Discussion

The determination of precautions for infection prevention comes from national guidelines, professional society position papers, and recommendations from groups such as the Healthcare Infection Control Practices Advisory Committee, which lag current research. The results highlight opportunities to optimize environmentally sustainable strategies for PPE use at VCUHS. Scant evidence supports COVID-19 transmission via clothing yet gowning in COVID-19 patients’ rooms remains hospital policy. ^{Reference Kvasnicka, Cohen Hubal, Siegel, Scott and Diamond6} The finding that less than half of respondents believe gowns reduce COVID-19 transmission, which is also supported by literature, suggests that a policy change ending mandatory gowning in COVID-19 patients’ rooms would be well accepted. Another potential policy change is minimizing non-essential encounters for patients with isolation precautions, such as limiting the team members entering an isolation room to only those directly caring for the patient.

We found that healthcare workers may need more education on the environmental impacts of health care. Research suggests that the use of reusable items leads to reduced pollution without increasing infection rates, ^{Reference Bolten, Kringos, Spijkerman and Sperna Weiland7} but less than half of respondents agreed that sterilized reusable PPE is safe compared to disposable PPE. Most respondents disagreed that the healthcare workplace promotes environmental sustainability. This is not unique to our facility. Inadequate hospital infrastructure and lack of management support have been identified as barriers in prior studies. ^{Reference Magadze, Nkhwashu, Moloko and Chetty8,Reference Petre, Bahrey and Levine9}

Twenty-eight percent (35/124) of respondents working in high acuity settings (ICU and ED) disagreed or strongly disagreed that the benefits of PPE use outweigh the environmental impacts, compared to 9% (13/138) of outpatient respondents. This runs counter to the theory that individuals are more likely to don PPE when they perceive a personal risk, as those working in high-acuity settings encounter infections more often than those in outpatient settings. A limitation is that respondents were not asked what they perceived to be the environmental impacts, so their response may be influenced by how much they know about sustainability.

This study elucidates VCUHS staff perceptions related to PPE practices, and this study may serve to promote discussion and further development at VCUHS. However, external validity is limited due to the relatively small sample size and the single-center study design. Additionally, resident physicians and fellows were not surveyed. Although the survey was anonymous, respondents may not have provided truthful answers either due to recall bias or out of a desire to provide the most socially acceptable answer. Respondents also received heterogeneous training on PPE policy. A distinction was not made between sterile PPE used in procedures and non-sterile PPE used in isolation precautions.

This study is the first to measure attitudes and practices around PPE use as it relates to environmental sustainability. Our study found mixed practices on the use of gowns by discipline and setting and mixed views on whether the benefit of PPE outweighed their impact on the environment. Thoughtful workflow may aid in judicious PPE use. Future directions may include ending the policy of gowning in COVID-19 patient rooms. Sustainability in healthcare remains a still largely untapped frontier for health promotion.