COVID-19, Personal Protective Equipment, and Human Performance

Keith J. Ruskin, M.D.; Anna Clebone Ruskin, M.D.; Brian T. Musselman, C.As.P.; Jaime Rivas Harvey, C.As.P.; Thomas E. Nesthus, Ph.D.; Michael O'Connor, M.D.


Anesthesiology. 2021;134(4):518-525. 

In This Article

Abstract and Introduction


Clinicians who care for patients infected with coronavirus disease 2019 (COVID-19) must wear a full suite of personal protective equipment, including an N95 mask or powered air purifying respirator, eye protection, a fluid-impermeable gown, and gloves. This combination of personal protective equipment may cause increased work of breathing, reduced field of vision, muffled speech, difficulty hearing, and heat stress. These effects are not caused by individual weakness; they are normal and expected reactions that any person will have when exposed to an unusual environment. The physiologic and psychologic challenges imposed by personal protective equipment may have multiple causes, but immediate countermeasures and long-term mitigation strategies can help to improve a clinician's ability to provide care. Ultimately, a systematic approach to the design and integration of personal protective equipment is needed to improve the safety of patients and clinicians.


Clinicians around the world use personal protective equipment while caring for patients affected by the coronavirus disease 2019 (COVID-19) pandemic. Physicians of all specialties perform aerosol-generating procedures (including tracheal intubation and extubation), administer treatments that generate aerosols (e.g., bilevel positive airway pressure ventilation and high-flow nasal cannulas), or must simply stand within two meters of an infectious patient. Personal protective equipment required for the care of these patients includes an N95 mask with a face shield or powered air-purifying respirator, a gown, and gloves. This combination of personal protective equipment causes increased work of breathing, reduced field of vision, reduced tactile sensation, and heat stress.[1–4] Additional problems include ill-fitting equipment and shortages that result in constant changes in the type and availability of equipment that healthcare professionals must use. Each of these challenges has the potential to impair a clinician's ability to care for his or her patients.

In the past, medical equipment was designed with the expectation that the user will adapt his or her workflow to the device. Instead, the device should be designed to accommodate the needs of the user. Advances in human factors engineering lead to equipment design that will enhance, rather than impair performance. Although a single piece of equipment (e.g., an N95 mask) may cause only a minor degradation in performance, multiple items used in combination have additive effects which may significantly impair a clinician's ability to provide care.[5] The authors have personally experienced this effect before the current pandemic but dismissed it as a mildly unpleasant, short-term problem. The COVID-19 pandemic requires that clinicians make continuous use of personal protective equipment for longer periods of time, exacerbating its effects on human performance. There is a paucity of information on the effects of prolonged use of the personal protective equipment required to care for COVID-19 patients, but at least one study has concluded that personal protective equipment produces negative effects on both the physical and mental health of healthcare workers.[4]

The diverse array of personal protective equipment worn by healthcare workers varies by location and availability and may also change over time. This lack of standardization can prevent clinicians from developing proficiency in its use and may negatively affect their ability to provide care.[6] One possible advancement would be for health care systems, the government (e.g., National Institute for Occupational Safety and Health), and organizations with expertise to align and insist on higher and universal manufacturer standards for design, fit, and performance, which would allow for preemptive universal training, possibly translating to improved clinician safety and performance. This review will discuss how personal protective equipment can impair performance and propose immediate and long-term solutions for wearable, functional, and comfortable personal protective equipment in the patient care environment.