Introduction
============

COVID-19 frequently presents as mild or uncomplicated illness. About 14% develop severe disease and 5% require intensive care \[[@B1]\].

COVID-19 can be complicated by the severe acute respiratory infection (SARI) and often multisystem involvement is encountered \[[@B2]\].

SARI is defined as "an acute respiratory illness with a history of fever or measured fever of ≥38°C and cough, with onset within the past 10 days, requiring hospitalization" \[[@B3]\].

SARI increases morbidity and mortality associated with COVID-19.

This potentiates the need to review the clinical management of SARI in detail and determine the existing knowledge of healthcare professions currently working in various hospital settings related to COVID-19 treatment.

In a survey conducted among patients in India with SARI, a total of 104 (1.8%) of the 5,911 SARI patients tested were positive for COVID-19 and the number of patients is still on the rise \[[@B4]\].

COVID-19 presenting as SARI mandates the need for ICU (Intensive Care Unit) hospitalization and mechanical ventilation which increases cost of healthcare \[[@B5],[@B6]\].

The sudden rise of the pandemic has placed tremendous demands on both public health and healthcare systems, and also on providers of essential community services \[[@B7]\].

Thus, appropriate knowledge of SARI and its management protocols will help in reducing the burden of healthcare.

The interim guidelines developed by a multidisciplinary panel of experienced healthcare providers who have laid the foundation for management of previous similar viral epidemics such as MERS (Middle Eastern Respiratory Syndrome), SARS (Severe Acute Respiratory Syndrome) and ARDS (Acute Respiratory Distress Syndrome) should serve to provide best possible supportive care which may increase the odds of survival \[[@B8],[@B9]\].

The questionnaire was derived from the current interim guidance and information for healthcare professionals published by the WHO on 13^th^ March 2020 \[[@B10]\].

It is of utmost importance that the interim guidelines are formed regionally and must be uniformly structured to suit all healthcare professionals working in various hospital settings with or without prior COVID-19 training.

To the best of our knowledge, this particular area of COVID-19 management has not been well studied or reported so far.

The need for such studies helps in assessment of knowledge of treatment guidelines for management of SARI in COVID-19 suspected cases, identify areas of deficiencies and help in reinforcing the present knowledge with the apt resources and guidance \[[@B11],[@B12]\].

Methods
=======

The study was a questionnaire based cross-sectional survey conducted at a university affiliated tertiary-care hospital in Navi Mumbai, India.

An online survey link was sent to 1250 healthcare professionals including doctors and nursing staff at various healthcare institutions in the state of Maharashtra, India.

The period of the survey was from 22 April, 2020 to 1 May, 2020 and a total of 313 responders completed the survey with a response rate of 25.04%.

The self-administered questionnaire was adapted from the WHO interim guidance for clinical management of SARI when COVID-19 is suspected, updated on March 13, 2020 \[[@B10]\].

The questionnaire was reviewed by an internal expert panel on COVID-19 and modifications were made according to discussions.

The questionnaire was distributed with a link to the survey through various social media platforms concerning healthcare professionals and the participation was purely voluntary.

The questions covering various aspects of management of SARI in COVID-19 and appropriate abbreviation for each question is presented in Table [1](#T1){ref-type="table"}.

###### 

Survey sections

  ----- --------------------------------------------------------------------------------------------------------------------------------
  Q3    The correct sequence of donning of a mask/respirator.
  Q5    Diagnostic criteria for COVID-19.
  Q6    Most common clinical syndrome in COVID-19.
  Q7    The use of SOFA (Sequential Organ Failure Assessment) scoring system.
  Q8    IPC (Infection Prevention and Control) measures for aerosol generating procedures in suspected or confirmed COVID-19 patients.
  Q9    Method of sample collection for COVID-19 suspected patients.
  Q10   Management of mild COVID-19.
  Q11   Management of severe COVID-19.
  Q12   Management of acute respiratory distress syndrome (ARDS) in mechanically ventilated COVID-19 patients.
  Q13   Interventions reduce incidence of ventilator associated pneumonia in COVID-19 patients.
  Q14   Septic shock in COVID-19 suspected or confirmed adult patients.
  Q15   Management of septic shock in COVID-19 suspected or confirmed adult patients.
  Q17   Caring for pregnant women with COVID-19.
  Q18   Caring for infants and mothers with COVID-19.
  Q19   Use of corticosteroids in COVID-19 suspected or confirmed patients that develop pneumonia.
  ----- --------------------------------------------------------------------------------------------------------------------------------

The questionnaire included open as well as closed ended questions with the initial part of the survey (questions 1 and 2) focusing on socio-demographic information, and the remainder of the survey focused on the management guidelines for SARI based on the WHO interim guidance.

Question 4 was a polar question (yes-no question) regarding formal training in hand hygiene which is indirectly related to SARI management and is discussed separately.

Question 16 was an open-ended question seeking the participants opinion regarding their barriers in COVID-19 management.

As inclusion criteria for participants, we considered healthcare professionals from various medical and paramedical fields involved directly in management of COVID-19 cases.

This included the medical graduates and postgraduates, super-specialists, nurses and allied healthcare workers in the ICU as well as non-ICU settings.

Professionals not involved in direct COVID-19 management were excluded.

A written consent was obtained for all participants in the beginning of the study.

The Institutional Ethics Committee (IEC) reviewed and approved the study-related documentation (DYP/IECBH/2020/02).

Convenience sampling method was used for data collection.

The distribution of responses has been presented as frequency and percentages.

Sub-groups were further classified on the basis of gender (male vs. female), age (18-30 years, 31-45 years, more than 45 years), profession (medical professional, nursing and allied healthcare) and job profile (ICU vs. Non-ICU setting).

Data were tabulated in excel, and descriptive statistics was performed using SPSS 17.

Overall percentages of correct responses were assessed for all subgroups by the median test. Individual pairwise comparisons were done for categorical data using the Chi-Square test.

Results
=======

A total of 313 healthcare professionals from the state of Maharashtra responded to the survey and the maximum responses were from the Mumbai Metropolitan Region (88.5%).

Of the total responders 48.2% were males and 51.8% were females.

The distribution of the participants in the various subgroups of age, profession, qualification and job profile is provided in Table [2](#T2){ref-type="table"}.

More participants in the survey were from non-ICU setup (hospital wards, outpatient department), as compared to the ICU setting.

Data for participants in the ICU setup mainly included medical professionals from the fields of critical care, internal medicine, pulmonary medicine, emergency medicine and anesthesia.

###### 

Responder profile (n=313)

  ------------------------ --------- --------- ------------------------- --------- ---------
                           No.       \%                                  No.       \%
  **Age**                  *** ***   *** ***   **Qualification**         *** ***   *** ***
  18 to 30 years           198       63.3      Medical graduate          73        23.3
  31 to 45 years           73        23.3      Nursing & allied          77        24.6
  46 to 75 years           41        13.1      Medical post-graduation   155       49.5
  76+years                 1         0.3       Super-specialty           8         2.6
  **Healthcare Setting**   ** **     ** **     **Profession**            ** **     ** **
  ICU                      107       34.2      Medical professionals     235       75.1
  Non-ICU                  206       65.8      Nursing & allied staff    78        24.9
  ------------------------ --------- --------- ------------------------- --------- ---------

The median and mean values for the overall percentage of correct responses for all sub groups were 66.8 and 58.62% respectively (Figures [1](#F1){ref-type="fig"}, [2](#F2){ref-type="fig"}).

Areas where all subgroups had a low total percentage of correct responses were related to sequence of donning and doffing PPE (Personal Protective Equipment), IPC measures for aerosol generating procedures, identification of COVID-19 related clinical syndromes and management of severe COVID-19 disease and interventions to reduce ventilator associated pneumonia.

Lower percentage of correct responses was observed with respect to caring for infants and mothers with COVID-19 disease.

It was observed from comparisons of individual subgroups that the total percentage of correct responses from the medical professionals was significantly higher as compared to nursing and allied healthcare professionals (P=\<0.05) (Figure [2](#F2){ref-type="fig"}).

Among the medical professionals, it was observed that a significantly higher total percentage of correct responses were obtained from postgraduates (P=\<0.05).

![Overall percentage correct responses (median) among all subgroups](CHSJ-46-02-156-figure1){#F1}

![Correct responses (median and quartiles) for profession and qualification (\*, P\<0.05).](CHSJ-46-02-156-figure2){#F2}

More than 78% of the responders had a COVID-19 ICU protocol in their hospital but only about 44% received special training related to management of COVID-19 patients.

However, more than 80% of the responders had received training in hand hygiene practices in the last three years (Figure [3](#F3){ref-type="fig"}).

![Correct responses (median and quartiles) for subgroups based on COVID-19 training, COVID-19 protocols and hand hygiene training in the last 3 years (P\<0.05)](CHSJ-46-02-156-figure3){#F3}

Knowledge of surveillance case definitions for COVID-19 plays a vital role in appropriate screening and triage and it was observed that medical professionals with a graduate degree performed better as compared to nursing and allied healthcare professionals (P\<0.05) (Figure [2](#F2){ref-type="fig"}).

More number of medical professionals, especially in the ICU setting, from the age group of 18-30 and with a graduate degree were able to identify mild illness as the most common clinical syndrome associated with COVID-19 as compared to other subgroups (P\<0.05) (Figure [4](#F4){ref-type="fig"}).

In case of management of sepsis in COVID-19 suspected cases, the SOFA scoring system is used to predict outcomes and mortality.

While responding to the use of SOFA score, professionals working in the ICU setting did better than the Non-ICU setting; whereas nursing and allied healthcare professionals performed poorly as compared to the medical professionals (P\<0.05).

![Correct responses (median and quartiles) for ICU vs. Non-ICU setting (\*, P\<0.05)](CHSJ-46-02-156-figure4){#F4}

Those in the ICU setting, medical professionals and graduates could answer about the parameters that indicate septic shock in COVID-19 suspected or confirmed adult patients better as compared to other groups (P\<0.05).

The younger individuals (age 18-30 years) performed better with respect to fluid resuscitation for septic shock in COVID-19 suspected or confirmed adults (P\<0.05) (Figure [5](#F5){ref-type="fig"}).

The interventions involved in the management of ARDS in mechanically ventilated COVID-19 patients along with the interventions to reduce incidence of ventilator associated pneumonia in COVID-19 were best answered by those in ICU setting.

Medical professionals performed better than nursing and allied professionals and those with a graduate degree did better than the rest (P\<0.05).

![Correct responses (median and quartiles) for various age groups and gender (P\<0.05)](CHSJ-46-02-156-figure5){#F5}

Another key concept is the care of pregnant women with COVID-19 and younger individuals (age 18-30 years), medical professionals comparatively performed better in this area (P\<0.05).

As per the WHO interim guidance, routine use of corticosteroids is not recommended for COVID-19 suspected or confirmed patients that develop pneumonia \[[@B10]\].

Those from the medical profession and the graduates performed better while answering this question than other subgroups (P\<0.05).

Knowledge of IPC measures for aerosol generating procedures in suspected or confirmed COVID-19 patients is crucial to check the spread of disease.

Those from nursing and allied professions did poorly than others with respect to the correct sequence of donning and doffing of PPE and appropriate IPC measures for sampling and aerosol generating procedures as compared to other sub groups (P\<0.05).

Those from ICU settings answered better than others.

Oddly, those who previously received training for COVID-19 and had management protocols in their hospitals did poorly only with respect to describing the most common symptoms of mild illness as seen in most cases of COVID-19 and about the IPC measures.

It was observed that a number of those who received special training for COVID-19 also did poorly in questions regarding symptoms, IPC, sample collection, management of COVID-19, ARDS, VAP and use of corticosteroids (Table [3](#Ft3){ref-type="fig"}).

![Item wise correct responses for subgroups based on healthcare setting, profession type, qualification and correct responses for subgroups based on training for COVID-19, presence of COVID-19 ICU management protocol and hand hygiene training.](CHSJ-46-02-156-ftable3){#Ft3}

An additional question regarding barriers for providing patient care was included in the survey.

It has been established in this study that the major barrier in caring for patients with COVID-19 was the lack of appropriate PPE (Figure [6](#F6){ref-type="fig"}).

![Barriers in caring for patients with COVID-19](CHSJ-46-02-156-figure6){#F6}

Discussion
==========

To the best of our knowledge, this is one of the first surveys of this kind addressing the key areas of management of SARI in COVID-19 suspected cases and our findings from this study showed multiple areas of deficit in knowledge.

The median and mean percentage of correct responses for all sub groups was only 66.80% and 58.62% respectively.

Overall a deficit in knowledge about sequence of donning and doffing PPE, IPC measures for aerosol generating procedures, identification of COVID-19 related clinical syndromes, interventions to reduce ventilator associated pneumonia and with respect to caring for infants and mothers with COVID-19 disease.

Previous studies based on practices towards MERS showed low adherence to PPE, IPC and poor knowledge about ventilator associated pneumonia (VAP) \[[@B11],[@B12],[@B13]\].

Resident doctors all over the world are struggling with fear, fatigue and burnout \[[@B14]\].

However, along with the intense training curriculum, most of the current frontline medical services during this pandemic are being provided by resident doctors worldwide.

It is not surprising that the majority of those who answered correctly during the study were postgraduates (P\<0.05).

In a similar study about COVID-19 awareness among medical students and professionals, the highest responses were obtained from undergraduates \[[@B15]\].

It was observed that the medical professionals answered more correctly than the nursing and allied professionals; a similar outcome was achieved in a previous study done for MERS \[[@B13]\].

Among the various outcomes of our study, healthcare professionals from the age group of 18-30 years were more aware about SARI management (P\>0.05).

This was contrary to the previous studies with other pandemics in which older healthcare professionals showed higher rates of knowledge and awareness \[[@B16],[@B17]\].

However, with respect to care for pregnant women with COVID-19, the younger age group was more aware.

This might be due to greater access to evidence-based practices and online updates as observed in this study \[[@B18]\].

In our study those in the ICU setting answered more correctly than those from non-ICU (P\>0.05).

Similar outcome was seen in an older study by Ahmed Asaad Donea among healthcare workers in Saudi Arabia during the MERS outbreak where those who worked in areas where preventive programmes and infection control policies had better knowledge \[[@B16]\].

Though a slight deviation from the topic of SARI, it is of utmost importance to carry out donning and doffing of PPE as healthcare professionals are at maximum risk of exposure, especially in the ICU setting and hence knowledge of the order of donning appropriate PPE must be imbibed in depth.

However, in our study we found poor knowledge among all subgroups with the lowest in nursing and allied subgroups with respect to following the correct sequence of donning a mask or respirator.

This could be due to lack of adequate training practices to nursing and allied healthcare professionals.

IPC measures and correct collection methods including avoiding inducing sputum or aerosol generation, contribute a long way in preventing the spread of disease to non-infected areas and to others.

The IPC measures for aerosol generating procedures in suspected or confirmed COVID-19 patients were most appropriately answered by the younger age group (18-30 years).

Ideally, aerosol generating procedures in COVID-19 patients both suspected and confirmed must be done in negative pressure rooms which was incorrectly answered by most responders.

The medical professionals seemed to be better trained than rest, with those from super speciality answering about negative pressure rooms more appropriately.

Knowledge regarding case definitions for suspected or confirmed patients was found to be inadequate overall.

However, medical graduates answered correctly that a person with laboratory confirmation of COVID-19 infection is known as a confirmed case, irrespective of clinical signs and symptoms.

This is probably due to a good amount of work exposure in the current scenario.

Those in ICU answered questions about COVID-19 case definitions better than the other groups, as similarly seen in published literature based on intensive care management of COVID-19 \[[@B19]\].

Lack of knowledge about key areas was seen even in those who had received special training in COVID-19.

This corresponds to the need of repeated knowledge imparting and training programmes to increase awareness among healthcare professionals.

Early recognition of SARI starts with screening and triage with appropriate knowledge of disease classification.

Mild illness is commonly seen in most COVID suspected individuals which includes non-specific symptoms like fever, cough, fatigue and rarely diarrhoea.

Patients may also present with severe conditions like ARDS diagnosed by a P/F (PaO~2~/FiO~2~) ratio ≤300, sepsis and septic shock and better knowledge about it was seen in medical professionals as compared the nursing and allied health staff, probably due to the lack of these topics in their curriculum as demonstrated in a study conducted in São Paulo by Santos JFD \[[@B20]\].

The Sequential Organ Failure Assessment (SOFA) score is a predictor of ICU mortality. Sepsis can be defined as an increase in the sepsis-related SOFA score of≥2 points.

It includes scores, one each system such as the respiratory, hepatic, cardiovascular, coagulation, renal and neurological systems.

Septic shock in COVID-19 patients is defined as serum lactate ≥2mmol/L and requirement of vasopressors to maintain MAP (Mean arterial pressure) ≥65mmHg \[[@B10]\].

A higher percentage of correct responses with respect to septic shock and SOFA scoring were from medical graduates, probably due to an increased emphasis on management of sepsis in teaching programmes as demonstrated in a study by H.M Ziglam \[[@B21]\].

Moreover questions were aptly answered in the ICU settings.

Management of SARI requires the use of a ventilator, often for prolonged time.

In such scenarios the incidence of ventilator associated pneumonias (VAP) is high. WHO recommends various guidelines to prevent VAP.

Use of recumbent position and change of ventilator circuits with appropriate replacements in case of damage must be done \[[@B10]\].

This was correctly answered mostly by medical graduates, especially those in ICU settings.

The nursing and allied professionals were deficit in knowledge of this.

Another important patient category is the paediatric and neonatal population.

The preferred method of oxygen delivery in case of severe respiratory infection among infants was via nasal prongs.

Children with severe respiratory distress need oxygen therapy during resuscitation.

The ideal method of oxygen delivery is by the use of nasal prongs or nasal cannula in young children, as it may be better tolerated \[[@B10]\].

It has been established in this study that the major barrier as perceived by healthcare professionals in caring for patients with COVID-19 was the lack of appropriate PPE, while the lack of time was least of the concerns.

The lack of PPE has been observed, debated and is of alarming concern worldwide \[[@B22]\].

Although a previous study with respect to MERS suggested that anxiety about the disease was a major barrier which was one of the barriers observed in our study but wasn\'t seen in a considerably large group of healthcare professionals \[[@B23]\].

There are several limitations of this study.

Responses were mainly obtained from teaching hospitals in and around Mumbai and Navi Mumbai metropolitan region and hence the finding may not be generalisable to other settings.

Thereafter nationwide studies with a larger sample size need to be carried out especially in remote areas where management of COVID-19 and its related complications could be a major concern.

Another drawback of the study is the low response rate, probably due to the COVID-19 related healthcare crisis. In this study, responses of the participants may differ since the participants worked in different areas of the hospital and could have varying levels of training and pre-existing knowledge of COVID-19.

However, the COVID-19 pandemic is rapidly evolving and there is a need for development of universal measurement tools that can be used in all healthcare settings to evaluate training and formulate strategies for COVID-19 management and make comparisons between different groups.

Conclusions
===========

With the COVID-19 situation yet to reach its peak in India and many parts of the world, outcomes from the current study have important implications for future interventions with management of patients with COVID-19 related SARI.

The present study was able to identify lacunae in knowledge with several aspects of SARI which calls for major awareness and implementation programs that need emphasis among all groups of healthcare professionals besides those in the ICU setting.

A uniform and well-structured training program must be implemented at local and national level that targets physicians, nursing and allied healthcare professionals with varying levels of COVID-19 training.

Also, team-oriented crisis resource management would also help in effectively managing the COVID-19 crisis.

The findings of this study can be used as a baseline for further development of training resources for healthcare professionals.

None to declare.
