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Personal protective equipment portraits in the era of COVID-19

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    Christopher Hansen-Barkun
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    Research Institute of the McGill University Health Centre, Montreal, Canada
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    Omar Kherad
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    Department of Internal Medicine, Hôpital de la Tour and University of Geneva, Switzerland
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    Adamo A Donovan
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    Affiliations
    Department of Medicine, McGill University, Montreal, Canada
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    Anupa J Prashad
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    Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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    Maida J Sewitch
    Correspondence
    Corresponding author.
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    Department of Medicine, McGill University, Montreal, Canada

    Division of Clinical Epidemiology, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
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      Keywords

      Dear Editor

      Use of personal protective equipment (PPE) aims to prevent SARS CoV-2 transmission in the healthcare setting. However, PPE limits human connection and non-verbal communication by masking individuals’ facial gestures and body language. Contact isolation potentially presents considerable psychological consequences for patients and healthcare providers (HCPs) [
      • Abad C
      • Fearday A
      • Safdar N
      Adverse effects of isolation in hospitalised patients: a systematic review.
      ]. During the 2015 Ebola outbreak, HCPs utilized PPE portraits to humanize care and bridge communication gaps [
      • Molnar-Szakacs I
      • Uddin LQ
      • Heffernan MB
      The face behind the mask: the future of interpersonal interaction.
      ]. With increasing PPE portrait use during the coronavirus disease 2019 (COVID-19) pandemic, we sought to summarize and critically evaluate the available evidence of PPE portraits on clinical care.
      The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A comprehensive literature search of Medline, Embase, ISI Web of Science, and PsyInfo was performed from the recorded start of databases until January 2022 using terms related to personal protective equipment and portraits (or picture, image, or photo) or patient-provider relationship/connection and COVID. Cross-referencing of selected articles was also conducted. After removal of duplicates, two reviewers (CHB and MM) independently evaluated the eligibility of citations based on title and abstract. The full texts of the remaining citations were then reviewed for assessment of final study selection. A third reviewer (AB) resolved conflicts. Study inclusion criteria were fully published articles in English or French that addressed the use of PPE portraits in a clinical setting from either the patient or HCP perspective, using qualitative or quantitative methods. We excluded review articles and non-human studies. Data extraction was completed by one author (CHB) and verified by a second (MJS). Predefined variables such as study characteristics (country, year of publication), study design, population characteristics, sample size, and outcomes were extracted. Methodological study quality was assessed using the Newcastle-Ottawa quality assessment scale for non-randomized studies and the Critical Appraisal Skills Programme for qualitative studies. Certainty of evidence was assessed using the GRADE approach. Because of the nature and amount of available data, only descriptive analyses could be carried out. Outcomes are reported as proportions and 95% confidence intervals for categorical variables and as means and standard deviations for continuous variables, with statistical comparisons collected as reported from the appropriate study publication, where applicable.
      The literature search revealed three relevant studies (PRISMA diagram, Appendix 1). Detailed study descriptions and quality assessments are shown in Table 1 and Appendices 2 and 3. The first study provided qualitative insights from frontline HCPs who reported increased comfort with patient interactions while wearing PPE portraits and noted significant adoption [
      • Brown-Johnson C
      • Vilendrer S
      • Heffernan MB
      • et al.
      PPE Portraits-a Way to Humanize Personal Protective Equipment.
      ]. The second study was a survey of 173 HCPs in a palliative care setting (78% female); 64% were exposed to PPE portraits, although only 9.8% had used them [
      • Reidy J
      • Brown-Johnson C
      • McCool N
      • et al.
      Provider perceptions of a humanizing intervention for health care workers-a survey study of PPE portraits.
      ]. Attitudes toward PPE portraits were positive among all HCPs and more positive among those exposed to PPE portraits. Most HCPs exposed to PPE portraits reported these improved their mood and helped them feel connected to the person wearing the portrait (Table 1). Moreover, most had received positive feedback from staff, patients, and families, and described enhanced meaningful connections and an increased sense of well-being. A few HCPs were concerned with infection control and cleaning/decontamination, costs and logistics, and vulnerability by those wearing PPE portraits. The third was a pre-post intervention study investigating the effects of physicians wearing PPE portraits by administering a survey to 31 patients and 20 physicians [
      • George AJ
      • Mathew DE
      • Lazarus E
      • et al.
      Effectiveness of self-portraits used over personal protective equipment during the COVID-19 pandemic among patients and healthcare workers.
      ]. Significant improvements were reported in time spent with doctors, between-doctor communication, colleague identification, and doctor perceptions of patient happiness. No significant differences were noted in patient satisfaction, interpersonal interaction, communication, or in doctors feeling the need to remove their masks to communicate (Table 1). The overall certainty of evidence across all studies was very low owing principally to limitations in study design and small sample size (Appendix 4).
      Table 1Summary of studies addressing use of PPE portraits
      Study Year CountryStudy design Study quality assessmentStudy population Study SampleMeasurement of outcomeResults / Quotes
      Brown-Johnson et al. 2020
      • Brown-Johnson C
      • Vilendrer S
      • Heffernan MB
      • et al.
      PPE Portraits-a Way to Humanize Personal Protective Equipment.
      USA
      Initial qualitative insights – pilot study CASP Score – dichotomous and qualitative assessment of the criteria presented in AppendixHCPs working at a drive-thru COVID-19 testing, Stanford Express Care, USA n = not specified - HCPsQualitative data on implementation barriers and facilitators of PPE portraits No standard qualitative methods were described- Front-line providers reported more comfort with patient interactions while wearing PPE Portraits

      - Signs of significant adoption by HCPs

      - “It makes it feel less like a disaster zone [for the patient].”
      Reidy et al. 20204 USACross-sectional survey Newcastle-Ottawa quality assessment scale = 1 star out of 8 Rating details provided in AppendixHCPs at UMass Memorial Medical Center in an inpatient palliative care service, USA n = 173

      - Physicians (n = 33)

      - Advanced practice providers (n= 81)

      -Trainees/residents/ fellows (n = 19)

      - Case managers/ social workers (n = 25)

      - Nurses (n = 11)

      - Administrative

      assistants (n = 3)

      - Women amongst all responders (n = 135)
      Survey assessing: - Exposure to PPE portraits

      - Attitudes toward PPE portraits (impacts on

      mood and inter-staff connection)

      - Potential program expansion

      - Perceptions of interactions with other

      staff and patients/families

      - Impact on personal

      well-being

      Survey items used a five-point Likert scale (strongly agree to strongly disagree), with an open-ended comments option
      Reported exposure to PPE portraits (n = 111):

      - Agreed that PPE portraits were a good idea (89%)

      - Improved provider mood (79%)

      - Enhanced perception of team connection (72%)

      - Wanting PPE portraits implemented in their department (59%) and system-wide (59%)

      - Had talked to colleagues about PPE portraits (47%)

      Used PPE portraits and agreed or strongly agreed (n = 17):

      - Receiving positive feedback from staff (65%) and patients and families (69%)

      - PPE portraits augmented interactions with staff (71%)

      - Enhanced meaningful connection with patients and families (65%)

      - Increased provider sense of well-being (69%)

      Open-ended comments regarding PPE portraits addressed (n = 41):

      - Needs for connection (37%)

      - Infection control and cleaning/decontamination (15%)

      - Costs and logistics (12%)

      - Provider vulnerability in wearing PPE portraits (7%)
      George et al. 20215 IndiaPre-post intervention study Newcastle-Ottawa quality assessment scale = 7 stars out of 9 Rating details provided in AppendixHCPs and patients at a tertiary COVID-19 specialty hospital, Christian Medical College Vellore, India n = 51

      - Patients (n = 31)

      - Physicians (n = 20)
      Modified validated Patient Satisfaction Questionnaire 18 administered prior to and four days following the interventionPre- vs. Post-intervention means (SD) in participant response scores (p value):

      Patients:

      - General satisfaction = 3.80 (0.87) vs 4.00 (0.61) (p=0.32)

      - Interpersonal interaction = 3.91 (0.74) vs 3.96 (0.54) (p=0.77)

      - Communication = 3.66 (0.94) vs 3.85 (0.41) (p=0.31)

      - Time spent with doctor = 3.20 (0.89) vs 3.70 (0.53) (p=0.02)

      Physicians:

      - I feel the communication between doctors has improved = 2.90 (0.64) vs 3.60 (0.88) (p<0.01)

      - I feel it was easy to identify my colleagues = 2.50 (0.99) vs 3.90 (0.85) (p<0.01)

      - I need to remove my mask to communicate = 3.90 (0.72) vs 4.00 (0.79) (p=0.68)

      - My patients are happy with doctors in PPE = 2.10 (0.85) vs 2.80 (1.11) (p=0.03)
      PPE = Personal protective equipment; HCPs = Health care providers; SD = standard deviation; NS = Not significant; CASP = Critical Appraisal Skills Programme checklist
      Use of PPE portraits continues to increase during the COVID-19 pandemic despite a paucity of data examining its impact on patients and HCPs [
      • Molnar-Szakacs I
      • Uddin LQ
      • Heffernan MB
      The face behind the mask: the future of interpersonal interaction.
      ]. Overall, less than 250 participants were enrolled, including only 31 patients. The three studies included in this review are heterogeneous in design, of low to moderate quality, and are all at serious risk of bias. All studies address HCPs experiences or their perceptions of patient experiences. Study findings among HCPs show promise that PPE portraits are helpful in building connections with colleagues. However, the only study to directly measure patient perceptions showed that the use of PPE portraits resulted in a significant increase in time spent with doctors, but no significant improvements in general satisfaction, interpersonal interaction and communication [
      • George AJ
      • Mathew DE
      • Lazarus E
      • et al.
      Effectiveness of self-portraits used over personal protective equipment during the COVID-19 pandemic among patients and healthcare workers.
      ].
      The rationale underlying the use of PPE portraits is that facial expression recognition is impaired by wearing a mask. Facial masks conceal the lower part of the face, including the mouth and nose, which provide essential information for the interpretation of expression. Indeed, both the upper and lower face are important for conveying and decoding emotional facial expressions. A randomized controlled study performed before the COVID-19 pandemic was conducted in primary care to explore the effects of doctors wearing facemasks on patient perception of doctors’ empathy, patient enablement and patient satisfaction [
      • Wong CK
      • Yip BH
      • Mercer S
      • et al.
      Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care.
      ]. A significant negative effect was found in the patient's perception of the doctor's empathy, potentially thwarting the necessary development of trust, communication, and a therapeutic alliance [
      • Mercer SW
      • Reynolds WJ
      Empathy and quality of care.
      ]. Alternatively, use of PPE portraits showing smiling headshots may help the facial mimicry where the brain recreates and mirrors the emotional experience of the other person and affects how people empathise with others and interact socially. However, the dynamic and heterogeneous nature of the messages communicated by HCPs to patients and their families may run the risk of confusion when incongruent with the static nature of the portrait. An example would be a patient receiving troubling news from an HCP while looking at their smiling face on the portrait. Further qualitative research is needed to shed light on these areas.
      This systematic review is the first to summarize and critically evaluate the available evidence about use of PPE portraits on clinical care. We included both qualitative and quantitative evidence using state of the art adapted methodology. Surprisingly only one study questioned patients regarding their experiences with PPE portraits using a validated outcome measurement tool that was modified. Overall conclusions are limited by the very low certainty of the evidence, the heterogeneity of outcomes assessed, and the small number of studies and participants. Ideally, in future original research, the choice of outcomes will be informed by an understanding of the psychological and biological rationale underpinning the impact of PPE on patients. Additional qualitative research should employ a phenomenological approach to inform a selection of clinically pertinent outcomes. Quantitative research must then employ validated measurement tools when surveying patients and HCPs. As dissemination and adaptations are often driven by clinician and institutional preferences and protocols, issues of decontamination, feasibility, sustainability, and cost-effectiveness will also require characterization [
      • Brown-Johnson C
      • Vilendrer S
      • Heffernan MB
      • et al.
      PPE Portraits-a Way to Humanize Personal Protective Equipment.
      ]. Volunteer organizations have begun supporting the creation and distribution of PPE portraits. [[

      Humanizing Coronavirus Care. https://ppeportrait.org/Accessed January 2022.

      ,

      Sharing the smile behind your PPE. https://www.ppeportraits.ca. Accessed January 2022.

      ]] While possible limitations exist, PPE portraits present a potentially impactful low-risk solution to the challenge of delivering compassionate patient care under contact isolation precautions. Contact isolation remains a necessity both during the COVID-19 pandemic, emergence of future infections, and new clinical scenarios of high PPE use.

      Contributors

      Study concept and design; Christopher Hansen-Barkun, Omar Kherad, Adamo A Donovan, Anupa J Prashad, Maida J Sewitch. Acquisition of data; Christopher Hansen-Barkun, Omar Kherad, Adamo A Donovan, Anupa J Prashad, Maida J Sewitch. Analysis and interpretation of data; Christopher Hansen-Barkun, Omar Kherad, Adamo A Donovan, Anupa J Prashad, Maida J Sewitch. Drafting of the manuscript: Christopher Hansen-Barkun, Omar Kherad, Maida J Sewitch. Critical revision of the manuscript for important intellectual content: Christopher Hansen-Barkun, Omar Kherad, Adamo A Donovan, Anupa J Prashad, Maida J Sewitch Statistical analysis: Christopher Hansen-Barkun, Maida J Sewitch.

      Obtained funding

      N/A

      Technical, or material support

      N/A

      Study supervision

      Maida J Sewitch

      Acknowledgment

      The authors thank Alan Barkun and Myriam Martel for their contributions.

      Appendix. Supplementary materials

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      1. Humanizing Coronavirus Care. https://ppeportrait.org/Accessed January 2022.

      2. Sharing the smile behind your PPE. https://www.ppeportraits.ca. Accessed January 2022.