182


0. Doff PAPR + Gown


Ayse P. Gurses et al


Plan 0: do 1 through 19 in order in accordance with trained observer instructions


1. Prepare to Doff


2. Engage trained observer


3. Disinfect outer gloves


Plan 4: Is apron used?


4. Remove outer apron


Yes No


5. Disinfect outer gloves


6. Remove outer boots


7. Disinfect outer gloves


8. Remove outer gloves


9. Inspect inner gloves


10. Remove PAPR


11. Remove hood


12. Remove gown


13. Disinfect inner gloves


14. Disinfect shoes


15. Disinfect inner gloves


16. Remove inner gloves


17. Perform hand hygiene


18. Inspect body for


contamination


19. Exit doffing area


Fig. 1. Overview of enhanced PPE doffing process depicting the 19 main steps based on hierarchical task analysis.


breaches and contamination are more likely and more difficult to detect if the PPE size is too big or too small for a particular user. The risk of PAPR hood contamination is higher if hoods are long, and aprons are of higher risk if their removal requires the HCW to lift it over their head rather than to tear it away. Organizational contributing factors include culture (eg, dis-


comfort speaking up), availability of various training opportu- nities in the organization needed to enhance skills, and organizational commitment and efforts for readiness (eg, having updated and user-friendly protocols and adequate resources). Most environmental contributing factors concern the size and configuration of the doffing area. Small doffing areas that cannot easily accommodate 3 people with comfortable space between them and room for trash make it more likely for team members to bump into equipment or each other, potentially causing con- tamination. Visual cues are important to help team members identify clean versus contaminated areas of the doffing room. Finally, the PPE doffing task itself, and the characteristics of


tasks performed before doffing, contribute to failure modes. For example, more PPE contamination likely occurs following care of a patient with active diarrhea. Also, combative or anxious patients may pose a greater risk of PPE contamination. Furthermore, a small breach or PPE contamination may not be visible.


Risk mitigation strategies


We identified 86 risk mitigation strategies; Table 4 provides example strategies and Appendix 3 includes the complete list. Training and education were the primary considerations for mitigating risk. The 4 primary areas for doffing training include the correct use of tools and technology (eg, PPE, communication technologies), teamwork skills (eg, closed-loop communica- tion),28 IP topics (eg, gross decontamination strategies), and resiliency skills (eg, recovery from errors or task perturbations).


Further, participants emphasized the importance of matching the physical characteristics of the training environment to the actual doffing environment and incorporating elements such as time pressure, stress, and patient activities to elicit similar cognitive, behavioral, and attitudinal reactions from the doffing team as they might experience in actual situations. A main organizational risk-mitigation strategy focuses on


reducing guideline and protocol ambiguity. This aspect includes provision of explicit guidance for managing breaches and/or contamination, and systematically evaluating, and validating protocols and instructional materials prior to implementation. Participants suggested that the development, testing, and eva- luation of institutional protocols should involve a transdisci- plinary team of infection preventionists, HF experts, clinicians, laboratory technicians, and other relevant personnel. With respect to tools and technology, a recurring theme was to


employ visual cues, such as PPE elements with distinct colors, to help differentiate between the inside (clean) and outside (con- taminated). Additionally, participants identified that aprons should tear away easily, allowing the HCW to pull it off them- selves and reducing unnecessary risk associated with another team member helping with removal. Participants also suggested securing gloves to the gown to prevent the cuff from slipping and possibly exposing the HCW to contamination. Another identified strategy was to include technology that provides a bidirectional communication channels amongst the doffing team members and personnel outside the doffing room. Environmental strategies centered on room configuration optimization with respect to both the room size and the relative positions of equipment and people. Participants noted the importance of (1) visual zoning to clearly demarcate clean versus contaminated areas and (2) equipping the room with mirrors to help HCW complete visual inspection to identify and address gross contamination prior to leaving the patient room.


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