Design Strategies for Biocontainment Units to Reduce Risk During Doffing of High-level Personal Protective Equipment

Abstract

Background Few data exist to guide the physical design of biocontainment units, particularly the doffing area. This can impact the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment (PPE). Methods In phase I of our study, we analyzed simulations of a standard patient care task with 56 trained HCWs focusing on doffing of high-level PPE. In phase II, using a rapid cycle improvement approach, we tested different balance aids and redesigned doffing area layouts with 38 students. In phase III, we tested 1 redesigned layout with an additional 10 trained HCWs. We assessed the effectiveness of design changes on improving the HCW performance (measured by occurrence and number of risky behaviors) and reducing the physical and cognitive load by comparing the results from phase I and phase III. Results The physical load was highest when participants were removing their shoe covers without any balance aid; the use of a chair required the lowest physical effort, followed by horizontal and vertical grab bars. In the revised design (phase III), the overall performance of participants improved. There was a significant decrease in the number of HCW risky behaviors (P = .004); 5 risky behaviors were eliminated and 2 others increased. There was a significant decrease in physical load when removing disposable shoe covers (P = .04), and participants reported a similar workload in the redesigned doffing layout (P = .43). Conclusions Through optimizing the design and layout of the doffing space, we reduced risky behaviors of HCWs during doffing of high-level PPE.

How to rapidly design and operationalise PPE donning and doffing areas for a COVID-19 care facility: quality improvement initiative

“…4 Studies describing the layout and design for doffing rooms specific to Clostridium difficile and Ebola virus have established that the space and design of built environment for donning and doffing improves HCW safety, influences compliance and has a measurable impact on HCW contamination risk while doffing PPE. [15][16][17][18] The coronavirus is not transmitted in the same way and it is not clear if these recommendations translate to Open access COVID-19. Also, literature is limited on the ideal size for a donning and doffing room and managerial issues of donning and doffing areas.…”

European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients

“…We recommend transport teams to train and simulate donning and doffing procedures of PPEs (strong recommendation). [16][17][18] See attached chart for donning and doffing procedure: https:// www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf.…”

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

“…There is a need for ensuring optimal design and layout of doffing zone, to ensure adequate space in order to dilute the biological infective load, as there can be more than two to three persons doffing simultaneously after a working shift. 10 Apart from being separately located from the donning zone, this zone should have separate access points for HCW, bio-medical waste (BMW) disposal teams and the monitor or the supervisor called "the dofficer" preferably with real time monitoring. 11 This zone should have appropriately placed full body length mirrors, hand rails or sitting arrangement aiding in the doffing of various components of the PPE.…”

“…11 This zone should have appropriately placed full body length mirrors, hand rails or sitting arrangement aiding in the doffing of various components of the PPE. 10 Doffing zone should be equipped with a separate air handling unit (AHU), negative pressurization, use of 100% fresh flow, a higher number (more than 20) of air changes per hour with minimal or no re-circulation, and directed airflow from clean to dirty zone (preferably laminar pattern) to reduce the concentration of the virus in air. 8,12 Air changes per hour (ACH) can be decided based on the bio-load in the doffing zone, as even up to 100 were considered in walk-through screening centers for COVID-19, which can remove 99.99% of particles in air with in 3 to 5 minutes.…”

“…9 Use of computer simulations ensuring proper sequence of removal of PPE, incorporation of alarm systems in case the sequence is failed and also the use of telecommunication (a supervisor giving instructions to the HCW through audio-visual interface) can ensure safe passage of the HCWs through the doffing zone, with minimal self-and crosscontamination risks. 10,19…”