Infection Control & Hospital Epidemiology


963


Fig. 1. A framework using ‘risky behaviors’ observed during simulations to identify environmental strategies to support safe doffing of Ebola-level personal protective equipment.


Finally, some risky behaviors were the result of incompatibility


between the physical environment and the adopted protocol. Some HCWs tried to read the instructions from the wall-mounted poster instead of listening to the TO’s instructions, which resulted in desynchronization of the HCW and TO during doffing. Similarly, at site D, the HCW was responsible for establishing a chemical mat by laying out 4–6 wipes on the floor (Figure 2A). Without guidance, the HCW occasionally created the mat too far from the hand sanitizer or trash bin to be easily reached.


DISCUSSION


From a review of published literature on the risk of self- contamination while doffing PPE, observation of the simulations, feedback from study participants at all 4 sites, and analysis of the layouts of the Ebola treatment centers, we identified 5 require- ments the doffing area should accomplish to increase process safety (Figure 3), as detailed below.


Facilitate Communication Between HCWs and TOs


Communication challenges were associated with failure to clean some items and with either omitting steps or performing steps out of order. Because doffing requires precise attention to detail and occurs when the HCW is potentially fatigued and stressed, a TO supervises and reads out the steps of the doffing proce- dure.21 The TO and doffing HCW need (1) to be able to see


each other, (2) to be able to obtain each other’s attention easily, and (3) to be able to communicate complex instructions while the HCW is wearing complex PPE that usually includes a powered air purifying respirator (PAPR), which can limit both hearing and vision. The TO must also be able to see the HCW from head to toe to visualize any breaches in PPE or potential contamination. Good communication can be facilitated by spatial designs that


increase visual and auditory connections between the TO and HCW. The design of the physical space, such as the location and size of windows and doors, influences the ability of HCWs to communicate with TOs.13 Communication is easier if the TO and HCW are in the same space; collocation can also make it easier for the TO to see the HCW from head to toe. Good visibility between the TO and the HCW can be achieved even if the 2 are stationed in separate rooms through the thoughtful placement of the doffing area and positioning of the TO. Windows, without obstructions, need to be adequately sized, and the doffing area must be sufficiently distant from the window so that the TO can see the HCW’s feet. Other communication improvement strategies include the use of


headsets or intercoms. Headsets can be used inside the PPE to help overcome noise generated by the PAPR.13 Alternatively, audio speakers in the patient room can amplify the voice of the TO, but this approach may be disruptive to patients.22 Study participants stated that they used white boards to communicate messages during patient care and doffing, but this was not observed during


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