Of the 43 clinicians and administrators who contacted our team for consultation, 25 implemented PPE Portraits at their affiliated organization from March-November 2020. Several requests for adaptations to the portrait format and implementation process arose during early development across these diverse settings. Adaptations were made to meet the needs of clinicians, staff, patients, and beneficiaries, and to adhere to adopting organization’s policies and preferences. Adaptations primarily related to 1) clinician convenience and comfort for acceptability, 2) fit to patient populations for appropriateness, and to 3) maximize implementation and scaling the intervention for feasibility and sustainability of PPE Portraits. To support PPE Portrait’s acceptability, adaptations revolved around physical portrait attributes including size, material, and method of affixing the portrait. Adaptations were made to ensure safety and appropriateness for the population on the receiving end of PPE Portraits. Other adaptations focused on implementation and scaling processes: streamlining adoption by hospitals to ensure there was early buy-in from both administrators and clinic staff. Administrators most commonly spearheaded these adaptations, with support from other key stakeholders including clinicians and other care staff. There were pros and cons to each PPE Portrait adaptation.
1. Clinician convenience and comfort → Acceptability
Smaller portrait to enhance staff acceptability
Within a memory unity of an assisted living facility, staff requested modifications to enhance acceptability. The staff were willing to wear a smaller 3X4 inch portrait, instead of the recommended 4X6 inch portrait, due to anticipated discomfort and self-consciousness associated with wearing the larger portrait. This adaptation was made during early development, and therefore it took less time to modify the portrait before official implementation spread to other staff members.
There were several unintended consequences to this adaptation that impacted initiation, adaptation time, and long-term sustainability. It took a longer time up-front to prepare the materials including cutting the 4X6 lamination pouch in half. Also pictures were not available to print in this size, so it required someone familiar with photo manipulation software to specially process the photo files. However, material needs were cut in half, which in the long run, reduced resource costs to create the portraits. In addition, the smaller portrait was physically more comfortable to wear, lighter, and less likely to fall off, which further enhanced staff members’ acceptance of the portrait. After this early adaptation we continued to use 3X4 inch portraits at other adopting organizations.
2. Patient Needs → Appropriateness and Fit
Rounded portrait edges and affixed with a lanyard
Modifications were made to PPE Portraits to also ensure the safety of patient populations. All modification decisions were made by the portrait wearers for the protection of portrait viewers. In the assisted living center’s memory unit, the square edges of the laminated portrait pouch were perceived to be sharp enough to potentially injure a patient. During early development, staff members requested for the edges to be rounded to remove the risk of poking a patient’s eye or piercing the skin.
While magnets were used to affix the portrait, this method of affixation was rejected by preschools, infant centers, as well as assisted living facilities given the potential choking hazard the magnetic strip presented. Alligator clips were used instead and became the primary attachment mechanism. Fidelity to the original intervention was preserved and some teachers used a larger picture portrait so it would be easier to see at a distance. Some staff used lanyards when socially distanced from patients, residents or students. However, this attachment method was reserved for non-clinical setting due to the risk of cross contamination caused by the lanyard swinging or flapping and due to the difficulty of lanyard decontamination.
3. Alignment with Organization → Feasibility and Sustainability of implementation and scale
Facilitative role of onsite champions
PPE Portraits at a majority of sites were initiated by a physician, nurse, or administrative champion who contacted our evaluation team with inquiries on how to adopt and roll out the intervention. We observed that having a clinician and administrative lead at the site hastened implementation since the priorities of the both the health care organization and stakeholders were reflected in the adaptions, leading to long-term acceptability and fewer changes post-implementation. For example, at one hospital, a clinic staff member was concerned about the safety of the portrait affixation method which was escalated to the administrative champion who wrote to our evaluation team: “Currently we are using laminated photos, with clips, and the question has been raised about the possibility of puncturing the gown if using a clip (by one of our ICU nurses). I love this idea of creating a magnet fastener, and if you don't mind sending the instructions, I will make sure to meet with the person attached to this project on our end. This seems like a great adaptation, and look forward to exploring this” (A. Seara, personal communication, June 23, 2020). This adaptation, while voiced by an administrative champion, reflected the needs and concerns of clinic staff. Having the two roles in close communication facilitated delivery and sustainability of PPE Portraits.
Other adaptations related to ease of dissemination included slowing down the process during early development and providing buttons, which were produced easily at scale, but required expensive equipment to produce. Portrait buttons were a novel reusable form, fastened with a safety clip and made out of metal or plastic. The adaptation of the button was spearheaded by hospital administrators and clinicians. The pros of the button include secure attachment, ease to put on and take off, and greater societal familiarity with this format enhancing acceptability from onlookers and adopters. Conversely, the button can be difficult to decontaminate and there is a risk of puncturing PPE, therefore the button format is recommended in low-risk contamination settings. This portrait modification has limited fidelity to the original intervention since a button is very different from a rectangular portrait, it is circular, and it is seen as less formal, less noticeable, and smaller than a rectangular badge. The button also has wider cultural uses (i.e. sports, politics) where the wearer of the button may not match the subject of the portrait. This can cause confusion when the button is used as a PPE Portrait in the clinical context. However, the button was easier to put on, and did not interfere with clinician workflow, proving more feasible to implement.
Encouraging implementation feasibility with onsite photoshoots
The success of PPE Portraits is dependent on receiving a clear headshots of health care staff members. Coordinating an onsite photoshoot day was the most common and successful model used by clinics. The clinician or administrator champion chose a time when healthcare staff would naturally convene during their busy days including before staff meetings or at the start of a shift, during an organized staff lunch, or during break. Having a point-person to usher staff to the photoshoot location was instrumental in motivating and reminding staff to have their photos taken, especially when the photographer could not enter the building. For clinics where staff were spread over multiple locations, staff would go to the photographer during breaks or time off instead of a coordinated, singular site photoshoot. This allowed staff more flexibility to a choose a time that was convenient for them to have their picture taken. Coordinating within the limits of the clinic organization and remaining flexible were both key to successful photoshoots.
Alignment with site needs: one-time use stickers versus reusable laminated portraits
Between March and May 2020, during the initial phase of the COVID-19 pandemic and early development of PPE Portraits, there was much deliberation on the use of laminated portraits that were reusable versus disposable portrait picture stickers. The portrait picture stickers were the appropriate option in high-risk clinical settings where clinicians would don one-time PPE in order to have direct contact with patients with confirmed or suspected COVID-19 (e.g. ICU, emergency departments). However, drawbacks stickers included the need for a volume of stickers, depending on the clinical context. Staff time and resources to replenish these stickers were often not available in settings with competing clinical priorities; leaders observed the practice would be abandoned when stickers ran out.
Reusable portraits became the most widely used practice for outpatient settings and other low-risk infection settings where direct contact with COVID-19 was not anticipated. Reusable portrait had several pros: environmentally friendly, higher fidelity images, matted/low-gloss surface to improve patient visibility of the portrait, and no ongoing labor/resources to support. Cons to reusable portraits included highest labor/skill to initially create; greater difficulty to take on and off; more supplies, time, and costs to get started; and requiring consistent decontamination (Fig. 2). In pilot testing, reusable portraits tolerated frequent decontamination with alcohol swabs at 70% Isopropanol, 10% bleach, or other hospital-grade disinfectant wipes without damage. To prevent cross contamination, reusable portraits were securely affixed at the top and bottom of the portrait with magnets, which is a puncture-free attachment method. Magnets are also easily decontaminated, and are least likely to damage the PPE portrait and clothing. Training was required to ensure proper decontamination of the portrait, and affixing to clothing (e.g. placing the magnets underneath the clothing at the top and bottom of the portrait.)
Although widely preferred, the laminated portrait option was not always adopted. Reasons for non-adoption included: hospital policy, lack of clinician or administrative support, upfront time constraints especially during the first few months of COVID-19, and lack of knowledge about virus transmission early on in the pandemic. Fears of cross-contamination and hospital workflow barriers were reason for non-adoption as expressed by one administrative champion, “My only concern for our ICU wards is that the image must stay in the patient's room for the day, and cannot be taken room to room. So the removal of the portrait badge would be tricky, if the magnet backing will become loose, under the gown. Regarding using these in other parts of the hospital, this would be completely fine.” While laminated portraits required more time, labor, and resource costs upfront they incurred little to no cost once the portrait was created. In addition, we heard from some sites that the laminated portrait became a memento.
Why was the adaptation needed
The driving need for each adaptation was associated with the adaptations’ added value to the portrait from the stakeholder’s perspective. Tracking the justification for an adaptation allowed our team to retrospectively identify whether the solution met the initial need. The specific adaptation need is also closely linked to the nature of the stakeholder requesting the modification, which can inform dissemination to similar organizations. For example, the rounding of portrait edges was initially spurred by staff members concerned about the safety of elderly residents in a memory unit. This form of the portrait is beneficial for the safety of portrait viewers in all implementation contexts. The driving needs for an adaptation are often not visible following modification and implementation, and therefore are important to track to inform future dissemination.
Previous frameworks did not track alternative modifications, leaving practitioners without a set of modification options, even though multiple modifications may have addressed the same need. For example, to meet the need for a reusable PPE Portrait several modifications arose: non-laminated photo, laminated photo attached with magnets or lanyard, and portrait pins. The systematic consideration and tracking of all potential modification types may help clinicians and administrators identify which adaption will best fit their needs and other stakeholders’ preferences.
While tracking adaptations using the FRAME, we noticed that every adaptation had unintended consequences. This crucial component was absent from the original FRAME. For example, smaller and laminated (versus non-reusable sticker) portraits reduced material costs. This unintended effect could improve sustainability, but the increased labor upfront (i.e. cut and round portrait edges) could serve as a barrier to adoption and widespread dissemination. In addition, the development of laminated, reusable portraits had the unintended consequences of creating meaningful mementos of COVID-19 for healthcare staff members. This addition of unintended consequences to the FRAME helped tie this implementation framework to overall aspects of implementation feasibility and downstream sustainability. Our three additions to the FRAME were tracked side-by-side to assess the relationship between need, goal, and unintended consequences of each adaptation (Table 1).