Clinical challenges in isolation care

Unfamiliar personal protective equipment: The role of routine practice and other factors affecting healthcare personnel doffing strategies

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.

Healthcare Workers' Strategies for Doffing Personal Protective Equipment

Background

Personal protective equipment (PPE) helps protect healthcare workers (HCWs) from pathogens and prevents cross-contamination. PPE effectiveness is often undermined by inappropriate doffing methods. Our knowledge of how HCWs approach doffing PPE in practice is limited. In this qualitative study, we examine HCWs’ perspectives about doffing PPE.

Methods

Thirty participants at a Midwestern academic hospital were recruited and assigned to 1 of 3 doffing simulation scenarios: 3 mask designs (n = 10), 2 gown designs (n = 10), or 2 glove designs (n = 10). Participants were instructed to doff PPE as they would in routine practice. Their performances were video-recorded and reviewed with participants. Semistructured interviews about their doffing approaches were conducted and audio-recorded, then transcribed and thematically analyzed.

Results

Three overarching themes were identified in interviews: doffing strategies, cognitive processes, and barriers and facilitators. Doffing strategies included doffing safely (minimizing self-contamination) and doffing expediently (eg, ripping PPE off). Cognitive processes during doffing largely pertained to tracking contaminated PPE surfaces, examining PPE design cues (eg, straps), or improvising based on prior experience from training or similar PPE designs. Doffing barriers and facilitators typically related to PPE design, such as PPE fit (or lack of it) and fastener type. Some participants also described personal barriers (eg, glasses, long hair); however, some PPE designs helped mitigate these barriers.

Conclusions

Efforts to improve HCWs’ doffing performance need to address HCWs’ preferences for both safety and expediency when using PPE, which has implications for PPE design, training approaches, and hospital policies and procedures.

Effect of Different Instructional Methods on Contamination and Personal Protective Equipment Protocol Adherence among Veterinary Students

Proper use of personal protective equipment (PPE) is crucial to prevent disease spread. Recent studies in human medicine have shown disconcerting inconsistencies in the use of PPE in hospital wards. In this study, we compared the effect of three instructional methods for PPE use on contamination and protocol adherence among veterinary students. Students were divided into three groups according to the instructional method to which they had access (instructional video, wall chart, or both). They underwent an isolation exercise consisting of donning, patient examination (mock patient prepared with contamination marker), and doffing. Student contamination after the exercise was evaluated using UV light. Videos of student performance were reviewed for errors committed. Results showed that the number of students with contamination was higher in the group who only had access to video instruction than in the two other groups. The number of students with contamination on forearms, hands, and wrists was higher in the group who only had access to charts. Disinfecting gloves between doffing steps was the most frequently omitted step. The number of students who touched the environment with unprotected areas of their bodies was higher in the group who only had access to video instruction than in the other two groups. In conclusion, video instruction was less effective in achieving PPE protocol adherence among veterinary students than was instruction with a chart or chart-video combination. Incorporating video instruction as part of the instructions may be valuable to reinforce individual steps of donning and doffing.

Observed variation in N95 respirator use by nurses demonstrating isolation care

Video review and scoring was used to evaluate the behaviors of nurses wearing N95 filtering face piece respirators while providing isolation care in a simulated patient care environment. This study yielded a detailed description of behaviors related to N95 respirator use in a health care setting. Developing a more robust and systematic behavior analysis tool for use in demonstration, simulation, and clinical care would allow for improved respiratory protection of health care workers.

Viral Hemorrhagic Fever Preparedness

The 2014–2016 outbreak of Ebola virus disease (EVD) in West Africa marked the 25th such occurrence but was noteworthy in its massive scope, causing more human morbidity and mortality than the previous 24 recorded outbreaks combined. As of April 2016, there were 28,652 cases resulting in at least 11,325 deaths, nearly all in the three nations of Guinea, Liberia, and Sierra Leone (Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html. Accessed 2 June 2016). Moreover, the 2014–2016 outbreak was the first in which patients, albeit few in number, were afforded sophisticated intensive care in the United States and in Europe. This “high-level containment care” (HLCC) was provided in specially designed purpose-built biocontainment units (BCUs). In this chapter, we explore the history and evolution of biocontainment, discuss its unique engineering and infection control modalities, and offer recommendations for the clinical and operational management of Ebola and other viral hemorrhagic fevers (VHFs).

Rapid Development and Deployment of Ebola Readiness Training Across an Academic Health System: The Critical Role of Simulation Education, Consulting, and Systems Integration

STATEMENT

In this article, we describe an Ebola preparedness initiative with implementation across an academic health system. Key stakeholder centers of various disciplines and clinical experts collaborated in the development and design. Subject matter experts in the areas of Centers for Disease Control and Prevention and World Health Organization protocols for personal protective equipment donning and doffing conducted initial train-the-trainer sessions for program instructors. These trainers represented a cross-section of key clinical responders and environmental services. Through a parallel development process, a blended learning curriculum consisting of online modules followed by on-site training sessions was developed and implemented in both the simulation laboratory and the actual clinical care spaces in preparation for a Department of Health inspection. Lessons learned included identification of the need for iterative refinement based on instructor and trainee feedback, the lack of tolerance of practitioners in wearing full-body personal protective equipment for extended periods, and the ability of a large system to mount a rapid response to a potential public health threat through leveraging of expertise of its Simulation Program, Center for Quality, Safety and Innovation as well as a wide variety of clinical departments.