962 METHODS
As part of a larger project including experts in human factors and microbiology, the built environment team analyzed a series of 10 simulations each in the BCUs of the 4 state-designated Ebola treatment centers in Georgia (sites A, B, C, and D) to identify ways HCWs interacted with the built environment. For 6 of the simulations, we built a geometrically accurate, high-fidelity mock-up of site D in the SimTigrate Design Lab at Georgia Institute of Technology because the BCU was being used for patient care. At site A, an additional simulation was performed because the micro- biologic data from the first simulation attempt were not processed. The HCWs in each simulation followed donning and doffing procedures and used PPE adopted by their BCU, including the use of a trained observer (TO) to monitor and guide the HCW while doffing. The participating HCWs (n = 41) and TOs (n = 15) had prior training for complex PPE as part of their readiness to care for a potential EVD patient. After donning, the PPE was contaminated with harmless bacteriophages mimicking Ebola (ϕ6) and other emerging viruses (MS2). The HCWs conducted a simulated patient care task on a mannequin before doffing the PPE. After doffing, the HCW’s PPE, hands, and face were sam- pled to assess whether cross contamination occurred; these results have been reported elsewhere.18 The simulations were recorded from different angles using 4
stationary cameras and 1 handheld camera to document the actions and dialogue of participants. The HCW behaviors were docu- mented in real time and through video analysis. In addition, 2 human factors experts reviewed video recordings of the simulations to identify the unique ways that the doffing process can fail. For each major doffing step, as defined by the facility’s protocol, the human factors experts identified events with potentially adverse consequences, including events that spread contamination, delayed or disrupted the doffing process, or compromised PPE. These included behaviors such as reduced adherence to protocols (eg, abbreviated hand hygiene) and potential spread of contamination to the environment (eg, bumping into objects).19 We modified a list of “risky behaviors” based on the team’s
findings, and we included other actions where the failure of the physical environment to support a safe process (eg, communication failures) could compromise HCW safety. The ‘risky behaviors’ highlighted in this paper do not include challenges with the PPE itself, nor have we attempted to link them to incidences of actual contamination, as has been reported elsewhere.18–20 Characteristics of BCU layouts measured onsite and on architectural drawings included key environmental elements such as the size of the spaces, location of the TO and HCW during doffing, and distance to supplies and equipment from the doffing area, including the hand hygiene dispenser and trash bin. Addi- tionally, we noted the height of mounted equipment, hand hygiene dispensers, and the type and size of trash bins and sta- bilization aids for balance such as stools and hand grips. A preliminary analysis of the risky behaviors at each site and
their environmental contributors was presented to representative HCWs and BCU leadership of the individual sites. Feedback from these discussion sessions was combined with our observations from simulations to develop a framework focusing on how environmental conditions (layout and design) encourage certain behaviors (Figure 1). This framework identified insufficiencies in the environment that allowed observed behaviors potentially leading to self- and cross contamination. Finally, we defined requirements the built environment must achieve to support
Jennifer R. DuBose et al
more desirable, safe behaviors that improve HCW safety. We also developed a matrix proposing the design strategies that can be implemented to meet those requirements.
RESULTS
In all of the study settings, we observed the physical environment influencing risky behaviors by the HCW. We noted distinct design differences among the doffing spaces and equipment across all BCUs including the HCW’s relative location, the tools available for stabilization of balance, and accessibility of supplies (Table 1). Even within the same location, we observed variations in where the HCW stood and their relationship with the other critical elements, such as the trash bin and the hand sanitizer. During the simulations, HCWs reached, leaned, or even left the doffing zone after partially removing PPE to access supplies (eg, canisters of hand sanitizer) that were not in a standard location. Deviations from the standard location occurred both from being moved during the simulation and from being placed elsewhere prior to starting the doffing. The most notable and pervasive challenge was communication
between the HCW and TO. In sites C and D, where the HCW doffs inside the patient room and the TO stands behind a closed door, each reported difficulty hearing the other, and visual inspection was constrained by the limited size of windows or other obstructions. At site C, the TO frequently leaned over a counter to monitor the HCW through a side window because the door’swindowhad louvers. These communication challenges did not occur when the TO and HCW were in the same space, as in site A (Figure 2C) or in site B, where they were separated by a clear plastic curtain (Figure 2D). However, the HCW in site A turned their back on the TO during doffing when they used the hand grip. Another challenge observed during the simulations was maintaining balance. The HCWs were unsteady as they stood on 1 foot to remove their shoe covers (Figure 2F), resulting in a number of risky behaviors including HCWs crossing their legs or stumbling and losing balance, though no one fell or grasped objects other than those designated for stabilization. At site C, the HCW used an L-shaped step stool for stabilization and often crossed their legs while removing the shoe covers (Figure 2F), resulting in possible cross contamination. The step stool also wobbled during use; thus, the model used may not have provided sufficient stability. Of the 10 HCWs observed in site B where a chair was available, only 3 sat in the chair. A third challenge was access to and disposal of needed equ-
pipment and supplies. Often when these items were far apart, the HCW leaned over to reach them, which increased the risk of losing balance or touching a contaminated surface. During our simulations, we observed HCWs tossing their shoe covers or balled-up coveralls into a trash bin beyond their reach (a pre- viously reported phenomenon), at times missing the trash bin entirely.11,13 Occasionally, HCWs bumped into potentially con- taminated objects while doffing or touched items in the envir- onment, potentially spreading contamination. At site B, several HCWs touched the disposable plastic curtain during doffing due to limited space. In site A, where the TO was in the room with the HCW and assisted with preparing the doffing zone, the TO and HCW crossed paths multiple times because both used the same wall-mounted hand sanitizer. At 2 different sites (A and D), HCWs moved outside their doffing zone to use a hand sanitizer even though a closer one was available.
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