To our knowledge, this is the first study to investigate the level and key risk factors of IPC self-reported behaviors of HCWs at the early stage of COVID-19 outbreak, which has practical significance for optimal IPC management among broader populations under the risk of COVID-19 infection.
Overall, IPC self-reported behaviors of HCWs were basically satisfactory. HCWs reported good hand hygiene, especially after body fluid exposure and before aseptic procedure. Hand hygiene is recognized globally as a leading measure of IPC, which has been shown to be effective in decreasing the transmission of common respiratory viruses, including human coronaviruses [9, 10], and it has also been used in respond to SARS [11,12,13], Ebola [14], bird flu [15], and Plague [16], etc. HCWs who reported higher hand hygiene during patient care experienced a lower risk of developing SARS [11]. However, the self-reported compliance of hand hygiene before touching patients and after touching patient surroundings was relatively low as showed in previous studies [17], which may hinder the prevention and control of COVID-19. Besides, given the high transmissibility of the COVID-19 [18], appropriate patient placement was the primary measure to contain the epidemics, and a high rate of appropriate patient placement was found in this study.
The self-reported compliance of mask and glove use when caring confirmed and suspected patients was high, but the self-reported compliance of goggle and gown use were unsatisfactory, which might suggest the insufficient awareness of HCWs on controlling new epidemic. As we know, the main transmitted routes of COVID-19 were droplets and contact [19, 20], which means that PPE is crucial for controlling COVID-19. The only way to control new life-threatening epidemics at the early stage is optimal IPC behaviors and the maximal protection including masks, gloves, gowns, and eye protection [21]. Thus, the substandard use of goggle and gown would put HCWs at the risk of virus exposure and a significant risk of cross-infection in hospitals. Researchers found that lack of awareness and discomfort of the equipment may hinder PPE use [22]. For example, a survey found that gowns and goggles were tight, foggy and induced intense perspiration and visual acuity, which hindered the care for patient of HCWs [22]. In our study, most HCWs reported to superior when encountering confirmed and suspected patients. According to guidelines, early identification and reporting of an epidemic was important to contain the infection [9]. Reporting can be regarded as the starting point of all subsequent IPC, and 100% reporting rate should be the goal.
Not surprising, the outbreak risk promoted self-reported IPC behaviors of HCWs, especially hand hygiene before touching patients, use of goggle and gown. Previous study also found positive changes of hand hygiene and other IPC measures during or one-year after the outbreak of SARS, which means that the outbreak risk has an effective and long-term impact on the practice of IPC measures [23, 24]. As we expected, HCWs in the affected city behave better than unaffected, indicating the increasing risk affects behavior [25].
Contrary to our expected hypothesis, the increased of exposure risk to COVID-19 patients did not promote self-reported IPC behaviors. HCWs who had direct contact with confirmed and suspected COVID-19 patients even reported worse in some IPC. It may be due to short supply of resources, human deficiency and high workload, which can be explained that the subsequent lack of protective materials and human resources, and timely assistance are in urgent need in combating COVID-19.
HCWs in high-risk department reported better behaviors in some IPC than those not. Perhaps because of the daily high incidence and cross transmission of infection in high-risk departments, HCWs usually payed more attention to IPC measures. It enlightens us that daily training and practice of IPC help to cope with sudden epidemic outbreak.
HCWs with lower workload, male and nurse profession promoted IPC behavior, compared to higher workload, female and doctor profession. This revealed that increasing number of HCWs especially male and nurses to reduce workload may be an effective measure. HCWs from all over China to support Wuhan, Hubei are the appropriate measures.
This work reveals implications to improve care in a highly dynamic, resource limited pandemic setting. Firstly, it may be constructive to equip the core clinical department of COVID-19 with sufficient HCWs, especially male and nurse profession, to relieve the high work load and ensure the higher compliance of IPC measures to reduce the risk of HCAI. Secondly, it is a priority to guarantee the supply of PPE in the core clinical department of COVID-19. Thirdly, the storage of human resources and PPE, the emergent purchase flow in hospital, the encouragement of PPE production and the development of vaccine, etc. are vital in future preparedness.
The limitation of this study is that the compliance of IPC behaviors of HCWs may be overestimated, because HCWs may respond to interview questions in a way that they believe is socially acceptable rather than being completely accurate, namely “Social desirability” [26]. However, the impact of self-reported behavior on the regression result was hard to determine, comparing to directly observed, because researchers found that the influencing factors were quite different even in the same group and no statistically significant correlations were found between observed and self-reported compliance [27]. To make the self-reported compliance closer to the actual, we devoted all the staffs in research group and trained carefully, to educate HCWs that they should complete the questionnaires based on actual situation.
