Infection Control & Hospital Epidemiology (2018), 39, 961–967 doi:10.1017/ice.2018.125
Original Article
Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness
Jennifer R. DuBose MS, EDAC1, Zorana Matić MArch1, Maria Fernanda Wong Sala BS1,2, Joel M. Mumma MS3, Colleen S. Kraft MD, MSc4,5, Lisa M. Casanova PhD6, Kimberly Erukunuakpor MPH6, Francis T. Durso PhD3, Victoria L. Walsh MPH5, Puja Shah MPH, CLSSGB5, Craig M. Zimring PhD1,a and Jesse T. Jacob MD5,a
for the CDC Prevention Epicenters Program 1SimTigrate Design Lab, School of Architecture, Georgia Institute of Technology, Atlanta, Georgia, 2School of Industrial Design, Georgia Institute of Technology, Atlanta, Georgia, 3School of Psychology, Georgia Institute of Technology, Atlanta, Georgia, 4Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, 5Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia and 6Division of Environmental Health, School of Public Health, Georgia State University, Atlanta, Georgia
Abstract
Objective: To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU). Design: We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises. Setting: The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup. Participants: A total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study. Results: In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) andHCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCWadherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements. Conclusions: Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.
(Received 14 March 2018; accepted 2 May 2018; electronically published June 18, 2018)
During the 2014–2015 Ebola outbreak, ensuring healthcare worker (HCW) safety during delivery of patient care, particu- larly preventing the acquisition of a potentially lethal infection, emerged as a major challenge in US hospitals. Ebola virus disease (EVD) spreads directly, by contact with blood or body fluids of a person infected with the virus, and indirectly, through contact with contaminated objects (eg, surfaces, medical equipment). Healthcare workers employ standard and transmission-based precautions that involve the use of personal protective equipment (PPE), including gloves and gowns. For patients with serious
Author for correspondence: Jennifer R. DuBose, SimTigrate Design Lab, 828 West Peachtree St. NW, Suite #334, Atlanta, GA 30332-0477. E-mail: Jennifer.dubose@design.
gatech.edu a Authors of equal contribution. Cite this article: DuBose JR, et al. (2018). Design Strategies to Improve Healthcare
Worker Safety in Biocontainment Units: Learning from Ebola Preparedness. Infection Control & Hospital Epidemiology 2018, 39, 961–967. doi: 10.1017/ice.2018.125
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
communicable diseases such as EVD, HCWs require more complex PPE such as coveralls, aprons, and hoods. Appropriate and consistent use of PPE is essential for reducing transmission of infectious diseases to HCWs. Doffing PPE is a high-risk activity because of potential self-contamination,1–4 even when HCWs believe they have done everything correctly.5 While opportunities to improve PPE elements6–8 and doffing
protocol compliance9–11 have been assessed, a small but growing body of literature on the design of biocontainment units (BCUs) suggests the importance of a designated doffing space.12–16 However, only 1 study has assessed environmental design stra- tegies in depth.17 Our study was informed by and expanded on previously tested design strategies including doffing zone demarcation, balance aids, and visibility. Using data gathered from 4 US Ebola treatment centers, we developed a framework regarding how the design and layout of the doffing space may improve the safety of HCWs when doffing PPE after caring for patients with high-consequence pathogens.
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