      • Alli OE
      Level of implementation of WHO COVID-19 document on rights, roles and responsibilities of health care workers in a tertiary hospital in Southwest Nigeria.
      ,
      • Chiu CK
      • Chan CYW
      • Cheung JPY
      • Cheung PWH
      • Gan SMA
      • Kwan MK
      Personal protective equipment usage, recycling and disposal among spine surgeons: an Asia Pacific Spine Society survey.
      Implementation interventions: To minimize PPE shortages masks can be donated,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      mobile teams can provide PPE to hospitals actively evaluating patients for respiratory infection disease,
      • Lee NE
      • Siriarayapon P
      • Tappero J
      • et al.
      Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: Experience from mobile SARS containment teams, 2003.
      non-disposable respirators can be allocated preferentially to clinical staff with direct airway manipulation,

      Carvalho JF de S, Chaves LDP. Nursing supervision of the use of protective equipment in a general hospital. Cogitare enferm. 5:513-20.

      ,
      • Chalikonda S
      • Waltenbaugh H
      • Angelilli S
      • et al.
      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      ,
      • Malotle MM
      • Spiegel JM
      • Yassi A
      • et al.
      Occupational tuberculosis in South Africa: are health care workers adequately protected?.
      ,
      • DuBose JR
      • Matic Z
      • Sala MFW
      • et al.
      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
      ,
      • Lee NE
      • Siriarayapon P
      • Tappero J
      • et al.
      Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: Experience from mobile SARS containment teams, 2003.
      and procedures to reduce the degradation of the equipment can be employed.
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      Education was reported to reduce unnecessary PPE use and waste.
      • Chiu T-FF
      • Chu D
      • Huang S-JJ
      • Chang M
      • Liu Y
      • Lee JJ
      Facing the coronavirus pandemic: an integrated continuing education program in Taiwan.
      PPE reprocessing systems can be operated during extreme conditions
      • Chalikonda S
      • Waltenbaugh H
      • Angelilli S
      • et al.
      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      ,
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      ,
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      ,
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.
      with improved implementation of PPE stock control and supply procedures.
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Dibbs RPRP
      • Ferry AMAM
      • Enochs J
      • et al.
      The use of personal protective equipment during the COVID-19 pandemic in a tertiary pediatric hospital.
      Identification and tracking of reprocessed PPE and return to stock and entry into the HF inventory was advised.
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Dibbs RPRP
      • Ferry AMAM
      • Enochs J
      • et al.
      The use of personal protective equipment during the COVID-19 pandemic in a tertiary pediatric hospital.
      ,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      To ensure HWs’ safety, sterile and processing personnel can be trained.
      • Chalikonda S
      • Waltenbaugh H
      • Angelilli S
      • et al.
      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      ,
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      Distinct sterilization and disinfection methods should be used according to the type of PPE and filtering facepiece respirators.
      • Brosseau LM
      • Conroy LM
      • Sietsema M
      • Cline K
      • Durski K
      Evaluation of minnesota and illinois hospital respiratory protection programs and health care worker respirator use.
      ,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ,
      • Unoki T
      • Tamoto M
      • Ouchi A
      • et al.
      Personal protective equipment use by health-care workers in intensive care units during the COVID-19 pandemic in Japan: comparative analysis with the PPE-SAFE survey.

      Supply and logistics problems

      PPE supply chain and stockpiling efforts
      • Ratnayake R
      • Ho LS
      • Ansumana R
      • et al.
      Improving Ebola infection prevention and control in primary healthcare facilities in Sierra Leone: a single-group pretest post-test, mixed-methods study.
      ,
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      ,
      • Ghanchi A
      Challenges in implementing ebola protection procedures and personal protective equipment training in a french maternity unit.
      ,
      • Mantelakis A
      • Spiers HVM
      • Lee CW
      • Chambers A
      • Joshi A
      Availability of personal protective equipment in NHS hospitals during COVID-19: a national survey.
      ,
      • Rajamani A
      • Subramaniam A
      • Shekar K
      • et al.
      Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: a multinational survey.
      were thwarted by logistics, planning and communication challenges.
      • Kumar P
      • Rajamani A
      • Haji JY
      • et al.
      State of personal protective equipment practice in indian intensive care units amidst COVID-19 pandemic: a nationwide survey.
      ,
      • DuBose JR
      • Matic Z
      • Sala MFW
      • et al.
      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
      ,
      • Timen A
      • Hulscher MEJL
      • Rust L
      • et al.
      Barriers to implementing infection prevention and control guidelines during crises: Experiences of health care professionals.
      ,
      • Tomizuka T
      • Kanatani Y
      • Kawahara K
      Insufficient preparedness of primary care practices for pandemic influenza and the effect of a preparedness plan in Japan: a prefecture-wide cross-sectional study.

      Implementation interventions

      PPE can be selected and purchased according to HW's body sizes and preferences (eg, long sleeves are preferred by some HWs but may not always be available; or HWs may prefer a surgical cap for the hood of the coverall suit to protect the head.
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      ,
      • Schultz CH
      • Koenig KL
      • Alassaf W
      Preparing an academic medical center to manage patients infected with ebola: experiences of a university hospital.
      Institutional IPC processes should be established and monitored for quality and performance.
      • Reidy P
      • Fletcher T
      • Shieber C
      • et al.
      Personal protective equipment solution for UK military medical personnel working in an Ebola virus disease treatment unit in Sierra Leone.
      ,
      • Bleasdale SC
      • Sikka MK
      • Moritz DC
      • Fritzen-Pedicini C
      • Stiehl E
      Brosseaulm. Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015.
      Processes should be developed to manage supply of PPE
      • Kay MB
      • Braun A
      • Fox C
      • et al.
      A California Hospital's response to COVID-19: from a ripple to a Tsunami warning.
      and maintain a baseline inventory of every critical item.
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      It may be advisable to conduct a routine and regular facility-level assessment of the PPE supply. PPE can be allocated and organized to maximize space and to optimize access and distribution.
      • Kay MB
      • Braun A
      • Fox C
      • et al.
      A California Hospital's response to COVID-19: from a ripple to a Tsunami warning.
      ,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.

      HF inadequate infrastructure, lack of preparedness and policies

      IPC inconsistencies that may jeopardize HWs and patient safety, such as inadequacies of facility infrastructure like the lack of adequate equipment storage space, were reported.

      Carvalho JF de S, Chaves LDP. Nursing supervision of the use of protective equipment in a general hospital. Cogitare enferm. 5:513-20.

      Other issues included not having a dedicated biocontainment unit to discharge disposable PPE,
      • Cummings KJ
      • Choi MJ
      • Esswein EJ
      • et al.
      Addressing infection prevention and control in the first US community hospital to care for patients with ebola virus disease: context for national recommendations and future strategies.
      inadequate space layout between clean and contaminated area,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      and inadequate donning and doffing zones and procedures.
      • DuBose JR
      • Matic Z
      • Sala MFW
      • et al.
      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
      ,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      In some clinical setting plans, IPC measures concerning the doffing area, demarcation of zones, and lack of standard locations for items and compatibility between the physical environment and the adopted ICP measures were not considered.
      • DuBose JR
      • Matic Z
      • Sala MFW
      • et al.
      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
      ,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      Regarding respirators, the unavailability or low frequency of fit test performance
      • Kumar P
      • Rajamani A
      • Haji JY
      • et al.
      State of personal protective equipment practice in indian intensive care units amidst COVID-19 pandemic: a nationwide survey.
      ,
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      was cited as a barrier. Several papers mentioned conflicting or lack of PPE protocols.
      • Wang H
      • Kang K
      • Gao Y
      • et al.
      Remote nursing training model combined with proceduralization in the intensive care unit dealing with patients with COVID-19.
      ,
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • DuBose JR
      • Matic Z
      • Sala MFW
      • et al.
      Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.
      ,
      • Ippolito M
      • Ramanan M
      • Bellina D
      • et al.
      Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.
      ,
      • Fan J
      • Jiang Y
      • Hu K
      • et al.
      Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China.
      One study reported that inefficient communication between HF leaders or managers and frontline HWs, and the lack of support from the community and government were factors that influenced adherence to PPE good practice.
      • Mersha A
      • Shibiru S
      • Girma M
      • et al.
      Perceived barriers to the practice of preventive measures for COVID-19 pandemic among health professionals in public health facilities of the Gamo zone, southern Ethiopia: a phenomenological study.
      Implementation interventions: The implementation of specific PPE protocols and operating procedures as part of a multidimensional HF policy developed with the involvement of HWs was recommended.
      • Autrán-Gómez AM
      • Tobia I
      • Molina RC
      • et al.
      Exploring urological experience in the COVID-19 outbreak: American Confederation of Urology (CAU) Survey.
      ,
      • Dutta U
      • Sachan A
      • Premkumar M
      • et al.
      Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.
      ,
      • Bessesen MT
      • Adams JC
      • Radonovich L
      • Anderson J
      Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures.
      ,
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      In a pandemic context a distinct response plan is especially needed.
      • Kay MB
      • Braun A
      • Fox C
      • et al.
      A California Hospital's response to COVID-19: from a ripple to a Tsunami warning.
      Besides standard universal masking adoption in the whole HF for respiratory diseases like COVID-19,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      critical policy elements would include (1)robust regular training and qualifications as a requirement to provide care of patients requiring additional transmission-based precautions
      • Wang H
      • Kang K
      • Gao Y
      • et al.
      Remote nursing training model combined with proceduralization in the intensive care unit dealing with patients with COVID-19.
      ,
      • Pokrajac N
      • Schertzer K
      • Poffenberger CMCM
      • et al.
      Mastery learning ensures correct personal protective equipment use in simulated clinical encounters of COVID-19.
      ,
      • Schultz CH
      • Koenig KL
      • Alassaf W
      Preparing an academic medical center to manage patients infected with ebola: experiences of a university hospital.
      ,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      ; periodic fit testing and appropriate mask sizing
      • Chalikonda S
      • Waltenbaugh H
      • Angelilli S
      • et al.
      Implementation of an elastomeric mask program as a strategy to eliminate disposable N95 mask use and resterilization: results from a large academic medical center.
      ,
      • Brosseau LM
      • Conroy LM
      • Sietsema M
      • Cline K
      • Durski K
      Evaluation of minnesota and illinois hospital respiratory protection programs and health care worker respirator use.
      ,
      • Corley A
      • Hammond NE
      • Fraser JF
      The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study.
      ,
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Gershon RRM
      • Vandelinde N
      • Magda LA
      • Pearson JM
      • Werner A
      • Prezant D
      Evaluation of a pandemic preparedness training intervention for emergency medical services personnel.
      ,
      • Pompeii L
      • Byrd A
      • Delclos GL
      • Conway SH
      Training and fit testing of health care personnel for reusable elastomeric half-mask respirators compared with disposable N95 respirators.
      ,
      • Quah LJJ
      • Tan BKK
      • Fua T-PP
      • et al.
      Reorganising the emergency department to manage the COVID-19 outbreak.
      ,
      • Schultz CH
      • Koenig KL
      • Alassaf W
      Preparing an academic medical center to manage patients infected with ebola: experiences of a university hospital.
      ,
      • Tadavarthy SN
      • Finnegan K
      • Bernatowicz G
      • Lowe E
      • Coffin SE
      • Manning M
      Developing and implementing an infection prevention and control program for a COVID-19 alternative care site in Philadelphia, PA.
      ,
      • Brown LMLM
      • Rogers B
      • Buckheit K
      • Curran JPJP
      Evaluation of 9 health care organizations’ respiratory protection programs and respiratory protective device practices: Implications for adoption of elastomerics.
      ,
      • Leiker B
      • Wise K
      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      ; (2)PPE compliance monitoring by checking expiration date, proper stock management, and ensuring the adherence to PPE manufacturer instructions
      • De Iaco G
      • Puro V
      • Fusco FMFM
      • et al.
      Personal protective equipment management and policies: european network for highly infectious diseases data from 48 isolation facilities in 16 European Countries.
      ,
      • Fadaak R
      • Davies JM
      • Blaak MJ
      • et al.
      Rapid conversion of an in-patient hospital unit to accommodate COVID-19: an interdisciplinary human factors, ethnography, and infection prevention and control approach.
      ; (3)PPE provision as per the level of risk in 3 different zones (eg, high, medium or low risk)
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      ; use of additional PPE like powered air purifying respirators (PAPRs)
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      in all areas allocated for aerosol-generating procedures; (4)donning and doffing area designations and establishment of standard PPE ensemble and illustrations of step-by-step instructions for safe donning and doffing ensuring separation of clean PPE from contaminated items, preferably in negative-pressure rooms with mirrors.
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      ,
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      ,
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      ,
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      In case of full body coverage, simple tools for maintaining balance while removing shoe covers are advised, such as chairs, hand grips, and step stool
      • DuBose JR
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      ; (5) organization of the PPE carts and supplies
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      ; (6) adoption of reuse and waste disposal policies, designating appropriate storage, contamination areas and disposal arrangements
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      The responsibility for the implementation of PPE policy should be shared among HWs, administrative staff, and IPC and engineering teams.

      Policy and procedure communications

      It was found that PPE policies were not consistent in HFs and/or were constantly changing. Too much irrelevant information created confusion among HWs,
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      Daily updates were not helpful because HWs needed consistent PPE recommendations and guidelines. Also, lack of leadership and team cohesion and loss of accuracy of the tasks led to PPE incorrect use.

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      Implementation interventions: To overcome communication barriers simple strategies as alternative communication might be used: hand-signs taught to all HWs, writing on glass doors with markers,
      • Leiker B
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      COVID –19 case study in emergency medicine preparedness and response: from personal protective equipment to delivery of care.
      creation of laminated cards for use by the team,
      • Kay MB
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      and text messaging apps to discuss key points with the staff.
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      More complex strategies were found to be valuable, such as the implementation of routine evaluation and feedback regarding HF's PPE adherence
      • Dibbs RPRP
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      and establishment of daily routine meetings and instructions, departmental bulletins, and face-to-face briefings.
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