Infection Control & Hospital Epidemiology
well as patient and organizational outcomes (eg, safety cli- mate).35,36 Given the importance of teamwork in safe PPE doffing, organizations should emphasize relevant team skills during training. Beyond training, organizations can improve teamwork by incorporating prompts to encourage team skills such as closed-loop communication28 and mutual performance monitoring.28 2. A comprehensive competency assessment system for PPE
doffing is needed to reliably and accurately measure doffing team members’ competencies. Because competencies related to doffing, teamwork, and IP are
critical for safety, organizations need to ensure that doffing team members are competent in these areas. Assessment is needed to accurately evaluate performance of doffing team members, to determine the impact of training or other improvement initia- tives, to select team members correctly, and to provide structured feedback around key competency areas.37,38 3. The doffing team composition should include the HCW, TO,
and DA. Doffing PPE is complex, requiring assistance and vigilance
to recognize and mitigate the self-contamination risk. Although staffing all 3 roles can stress an organization’s resources, HCWs are at greater risk if the TO and DA are combined into a single role. The likelihood is higher that the person assisting the HCW might not notice a breach or contamination, contaminate themselves, or contaminate equipment if these roles are combined. Therefore, the CDC has amended their original guidance to recommend the TO and DA to be separate roles.39 In addition to ensuring this role structure, organizations
should have contingencies in place if a TO or DA becomes contaminated or experiences an equipment breach while helping an HCW doff. Neither role should proceed to help other HCWs if they experience a breach or are exposed to contamination; this requires a contingency plan for continued support of HCW PPE doffing.
Another concern relates to staffing and the anthropomorphic differences of individuals. Doffing is a physically rigorous task that demands flexibility, balance, and constant vigilance. HCWs endure extreme heat, long periods of standing during patient care, and then remove PPE, which requires patience, attention, and some unusual movements. Selecting personnel based on their physical attributes (eg, fitness, physical endurance) is common- place in other high-risk domains such as aviation and in the military.40 Given the severity of potential risks associated with anthropometric characteristics of HCWs, organizations should consider, if feasible, the physical and other attributes of team members and their capacity to fill each role without endangering themselves or others. 4. Improved PPE designs and doffing protocols are needed to
improve safety and provide additional guidance for intricate tasks. In this study, we identified several opportunities for protocol improvement to enhance safety. Glove removal, for example, was identified as a major source of potential contamination. Current guidelines instruct the HCW to remove the first outer glove, ball it into their other hand, remove the second outer glove over the first one, and then discard them both. The safety and simplicity of this step can be improved if the HCW discards the first outer glove into a waste receptacle before removing and discarding the second one. This subtle change simplifies the second glove removal and reduces the possibility of the first outer glove touching and contaminating other PPE components. More
185
detailed instructions for folding back the gown edges to provide the DA with an uncontaminated area to hold while helping the HCW can reduce the likelihood the DA or HCW becomes con- taminated during gown removal. More explicit guidance about how to manage and respond to specific types of breaches should be undertaken to minimize ambiguity for how team members should respond.4,5 5. The doffing area must be optimized for team members and equipment. Doffing areas that are too small result in the risk of team
members bumping into one another or equipment. Organizations need to evaluate the extent to which their dedicated doffing space affords team members room to move around safely. Furthermore, clean and contaminated areas of the doffing room should be delineated using visual cues. Zoning clean from potentially con- taminated areas reduces the likelihood that team members cross over between these areas, spreading contamination. 6. Guideline development should include human factors
analyses. Our findings also suggest the opportunity for integrating HF
methods into guideline development. Similar to the US Food and Drug Administration requirement to incorporate HF evaluation prior to the approval of medical devices, HF could be integrated into infection prevention guideline development by proactively assessing potential failure modes and testing the usability of newly developed guidance. This study has several limitations. First, focus groups were
conducted at a single institution and examined only 1 specific PPE combination (PAPR and gown). Although the steps of the doffing sequence differ in terms of prescribed guidance for each type of PPE combination, many of the steps and substeps are the same, suggesting the generalizability of our findings across combination types. Institutions should evaluate the efficacy and likely breakdowns unique to manufacturer instructions for use during the development, testing, and evaluation of their doffing protocol. Finally, the IP experts study participants have devel- oped, tested, and researched safe PPE doffing procedures but do not have direct experience caring for patients with Ebola.
Acknowledgments. We thank Dr Sallie J. Weaver for her contributions and feedback on the overall project. The views expressed in this manuscript are those of the authors and not necessarily those of the CDC, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, or Johns Hopkins University.
Financial support. This work was supported by funding from the CDC Prevention Epicenter Program.
Conflicts of interest. All of the authors report no conflict of interest related to the contents of this manuscript.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.292
References
1. 2014 Ebola outbreak inWest Africa—case counts. Center for Disease Control and Prevention website.
https://www.cdc.gov/vhf/ebola/outbreaks/2014-west- africa/
case-counts.html. Published 2016. Accessed October 25, 2018.
2. Health worker Ebola infections in Guinea, Liberia and Sierra Leone: a preliminary report. World Health Organization website. http://www.who. int/hrh/documents/21may2015_web_final.pdf. Published 2015. Accessed October 25, 2018.
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