'VIOLET': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment

High-consequence infectious diseases: the conception and development of a multi-disciplinary, interprofessional simulation training programme

BACKGROUND

High-consequence infectious diseases (HCIDs) represent a group of acute infectious diseases with the potential to impact healthcare systems and public health profoundly. Effective management requires a system-based strategy focused on early detection, initiation of infection prevention and control measures, and appropriate use of personal protective equipment (PPE). Inadequate training in the safe use of HCID PPE, and lack of familiarity with key processes such as HCID waste and spills management, exacerbates the risk posed to healthcare workers (HCWs). Enhanced training opportunities are required to ensure that staff are equipped with the necessary knowledge and capabilities to protect themselves from pathogen exposure and infection.

AIM

To create a bespoke interprofessional HCID simulation training programme.

METHODS

A detailed learning needs analysis was undertaken, which identified multiple areas amenable to educational intervention. A full-day HCID simulation programme was developed, providing HCWs the opportunity to practice and gain proficiency in various domains.

FINDINGS

Six interprofessional participants took part in the HCID simulation programme pilot. All six (100%) participants felt that the stated learning objectives had been achieved, and five and one participants found the programme to be extremely useful (83%) or very useful (17%), respectively. Following refinement based on pilot feedback, a further six courses have been run for 38 participants, of whom 97% found the programme to be extremely useful or very useful.

CONCLUSION

The development of a training intervention in the low-frequency, high-risk field of HCIDs had a positive impact. Given the disproportionate impact on HCWs at times of HCID outbreaks, more investment is needed to keep the workforce upskilled.

Personal protection equipment: Preliminary evidence of effectiveness from a three-phase simulation program

Background

Healthcare providers carry the occupational risk of being exposed to pathogens. Personal Protection Equipment (PPE) requires proficiency whenever used. Yet, evidence shows significant errors and variation in competency when applying PPE.

Objective

In this study, we developed a three-phase intervention to promote PPE proficiency.

Methods

Education and assessment of participants' PPE knowledge and skills occurred at a large academic university in Western Canada. Participants first completed an online module; second, they experienced one-on-one coaching and deliberate practice with infection control professionals; and third, participants managed a COVID-19 clinical simulation scenario. The measured outcomes include a 15-item pre- and post-knowledge test and a pre- and post-skills assessment of donning and doffing behaviors. These behaviors were observed from video recordings and were assessed using two standardized checklists.

Results

Knowledge and donning/doffing post-test scores (11.73, 0.95, and 0.96, respectively) were significantly higher after completing all three phases of the educational intervention, p < .001.

Conclusions

An online module alone is insufficient for PPE knowledge and skill development. Rather, a module followed by practice and simulation allows learners to gain proficiency.

A methodology for using Lambda phages as a proxy for pathogen transmission in hospitals

BACKGROUND

One major concern in hospitalized patients is acquiring infections from pathogens borne on surfaces, patients, and healthcare workers (HCWs). Fundamental to controlling healthcare-associated infections is identifying the sources of pathogens, monitoring the processes responsible for their transmission, and evaluating the efficacy of the procedures employed for restricting their transmission.

AIM

To present a method using the bacteriophage Lambda (λ) to achieve these ends.

METHODS

Defined densities of multiple genetically marked λ phages were inoculated at known hotspots for contamination on high-fidelity mannequins. HCWs then entered a pre-sanitized simulated hospital room and performed a series of patient care tasks on the mannequins. Sampling occurred on the scrubs and hands of the HCWs, as well as previously defined high-touch surfaces in hospital rooms. Following sampling, the rooms were decontaminated using procedures demonstrated to be effective. Following the conclusion of the simulation, the samples were tested for the presence, identity, and densities of these λ phages.

FINDINGS

The data generated enabled the determination of the sources and magnitude of contamination caused by the breakdown of established infection prevention practices by HCWs. This technique enabled the standardized tracking of multiple contaminants during a single episode of patient care. Unlike other biological surrogates, λ phages are susceptible to common hospital disinfectants, and allow for a more accurate evaluation of pathogen transmission.

CONCLUSION

Whereas our application of these methods focused on healthcare-associated infections and the role of HCW behaviours in their spread, these methods could be employed for identifying the sources and sites of microbial contamination in other settings.

Validation of personal protective equipment ensembles, incorporating powered air-purifying respirators protected from contamination, for the care of patients with high-consequence infectious diseases

BACKGROUND

The UK High-Consequence Infectious Diseases (HCID) Network of high-level isolation units provides care for patients with contact- or airborne-transmissible highly infectious and highly dangerous diseases. In most HCID units, the healthcare workers (HCWs) wear personal protective equipment (PPE) ensembles incorporating a powered air-purifying respirator (PAPR) for head and respiratory protection. Some PAPRs have components worn outside/over other PPE, necessitating decontamination of re-usable elements. Two alternative PAPRs, with all re-usable elements worn under PPE, were trialled in this study.

AIM

To undertake scenario-based testing of PAPRs and PPE to determine usability, comfort and ability to remove contaminated PPE without personal cross-contamination.

METHODS

Trained healthcare volunteers (N=20) wearing PAPR/PPE ensembles were sprayed with ultraviolet fluorescent markers. They undertook exercises to mimic patient care, and subsequently, after doffing the contaminated PPE following an established protocol, any personal cross-contamination was visualized under ultraviolet light. Participants also completed a questionnaire to gauge how comfortable they found the PPE.

FINDINGS AND CONCLUSIONS

The ensembles were tested under extreme 'worst case scenario' conditions, augmented by physical and manual dexterity tests. Participating volunteers considered the exercise to be beneficial in terms of training and PPE evaluation. Data obtained, including feedback from questionnaires and doffing buddy observations, supported evidence-based decisions on the PAPR/PPE ensemble to be adopted by the HCID Network. One cross-contamination event was recorded in the ensemble chosen; this could be attributed to doffing error, and could therefore be eliminated with further practice.

Rethinking risk communication in the hospital: infection prevention, risk perceptions, and lived experience

BACKGROUND

We conceptualize infection prevention and control (IPAC) as a form of risk communication in the hospital and examine how doctors and nurses interpret and adopt IPAC measures in the wards.

METHODS

We conducted a 20-week ethnography in a Canadian hospital in which we observed doctors' and nurses' routines, infection prevention practices, and barriers they encountered when following IPAC guidelines. After the observation period, we conducted interviews with doctors and nurses to gauge their perceptions of risk and how they make IPAC decisions while working in the wards.

RESULTS

Doctors and nurses perceive the hospital as a site of risk, and expressed this anxiety in disinfection routines and cleansing rituals. This risk prevention behaviour is mediated by situational and lived experience, and not expressed consistently. Doctors and nurses negotiate IPAC protocols with individual perceptions of risk, material limitations, and more pressing needs.

CONCLUSION

IPAC behaviour could be reinforced by improving risk communication in the hospital, first, by involving workers as stakeholders in managing the risk of infection, and second, by acknowledging various forms of risk knowledge, including embodied and situated experience, as well as material constraints. We recommend developing participatory models of risk communication that engage stakeholders in long-term dialogue, considering their risk perceptions, risk tolerance, and challenges to comply with guidelines; communicating IPAC measures as a way to protect patients and emphasizing personal risk for hospital workers; and conducting regular in-person training sessions to ensure that any concerns can be voiced.

How Can Personal Protective Equipment Be Best Used and Reused: A Closer Look at Donning and Doffing Procedures

OBJECTIVE

The aim of this study was to examine safety-related contamination threats and risks to health-care workers (HCWs) due to the reuse of personal protective equipment (PPE) among emergency department (ED) personnel.

METHODS

We used a Participatory Design (PD) approach to conduct task analysis (TA) of PPE use and reuse. TA identified the steps, risks, and protective behaviors involved in PPE reuse. We used the Centers for Disease Control and Prevention (CDC) guidance for PPE donning and doffing specifying the recommended task order. Then, we convened subject matter experts (SMEs) with relevant backgrounds in Patient Safety, Human Factors and Emergency Medicine to iteratively identify and map the tasks, risks, and protective behaviors involved in the PPE use and reuse.

RESULTS

Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE ties and materials.

CONCLUSIONS

TA was helpful revealed that the procedure for donning and doffing of re-used PPE does not protect ED personnel from contaminant spread and risk of exposure, even with protective behaviors present (e.g., hand hygiene, respirator use, etc.). Future work should make more apparent the underlying risks associated with PPE use and reuse.

Assessing Patterns of Body Contamination after Personal Protective Equipment Removal among Healthcare Workers: A Scoping Review

BACKGROUND

It is now widely recognized that healthcare personnel (HCP) are at risk of contamination with pathogens during personal protective equipment (PPE) doffing. Studies of this phenonemona, have utilized a variety of PPE ensembles, doffing methods and experimental methods.

METHODS

A scoping review was performed, consistent with PRISMA guidance. The PubMed and sciVerse Scopus databases were searched using an a priori search strategy. Data were extracted for analysis using the matrix method, and then a narrative analysis performed. Articles were classified based on PPE ensemble.

RESULTS

Only 19 of 151 articles were included in the final anlaysis. All included studies reported some post-doffing contamination, and this contamination was most frequently observed on the hands, wrist, face and neck. Reviewed studies used a variety of tracer contaminants, PPE ensembles, doffing protocols, tracer assessment locations and methods, making it difficult to identify patterns across studies.

DISCUSSION&CONCLUISONS

Additional research is needed to improve study methodology related to the selection and placement of tracers to ensure sensitive detection of post-doffing contamination, compare how specific doffing procedures or pieces of PPE influence post-doffing contamination, and to understand what post-doffing contamination means for patient and HCP infection risk.

Development and Simulation of Cyberdisaster Situation Awareness Models

Cyberdisasters require an organization’s disaster team to be prepared. Disaster events are difficult to predict, but the impact of this risk on an organization is large. However, organizations sometimes struggle in being prepared for disaster situations. Here, awareness of disaster situations when analysing priority disasters (e.g., earthquakes and pandemics) and how to mitigate them can help an organization’s preparedness. Mitigation scenarios need to be determined and simulated so that a disaster team is ready to face disaster. Using Endsley’s situational awareness model and a tabletop exercise, this study aimed to help a disaster team determine cyberdisaster risk priority and assess a team’s preparedness for dealing with a cyberdisaster. The situation awareness model was divided into two stages: awareness of cyberdisaster situations and tabletop evaluations. Awareness of a disaster situation was carried out by determining the highest priority for disaster risk using the fuzzy failure modes and effects analysis (FMEA) method. The results of the first study show that the high-risk category contains ransomware attacks during pandemics and earthquakes. The second study performed a tabletop simulation questionnaire survey of earthquakes and ransomware attacks during a pandemic for several disaster teams with 152 respondents. The results of the survey evaluation of the earthquakes and ransomware attacks simulation survey show that the effect factors of cyberdisaster simulation decisions are 95% system capability (p < 0.05), 90% knowledge (p < 0.05), and 90% awareness of a disaster situation (p < 0.05); these factors show the effect of a disaster team’s decision during a tabletop simulation. The novelty of this research lies in building a model for how an organizational process determines the priority of a cyberdisaster tabletop simulation and the factors that contribute to increasing a disaster team’s awareness in dealing with cyberattacks.

Personal protective equipment training for non-healthcare workers in the Covid-19 pandemic: Effectiveness of an evidence-based skills training framework

Background

Large-scale quarantine facilities staffed with non-healthcare workers (NHCW) were instrumental in preventing community spread of COVID-19 (coronavirus disease of 2019). The objective of this study was to determine the effectiveness of a newly developed procedural skills training framework in ensuring personal protective equipment (PPE) compliance of PPE-naïve NHCWs.

Methods

We developed a PPE procedural skills training framework for NHCWs using the Learn, See, Practice, Prove, Do, and Maintain (LSPPDM) framework and international guidelines on PPE for healthcare workers. The NHCWs underwent PPE training using this framework, conducted by a team of Infection Prevention nurses, prior to being stationed within the CCF. Effectiveness of the LSPPDM PPE training framework was assessed using: 1) competency assessment scores for NHCWs, 2) PPE compliance rates from daily audit findings, and, 3) healthcare-associated COVID-19 infection rates of NHCWs.

Results

A total of 883 NHCWs had completed the PPE training and demonstrated competency in PPE compliance, fulfilling 100% of the checklist requirements. Mean PPE compliance of all NHCWs during the 11-week study period was noted to be >96%. The post-implementation improvement was statistically significant when the compliance was expressed in 3-days blocks) and in bed management staff (P = < 0.05). None of the 883 NHCWs who underwent PPE training via the LSPPDM framework were diagnosed with healthcare-associated COVID-19 infection.

Conclusion

An evidence-based skills training framework is effective in PPE training of large numbers of NHCWs, resulting in high compliance of appropriate PPE use and prevention of healthcare-associated COVID-19 infection.

Self-contamination following removal of two personal protective equipment suits: a randomized, controlled, crossover simulation trial

BACKGROUND

Healthcare personnel are often at high risk of contamination when participating in airway management and other aerosol-generating procedures.

AIM

To explore the differences in self-contamination after removal of gown and coverall personal protective equipment (PPE) using an ultraviolet-fluorescent solution.

METHODS

This prospective, randomized, controlled crossover trial was set in a third-level university health centre in Buenos Aires, Argentina between August and October 2020. The study included 60 anaesthesia personnel volunteers, and no participants were excluded from the study. A two-period/two-intervention design was chosen; each intervention comprised audio-guided placement of PPE, full-body spraying of fluorescent solution, audio-guided removal of PPE, and self-contamination assessment through ultraviolet light scanning. The primary outcome was the mean within-participant difference (any traces) between PPE suits. Statistical significance was tested using t-tests for paired data. The allocation ratio was 25/35 (gown followed by coverall/coverall followed by gown).

FINDINGS

Self-contamination after removal of coveralls was greater than that after removal of gowns, with a mean within-participant difference of 11.45 traces (95% confidence interval 8.26-14.635; P<0.001). Significant differences were found for the number of self-contaminated body zones, small fluorescent traces and large fluorescent traces. Removal of a gown was associated with a markedly lower risk of self-contamination.

CONCLUSIONS

Quick one-step removal of a gown and gloves may reduce self-contamination in the arm/hand area. Fluorescent solutions can help to identify self-contamination and compare outcomes between available PPE suits. Repeated training sessions and enhanced knowledge on self-contamination following removal of PPE are paramount.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04763304 (on ClinicalTrials.gov).

What Not to Do with PPE: A Digital Application to Raise Awareness of Proper PPE Protocol

With a rise in personal protective equipment (PPE) use by all healthcare professionals (HCP) as a prime infection control strategy in the wake of the COVID-19 pandemic comes the potential increase in its misuse. Evidence suggests this failure to follow proper PPE protocol to prevent self-contamination and transmission can be attributed to both a lack of formal training and guidance and, now, atrophy of infrequently used skills, with many senior professionals demonstrating a lack of proficiency despite years of service. Previous research shows current written and illustrated instructional material depicting PPE guidelines are abundant but does not provide an answer on how best to target violations in protocol and better instruct those that are providing pre-hospital emergency healthcare.In this chapter, we aim to address the gap in paramedic-specific research into PPE protocol and provide an educational, digital tool to work alongside the current guidelines, potentially exploring the cognitive load theory as a design strategy. The use of 3D, interactive animations depicting errors in protocol and their potential contamination consequences in a device-based application could engage clinicians in a more effective way, thus increasing protection and decreasing transmission. This chapter describes the methodology behind the design and development of such an application for emergency care providers and provides the relevant materials needed to carry out user testing and evaluation once participants have been recruited.

Infection Prevention Performance among In-Flight Cabin Crew in South Korea

COVID-19 was declared a worldwide pandemic in 2020; thus, preventing in-flight infection transmission is important for stopping global spread via air travel. Infection prevention (IP) performance among aircraft cabin crew is crucial for preventing in-flight transmission. We aimed to identify the level of IP performance and factors affecting IP performance among aircraft cabin crew during the COVID-19 pandemic in South Korea. An online survey was conducted with 177 cabin crew members between August and September 2020. The survey assessed IP performance, and IP awareness, using a five-point Likert scale, and also evaluated simulation-based personal protective equipment (PPE) training experience, and organizational culture. The average IP performance score was 4.56 ± 0.44. Although the performance level for mask-wearing was high (4.73 ± 0.35), hand hygiene (HH) performance (4.47 ± 0.56) was low. Multivariate analysis showed that IP performance was significantly associated with IP awareness (p < 0.05) and simulation-based PPE training experience (p < 0.05). Since HH performance was relatively low, cabin crew and airlines should make efforts to improve HH performance. Furthermore, a high level of IP awareness and PPE training experience can improve IP performance among cabin crew members. Therefore, simulation-based PPE training and strategies to improve IP awareness are essential for preventing in-flight infection transmission.

The Error-Prone Operational Steps and Key Sites of Self-Contamination During Donning and Doffing of Personal Protective Equipment by Health Care Workers

OBJECTIVE

This study aims to identify error-prone operational steps and key sites of self-contamination during donning and doffing of personal protective equipment (PPE).

METHODS

A total of 56 health care workers, including 37 nurses and 19 physicians, were recruited to don and doff the PPE recommended by the Chinese Center for Disease Control and Prevention. Operational errors and sites of self-contamination were recorded using UV-fluorescent labeling and video surveillance.

RESULTS

Three main errors during donning were identified: choosing a loose-fitting coverall that was difficult to handle; ignoring to inspect the seal of N95 respirator or gloves; and forgetting to pull up the zipper completely. Four main errors during doffing were identified: removing the N95 respirator in a wrong way; touching the scrubs with contaminated hands and elbows; touching contaminated external surfaces of the goggles; and performing insufficient hand hygiene. Key sites that were easily contaminated during the doffing of PPE included left hand and wrist, left lower leg, chest, and left abdomen.

CONCLUSION

Identifying the steps prone to errors and key sites of self-contamination in the process of PPE donning and doffing can facilitate the training of PPE use and provide detailed evidence for optimizing standardized protocols to reduce contamination.

Knowledge of COVID-19 and its implications in dental treatment, and practices of personal protective equipment among dentists: A survey-based assessment

BACKGROUND

Oral health-care providers are always at a risk of transmitting or acquiring airborne, saliva-borne, or blood-borne infections due to their proximity to the patient's mouth, contact with saliva, and handling of sharp instruments. the aim this study was to evaluate the knowledge of the dentists regarding COVID-19, methods to prevent its transmission, and implications of COVID-19 in dental treatment.

MATERIALS AND METHODS

It was a cross-sectional online survey. There were 35 questions in total, divided into sections of knowledge of COVID-19, practices of personal protective equipment (PPE), and knowledge of implications of COVID-19 in dental treatment. Both convenience sampling and snowball sampling were used, so that maximal participation could be ensured. The results were analyzed using descriptive statistics and making comparisons among various groups. The data were summarized as proportions and percentages (%). All the associations were tested using the Chi-square test, ANOVA, and Pearson's correlation coefficient. Statistical analyses were performed using SPSS version 19.0.

RESULTS

26.8% of respondents had a high knowledge, 61.5% had good knowledge, 10.1% had low knowledge, and 6 (1.5%) had nil knowledge about COVID-19. No significant association was found between qualification and knowledge level among the respondents (P = 0.053). Both graduates and postgraduates had low knowledge regarding effective PPE components (P = 0.053), donning (P = 0.888), and doffing (P = 0.745). Only 52.9% of postgraduates and 43.7% graduates answered correctly about the sequence of donning, and 47.9% of postgraduates and 46.1% of graduates had knowledge regarding correct doffing sequence of PPE. Furthermore, knowledge was low regarding the implications of COVID-19 in dental treatment.

CONCLUSION

Although the dentists were found to have high/good knowledge scores regarding COVID-19, there was a lack of knowledge regarding hand hygiene, proper use of PPE, and implications of COVID-19 in dental treatment. Thus, they need to be trained and sensitized regarding the same.

Personal protective equipment (PPE) and infection among healthcare workers - What is the evidence?

BACKGROUND

The worldwide outbreak of coronavirus disease-19 (COVID-19) has already put healthcare workers (HCWs) at a high risk of infection. The question of how to give HCWs the best protection against infection is a priority.

METHODS

We searched systematic reviews and original studies in Medline (via Ovid) and Chinese Wan Fang digital database from inception to May, 2020, using terms 'coronavirus', 'health personnel', and 'personal protective equipment' to find evidence about the use of full-body PPEs and other PPEs by HCW exposed highly infectious diseases.

RESULTS

Covering more of the body could provide better protection for HCWs. Of importance, it is not just the provision of PPE but the skills in donning and doffing of PPE that are important, this being a key time for potential transmission of pathogen to the HCW and in due time from them to others. In relation to face masks, the evidence indicates that a higher-level specification of face masks and respirators (such as N95) seems to be essential to protect HCWs from coronavirus infection. In community setting, the use of masks in the case of well individuals could be beneficial. Evidence specifically around PPE and protection from the COVID-19 virus is limited.

CONCLUSION

Covering more of the body, and a higher-level specification of masks and respirators could provide better protection for HCWs. Community mask usecould be beneficial. High quality studies still need to examine the protection of PPE against COVID-19.

A Cross-Sectional Study on Knowledge, Attitude, and Practices of Donning and Doffing of Personal Protective Equipment: An Institutional Survey of Health-Care Staff during the COVID-19 Pandemic

Background:

Personal protective equipment (PPE) is used to protect the health-care professional from bacterial, viral, or other hazards during this COVID-19 pandemic, and they should be made aware of proper usage of this equipment.

Aims:

The aim was to evaluate how adequate knowledge, attitude, and practices (KAP) of health-care worker toward the appropriate use of PPE, which can prevent them and the community from virus contamination.

Methodology:

This study was conducted in a tertiary care hospital during the COVID-19 pandemic in a span of approximately 50 days. This cross-sectional questionnaire-based survey was done in 155 health-care providers posted in the COVID-19 area.

Statistical Analysis:

Data were described in terms of range; mean ± standard deviation, frequencies (number of cases) and relative frequencies (percentages) as appropriate.

Results:

Health-care workers (HCWs) were aware of the importance and criticality of donning and doffing procedure, but they lack the knowledge about dispersion of virus as 62% responded that virus dispersion occurs more during donning than doffing. Gaps were found in attitude as 51% of HCWs found it inconvenient to don PPE that they sometimes think of compromising their own safety. Nearly 33.5% of HCWs move out of the doffing area without removing gloves and N-95, which needs serious correction in their practice.

Conclusion:

There were major gaps in KAP at institutional level among the health-care providers with regard to donning and doffing of PPE during the beginning of this pandemic.

Behavioral strategies for reducing disease transmission in the workplace

The coronavirus pandemic highlighted that workplaces may serve as a hub of disease transmission if proper precautions are not enacted. The Centers for Disease Control recommends several strategies for decreasing the spread of illnesses in the workplace, including a) promoting proper hand hygiene, b) cleaning and sanitizing the work area, c) encouraging sick employees to stay home, d) personal protective equipment, and, e) social distancing. Research suggests that instructions are often not sufficient to change work behaviors, and behavioral interventions may be needed. Thus, the present paper reviews existing research that informs the implementation of behavioral strategies to reduce the spread of disease in the workplace, and makes recommendations for organizations to protect employees, clients, and customers. Intervention components such as training, prompts, the reduction of response effort, clear workplace policies, feedback, and consequences are discussed, and practical recommendations and suggestions for future research are provided.

How to rapidly design and operationalise PPE donning and doffing areas for a COVID-19 care facility: quality improvement initiative

Introduction

Effective implementation of standard precautions specific to COVID-19 is a challenge for hospitals within the existing constraints of time and resources.

Aim

To rapidly design and operationalise personal protective equipment (PPE) donning and doffing areas required for a COVID-19 care facility.

Methods

Literature review was done to identify all issues pertaining to donning and doffing in terms of Donabedian’s structure, process and outcome. Training on donning and doffing was given to hospital staff. Donning and doffing mock drills were held. 5S was used as a tool to set up donning and doffing areas. Instances of donning and doffing were observed for protocol deviations and errors. Plan–do–study–act cycles were conducted every alternate day for 4 weeks. The initiative was reported using Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Results

Best practices in donning and doffing were described. Our study recommends a minimum area of 16 m² each for donning and doffing rooms. Verbally assisted doffing was found most useful than visual prompts.

Discussion

Challenges included sustaining the structure and process of donning and doffing, varied supplies of PPE which altered sequencing of donning and/or doffing, and training non-healthcare workers such as plumbers, electricians and drivers who were required during emergencies in the facility.

Conclusion

Our study used evidence-based literature and quality improvement (QI) tools to design and operationalise donning and doffing areas with focus on people, task and environment. Our QI will enable healthcare facilities to rapidly prototype donning and doffing areas in a systematic way.

Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey

Background

Using personal protective equipment (PPE) is one of several fundamental measures to prevent the transmission of infection and infectious diseases and is particularly pertinent in the current COVID-19 pandemic. Appropriate use of PPE by healthcare workers is, however, often suboptimal. Training and monitoring of PPE competency are essential components of an infection prevention and control program but there is a paucity of research and data on the content of such training programs across Australasia. This paper reports the results of a survey that characterised the nature of PPE training in Australian and New Zealand hospitals.

Methods

A population-based online survey was distributed to members of three major Australasian colleges representing infection prevention and control.

Results

Results indicate that, although training is frequently provided at orientation, many healthcare workers do not receive regular updates. Training programmes combine online and classroom sessions, but over a third do not include a practical component. The frequency of monitoring PPE competency is variable with one third of respondents indicating that no auditing occurs. PPE items used for high-level training are variable, with use of powered air purifying respirators (PAPRs) uncommon.

Conclusion

The results of this study suggest that HCWs’ confidence, competence and familiarity with PPE are a concern, which in the context of the current global COVID-19 pandemic is problematic. More research is needed into how PPE training programs could be better designed, to prepare HCWs for practice using PPE safely and confidently.

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Most HCW orientation programmes include PPE training but fewer than half are updated annually.

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One third of PPE programmes do not include a practical component.

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Only two thirds of PPE training programmes monitor PPE compliance.

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Future research should consider the design of PPE training programs to optimise HCW PPE practice.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015

During the 2014-2015 Ebola Virus Disease (EVD) outbreak, hospitals in the United States selected personal protective equipment (PPE) and trained healthcare personnel (HCP) in anticipation of receiving EVD patients. To improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected PPE selection and training in the context of the EVD outbreak. Semistructured interviews were conducted with HCP involved with decision-making during EVD preparations at acute care hospitals in the Chicago, IL area to gather information about the PPE selection and training process. HCP who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. A total of 28 HCP from 15 hospitals were interviewed, and 55 HCP completed the survey. Factors affecting PPE selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for HCP. Cost did not affect selection. PPE acquisition challenges were mitigated by: sharing within hospital networks, reusing PPE during training, and improvising with existing PPE stock. Selected PPE ensembles were similar across sites. Training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase HCP confidence. Many felt refresher training would be helpful. Hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. Lacking confidence in the CDC guidance, interviewed trainers described turning to other sources of information and developing independent PPE evaluation and selection. Response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for PPE selection and training that addresses protection level, ease of use, ensembles, and availability.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.

OBJECTIVES

To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.

AUTHORS' CONCLUSIONS

We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

Environmental and Personal Protective Equipment Contamination during Simulated Healthcare Activities

Providing care to patients with an infectious disease can result in the exposure of healthcare workers (HCWs) to pathogen-containing bodily fluids. We performed a series of experiments to characterize the magnitude of environmental contamination—in air, on surfaces and on participants—associated with seven common healthcare activities. The seven activities studied were bathing, central venous access, intravenous access, intubation, physical examination, suctioning and vital signs assessment. HCWs with experience in one or more activities were recruited to participate and performed one to two activities in the laboratory using task trainers that contained or were contaminated with fluorescein-containing simulated bodily fluid. Fluorescein was quantitatively measured in the air and on seven environmental surfaces. Fluorescein was quantitatively and qualitatively measured on the personal protective equipment (PPE) worn by participants. A total of 39 participants performed 74 experiments, involving 10–12 experimental trials for each healthcare activity. Healthcare activities resulted in diverse patterns and levels of contamination in the environment and on PPE that are consistent with the nature of the activity. Glove and gown contamination were ubiquitous, affirming the value of wearing these pieces of PPE to protect HCW’s clothing and skin. Though intubation and suctioning are considered aerosol-generating procedures, fluorescein was detected less frequently in air and at lower levels on face shields and facemasks than other activities, which suggests that the definition of aerosol-generating procedure may need to be revised. Face shields may protect the face and facemask from splashes and sprays of bodily fluids and should be used for more healthcare activities.

Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission

Background

Healthcare workers (HCWs) use personal protective equipment (PPE) in Ebola virus disease (EVD) situations. However, preventing the contamination of HCWs and the environment during PPE removal crucially requires improved strategies. This study aimed to compare the efficacy of three PPE ensembles, namely, Hospital Authority (HA) Standard Ebola PPE set (PPE1), Dupont Tyvek Model, style 1422A (PPE2), and HA isolation gown for routine patient care and performing aerosol-generating procedures (PPE3) to prevent EVD transmission by measuring the degree of contamination of HCWs and the environment.

Methods

A total of 59 participants randomly performed PPE donning and doffing. The trial consisted of PPE donning, applying fluorescent solution on the PPE surface, PPE doffing of participants, and estimation of the degree of contamination as indicated by the number of fluorescent stains on the working clothes and environment. Protocol deviations during PPE donning and doffing were monitored.

Results

PPE2 and PPE3 presented higher contamination risks than PPE1. Environmental contaminations such as those originating from rubbish bin covers, chairs, faucets, and sinks were detected. Procedure deviations were observed during PPE donning and doffing, with PPE1 presenting the lowest overall deviation rate (%) among the three PPE ensembles (p < 0.05).

Conclusion

Contamination of the subjects’ working clothes and surrounding environment occurred frequently during PPE doffing. Procedure deviations were observed during PPE donning and doffing. Although PPE1 presented a lower contamination risk than PPE2 and PPE3 during doffing and protocol deviations, the design of PPE1 can still be further improved. Future directions should focus on designing a high-coverage-area PPE with simple ergonomic features and on evaluating the doffing procedure to minimise the risk of recontamination. Regular training for users should be emphasised to minimise protocol deviations, and in turn, guarantee the best protection to HCWs.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0433-y) contains supplementary material, which is available to authorized users.

A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of the HCID programme

The importance of appropriate personal protective equipment (PPE) as a component of healthcare worker (HCW) protection was highlighted during the Ebola virus disease (EVD) outbreak in West Africa. The large number of HCW deaths in Africa was in part due to lack of resources or prior training in PPE usage. As part of the Ebola legacy, the High Consequence Infectious Disease (HCID) programme was initiated by NHS England and Public Health England (PHE) to improve preparedness for Ebola and other infections that not only endanger the life of the patient, but also pose particular dangers to HCWs. A systematic review identified national standardisation of PPE protocols as a priority, but recognised that a lack of safety data limited the ability to mandate any one protocol. A simulation-based exercise was developed to assess the safety of PPE ensembles in use in the UK during first assessment of a patient with a possible HCID. A mannequin was adapted to expose volunteer HCWs to synthetic bodily fluids (vomit, sweat, diarrhoea and cough), each with a different coloured fluorescent tracer, invisible other than under ultraviolet (UV) light. After exposure, HCWs were examined under UV lights to locate fluorescent contamination, and were screened again after removing PPE (doffing) to detect any personal contamination. The exercise was videoed, allowing retrospective analysis of contamination events and user errors. The simulation testing identified significant HCW contamination events after doffing, related to protocol failure or complications in PPE doffing, providing conclusive evidence that improvements could be made. At a workshop with an expert stakeholder group, the data were examined and a unified PPE ensemble agreed. This ensemble was then tested in the same simulation exercise and no evidence of any HCW contamination was seen after doffing. Following further review by the working group, a consensus agreement has been reached and a unified 'HCID assessment PPE' ensemble, with accompanying donning and doffing protocols, is presented here.

Use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease

BACKGROUND

Variations currently exist across the UK in the choice of personal protective equipment (PPE) used by healthcare workers when caring for patients with suspected high-consequence infectious diseases (HCIDs).

AIM

To test the protection afforded to healthcare workers by current PPE ensembles during assessment of a suspected HCID case, and to provide an evidence base to justify proposal of a unified PPE ensemble for healthcare workers across the UK.

METHODS

One 'basic level' (enhanced precautions) PPE ensemble and five 'suspected case' PPE ensembles were evaluated in volunteer trials using 'Violet'; an ultraviolet-fluorescence-based simulation exercise to visualize exposure/contamination events. Contamination was photographed and mapped.

FINDINGS

There were 147 post-simulation and 31 post-doffing contamination events, from a maximum of 980, when evaluating the basic level of PPE. Therefore, this PPE ensemble did not afford adequate protection, primarily due to direct contamination of exposed areas of the skin. For the five suspected case ensembles, 1584 post-simulation contamination events were recorded, from a maximum of 5110. Twelve post-doffing contamination events were also observed (face, two events; neck, one event; forearm, one event; lower legs, eight events).

CONCLUSION

All suspected case PPE ensembles either had post-doffing contamination events or other significant disadvantages to their use. This identified the need to design a unified PPE ensemble and doffing procedure, incorporating the most protective PPE considered for each body area. This work has been presented to, and reviewed by, key stakeholders to decide on a proposed unified ensemble, subject to further evaluation.