Common Behaviors and Faults When Doffing Personal Protective Equipment for Patients With Serious Communicable Diseases

Abstract

Background The safe removal of personal protective equipment (PPE) can limit transmission of serious communicable diseases, but this process poses challenges to healthcare workers (HCWs). Methods We observed 41 HCWs across 4 Ebola treatment centers in Georgia doffing PPE for simulated patients with serious communicable diseases. Using human factors methodologies, we obtained the details, sequences, and durations of doffing steps; identified the ways each step can fail (failure modes [FMs]); quantified the riskiness of FMs; and characterized the workload of doffing steps. Results Eight doffing steps were common to all hospitals—removal of boot covers, gloves (outer and inner pairs), the outermost garment, the powered air purifying respirator (PAPR) hood, and the PAPR helmet assembly; repeated hand hygiene (eg, with hand sanitizer); and a final handwashing with soap and water. Across hospitals, we identified 256 FMs during the common doffing steps, 61 of which comprised 19 common FMs. Most of these common FMs were above average in their riskiness at each hospital. At all hospitals, hand hygiene, removal of the outermost garment, and removal of boot covers were above average in their overall riskiness. Measurements of workload revealed that doffing steps were often mentally demanding, and this facet of workload correlated most strongly with the effortfulness of a doffing step. Conclusions We systematically identified common points of concern in protocols for doffing high-level PPE. Addressing FMs related to hand hygiene and the removal of the outermost garment, boot covers, and PAPR hood could improve HCW safety when doffing high-level PPE. We identified ways that doffing protocols for high-level personal protective equipment may fail to protect healthcare workers. Hand hygiene, removing the outermost garment, boot covers, and respirator hood harbored the greatest risk and failed in similar ways across different hospitals.

“The Art of War” in the Era of Coronavirus Disease 2019 (COVID-19)

“…The rationale was simple. Prior research demonstrates that using unfamiliar or increasingly complex PPE increases the risk of selfcontamination 3 . Consequently, training for healthcare workers (HCW) focused on ensuring proper donning and doffing techniques with familiar, well-rehearsed PPE procedures.…”

Diagnosis and Management of First Case of COVID-19 in Canada: Lessons Applied From SARS-CoV-1

“…Second, what allows our hospital to maintain baseline preparedness for novel high-consequence pathogens is that our standard PPE for managing these patients only includes components that are already familiar to our HCWs. This decision was made based on evidence demonstrating that additional PPE complexity is associated with risks of self-contamination during doffing (12). This approach is also consistent with prior evidence from SARS-CoV-1 suggesting that transmission occurs by the droplet or contact route (13).…”

Identifying and Implementing Strategies to Reduce the Risk of Self-Contamination of Health Care Workers Caused by Doffing of Personal Protective Equipment During the COVID-19 Pandemic

“…11 The study done by Mumma JM, et al assessing common behavioral faults during doffing found that the most frequent steps leading to maximal non-compliance involved removing the outermost garment, boot covers, and respirator hood apart from hand hygiene. 26 Ensuring hand hygiene with alcohol based sanitizers with a minimum contact time of 20 seconds, at every step of removal of each item of PPE is crucial. 7 This could be ensured with the help of audible alarms or music for a requisite duration (20 seconds) after pressing the foot operated sanitizer systems.…”