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Chasco EE, Pereira da Silva J, Dukes K, Baloh J, Ward M, Salehi HP, Reisinger HS, Pennathur PR, Herwaldt L. Unfamiliar personal protective equipment: The role of routine practice and other factors affecting healthcare personnel doffing strategies. Infect Control Hosp Epidemiol 2023; 44:1979-1986. [PMID: 37042615 PMCID: PMC10755157 DOI: 10.1017/ice.2023.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Healthcare personnel (HCP) may encounter unfamiliar personal protective equipment (PPE) during clinical duties, yet we know little about their doffing strategies in such situations. OBJECTIVE To better understand how HCP navigate encounters with unfamiliar PPE and the factors that influence their doffing strategies. SETTING The study was conducted at 2 Midwestern academic hospitals. PARTICIPANTS The study included 70 HCP: 24 physicians and resident physicians, 31 nurses, 5 medical or nursing students, and 10 other staff. Among them, 20 had special isolation unit training. METHODS Participants completed 1 of 4 doffing simulation scenarios involving 3 mask designs, 2 gown designs, 2 glove designs, and a full PPE ensemble. Doffing simulations were video-recorded and reviewed with participants during think-aloud interviews. Interviews were audio-recorded and analyzed using thematic analysis. RESULTS Participants identified familiarity with PPE items and designs as an important factor in doffing. When encountering unfamiliar PPE, participants cited aspects of their routine practices such as designs typically used, donning and doffing frequency, and design cues, and their training as impacting their doffing strategies. Furthermore, they identified nonintuitive design and lack of training as barriers to doffing unfamiliar PPE appropriately. CONCLUSION PPE designs may not be interchangeable, and their use may not be intuitive. HCP drew on routine practices, experiences with familiar PPE, and training to adapt doffing strategies for unfamiliar PPE. In doing so, HCP sometimes deviated from best practices meant to prevent self-contamination. Hospital policies and procedures should include ongoing and/or just-in-time training to ensure HCP are equipped to doff different PPE designs encountered during clinical care.
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Affiliation(s)
- Emily E. Chasco
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jaqueline Pereira da Silva
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
| | - Kimberly Dukes
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Jure Baloh
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Melissa Ward
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Hugh P. Salehi
- Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
- Department of Engineering Education, The Ohio State University, Columbus, Ohio
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Priyadarshini R. Pennathur
- Department of Industrial, Manufacturing and Systems Engineering, University of Texas at El Paso, El Paso, Texas
| | - Loreen Herwaldt
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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Altabbaa G, Pidhorney C, Beran T, Kim J, Ledgerwood D, Cowan M, Paolucci EO. Personal protection equipment: Preliminary evidence of effectiveness from a three-phase simulation program. J Infect Prev 2023; 24:244-251. [PMID: 37969467 PMCID: PMC10638951 DOI: 10.1177/17571774231208118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 09/29/2023] [Indexed: 11/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ghazwan Altabbaa
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | | | - Tanya Beran
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Joseph Kim
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Donna Ledgerwood
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Michèle Cowan
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Staying proper with your personal protective equipment: How to don and doff. J Clin Anesth 2023; 86:111057. [PMID: 36696834 PMCID: PMC9869806 DOI: 10.1016/j.jclinane.2023.111057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/09/2023] [Accepted: 01/15/2023] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The global COVID-19 pandemic highlighted the importance of protecting frontline healthcare workers from novel respiratory infections while also exposing the limited instruction that medical students receive on proper donning of personal protective equipment (PPE) and more importantly the safe doffing of contaminated PPE to minimize their risk of nosocomial infection. The best methods of providing this kind of instruction have not yet been determined. METHODS Anesthesiology interns and CA-1 residents were trained on proper PPE donning and doffing for AGPs using a methodology based on Miller's pyramid and following a "knows-knows how-shows-does" progression. Participants donned PPE without instruction and were sprayed with Glo Germ® to identify areas of contamination, after which they received both video and in-person instruction on best practices for donning and doffing PPE for AGPs. Following instruction, they again donned PPE and were sprayed with Glo Germ® to identify areas of contamination. RESULTS 54 participants completed the study. Before training, overall donning compliance was 60% and overall doffing compliance was 48%. Overall, 70% were contaminated after PPE doffing, with 46% having multiple sites of contamination. After training, donning compliance increased by nearly 30% (P < 0.001), doffing compliance increased by over 20% (P < 0.001), and overall contamination decreased by nearly 30% (P = 0.029), with multiple-site contamination decreasing to only 6% (P = 0.013). DISCUSSION While best methods for providing instruction regarding topics such as PPE donning and doffing have not yet been determined, we have demonstrated that the underlying knowledge base from medical school regarding proper donning and doffing for respiratory isolation is insufficient for preventing self-contamination, and that Miller's pyramid-based training using both video and in-person instruction combined with task execution by learners can improve compliance with PPE donning and doffing protocols and more importantly decrease skin contamination among a group of early training anesthesiology residents.
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Obuhoro O, Jones RM. Assessing Patterns of Body Contamination after Personal Protective Equipment Removal among Healthcare Workers: A Scoping Review. Am J Infect Control 2022:S0196-6553(22)00674-5. [PMID: 36116680 DOI: 10.1016/j.ajic.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Olosengbuan Obuhoro
- Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Rachael M Jones
- Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT; Department of Environmental Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA.
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Impact of Infection Control Education on Gastrointestinal Endoscopy Procedural Staff. Gastroenterol Nurs 2022; 45:91-100. [PMID: 35220373 DOI: 10.1097/sga.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/13/2021] [Indexed: 11/26/2022] Open
Abstract
To date, minimal research has been conducted on proper use of personal protective equipment and hand hygiene within endoscopy. The American Society for Gastrointestinal Endoscopy has developed guidelines for infection control within the endoscopy suite. A practice change based upon these guidelines was implemented. Education was provided to endoscopy procedural staff within a Midwestern hospital based upon the World Health Organization 5 Moments for Hand Hygiene initiative and included personal protective equipment. Knowledge, skills, and attitudes of the participant group were compared from paired pre- to posteducation surveys pertaining to hand hygiene and personal protective equipment. Observation of personal protective equipment use and hand hygiene implementation during procedures was also documented pre- to posteducation. The project results revealed both willingness to implement proper donning and doffing of personal protective equipment and improved technique as evidenced by improved observed technique with the endoscopy suite and moderately improved hand hygiene questionnaire results. Although conducted as a quality improvement project, clinical significance was found via observation following education. These practices can aid in reduction of organism transmission from patients to staff.
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Self-contamination following removal of two personal protective equipment suits: a randomized, controlled, crossover simulation trial. J Hosp Infect 2021; 119:155-162. [PMID: 34606932 DOI: 10.1016/j.jhin.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 11/21/2022]
Abstract
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).
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 5:CD011621. [PMID: 32412096 PMCID: PMC8785899 DOI: 10.1002/14651858.cd011621.pub5] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Jos H Verbeek
- Cochrane Work Review Group, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Blair Rajamaki
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Bronagh Blackwood
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland
| | | | - F Selcen Kilinc Balci
- National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Pittsburgh, PA, USA
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 4:CD011621. [PMID: 32293717 PMCID: PMC7158881 DOI: 10.1002/14651858.cd011621.pub4] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Jos H Verbeek
- Academic Medical Center, University of Amsterdam, Cochrane Work Review Group, Amsterdam, Netherlands, 1105AZ
| | - Blair Rajamaki
- University of Eastern Finland, School of Pharmacy, Kuopio, Finland
| | - Sharea Ijaz
- University of Bristol, Population Health Sciences, Bristol Medical School, Bristol, UK, BS1 2NT
| | | | | | - Bronagh Blackwood
- Queen's University Belfast, Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Building, 97 Lisburn Road, Belfast, Northern Ireland, UK, BT9 7LB
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland, FI-70032
| | - Jani H Ruotsalainen
- Finnish Medicines Agency, Assessment of Pharmacotherapies, Microkatu 1, Kuopio, Finland, FI-70210
| | - F Selcen Kilinc Balci
- Centers for Disease Control and Prevention (CDC), National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), 626 Cochrans Mill Road, Pittsburgh, PA, USA, 15236
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