Infection Control & Hospital Epidemiology
965
Fig. 2. Space layouts and common issues encountered during doffing of complex personal protective equipment (PPE) by healthcare workers (HCWs). (A) HCW creating a chemical mat by laying out 4 wipes on the floor. (B) Colored floor tiles for demarcation of the doffing zone. (C) HCW steps into disinfectant pan. (D) HCW doffing in an area separated by a clear plastic curtain. (E) HCW using chair. (F) Stool for stabilization while removing shoe covers.
levels of risk (ie, green, yellow or orange, and red).4 The Johns Hopkins BCU has effectively used this color-coding strategy with progressive limitations to enforce unidirectional flow.14
Demarcation of zones and labeled supplies Clear lines for the doffing zone reduce inappropriate crossing between clean and contaminated zones. Labeling supplies with color coding andmarking can be a useful strategy.13 Once the HCWstarts the doffing process, they are generally required to stay in the doffing area, and any critical equipment, including hand sanitizer, wipes, and trash bins should be within easy reach. Fixing the location of items, color-coding equipment, limiting the number of options, and using dedicated equipment are all recognized as effective strategies to avoid HCWs inadvertently moving back into hot zones after they begin doffing. Even though sites A and C have colored floor tiles to demarcate the doffing zone (Figure 2B), HCWs had great latitude in deciding where to stand within this area during doffing.
Protocol checklist with the procedure Trained observers emphasized their role in reading the steps aloud and that the protocol should be placed where the TO could see it while simultaneously observing the HCW.13 Both TO and HCW need to be aware of where in the process they are and which step comes next. Although posters are helpful memory aids, adding a checklist forHCWsmay not reduce doffing sequence errors.7 Graphic checklists should be designed to visually communicate proper tech- nique while minimizing opportunity for misinterpretation.
Provide Stabilization for the HCW During PPE Doffing
Loss of stability was most commonly associated with removing shoe covers.12 Removing shoe covers while standing on one foot is often challenging and can lead to potential errors such as grabbing contaminated surfaces,12 but even HCWs sitting in a chair reported discomfort.24 Possible options to minimize fall risk and improve stability include step stools, stools, hand grips, and chairs. Chairs present a challenge for cleaning due to a larger surface area, and sitting also presents more opportunities for self- contamination.11 Although we rarely observed HCWs using chairs while doffing shoe covers, they reported a preference for having a chair available because of anticipated fatigue; this has also been noted in the literature.17 The placement of hand grips should be well thought out to
ensure appropriate use and to prevent risky behavior. In one setting, the location of the hand grip resulted in a HCW stepping out of the doffing zone to remove their left shoe cover.17 Addi- tionally, the placement of the hand grip should enable continuous eye contact between the HCW and the TO.
Nudge the Safest Choices
The environment itself can be configured in a way that makes certain behaviors easier, thereby ‘nudging’ people toward that behavior.25 Behavior nudge tactics can be used to improve and automate safe behavior while reducing cognitive burden for HCWs. The doffing space should be compact enough to present the HCW with all the needed items within easy reach, while not restricting movement or causing the HCW to bump into
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