Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19 patients

Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19 patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19 patients Susan Kraus, Romana Macherey, Lukas Rimkus, Sarah Tschudin-Sutter, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3845830/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Personal protective equipment (PPE) protects healthcare workers and patients. Data on guideline compliance on how to dress (donning) or remove (doffing) PPE and the effect of monitoring (buddying) are limited. This study assesses the quality of donning, doffing, and buddying of PPE in a simulated medical emergency. Method Physicians handling a simulated cardiac arrest of a COVID-19 patient. Adjacent to the victim, PPE (FFP2 masks, gowns, caps, protective eyewear, gloves) was available. Data analysis was performed on video recordings. The primary outcome was the number and timing of participants being appropriately protected, defined as both wearing a) all PPE items provided, and b) all PPE items correctly at the time of first patient contact (FPC). Secondary outcomes included compliance with doffing and buddying. Statistical analysis was performed using SPSS (version 28). Mann–Whitney test, Chi-square test, and linear regression analysis were performed as appropriate. Results At first patient contact 91/437 (21%) were correctly protected while 306/437 (70%) were partially incorrectly protected. One or more PPE items were missing in 62/437 (15%). Overall donning time was 63 (52–74) seconds, the time interval between donning start and FPC was 66 (55–78) sec. Time to FPC was longer in correctly than in incorrectly protected participants (77 [66–87] vs 64 [54–75] sec; P < 0.0001) and decreased by 7 ± 2 seconds per PPE item omitted (P = 0.002). Correct doffing was observed in 192/345 (56%), buddying in 120 participants (27%). Conclusions Our findings imply a need for education in correct and timely PPE donning and doffing. Donning PPE as intended delayed FPC. This and the influence of buddying needs further investigation (German study register number DRKS00023184). COVID-19 cardiopulmonary resuscitation controlled trial personal protective equipment simulation Figures Figure 1 Figure 2 1. Background During the pandemic, international and national recommendations regarding faultless dressing (“donning”) and removal (“doffing”) of personal protective equipment (PPE) have been published to minimize the risk of contagion during the cardiopulmonary resuscitation (CPR) of a suspected COVID-19 victim [( 1 , 2 )]. These recommendations are based in part on considerations of the potential transmission of droplet and airborne agents from the patient to the rescuer during CPR. Available data concerning CPR during COVID-19 show strikingly poor results compared to non-pandemic data; results from large studies range from no [( 3 , 4 )] and 3% survival in patients aged > 79 years, respectively [( 4 )]. Already at this point, attention was drawn to the possible role of the PPE to further optimize CPR for COVID-19 and the need for scientific research in this topic [( 3 , 4 )]. Until now, there are no large, randomized trials on the impact of PPE on CPR; available data mostly stems from smaller studies investigating the quality of chest compressions of single rescuers in simulated arrests [( 5 – 9 ) ( 10 , 11 )] with partially contradictory results ranging from no [( 8 , 9 )] to even negative effects of PPE [( 5 , 10 – 13 )]. Whereas beneficial effects of PPE include protection of the carrier from aerosol or droplet based transmission [( 1 , 2 , 14 )], particularly delays by “donning” PPE in COVID-19 CPR and hygienic issues have been discussed [( 2 , 15 , 16 )], but published data preferentially did not show any relevant delay during life-saving procedures in various populations [( 8 , 17 )]. So far, there are only very limited data, on whether buddying, the process of supervising each other, is able to mitigate negative effects of donning and doffing of PPE [( 18 )]. In emergency situations, high time pressure occurs as rescuers need to don prior to taking care of the patient. So far, the quality of donning in emergency situations is largely unknown. In real life situations, quality of donning and doffing could best be assessed by using trained observers, but during a pandemic, such resources may not be freely available. However, investigating the impact of donning and doffing on the overall quality of PPE especially for COVID-19 CPR in adequately powered prospective trials would be difficult in real cases for a variety of reasons. Simulation allows the investigation of team performance both globally and in specific subtasks in a realistic and standardized manner [( 19 )], and, as a particular advantage, allows recording data right from the start. Accordingly, the aim of this trial was to assess the quality of donning and doffing of PPE and the impact of buddying if any, in simulated cardiac arrests of a suspected COVID-19 victim. [( 20 )]. 2. Material and Methods 2.1. Participants The Working Group on Intensive Care Medicine (Arbeitsgemeinschaft Intensivmedizin) in Arnsberg, Germany, accessible at http://www.aim-arnsberg.de as of June 18, 2023, organizes continuing education programs for physicians. These programs primarily target residents in their second to third year of postgraduate medical training in fields of emergency and intensive care medicine, such as internal medicine, anesthesia, or surgery. Participants in these courses come from both Germany and German-speaking countries. During these courses, participants were given the opportunity to take part in optional simulator-based CPR workshops. It was made clear to them that these workshops were recorded for scientific purposes. Additionally, identical workshops were offered to physicians who wished to participate but preferred not to be filmed. The trial, conducted in accordance with the Declaration of Helsinki guidelines, received approval from the Ethics Committee of "Aerztekammer Westfalen-Lippe" (2020-602-f-S), which waived the requirement for obtaining consent. Furthermore, an amendment for the presented analysis of PPE was also exempted from consent requirements. The trial is registered in the German Clinical Trial Registry (accessible at www.drks.de as of August 19, 2022, DRKS-ID: DRKS00023184). The reporting of the study adheres to the extensions of the STROBE statements as outlined in the Reporting Guidelines for Health Care Simulation Research [( 21 )]. 2.2. Study Design This study reports hitherto unreported data from the PPE cohort of a prospective comparative trial involving two cohorts [( 20 )]. Throughout the years 2020 and 2021, all attendees of our workshops were required to perform CPR while wearing PPE. Participants from individual workshops were randomly divided into teams consisting of three to five physicians. 2.3. Simulator and Scenario The Ambu Man Wireless mannequin (Ambu GmbH, Bad Nauheim, Germany) was used for this study. All participants underwent a standardized briefing, which encompassed an introduction to the workshop, familiarization with the mannequins, and an overview of the available resuscitation equipment. Subsequently, each team member was apprised of their role in the upcoming scenario: they would be part of a resuscitation team responding to an unwitnessed cardiac arrest due to ventricular fibrillation. 2.4. Personal Protective Equipment (PPE) The teams were explicitly informed that, mirroring real-world practices at that time, they were required to fully don PPE before any contact with the patient. In adherence to stringent hygiene protocols, participants were mandated to wear N95 masks continuously throughout the duration of the course. Additionally, a variety of PPE items, including gloves, protective eyewear, gowns, and scrub caps, were readily available in ample quantities and various sizes, arranged on a table within the scenario room. This arrangement served the dual purpose of ensuring participants understood the need to prepare for a medical emergency after "donning" PPE. The time taken for the "donning" process was defined as the duration between the initial handling of PPE equipment by any team member and the first contact with the patient by any team member. The process of "doffing" (removing PPE) occurred after the return of spontaneous circulation (ROSC) and was observed until completion. Data on buddying were collected during both donning and doffing. All scenarios were supervised by trained tutors instructed not to interfere in any way with donning, doffing, or buddying. 2.6. Data Analysis Data analysis was performed using the video recordings obtained during the simulations. According to international guidelines [( 2 )], correctness of PPE worn was defined as follows: gloves: both hands completely covered; gown: no skin visible between gown and gloves AND gown completely closed at the backside; mask: both mouth and nose covered; cap: hair fully covered; goggles: both eyes protected. Full protection was defined as wearing a FFP2 mask, protective goggles, cap, gown, and gloves at 1st patient contact. Full and correct protection was defined as wearing all these protective items in the abovementioned correct way. Though international guidelines on doffing slightly vary, they agree that to prevent self-contamination by the removal of protective items with contaminated gloves, doffing should start with the removal of gloves and gown. Accordingly, we defined the doffing sequence as correct, if the first two items removed were gloves and gown all other protective items were removed thereafter. 2.7. Statistical Analysis The primary outcome was the number of participants wearing full and correct protection at 1st patient contact. Secondary outcomes included the time needed and the correct sequence for donning; buddying (within team help) and the quality of doffing. Data are expressed as medians [IQR], unless otherwise stated. Statistical analysis was performed using SPSS (version 28). Mann–Whitney test, Chi-square test, and linear regression analysis were performed as appropriate. The estimates for differences between the medians and their approximate confidence intervals were obtained by the Hodges–Lehmann estimation. A p < 0.05 (two-tailed) was considered to represent a statistical significance. 3. Results 3.1. Participants Overall, 437 (224 females and 213 males) participants randomized to 114 teams of 3–5 physicians each were evaluated. 3.2. Primary Outcome At the time of first patient contact, 21% (91/437) of the participating physicians donned all items of PPE correctly. 70% (306/437) donned all items of PPE, but not all items were worn correctly. One or more protective items were missing in 15% (62/437). An overview can be found in Table 1 and 2 . Participants’ sex had no effect on the extent of protection (P = 0.42) and on protective items missing (P = 0.15). Table 1 Compliance with donning PPE N percentage Fully and correctly protected (FFP2; protective googles; cap, gown, gloves; all correctly worn) at 1st patient contact 91 21% Fully protected (FFP2; protective googles; cap, gown, gloves; one or more items incorrectly worn) at 1st patient contact 306 70% Fully and correctly dressed (any mask; any glasses; cap; gown; gloves; all correctly worn) at 1st patient contact 110 25% Fully dressed (any mask; any glasses; cap; gown; gloves; one or more items incorrectly worn ) at 1st patient contact 375 86% Protective items missing at 1st patient contact One protective item missing at 1st patient contact (cap = 30; glasses = 21; gloves = 1) 51 12% Two protective items missing at 1st patient contact 11 3% Three or more protective items missing at 1st patient contact 0 0% Protective items incorrectly worn at 1st patient contact One protective item incorrectly worn (gown = 197; cap = 23) 220/375 59% Two protective items incorrectly worn 63/375 17% Three or more protective items incorrectly worn 0 0% Table 2 Compliance with wearing single PPE items N percentage Mask Wearing a mask prior to donning (mandatory) (FFP2 mask = 386; surgical mask 51) 437 100% Fitting a new mask during donning 10 2% Wearing any mask at 1st patient contact 437 100% Wearing a FFP2 mask at 1st patient contact 394 90% Wearing a surgical mask at 1st patient contact 43 10% Wearing no mask at 1st patient contact 0 0% Wearing mask correctly (mouse and nose covered) 437/437 100% Goggles Wearing protective glasses prior to donning (not mandatory) 0 0% Wearing any glasses at 1st patient contact 405 93% Wearing protective glasses at 1st patient contact (protective glasses only = 271; protective glasses over own glasses = 79) 350 80% Wearing own glasses only at 1st patient contact (vain attempt to fit protective glasses over own glasses = 16/59) 55 13% Wearing no glasses at 1st patient contact 32 7% Wearing glasses/goggles correctly (both eyes protected) 407/407 Gloves Wearing gloves prior to donning (not mandatory) 26 6% Fitting new gloves during donning 3/26 12% Wearing gloves at 1st patient contact 435 99.5% Wearing no gloves at 1st patient contact 2 0.5% Wearing gloves correctly (both hands covered) 435/435 Gown Wearing a gown prior to donning (not mandatory) 0 0% Wearing a gown at 1st patient contact 436 99.8% Wearing no gown at 1st patient contact (gown too small for body size = 1) 1 0.2% Wearing gown correctly (gown completely closed at backside) 148/436 34% Gown only partially closed at backside 244/436 56% Gown completely open at backside 44/436 10% Cap Wearing a cap prior to donning (not mandatory) 0 0% Wearing a cap at 1st patient contact 399 91% Wearing no cap at 1st patient contact 38 9% Wearing cap correctly (hair fully covered) 316/399 79% Wearing cap not correctly (hair not fully covered) 83/399 11% Table 1 Compliance with donning PPE Table 2 Compliance with wearing single PPE items 3.3 Secondary Outcomes Timing Overall donning time was 63 (52–74) seconds and the time interval between start of donning and first patient contact 66 (55–78) seconds. Participants’ sex had no effect on the duration of donning (P = 0.19 and 0.31 respectively). Time to first patient contact was longer after correct donning than after incorrect donning (77 [66–87] vs 64 [54–75] seconds; P < 0.0001, Tables 3 and 4 , Fig. 1 ). Time from start of donning to first patient contact was shorter for each item of PPE missing (P = 0.002), the respective regression coefficient of -7 ± 2 indicating a shortening of the time interval of approximately 7 seconds per protective item omitted. Table 3 Time for donning and doffing in relation to compliance with PPE Fully & correctly protected YES (n = 91) Fully & correctly protected NO (n = 346) ParamEst (95%CI); P Donning (sec) 70 (61-80) 61 (51-71) 10 (6-14); P<0.0001 Donning to 1 st patient contact (sec) 77 (66-87) 64 (54-75) 12 (8-16); P<0.0001 Doffing (sec) 50 (41-69) 46 835-60) 5 (-1 -10); P=0.09 Fully dressed YES (n = 375) Fully dressed NO (n = 62) ParamEst (95%CI); P Donning (sec) 63 (54-74) 56 (46-69) 7 (3-12); P=0.03 Donning to 1 st patient contact (sec) 67 (57-79) 60 (48-73) 8 (3-13); P=0.03 Doffing (sec) 48 (36-62) 42 (31-57) 5 (-1 -11); P=0.08 Table 4 Time for donning and doffing in relation to compliance with PPE (linear regression analyses) Fully but (partly) incorrectly dressed (n = 284) Fully & correctly dressed (n = 91) ParamEst (95%CI); P Donning (sec) 62 (52-71) 70 (61-80) 9 (6-13); P<0.001 Donning to 1 st patient contact (sec) 65 (55-75) 77 (66-87) 11 (7-15); P<0.001 Doffing (sec) 46 (36-61) 50 (41-69) 4 (-2 -9); P=0.17 Table 3 Time for donning and doffing in relation to compliance with PPE Table 4 Time for donning and doffing in relation to compliance with PPE (linear regression analyses) Figure 1 Relation between missing PPE items and time from donning to first patient contact Doffing 92/437 participants (21%) removed their PPE partly or completely outside of the range of the camera and, accordingly, were excluded from analysis. Thus, data from 345 participants (179 female) were analysed. A correct doffing sequence was observed in 56% (192/345) with no difference relating to participants’ sex (P = 0.41). The remaining participants (44%, 153/345) made at least one hygienic mistake. More data is presented in Fig. 1 . Figure 2 Doffing Buddying Buddying during donning and doffing was observed for 120 participants (27%), thereof 76 with provision of physical help, 44 with verbal help and 32 with both physical and verbal help. In return, 122 participants (28%) received help from their colleagues (active help = 69; verbal help = 53; both = 32). Participants’ sex did not influence providing (P = 0.30) or receiving help (P = 0.38). 4. Discussion This prospective trial demonstrates that only one in five participants wore all items of PPE correctly at their first patient contact in simulated cardiac arrest of a Covid-19 patient. Furthermore, putting on PPE as intended delayed the first patient contact by approximately 80 seconds. This delay was slightly shortened by omitting protective items and/or incorrect fitting of PPE. Buddying was provided during donning only by a minority of participants. Safe doffing of PPE was observed in only 56% and buddying during doffing, as a potential error reduction measure was recorded in only 22% of the cases. To the best of our knowledge, this is the largest trial investigating the effects of using PPE in a standardized, simulated CPR so far and the results may have an important influence on future CPR training in the context of pandemic events or simply on resuscitatation of patients under isolation precautions. Despite increasing promotion and most likely training and experience with the use of PPE during the study period during the pandemic, compliance with donning and doffing in terms of the use of all items and their correct fitting was low. Primary outcome Completeness, fitting, and timing of PPE protection during and after donning Our findings show that completeness as well as correctness of PPE donning are time sensitive. And, although COVID-19 publications have reached over 400 k, there were 118 hits (thereof only 9 studies) using the search string “Donning and doffing AND time” and a combination thereof, making a reliable comparison to the existing literature difficult. Depending on the complexity of the protection to be applied, the time required to don PPE ranged from 2 to 4.5 min [( 22 )] and 10 to > 20 min respectively [( 23 , 24 )]. An increase in time of 10% was described for the nurse workload and quality of care using process simulation [( 25 )]. Besides, our data suggest that a relevant proportion of participants had insufficient knowledge of how to correctly apply PPE. Concerning correctness, this is in line with data where the numbers of correctly donned and doffed PPE in observed health care workers ranged between 50% and 37% respectively [( 26 )]. This is significant as data from Italy, one of the earliest and hardest hit countries in Europe, from the early days of the pandemic suggests that formal training and support did take place and buddying was available – only 24% (91/380) were never buddied and 79% (299/380) had received formal training in PPE use at any time [( 27 )]. Supporting Italian data state, that approximately half of the physicians reported that the information received about the use of PPE was either clear (47%) or complete (54%) [( 28 )]. “Ill-fitting” as described by Janson et al [( 29 )] implies the discrepancy of PPE being generally designed around the size and shape of an average European or US white man's face and body and the anatomical difference in size that could lead to additional risk for female healthcare workers. In the present cohort with approximately 50% female participants we neither observed ill-fitting nor were confronted with corresponding participants’ complaints. However, there is a possibility that to be able to help the victim as quickly as possible, the participants may have accepted to protect themselves insufficiently. And, although the Geneva Pledge was revised in 2017, medical presenteeism has been referred to as a "public health hazard" in the past [( 30 )]. Concern for patients was also cited as one of the reasons for potentially harmful behavior [( 31 )]. In the context of testing this hypothesis one could argue that the time advantage of an overhasty PPE dressing may not medically relevant for the victim of a circulatory arrest (whether resuscitation starts after 65 or after 80 sec will not be relevant in terms of outcome). It is currently common sense that resuscitation should always be emphasized except in the case of obvious death (e.g., rigor mortis), signs of life (e.g., signs of responsiveness or breathing, eye movement, visible chest rise, purposeful movement) or unsafe scene – where PPE may be helpful. Beyond CPR, for most other medical emergencies (which are usually less time-critical than resuscitation), a fortiori is not relevant. Secondary outcomes Doffing Correct doffing is critical for both self-protection and the protection of others from cross-contamination, thus our finding of only 56% correct doffing procedures are somewhat worrisome. Interestingly, there was more data available on doffing than donning and time (150 vs. 118 hits). Self-contamination ranged between 40% in a mixed health care workers population (house-keeping sanitation staff, technicians, nursing staff and resident doctors), with 6.5% breaches in physicians only [( 32 )] and up to 90 (92.3%) [( 33 , 34 )] with the latter being found during doffing of simple PPE sets. And even despite well-trained teams of health care workers, contamination while doffing was observed with every type of PPE gown, and with each health care worker subject. All body areas were contaminated at least once, except the face [( 35 )]. Helpful for avoiding contamination, at least in a simulated setting, was PPE doffing following step-by-step verbal instructions from a trained supervisor but at the expense of prolonged doffing time [( 36 )].These findings need to be explored further and measures against this must be initiated. Buddying Since self-contamination during doffing of PPE is a serious issue, buddying has a high potential in reducing potentially deleterious errors. In a comprehensible large study, the introduction of “dofficers” led to a significant decrease in the mean error rate (9.8–2.9%, P < .001) with the largest reduction occurring in the category of PPE doffing errors [( 37 )]. In another study, “PPE marshals” intervened on 121 occasions, predominantly through buddying, explaining, and demonstrating correct PPE use, most frequently with medical staff (72%). This intervention led to a PPE compliance variation between 47.9% (Buddy check) and 91.8% (Bare below elbow) [( 18 )]. One of the potential disadvantages of supervised doffing may be an increase in time compared with unsupervised doffing (184 vs. 68 seconds, P < 0.001), but, since this measure also led to a significantly lower contamination rate (8% vs. 47%; p < 0.001) [( 36 )] and doffing after handling a medical emergency is seldom time crucial, this may probably be neglectable under these circumstances. Despite some, albeit very low-quality evidence that behavioral interventions, namely education and training, do not have a considerable effect on the frequency or correctness of PPE use in workers [( 38 )] we believe that any measure help to improve the results of donning, doffing, and buddying, should be undertaken. Our study has several implications: First, using PPE (donning, doffing) is an integral part of CPR not only during a pandemic but also in an increasing number of patients requiring isolation. Thus, teaching and training of rescuers must consider these two components CPR and PPE independently but also interdependently: Not only ACLS must be trained, but also the handling of PPE and its use during ACLS. Second, although the present trial was conducted during an ongoing severe pandemic lasting already several months, the quality of the protective skills of our participants was poor. Thus, frequent use of PPE alone is insufficient to ensure adequate protection of patients and health-care workers alike. Instead, regular supervision and strict enforcement of hygienic rules appears to be necessary in health-care institutions. Third, especially under pandemic conditions or with patients in isolation, buddying should be promoted to reduce errors, especially of doffing, and cross-contamination rates. Strengths and limitations Strengths of this trial include the large sample size and the perfectly standardized conditions for all teams. Limitations of simulator-based studies include the absence of real patients and, in the present trial, of real environment (i. e. locks or wardroom assessments). However, simulation is increasingly regarded as an accepted tool for evaluation [( 19 )] while performance markers in simulator-based studies show a high agreement with findings in real cases. It is possible that quite a number of the observed errors are contributory to the simulation setting (CPR simulation in a hospital room, but in a non-hospital setting). Moreover, in the present study simulation enabled investigating a topic that for a variety of practical and ethical reasons (“donning” of PPE in a COVID-19 emergency, recording right from the start difficult and personnel-intensive) would be very difficult to investigate in real cases. Our study population consisted of physicians in their 2nd to 3rd year of residency that, at the time of the study, acted as potential first responders for cardiac arrests in their hospitals. In addition, we refrained from using special teaching, special PPE protocols, or habituation with repetitive exposure prior to testing our participants in the simulated scenario. As such, our results reflect the actual state of our participants’ knowledge and skills and can be extrapolated to real-world settings. In combination with shortcomings and deviations from CPR algorithms associated with PPE, our finding of a substantial initial delay of CPR due to “donning” may well be of clinical relevance and contribute to poor outcomes of CPR in COVID-19 patients [( 20 )]. 5. Conclusions Wearing PPE during CPR places an additional burden on rescuers who already have a demanding job. Beside already published medical limitations during simulated CPR we were now able to show that only a minority of participants had a full and correct protection at the time of their first patient contact. Putting on PPE as intended delayed the first patient contact by approximately 80 seconds. This delay was slightly shortened by omitting protective items and incorrect protection. Safe removal of PPE was observed in only 56%. Buddying was not able to mitigate these effects. Abbreviations PPE Personal Protective Equiqment FPC First Patient Contact CPR Cardiopulmonary resuscitation ALS Advanced Life Support Declarations Author Contributions: Conceptualization, T.S. and S.M.; Data curation, S.K., R.M. and L.R.; Formal analysis, S.K., L.R.,R.M., T.S. and S.M.; Funding acquisition, T.S. and S.M.; Investigation, L.R. S.K., R.M. T.S. and S.M.; Methodology, T.S. and S.M.; Project administration, T.S. and S.M.; Resources, T.S. and S.M.; Software, S.M.; Supervision, T.S., L.R. and S.M.; Validation, T.S. and S.M.; Visualization, S.M.; Writing-Original draft, S.K., R.M. and L.R.; Writing-Review & editing, T.S. and S.M. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Aerztekammer Westfalen-Lippe (2020-602-f-S) that waived the obligation to obtain consent. The original study is registered at the German Clinical Trial Registry (www.drks.de (accessed on 7 October 2020); DRKS-ID: DRKS00023184). Informed Consent Statement: Participants consent was waived due to the anonymity of the compiled data. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Conflicts of Interest: The authors declare no conflict of interest. References Kundra P, Vinayagam S. COVID-19 cardiopulmonary resuscitation: Guidelines and modifications. J Anaesthesiol Clin Pharmacol. 2020;36(Suppl 1):S39-S44. Nolan JP, Monsieurs KG, Bossaert L, Bottiger BW, Greif R, Lott C, et al. European Resuscitation Council COVID-19 guidelines executive summary. 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Cognitive load and performance of health care professionals in donning and doffing PPE before and after a simulation-based educational intervention and its implications during the COVID-19 pandemic for biosafety. Infez Med. 2020;28(suppl 1):111-7. Zhang HL, Yang S, Luo HX, You JP. The Error-Prone Operational Steps and Key Sites of Self-Contamination During Donning and Doffing of Personal Protective Equipment by Health Care Workers. Disaster Med Public Health Prep. 2021:1-6. Doukas D, Arquilla B, Halpern P, Silverberg M, Sinert R. The Impact of Personal Protection Equipment on Intubation Times. Prehosp Disaster Med. 2021;36(4):375-9. Curtis K, Jansen P, Mains M, O'Hare A, Scotcher B, Alcorn D, et al. Rapid development and implementation of a behaviour change strategy to improve COVID-19 personal protective equipment use in a regional Australian emergency department. Australas Emerg Care. 2022;25(4):273-82. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-53. Sellmann T, Nur M, Wetzchewald D, Schwager H, Cleff C, Thal SC, et al. COVID-19 CPR-Impact of Personal Protective Equipment during a Simulated Cardiac Arrest in Times of the COVID-19 Pandemic: A Prospective Comparative Trial. J Clin Med. 2022;11(19). Cheng A, Kessler D, Mackinnon R, Chang TP, Nadkarni VM, Hunt EA, et al. Reporting Guidelines for Health Care Simulation Research: Extensions to the CONSORT and STROBE Statements. Simul Healthc. 2016;11(4):238-48. Rama A, Murray A, Fehr J, Tsui B. Individualized simulations in a time of social distancing: Learning on donning and doffing of an COVID-19 airway response team. J Clin Anesth. 2020;67:110019. Li Y, Wang Y, Li Y, Zhong M, Liu H, Wu C, 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. Risk Manag Healthc Policy. 2020;13:2325-35. Haward R, G R, Kalyan M. The Impact of Personal Protective Equipment on Healthcare Workers on COVID-19 Duty in a Tertiary Care Hospital in South India. Cureus. 2023;15(7):e41910. Qureshi SM, Bookey-Bassett S, Purdy N, Greig MA, Kelly H, Neumann WP. Modelling the impacts of COVID-19 on nurse workload and quality of care using process simulation. PLoS One. 2022;17(10):e0275890. Lamhoot T, Ben Shoshan N, Eisenberg H, Fainberg G, Mhiliya M, Cohen N, et al. Emergency department impaired adherence to personal protective equipment donning and doffing protocols during the COVID-19 pandemic. Isr J Health Policy Res. 2021;10(1):41. Ippolito M, Ramanan M, Bellina D, Catalisano G, Iozzo P, Di Guardo A, 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. Ther Adv Infect Dis. 2021;8:2049936121998562. Savoia E, Argentini G, Gori D, Neri E, Piltch-Loeb R, Fantini MP. Factors associated with access and use of PPE during COVID-19: A cross-sectional study of Italian physicians. PLoS One. 2020;15(10):e0239024. Janson DJ, Clift BC, Dhokia V. PPE fit of healthcare workers during the COVID-19 pandemic. Appl Ergon. 2022;99:103610. Braun J. Risks and side effects of medical presenteeism. . Uro-News. 2020;24 (7):35–7. Jena AB, Meltzer DO, Press VG, Arora VM. Why physicians work when sick. Arch Intern Med. 2012;172(14):1107-8. Naik BN, Singh A, Lazar MS, Ganesh V, Soni SL, Biswal M, et al. Performance of Health Care Workers in Doffing of Personal Protective Equipment Using Real-Time Remote Audio-Visual Doffing Surveillance System: Its Implications for Bio-Safety Amid COVID-19 Pandemic. Cureus. 2021;13(9):e18071. Singh A, Naik BN, Soni SL, Puri GD. Real-Time Remote Surveillance of Doffing During COVID-19 Pandemic: Enhancing Safety of Health Care Workers. Anesth Analg. 2020;131(2):e112-e3. Kang J, O'Donnell JM, Colaianne B, Bircher N, Ren D, Smith KJ. Use of personal protective equipment among health care personnel: Results of clinical observations and simulations. Am J Infect Control. 2017;45(1):17-23. Pottier F, Groizard C, Briche G, Haraczaj N, Garnier M, Loones V, et al. Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation. Int J Emerg Med. 2021;14(1):35. Somri M, Hochman O, Somri-Gannam L, Gaitini L, Paz A, Bumard T, et al. Removal of Contaminated Personal Protective Equipment With and Without Supervision. A Randomized Crossover Simulation-Based Study. Simul Healthc. 2023. Picard C, Edlund M, Keddie C, Asadi L, O'Dochartaigh D, Drew R, et al. The effects of trained observers (dofficers) and audits during a facility-wide COVID-19 outbreak: A mixed-methods quality improvement analysis. Am J Infect Control. 2021;49(9):1136-41. Luong Thanh BY, Laopaiboon M, Koh D, Sakunkoo P, Moe H. Behavioural interventions to promote workers' use of respiratory protective equipment. Cochrane Database Syst Rev. 2016;12(12):CD010157. (CDC) CfDC. How to safely remove personal protective equipment (PPE) [PDF]. Center for Disease Control (CDC); 2021 [Available from: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf. Additional Declarations Competing interest reported. The author, Susan Kraus, hereby discloses the following information regarding potential conflicts of interest related to the submitted manuscript entitled "Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19" for consideration in Antimicrobial Resistance & Infection Control. Susan Kraus declares that Prof. Dr. med Sarah Tschudin Sutter has a professional relationship with Antimicrobial Resistance & Infection Control as an Editor. It is important to note that Prof. Dr. med Tschudin Sutter possesses expertise in the subject matter discussed in the paper due to her extensive experience in clinical hygiene. Susan Kraus affirms that Prof. Dr. med Tschudin Sutter will not have any involvement in the peer-review process or the decision-making regarding the acceptance of the manuscript. The paper will be rigorously reviewed by independent, external reviewers appointed by the editorial team. The author declares that she has not received any direct financial support or other benefits from Antimicrobial Resistance & Infection Control in connection with the submitted manuscript. This disclosure statement is made in the interest of transparency and to maintain the highest standards of integrity in the publication process. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Mar, 2024 Reviews received at journal 30 Mar, 2024 Reviews received at journal 06 Feb, 2024 Reviewers agreed at journal 05 Feb, 2024 Reviewers agreed at journal 22 Jan, 2024 Reviewers invited by journal 15 Jan, 2024 Editor assigned by journal 11 Jan, 2024 Submission checks completed at journal 11 Jan, 2024 First submitted to journal 08 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3845830","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266421653,"identity":"69619a75-8fb9-40c7-854d-99bf665844e2","order_by":0,"name":"Susan Kraus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYPCCBBDB+ICBQQKGiNPCbECyFjaISkJa5GekP/xcwJCWzz8j/Vk17w4LBoPbDYw3PuDRYnAjx1h6BkOO5YwbOWa3ec9IMBjcOcBsOQOfFokcBmkehgoDhhs5bLd52yTqt91IYAOK4HXY498gLfI30p8VA7UwmIG0/MHnmRsJZkAzcwwMgAxmuBZ8OgzOvDGz5jFIMzA888ZYci5Qi/2NxGbLHnwOa09/fJunItlA7nj6ww9v2+oYJGckH7zxA581ELtQeIwNBDWMglEwCkbBKMAPAN9RRL4qTCPVAAAAAElFTkSuQmCC","orcid":"","institution":"Cand. Med, Witten/Herdecke University","correspondingAuthor":true,"prefix":"","firstName":"Susan","middleName":"","lastName":"Kraus","suffix":""},{"id":266421654,"identity":"121c36eb-3c57-44bf-a1ce-f535ff1001ce","order_by":1,"name":"Romana Macherey","email":"","orcid":"","institution":"Cand. Med, Witten/Herdecke University","correspondingAuthor":false,"prefix":"","firstName":"Romana","middleName":"","lastName":"Macherey","suffix":""},{"id":266421655,"identity":"05911e15-d261-4541-98a9-f972f40a3f42","order_by":2,"name":"Lukas Rimkus","email":"","orcid":"","institution":"Cand. Med, Witten/Herdecke University","correspondingAuthor":false,"prefix":"","firstName":"Lukas","middleName":"","lastName":"Rimkus","suffix":""},{"id":266421656,"identity":"059076e9-419b-489b-8ead-e6e583c16019","order_by":3,"name":"Sarah Tschudin-Sutter","email":"","orcid":"","institution":"University Hospital Basel","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Tschudin-Sutter","suffix":""},{"id":266421657,"identity":"41bf41da-c8f7-457b-829b-e984ef8dbd55","order_by":4,"name":"Stephan Marsch","email":"","orcid":"","institution":"University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Stephan","middleName":"","lastName":"Marsch","suffix":""},{"id":266421658,"identity":"4db2af2c-4b2c-457f-b07e-b225d7038b80","order_by":5,"name":"Timur Sellmann","email":"","orcid":"","institution":"Bethesda Hospital","correspondingAuthor":false,"prefix":"","firstName":"Timur","middleName":"","lastName":"Sellmann","suffix":""}],"badges":[],"createdAt":"2024-01-08 15:59:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3845830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3845830/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49547818,"identity":"165e7d2f-e016-441d-890b-c336a158d110","added_by":"auto","created_at":"2024-01-12 19:25:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelation between missing PPE items and time from donning to first patient contact\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBox and whisker plot of the time intervals from the start of donning to 1\u003csup\u003est\u003c/sup\u003e patient contact. Boxes indicate the median and the lower and upper quartiles while whiskers indicate the 5\u003csup\u003eth\u003c/sup\u003e and 95\u003csup\u003eth\u003c/sup\u003e percentile. Time intervals were significantly longer in fully and correctly protected participants than in fully but partially incorrectly protected (at least one protective item incorrectly worn) participants. In addition, time intervals were significantly longer in fully and correctly protected participants than in participants with one or two protective items missing.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3845830/v1/eb4d585b52aea31da4780c57.png"},{"id":49547820,"identity":"ccd0c3b4-1f2e-41eb-9db7-1277f426961a","added_by":"auto","created_at":"2024-01-12 19:25:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":131928,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDoffing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 92 participants had to be excluded because doffing was not completely captured by camera. A “correct sequence” according to guidelines [(39)] was defined as removal of gloves first OR removal of gown first and removal of gloves second. An “incorrect sequence“ was defined as removal of cap, goggles, or mask with contaminated gloves. None of the participants removed the mask with contaminated gloves. Please note that multiple entries are possible.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3845830/v1/075d7d82cd915ac5033e4b8c.png"},{"id":49548410,"identity":"e9105c0c-2813-47c3-989b-93e4a61e96e6","added_by":"auto","created_at":"2024-01-12 19:33:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":642605,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3845830/v1/a8db177f-62b6-4a09-bccd-98686894c1e7.pdf"}],"financialInterests":"Competing interest reported. The author, Susan Kraus, hereby discloses the following information regarding potential conflicts of interest related to the submitted manuscript entitled \"Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19\" for consideration in Antimicrobial Resistance \u0026 Infection Control. Susan Kraus declares that Prof. Dr. med Sarah Tschudin Sutter has a professional relationship with Antimicrobial Resistance \u0026 Infection Control as an Editor. It is important to note that Prof. Dr. med Tschudin Sutter possesses expertise in the subject matter discussed in the paper due to her extensive experience in clinical hygiene. Susan Kraus affirms that Prof. Dr. med Tschudin Sutter will not have any involvement in the peer-review process or the decision-making regarding the acceptance of the manuscript. The paper will be rigorously reviewed by independent, external reviewers appointed by the editorial team. The author declares that she has not received any direct financial support or other benefits from Antimicrobial Resistance \u0026 Infection Control in connection with the submitted manuscript. This disclosure statement is made in the interest of transparency and to maintain the highest standards of integrity in the publication process.","formattedTitle":"Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19 patients","fulltext":[{"header":"1. Background","content":"\u003cp\u003eDuring the pandemic, international and national recommendations regarding faultless dressing (\u0026ldquo;donning\u0026rdquo;) and removal (\u0026ldquo;doffing\u0026rdquo;) of personal protective equipment (PPE) have been published to minimize the risk of contagion during the cardiopulmonary resuscitation (CPR) of a suspected COVID-19 victim [(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)]. These recommendations are based in part on considerations of the potential transmission of droplet and airborne agents from the patient to the rescuer during CPR. Available data concerning CPR during COVID-19 show strikingly poor results compared to non-pandemic data; results from large studies range from no [(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)] and 3% survival in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;79 years, respectively [(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)]. Already at this point, attention was drawn to the possible role of the PPE to further optimize CPR for COVID-19 and the need for scientific research in this topic [(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)]. Until now, there are no large, randomized trials on the impact of PPE on CPR; available data mostly stems from smaller studies investigating the quality of chest compressions of single rescuers in simulated arrests [(\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)] with partially contradictory results ranging from no [(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)] to even negative effects of PPE [(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)]. Whereas beneficial effects of PPE include protection of the carrier from aerosol or droplet based transmission [(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)], particularly delays by \u0026ldquo;donning\u0026rdquo; PPE in COVID-19 CPR and hygienic issues have been discussed [(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)], but published data preferentially did not show any relevant delay during life-saving procedures in various populations [(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)]. So far, there are only very limited data, on whether buddying, the process of supervising each other, is able to mitigate negative effects of donning and doffing of PPE [(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)]. In emergency situations, high time pressure occurs as rescuers need to don prior to taking care of the patient. So far, the quality of donning in emergency situations is largely unknown. In real life situations, quality of donning and doffing could best be assessed by using trained observers, but during a pandemic, such resources may not be freely available. However, investigating the impact of donning and doffing on the overall quality of PPE especially for COVID-19 CPR in adequately powered prospective trials would be difficult in real cases for a variety of reasons. Simulation allows the investigation of team performance both globally and in specific subtasks in a realistic and standardized manner [(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)], and, as a particular advantage, allows recording data right from the start. Accordingly, the aim of this trial was to assess the quality of donning and doffing of PPE and the impact of buddying if any, in simulated cardiac arrests of a suspected COVID-19 victim. [(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)].\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1. Participants\u003c/h2\u003e\n \u003cp\u003eThe Working Group on Intensive Care Medicine (Arbeitsgemeinschaft Intensivmedizin) in Arnsberg, Germany, accessible at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.aim-arnsberg.de\u003c/span\u003e\u003c/span\u003e as of June 18, 2023, organizes continuing education programs for physicians. These programs primarily target residents in their second to third year of postgraduate medical training in fields of emergency and intensive care medicine, such as internal medicine, anesthesia, or surgery. Participants in these courses come from both Germany and German-speaking countries. During these courses, participants were given the opportunity to take part in optional simulator-based CPR workshops. It was made clear to them that these workshops were recorded for scientific purposes. Additionally, identical workshops were offered to physicians who wished to participate but preferred not to be filmed. The trial, conducted in accordance with the Declaration of Helsinki guidelines, received approval from the Ethics Committee of \u0026quot;Aerztekammer Westfalen-Lippe\u0026quot; (2020-602-f-S), which waived the requirement for obtaining consent. Furthermore, an amendment for the presented analysis of PPE was also exempted from consent requirements. The trial is registered in the German Clinical Trial Registry (accessible at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.drks.de\u003c/span\u003e\u003c/span\u003e as of August 19, 2022, DRKS-ID: DRKS00023184). The reporting of the study adheres to the extensions of the STROBE statements as outlined in the Reporting Guidelines for Health Care Simulation Research [(\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e)].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2. Study Design\u003c/h2\u003e\n \u003cp\u003eThis study reports hitherto unreported data from the PPE cohort of a prospective comparative trial involving two cohorts [(\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e)]. Throughout the years 2020 and 2021, all attendees of our workshops were required to perform CPR while wearing PPE. Participants from individual workshops were randomly divided into teams consisting of three to five physicians.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3. Simulator and Scenario\u003c/h2\u003e\n \u003cp\u003eThe Ambu Man Wireless mannequin (Ambu GmbH, Bad Nauheim, Germany) was used for this study. All participants underwent a standardized briefing, which encompassed an introduction to the workshop, familiarization with the mannequins, and an overview of the available resuscitation equipment. Subsequently, each team member was apprised of their role in the upcoming scenario: they would be part of a resuscitation team responding to an unwitnessed cardiac arrest due to ventricular fibrillation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4. Personal Protective Equipment (PPE)\u003c/h2\u003e\n \u003cp\u003eThe teams were explicitly informed that, mirroring real-world practices at that time, they were required to fully don PPE before any contact with the patient. In adherence to stringent hygiene protocols, participants were mandated to wear N95 masks continuously throughout the duration of the course. Additionally, a variety of PPE items, including gloves, protective eyewear, gowns, and scrub caps, were readily available in ample quantities and various sizes, arranged on a table within the scenario room. This arrangement served the dual purpose of ensuring participants understood the need to prepare for a medical emergency after \u0026quot;donning\u0026quot; PPE. The time taken for the \u0026quot;donning\u0026quot; process was defined as the duration between the initial handling of PPE equipment by any team member and the first contact with the patient by any team member. The process of \u0026quot;doffing\u0026quot; (removing PPE) occurred after the return of spontaneous circulation (ROSC) and was observed until completion. Data on buddying were collected during both donning and doffing. All scenarios were supervised by trained tutors instructed not to interfere in any way with donning, doffing, or buddying.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6. Data Analysis\u003c/h2\u003e\n \u003cp\u003eData analysis was performed using the video recordings obtained during the simulations. According to international guidelines [(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)], correctness of PPE worn was defined as follows: gloves: both hands completely covered; gown: no skin visible between gown and gloves AND gown completely closed at the backside; mask: both mouth and nose covered; cap: hair fully covered; goggles: both eyes protected. Full protection was defined as wearing a FFP2 mask, protective goggles, cap, gown, and gloves at 1st patient contact. Full and correct protection was defined as wearing all these protective items in the abovementioned correct way.\u003c/p\u003e\n \u003cp\u003eThough international guidelines on doffing slightly vary, they agree that to prevent self-contamination by the removal of protective items with contaminated gloves, doffing should start with the removal of gloves and gown. Accordingly, we defined the doffing sequence as correct, if the first two items removed were gloves and gown all other protective items were removed thereafter.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.7. Statistical Analysis\u003c/h2\u003e\n \u003cp\u003eThe primary outcome was the number of participants wearing full and correct protection at 1st patient contact. Secondary outcomes included the time needed and the correct sequence for donning; buddying (within team help) and the quality of doffing. Data are expressed as medians [IQR], unless otherwise stated. Statistical analysis was performed using SPSS (version 28). Mann\u0026ndash;Whitney test, Chi-square test, and linear regression analysis were performed as appropriate. The estimates for differences between the medians and their approximate confidence intervals were obtained by the Hodges\u0026ndash;Lehmann estimation. A p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed) was considered to represent a statistical significance.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Participants\u003c/h2\u003e\n \u003cp\u003eOverall, 437 (224 females and 213 males) participants randomized to 114 teams of 3\u0026ndash;5 physicians each were evaluated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Primary Outcome\u003c/h2\u003e\n \u003cp\u003eAt the time of first patient contact, 21% (91/437) of the participating physicians donned all items of PPE correctly. 70% (306/437) donned all items of PPE, but not all items were worn correctly. One or more protective items were missing in 15% (62/437). An overview can be found in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Participants\u0026rsquo; sex had no effect on the extent of protection (P\u0026thinsp;=\u0026thinsp;0.42) and on protective items missing (P\u0026thinsp;=\u0026thinsp;0.15).\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompliance with donning PPE\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFully and correctly protected\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(FFP2; protective googles; cap, gown, gloves; all correctly worn) at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFully protected\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(FFP2; protective googles; cap, gown, gloves; one or more items incorrectly worn) at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFully and correctly dressed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(any mask; any glasses; cap; gown; gloves; all correctly worn) at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFully dressed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(any mask; any glasses; cap; gown; gloves; one or more items incorrectly worn ) at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProtective items missing at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne protective item missing at 1st patient contact (cap\u0026thinsp;=\u0026thinsp;30; glasses\u0026thinsp;=\u0026thinsp;21; gloves\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo protective items missing at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThree or more protective items missing at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProtective items incorrectly worn at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne protective item incorrectly worn\u003c/p\u003e\n \u003cp\u003e(gown\u0026thinsp;=\u0026thinsp;197; cap\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e220/375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo protective items incorrectly worn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63/375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThree or more protective items incorrectly worn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompliance with wearing single PPE items\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMask\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a mask prior to donning (mandatory)\u003c/p\u003e\n \u003cp\u003e(FFP2 mask\u0026thinsp;=\u0026thinsp;386; surgical mask 51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFitting a new mask during donning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing any mask at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a FFP2 mask at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a surgical mask at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing no mask at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing mask correctly (mouse and nose covered)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e437/437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoggles\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing protective glasses prior to donning (not mandatory)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing any glasses at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e405\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing protective glasses at 1st patient contact\u003c/p\u003e\n \u003cp\u003e(protective glasses only\u0026thinsp;=\u0026thinsp;271; protective glasses over own glasses\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing own glasses only at 1st patient contact\u003c/p\u003e\n \u003cp\u003e(vain attempt to fit protective glasses over own glasses\u0026thinsp;=\u0026thinsp;16/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing no glasses at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing glasses/goggles correctly (both eyes protected)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e407/407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGloves\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing gloves prior to donning (not mandatory)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFitting new gloves during donning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3/26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing gloves at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e435\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing no gloves at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing gloves correctly (both hands covered)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e435/435\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGown\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a gown prior to donning (not mandatory)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a gown at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e436\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing no gown at 1st patient contact\u003c/p\u003e\n \u003cp\u003e(gown too small for body size\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing gown correctly\u003c/p\u003e\n \u003cp\u003e(gown completely closed at backside)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e148/436\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGown only partially closed at backside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e244/436\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGown completely open at backside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44/436\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eCap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a cap prior to donning (not mandatory)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing a cap at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing no cap at 1st patient contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing cap correctly (hair fully covered)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e316/399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWearing cap not correctly (hair not fully covered)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83/399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cstrong\u003eCompliance with donning PPE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cstrong\u003eCompliance with wearing single PPE items\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Secondary Outcomes\u003c/h2\u003e\n \u003cp\u003eTiming\u003c/p\u003e\n \u003cp\u003eOverall donning time was 63 (52\u0026ndash;74) seconds and the time interval between start of donning and first patient contact 66 (55\u0026ndash;78) seconds. Participants\u0026rsquo; sex had no effect on the duration of donning (P\u0026thinsp;=\u0026thinsp;0.19 and 0.31 respectively). Time to first patient contact was longer after correct donning than after incorrect donning (77 [66\u0026ndash;87] vs 64 [54\u0026ndash;75] seconds; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Tables \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Time from start of donning to first patient contact was shorter for each item of PPE missing (P\u0026thinsp;=\u0026thinsp;0.002), the respective regression coefficient of -7\u0026thinsp;\u0026plusmn;\u0026thinsp;2 indicating a shortening of the time interval of approximately 7 seconds per protective item omitted.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Time for donning and doffing in relation to compliance with PPE\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003eFully \u0026amp; correctly protected YES\u003c/p\u003e\n \u003cp\u003e(n = 91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003eFully \u0026amp; correctly protected NO\u003c/p\u003e\n \u003cp\u003e(n = 346)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003eParamEst (95%CI); P\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDonning (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e70 (61-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e61 (51-71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e10 (6-14); P\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDonning to 1\u003csup\u003est\u003c/sup\u003e patient contact (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e77 (66-87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e64 (54-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e12 (8-16); P\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDoffing (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e50 (41-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.061359867330015%\" valign=\"top\"\u003e\n \u003cp\u003e46 835-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e5 (-1 -10); P=0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\u003cbr\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.85950413223141%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003eFully dressed YES\u003c/p\u003e\n \u003cp\u003e(n = 375)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003eFully dressed NO\u003c/p\u003e\n \u003cp\u003e(n = 62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.487603305785125%\" valign=\"top\"\u003e\n \u003cp\u003eParamEst (95%CI); P\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.85950413223141%\" valign=\"top\"\u003e\n \u003cp\u003eDonning (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e63 (54-74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e56 (46-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.487603305785125%\" valign=\"top\"\u003e\n \u003cp\u003e7 (3-12); P=0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.85950413223141%\" valign=\"top\"\u003e\n \u003cp\u003eDonning to 1\u003csup\u003est\u003c/sup\u003e patient contact (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e67 (57-79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e60 (48-73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.487603305785125%\" valign=\"top\"\u003e\n \u003cp\u003e8 (3-13); P=0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.85950413223141%\" valign=\"top\"\u003e\n \u003cp\u003eDoffing (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e48 (36-62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e42 (31-57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.487603305785125%\" valign=\"top\"\u003e\n \u003cp\u003e5 (-1 -11); P=0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTime for donning and doffing in relation to compliance with PPE (linear regression analyses)\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.393034825870647%\" valign=\"top\"\u003e\n \u003cp\u003eFully but (partly) incorrectly dressed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n = 284)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.729684908789388%\" valign=\"top\"\u003e\n \u003cp\u003eFully \u0026amp; correctly dressed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n = 91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003eParamEst (95%CI); P\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDonning (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.393034825870647%\" valign=\"top\"\u003e\n \u003cp\u003e62 (52-71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.729684908789388%\" valign=\"top\"\u003e\n \u003cp\u003e70 (61-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e9 (6-13); P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDonning to 1\u003csup\u003est\u003c/sup\u003e patient contact (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.393034825870647%\" valign=\"top\"\u003e\n \u003cp\u003e65 (55-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.729684908789388%\" valign=\"top\"\u003e\n \u003cp\u003e77 (66-87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e11 (7-15); P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.650082918739635%\" valign=\"top\"\u003e\n \u003cp\u003eDoffing (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.393034825870647%\" valign=\"top\"\u003e\n \u003cp\u003e46 (36-61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.729684908789388%\" valign=\"top\"\u003e\n \u003cp\u003e50 (41-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.22719734660033%\" valign=\"top\"\u003e\n \u003cp\u003e4 (-2 -9); P=0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cstrong\u003eTime for donning and doffing in relation to compliance with PPE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cstrong\u003eTime for donning and doffing in relation to compliance with PPE (linear regression analyses)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cstrong\u003eRelation between missing PPE items and time from donning to first patient contact\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDoffing\u003c/p\u003e\n \u003cp\u003e92/437 participants (21%) removed their PPE partly or completely outside of the range of the camera and, accordingly, were excluded from analysis. Thus, data from 345 participants (179 female) were analysed. A correct doffing sequence was observed in 56% (192/345) with no difference relating to participants\u0026rsquo; sex (P\u0026thinsp;=\u0026thinsp;0.41). The remaining participants (44%, 153/345) made at least one hygienic mistake. More data is presented in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cstrong\u003eDoffing\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBuddying\u003c/p\u003e\n \u003cp\u003eBuddying during donning and doffing was observed for 120 participants (27%), thereof 76 with provision of physical help, 44 with verbal help and 32 with both physical and verbal help. In return, 122 participants (28%) received help from their colleagues (active help\u0026thinsp;=\u0026thinsp;69; verbal help\u0026thinsp;=\u0026thinsp;53; both =\u0026thinsp;32). Participants\u0026rsquo; sex did not influence providing (P\u0026thinsp;=\u0026thinsp;0.30) or receiving help (P\u0026thinsp;=\u0026thinsp;0.38).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis prospective trial demonstrates that only one in five participants wore all items of PPE correctly at their first patient contact in simulated cardiac arrest of a Covid-19 patient. Furthermore, putting on PPE as intended delayed the first patient contact by approximately 80 seconds. This delay was slightly shortened by omitting protective items and/or incorrect fitting of PPE. Buddying was provided during donning only by a minority of participants. Safe doffing of PPE was observed in only 56% and buddying during doffing, as a potential error reduction measure was recorded in only 22% of the cases. To the best of our knowledge, this is the largest trial investigating the effects of using PPE in a standardized, simulated CPR so far and the results may have an important influence on future CPR training in the context of pandemic events or simply on resuscitatation of patients under isolation precautions. Despite increasing promotion and most likely training and experience with the use of PPE during the study period during the pandemic, compliance with donning and doffing in terms of the use of all items and their correct fitting was low.\u003c/p\u003e \u003cp\u003ePrimary outcome\u003c/p\u003e \u003cp\u003eCompleteness, fitting, and timing of PPE protection during and after donning\u003c/p\u003e \u003cp\u003eOur findings show that completeness as well as correctness of PPE donning are time sensitive. And, although COVID-19 publications have reached over 400 k, there were 118 hits (thereof only 9 studies) using the search string \u0026ldquo;Donning and doffing AND time\u0026rdquo; and a combination thereof, making a reliable comparison to the existing literature difficult. Depending on the complexity of the protection to be applied, the time required to don PPE ranged from 2 to 4.5 min [(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)] and 10 to \u0026gt;\u0026thinsp;20 min respectively [(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)]. An increase in time of 10% was described for the nurse workload and quality of care using process simulation [(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)]. Besides, our data suggest that a relevant proportion of participants had insufficient knowledge of how to correctly apply PPE. Concerning correctness, this is in line with data where the numbers of correctly donned and doffed PPE in observed health care workers ranged between 50% and 37% respectively [(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)]. This is significant as data from Italy, one of the earliest and hardest hit countries in Europe, from the early days of the pandemic suggests that formal training and support did take place and buddying was available \u0026ndash; only 24% (91/380) were never buddied and 79% (299/380) had received formal training in PPE use at any time [(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)]. Supporting Italian data state, that approximately half of the physicians reported that the information received about the use of PPE was either clear (47%) or complete (54%) [(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)]. \u0026ldquo;Ill-fitting\u0026rdquo; as described by Janson \u003cem\u003eet al\u003c/em\u003e [(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)] implies the discrepancy of PPE being generally designed around the size and shape of an average European or US white man's face and body and the anatomical difference in size that could lead to additional risk for female healthcare workers. In the present cohort with approximately 50% female participants we neither observed ill-fitting nor were confronted with corresponding participants\u0026rsquo; complaints.\u003c/p\u003e \u003cp\u003eHowever, there is a possibility that to be able to help the victim as quickly as possible, the participants may have accepted to protect themselves insufficiently. And, although the Geneva Pledge was revised in 2017, medical presenteeism has been referred to as a \"public health hazard\" in the past [(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)]. Concern for patients was also cited as one of the reasons for potentially harmful behavior [(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)]. In the context of testing this hypothesis one could argue that the time advantage of an overhasty PPE dressing may not medically relevant for the victim of a circulatory arrest (whether resuscitation starts after 65 or after 80 sec will not be relevant in terms of outcome). It is currently common sense that resuscitation should always be emphasized except in the case of obvious death (e.g., rigor mortis), signs of life (e.g., signs of responsiveness or breathing, eye movement, visible chest rise, purposeful movement) or unsafe scene \u0026ndash; where PPE may be helpful. Beyond CPR, for most other medical emergencies (which are usually less time-critical than resuscitation), \u003cem\u003ea fortiori\u003c/em\u003e is not relevant.\u003c/p\u003e \u003cp\u003eSecondary outcomes\u003c/p\u003e \u003cp\u003eDoffing\u003c/p\u003e \u003cp\u003eCorrect doffing is critical for both self-protection and the protection of others from cross-contamination, thus our finding of only 56% correct doffing procedures are somewhat worrisome. Interestingly, there was more data available on doffing than donning and time (150 vs. 118 hits). Self-contamination ranged between 40% in a mixed health care workers population (house-keeping sanitation staff, technicians, nursing staff and resident doctors), with 6.5% breaches in physicians only [(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)] and up to 90 (92.3%) [(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)] with the latter being found during doffing of simple PPE sets. And even despite well-trained teams of health care workers, contamination while doffing was observed with every type of PPE gown, and with each health care worker subject. All body areas were contaminated at least once, except the face [(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)]. Helpful for avoiding contamination, at least in a simulated setting, was PPE doffing following step-by-step verbal instructions from a trained supervisor but at the expense of prolonged doffing time [(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)].These findings need to be explored further and measures against this must be initiated.\u003c/p\u003e \u003cp\u003eBuddying\u003c/p\u003e \u003cp\u003eSince self-contamination during doffing of PPE is a serious issue, buddying has a high potential in reducing potentially deleterious errors. In a comprehensible large study, the introduction of \u0026ldquo;dofficers\u0026rdquo; led to a significant decrease in the mean error rate (9.8\u0026ndash;2.9%, P\u0026thinsp;\u0026lt;\u0026thinsp;.001) with the largest reduction occurring in the category of PPE doffing errors [(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)]. In another study, \u0026ldquo;PPE marshals\u0026rdquo; intervened on 121 occasions, predominantly through buddying, explaining, and demonstrating correct PPE use, most frequently with medical staff (72%). This intervention led to a PPE compliance variation between 47.9% (Buddy check) and 91.8% (Bare below elbow) [(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)]. One of the potential disadvantages of supervised doffing may be an increase in time compared with unsupervised doffing (184 vs. 68 seconds, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but, since this measure also led to a significantly lower contamination rate (8% vs. 47%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)] and doffing after handling a medical emergency is seldom time crucial, this may probably be neglectable under these circumstances. Despite some, albeit very low-quality evidence that behavioral interventions, namely education and training, do not have a considerable effect on the frequency or correctness of PPE use in workers [(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)] we believe that any measure help to improve the results of donning, doffing, and buddying, should be undertaken.\u003c/p\u003e \u003cp\u003eOur study has several implications: First, using PPE (donning, doffing) is an integral part of CPR not only during a pandemic but also in an increasing number of patients requiring isolation. Thus, teaching and training of rescuers must consider these two components CPR and PPE independently but also interdependently: Not only ACLS must be trained, but also the handling of PPE and its use during ACLS. Second, although the present trial was conducted during an ongoing severe pandemic lasting already several months, the quality of the protective skills of our participants was poor. Thus, frequent use of PPE alone is insufficient to ensure adequate protection of patients and health-care workers alike. Instead, regular supervision and strict enforcement of hygienic rules appears to be necessary in health-care institutions. Third, especially under pandemic conditions or with patients in isolation, buddying should be promoted to reduce errors, especially of doffing, and cross-contamination rates.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eStrengths of this trial include the large sample size and the perfectly standardized conditions for all teams. Limitations of simulator-based studies include the absence of real patients and, in the present trial, of real environment (i. e. locks or wardroom assessments). However, simulation is increasingly regarded as an accepted tool for evaluation [(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)] while performance markers in simulator-based studies show a high agreement with findings in real cases. It is possible that quite a number of the observed errors are contributory to the simulation setting (CPR simulation in a hospital room, but in a non-hospital setting).\u003c/p\u003e \u003cp\u003eMoreover, in the present study simulation enabled investigating a topic that for a variety of practical and ethical reasons (\u0026ldquo;donning\u0026rdquo; of PPE in a COVID-19 emergency, recording right from the start difficult and personnel-intensive) would be very difficult to investigate in real cases.\u003c/p\u003e \u003cp\u003eOur study population consisted of physicians in their 2nd to 3rd year of residency that, at the time of the study, acted as potential first responders for cardiac arrests in their hospitals. In addition, we refrained from using special teaching, special PPE protocols, or habituation with repetitive exposure prior to testing our participants in the simulated scenario. As such, our results reflect the actual state of our participants\u0026rsquo; knowledge and skills and can be extrapolated to real-world settings.\u003c/p\u003e \u003cp\u003eIn combination with shortcomings and deviations from CPR algorithms associated with PPE, our finding of a substantial initial delay of CPR due to \u0026ldquo;donning\u0026rdquo; may well be of clinical relevance and contribute to poor outcomes of CPR in COVID-19 patients [(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)].\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eWearing PPE during CPR places an additional burden on rescuers who already have a demanding job. Beside already published medical limitations during simulated CPR we were now able to show that only a minority of participants had a full and correct protection at the time of their first patient contact. Putting on PPE as intended delayed the first patient contact by approximately 80 seconds. This delay was slightly shortened by omitting protective items and incorrect protection. Safe removal of PPE was observed in only 56%. Buddying was not able to mitigate these effects.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePPE Personal Protective Equiqment\u003c/p\u003e\n\u003cp\u003eFPC First Patient Contact\u003c/p\u003e\n\u003cp\u003eCPR Cardiopulmonary resuscitation\u003c/p\u003e\n\u003cp\u003eALS Advanced Life Support\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, T.S. and S.M.; Data curation, S.K., R.M. and L.R.; Formal analysis, S.K., L.R.,R.M., T.S. and S.M.; Funding acquisition, T.S. and S.M.; Investigation, L.R. S.K., R.M. T.S. and S.M.; Methodology, T.S. and S.M.; Project administration, T.S. and S.M.; Resources, T.S. and S.M.; Software, S.M.; Supervision, T.S., L.R. and S.M.; Validation, T.S. and S.M.; Visualization, S.M.; Writing-Original draft, S.K., R.M. and L.R.; Writing-Review \u0026amp; editing, T.S. and S.M. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e The study was conducted according to the guidelines of the Declaration of Helsinki and\u0026nbsp;approved by the Ethics Committee of Aerztekammer Westfalen-Lippe (2020-602-f-S) that waived the obligation to obtain consent. The original study is registered at the German Clinical Trial Registry (www.drks.de (accessed on 7 October 2020); DRKS-ID: DRKS00023184).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e Participants consent was waived due to the anonymity of the compiled data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKundra P, Vinayagam S. COVID-19 cardiopulmonary resuscitation: Guidelines and modifications. J Anaesthesiol Clin Pharmacol. 2020;36(Suppl 1):S39-S44.\u003c/li\u003e\n\u003cli\u003eNolan JP, Monsieurs KG, Bossaert L, Bottiger BW, Greif R, Lott C, et al. 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Ther Adv Infect Dis. 2021;8:2049936121998562.\u003c/li\u003e\n\u003cli\u003eSavoia E, Argentini G, Gori D, Neri E, Piltch-Loeb R, Fantini MP. Factors associated with access and use of PPE during COVID-19: A cross-sectional study of Italian physicians. PLoS One. 2020;15(10):e0239024.\u003c/li\u003e\n\u003cli\u003eJanson DJ, Clift BC, Dhokia V. PPE fit of healthcare workers during the COVID-19 pandemic. Appl Ergon. 2022;99:103610.\u003c/li\u003e\n\u003cli\u003eBraun J. Risks and side effects of medical presenteeism. . Uro-News. 2020;24 (7):35\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eJena AB, Meltzer DO, Press VG, Arora VM. Why physicians work when sick. Arch Intern Med. 2012;172(14):1107-8.\u003c/li\u003e\n\u003cli\u003eNaik BN, Singh A, Lazar MS, Ganesh V, Soni SL, Biswal M, et al. Performance of Health Care Workers in Doffing of Personal Protective Equipment Using Real-Time Remote Audio-Visual Doffing Surveillance System: Its Implications for Bio-Safety Amid COVID-19 Pandemic. Cureus. 2021;13(9):e18071.\u003c/li\u003e\n\u003cli\u003eSingh A, Naik BN, Soni SL, Puri GD. Real-Time Remote Surveillance of Doffing During COVID-19 Pandemic: Enhancing Safety of Health Care Workers. Anesth Analg. 2020;131(2):e112-e3.\u003c/li\u003e\n\u003cli\u003eKang J, O\u0026apos;Donnell JM, Colaianne B, Bircher N, Ren D, Smith KJ. Use of personal protective equipment among health care personnel: Results of clinical observations and simulations. Am J Infect Control. 2017;45(1):17-23.\u003c/li\u003e\n\u003cli\u003ePottier F, Groizard C, Briche G, Haraczaj N, Garnier M, Loones V, et al. Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation. Int J Emerg Med. 2021;14(1):35.\u003c/li\u003e\n\u003cli\u003eSomri M, Hochman O, Somri-Gannam L, Gaitini L, Paz A, Bumard T, et al. Removal of Contaminated Personal Protective Equipment With and Without Supervision. A Randomized Crossover Simulation-Based Study. Simul Healthc. 2023.\u003c/li\u003e\n\u003cli\u003ePicard C, Edlund M, Keddie C, Asadi L, O\u0026apos;Dochartaigh D, Drew R, et al. The effects of trained observers (dofficers) and audits during a facility-wide COVID-19 outbreak: A mixed-methods quality improvement analysis. Am J Infect Control. 2021;49(9):1136-41.\u003c/li\u003e\n\u003cli\u003eLuong Thanh BY, Laopaiboon M, Koh D, Sakunkoo P, Moe H. Behavioural interventions to promote workers\u0026apos; use of respiratory protective equipment. Cochrane Database Syst Rev. 2016;12(12):CD010157.\u003c/li\u003e\n\u003cli\u003e(CDC) CfDC. How to safely remove personal protective equipment (PPE) [PDF]. Center for Disease Control (CDC); 2021 [Available from: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, cardiopulmonary resuscitation, controlled trial, personal protective equipment, simulation","lastPublishedDoi":"10.21203/rs.3.rs-3845830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3845830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePersonal protective equipment (PPE) protects healthcare workers and patients. Data on guideline compliance on how to dress (donning) or remove (doffing) PPE and the effect of monitoring (buddying) are limited. This study assesses the quality of donning, doffing, and buddying of PPE in a simulated medical emergency.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003ePhysicians handling a simulated cardiac arrest of a COVID-19 patient. Adjacent to the victim, PPE (FFP2 masks, gowns, caps, protective eyewear, gloves) was available. Data analysis was performed on video recordings. The primary outcome was the number and timing of participants being appropriately protected, defined as both wearing a) all PPE items provided, and b) all PPE items correctly at the time of first patient contact (FPC). Secondary outcomes included compliance with doffing and buddying. Statistical analysis was performed using SPSS (version 28). Mann\u0026ndash;Whitney test, Chi-square test, and linear regression analysis were performed as appropriate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt first patient contact 91/437 (21%) were correctly protected while 306/437 (70%) were partially incorrectly protected. One or more PPE items were missing in 62/437 (15%). Overall donning time was 63 (52\u0026ndash;74) seconds, the time interval between donning start and FPC was 66 (55\u0026ndash;78) sec. Time to FPC was longer in correctly than in incorrectly protected participants (77 [66\u0026ndash;87] vs 64 [54\u0026ndash;75] sec; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and decreased by 7\u0026thinsp;\u0026plusmn;\u0026thinsp;2 seconds per PPE item omitted (P\u0026thinsp;=\u0026thinsp;0.002). Correct doffing was observed in 192/345 (56%), buddying in 120 participants (27%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings imply a need for education in correct and timely PPE donning and doffing. Donning PPE as intended delayed FPC. This and the influence of buddying needs further investigation (German study register number DRKS00023184).\u003c/p\u003e","manuscriptTitle":"Under ARMOUR - Donning and doffing of Personal Protective Equipment for simulated CPR of COVID-19 patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-12 19:25:20","doi":"10.21203/rs.3.rs-3845830/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-30T15:49:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-30T15:47:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-06T13:56:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"09428e07-a527-4aeb-aebb-d5531d0a2aa2","date":"2024-02-05T16:05:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59e7d72d-2d85-45a0-aeab-cbf845e3a172","date":"2024-01-22T16:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-15T07:57:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-11T06:28:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-11T06:28:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Antimicrobial Resistance \u0026 Infection Control","date":"2024-01-08T15:45:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3481a092-b20f-4e45-a05c-c2742f4a65ed","owner":[],"postedDate":"January 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-27T06:43:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-12 19:25:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3845830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3845830","identity":"rs-3845830","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}