PPE Use in the Early Days of COVID

In December 2020, we surveyed prehospital care providers in rural Northern New York State to see how their use of personal protective equipment may have changed in the early months of the COVID-19 pandemic. Our results showed prehospital providers had increased their use of PPE on both non-COVID-19 and COVID-19 suspected calls but PPE training was uneven. PPE use was greater for COVID-19 suspected calls and included N95 masks, gloves, gowns and goggles or a face shield. Eighty-three percent (83%) of respondents reported that they "felt comfortable" with the PPE they were supplied and 60% of respondents reported that they felt their agency had a sufficient supply of PPE. Sixty-four percent (64%) of respondents reported exposure to a patient with COVID-19 while they were working in healthcare. Fourteen percent (14%) who reported such an exposure also reported testing positive for COVID-19 though a positive test could not be directly attributed to patient contact. Deployment rates of full PPE for COVID-19 suspected encounters was higher in this rural area than what has been reported in other EMS jurisdictions. The high adoption/high risk but low and uneven training rates for PPE argue for effective design in EMS systems and equipment, including PPE.

In December 2020, less than a year into the COVID-19 pandemic and before vaccines were widely available to EMS personnel, we conducted a survey of EMS practitioners in rural Upstate New York. Our goal was to better understand how these rural agencies introduced more expansive personal protective equipment (PPE) practices during the pandemic. We were interested in the PPE EMS providers were using early in the pandemic, the types of training agencies implemented, and EMS providers’ perspectives on the quality and effectiveness of the new PPE requirements. The survey took place at a time when our knowledge about COVID-19 was still evolving and when the impact of the pandemic was disproportionately affecting front-line healthcare workers.

Over the past two years, PPE and infection-control measures have risen to the top of most EMS agencies’ agendas. Early into the COVID-19 pandemic, during a rapidly-changing clinical setting and with limited knowledge about disease transmission, prehospital providers began caring for more patients with symptoms consistent with COVID-19. Crews had to take extra precautions on every call in efforts to keep providers safe, reduce community spread, and maintain constant readiness of EMS personnel and equipment.1 During this time, new PPE requirements were introduced and PPE training and policy dissemination moved from in-person to hybrid and online formats. The move to adopt extra precautions was complicated by national shortages in PPE, misinformation campaigns, and a lack of appropriate funding for prehospital providers.2,3,4 Additionally, many prehospital providers opted to reuse PPE and some agencies adopted innovative technologies like UV decontamination units for PPE and ambulances.5

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During this context of a spreading pandemic, inadequate PPE resources, increasing risk to providers, and new innovations and practices in the field, we attempted to examine how practicing prehospital providers learned their agencies’ new PPE policies, how comfortable they were with using PPE, the types of PPE they had adopted, their confidence in their PPE during the pandemic, and the effectiveness of PPE use.

Using SurveyMonkey, we distributed a brief survey to EMS agencies and practicing prehospital providers across rural Northern New York State (Clinton, Essex, Franklin, Hamilton, Herkimer, Jefferson Lewis, and St. Lawrence counties). The survey was available from December 1 to December 31, 2020. Table 1 lists the survey questions. All responses were anonymous.

Table 1 Survey Questions

In this article, we share our results in hopes of documenting and providing useful operational information for EMS agencies. The results speak to EMS preparedness, training, and risk-minimization during the first months of the COVID-19 pandemic in rural Northern New York State.

Policies, Training, and PPE Utilization

We received 80 responses to the survey. Ninety-four percent (94%) of respondents reported that their agency developed operating guidelines for responding to patients who were potentially infected with COVID-19. Sixty-two percent (62%) of respondents reported that they received some type of formal agency training on the donning, wearing, and doffing of PPE with in-person training the most often cited form (38%). More informal, self-directed training was reported by 30% of respondents and 18% reported that they did not receive any training in donning, wearing, and doffing of PPE. Figure 1 shows the type of training received by respondents.

PPE on Non-COVID-19 Suspected Calls

All respondents reported wearing some PPE on routine, non-COVID-19 suspected prehospital patient calls. For these non-COVID-19 suspicious calls, nearly all respondents (95%) wore an N95 (61%), surgical mask (46%), or both; 93% wore gloves, 74% wore goggles or a face shield, and 14% wore a gown. In aggregate, 54% of respondents wore an N95, gloves, and goggles or a face shield during these calls and 88% wore a mask (N95 or surgical) and gloves.

PPE on COVID-19 Suspected Calls

Respondents reported that their PPE use increased when responding to patients with COVID-19 symptoms. Nearly all respondents reported wearing gloves (99%) and goggles or a face shield (98%). Ninety-five percent (95%) of respondents reported wearing an N95 mask, 75% wore gowns, 26% head covers, and 25% wore a surgical mask. Eighteen percent of respondents (16%) wore a Tyvek suit, and 10% wore powered air purifying respirators (PAPR). These results are reported in Table 2. In aggregate, 90% of respondents wore a combination of N95 mask (or PAPR), gloves, gown (or Tyvek suit), and goggles or a face shield when responding to patients who reported symptoms consistent with COVID-19.

Type of PPE Worn When Patients Reported COVID-19 Symptoms

Confidence in PPE

Eighty-three percent (83%) of respondents reported that they "felt comfortable" with the PPE they were supplied. Sixty percent (60%) of respondents reported that they felt their agency had a sufficient supply of PPE, 28% reported an insufficient supply, and 13% reported they did not know if their agency's supply was adequate. Twenty-four percent (24%) of respondents reported that they had to personally buy their own PPE for use at their agency.

PPE and COVID-19 Exposure

Sixty-four percent of respondents (64%) reported that while they were working in healthcare they were exposed to a patient known to be infected with the COVID-19 virus. Nineteen respondents (24%) reported that they were placed on quarantine or self-isolation due to a COVID-19 exposure. Thirteen (17%) claimed this exposure was in their role as a healthcare provider, five (6%) claimed the exposure occurred outside their role as a healthcare provider, and one respondent reported exposure in both environments. Seven respondents (14%) who reported that exposure occurred while in their role as a healthcare provider reported testing positive for COVID-19. However, it is unknown whether these positive results can be attributed to patient contact, inadequate PPE, or non-work exposures.

Our infection rate was too low to statistically validate training methods. There were no statistically significant differences found between the type of training respondents received (or no training) and the aggregate PPE worn (gloves, N95 or PAPR, face shield/goggles) to both standard calls and suspected COVID-19 calls.

We conducted this survey of PPE use among rural Northern New York State prehospital EMS providers in December 2020, less than one year into the COVID-19 pandemic and before vaccines were widely available for healthcare workers. Our results show that these EMS agencies were largely well-prepared and responded effectively to the early challenges of the pandemic. Our respondents reported wide adoption of operating guidelines and increased use of PPE on both routine and COVID-19 suspected calls. Training was uneven as 18% of respondents noted that they did not receive training on PPE donning, wearing, and doffing.

Our ability to assess PPE effectiveness was limited by not knowing if a respondent's positive COVID-19 test was the result of patient or community contact. Given that 64% of respondents reported exposure to patients with a known COVID-19 diagnosis, the relatively few respondents who contracted the disease (seven respondents or 14% of those who reported exposure) argues in favor of the PPE measures adopted by the EMS agencies surveyed.

The percentage of respondents who tested positive is lower than what has been reported by similar studies. For example, in their meta-review of 28 studies of healthcare workers, Gholami et al. found a 51.7% infection rate among healthcare workers treating patients with COVID-19.6 Gray et al., studying occupational exposure among healthcare workers at an English haemodialysis center reported a 23% infection rate.7 Wilkins et al., found a 37.8% rate of infection among healthcare workers who "definitely" had exposure to a patient with COVID-19.8 Healthcare workers treating patients on high flow oxygen had a 45% greater chance of contracting COVID-19.8,9

Our 90% full PPE adoption rate (gloves, N95, gown, goggles or face shield) for suspected COVID-19 calls was higher than the rate (41.7%) found by McCann-Pineo et al. (defined as gloves, eye protection, surgical, N95, or PAPR mask, and a gown).10 Our rate is also higher than the initial 67% rate found by Murphy et al, (any mask, eye protection, gown and gloves) and the individual rates Fernandez et al. reported for any mask (40.4%) and N95 mask or PAPR (85%) for COVID-19 suspicious calls.11,12 The higher rate of full PPE adoption and lower comparative infection rate than other health workers exposed to COVID-19 infer that the combination of N95 masks, gloves, and goggles or a face shield appeared to provide adequate risk mitigation for our respondents.

Our uneven training rates echo those found by Cash et al., who reported a high awareness (99%) of N95 respirators but lower annual fit testing (61%) and training (64%) in their national study of 15,339 working EMS personnel.13 They conclude that "substantial gaps" exist in PPE training and that lower odds of training were associated with part-time employment, 911 response agencies, non-fire-based EMS agencies, and rural agencies.12 These same factors are predominant throughout the Northern New York counties we surveyed for this study.

Our findings argue for attention to effective design in EMS systems and equipment, including PPE. While PPE adoption was better than reported in other jurisdictions, 18% of respondents did not receive training in PPE use and the type of training respondents received varied from in-person to simply reading instructions. As Robert Wears and Rollin Fairbanks have noted, the implementation of medical devices, safety equipment, and the operation of complex systems should not rely on training for effective use. Citing case reports on use error they write, "[d]evice design typically has much more influence on correct use than does medicine's favorite remedy, training." Further, they note that in reality, many users of medical devices like PPE will not have been adequately trained before they use this equipment in what will most likely be a high-risk scenario.14

We recognize that our study is limited by several factors. First, our results are self-reported by survey respondents and could contain bias, including a selection bias among those who chose to participate. Second, our dissemination method did not allow us to control for response rate or diversity among survey participants. Third, data collection did not include sufficient demographic information, agency information, or information about provider role to allow us to determine if infection could have been associated with experience, advanced care (nebulizer administration) or other factors. Lastly, our low infection rate did not allow us to statistically assess training modes across agencies.

At the same time, the high utilization and low incidence of infection among these respondents at this time in the pandemic speaks to the effectiveness of PPE design and the ability of these respondents to ensure appropriate and effective use during a highly dynamic and perilous time.

1. Cohen H. How Empress EMS (NY) responded to COVID-19 in the pandemic's epicenter. JEMS. 2020;12 https://www.jems.com/operations/how-empress-ems-responded-to-covid-19-in-the-pandemics-epicenter/.

2. Shekhar A. PPE in EMS moving forward: Lessons learned from COVID-19. JEMS. 2020; 6(2), https://www.jems.com/coronavirus/ppe-in-ems-moving-forward/.

3. Editorial. Does wearing a mask pose any health risks? JEMS. 2020; 7(2), https://www.jems.com/operations/equipment-gear/does-wearing-a-mask-pose-any-health-risks/.

4. Maguire BJ, O’Neill BJ, Maniscalco P, Phelps S, Gerard DR, Kirkwood S, Dean S, Handal KA. Personal Protective Equipment for emergency medical services; research and system needs. JEMS. 2021; 9(21), https://www.jems.com/operations/equipment-gear/personal-protective-equipment-for-emergency-medical-services/.

5. Bohl D, Towler C. Development and Characterization of Two Low-Cost UV Decontamination Units for PPE and Ambulances. JEMS. 2021; 2(16), https://emsrig.com/index.php/2021/02/16/low-cost-uv-decontamination-units-for-ppe-and-ambulances/.

6. Gholami M, Fawad I, Shadan S, Rowaiee R, Ghanem H, Khamis AH, Ho. S. COVID-19 and healthcare workers: A systematic review and meta-analysis. Int J Infec Dis. 2021;104:335-346. doi: 10.1016/j.ijid.2021.01.013.

7. Gray S. Clough T, Mcgee Y, Murphy T, Donne R, Poulikakos, D. Occupational exposure of healthcare workers to COVID-19 and infection prevention control measures in haemodialysis facilities in North West of England. Infect Prev Pract. 2021;3:100150. doi: 10.1016/j.infpip.2021.100150.

8. Wilkins J, Gray E, Wallia A, Hirschhorn LR, Zembower TR, Ho J, Kalume N, Agbo O, Shu A, Rasmussen-Torvik LJ, Khan SS, Carnethon M, Huffman M. Evans CT. Seroprevalence and correlates of SARS-CoV-2 antibodies in healthcare workers in Chicago. Open Forum Inf Dis. 2021;8. doi: 10.1093/ofid/ofaa582.

9. Thomas L. Critical insights into COVID-19 exposure for healthcare workers. News Medical Life Sciences 2020;9. https://www.news-medical.net/news/20200916/Critical-insights-into-COVID-19-exposure-for-healthcare-workers.aspx.

10. McCann-Pineo M, Li T, Barbara P, Levinsky B, Berkowitz J. Factors influencing use of personal protective equipment among Emergency Medical Services responders during the COVID-19 pandemic: A retrospective chart review. West J Emerg Med 2020;23:396-407. doi: 10.5811/westjem.2022.2.55217.

11. Murphy D, Barnard L, Drucker C, Yang B, Emert J, Schwarcz L, Counts C, Jacinto T, McCoy A, Morgan T, Whitney J, Bodenman J, Duchin J, Sayre M, Rea T. Occupational exposures and programmatic response to COVID-19 pandemic: An emergency medical services experience. Emerg Med J 2020; 37: 707-713. doi: 10.1136/emermed-2020-210095.

12. Fernandez A, Crowe R, Bourn S, Matt S, Brown A, Hawthorn B, Myers B. COVID-19 preliminary case series: Characteristics of EMS encounters with linked hospital diagnoses. Prehosp Emerg Care 2021;1:16-27. doi: 10.1080/10903127.2020.1792016.

13. Cash R, Rivard M, Camargo C, Powell J, Panchal A. Emergency medical services personnel awareness and training about personal protective equipment during the COVID-19 pandemic. Prehosp Emerg Care 2021;25:777-784. doi: 10.1080/10903127.2020.1853858.

14. Wears R, Fairbanks R. Design trumps training. Ann Emerg Med 2016;67:316-317. doi: http://dx.doi.org/10.1016/j.annemergmed.2015.10.014.