Common Behaviors and Faults When Doffing Personal Protective Equipment for Patients With Serious Communicable Diseases

• Type of Material: Article
• Authors: Joel M. Mumma, Georgia Institute of Technology; Francis T. Durso, Georgia Institute of Technology; Lisa M. Casanova, Georgia State University; Kimberly Erukunuakpor, Georgia State University; Colleen S Kraft, Emory University; Susan M Ray, Emory University; Andi L Shane, Emory University; Victoria L. Walsh, Emory University; Puja Y. Shah, Emory University; Craig Zimring, Georgia Institute of Technology; Jennifer DuBose, Georgia Institute of Technology; Jesse Thomas Jacob, Emory University
• Language: English
• Date: 2019-10-01
• Publisher: Oxford University Press (OUP): Policy B - Oxford Open Option C
• Publication Version: Final Published Version
• Copyright Statement: © 2019 The Author(s). Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1093/cid/ciz614
• Title of Journal or Parent Work: Clinical Infectious Diseases
• ISSN: 1058-4838
• Volume: 69
• Issue: Supplement_3
• Start Page: S214
• End Page: S220
• Grant/Funding Information: This work was supported by the Prevention Epicenters Program of the Centers for Disease Control and Prevention (award U54CK000164).; This article appears as part of the supplement “Personal Protective Equipment for Preventing Contact Transmission of Pathogens: Innovations from CDC’s Prevention Epicenters Program,” sponsored by the CDC’s Prevention Epicenters Program.; Emory University’s participation was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health (award UL1TR000454; Atlanta Clinical and Translational Science Institute).
• Keywords: LEVEL; Science & Technology; occupational health; Life Sciences & Biomedicine; personal protective equipment; Immunology; Infectious Diseases; SAFETY; Microbiology; risk analysis; serious communicable disease; AGREEMENT; IMPROVE; PROTOCOL; human factors; NEED; DESIGN
• Research Categories: Health Sciences, Immunology; Biology, Microbiology

Abstract

Background: The safe removal of personal protective equipment (PPE) can limit transmission of serious communicable diseases, but this process poses challenges to healthcare workers (HCWs). Methods: We observed 41 HCWs across 4 Ebola treatment centers in Georgia doffing PPE for simulated patients with serious communicable diseases. Using human factors methodologies, we obtained the details, sequences, and durations of doffing steps; identified the ways each step can fail (failure modes [FMs]); quantified the riskiness of FMs; and characterized the workload of doffing steps. Results: Eight doffing steps were common to all hospitals-removal of boot covers, gloves (outer and inner pairs), the outermost garment, the powered air purifying respirator (PAPR) hood, and the PAPR helmet assembly; repeated hand hygiene (eg, with hand sanitizer); and a final handwashing with soap and water. Across hospitals, we identified 256 FMs during the common doffing steps, 61 of which comprised 19 common FMs. Most of these common FMs were above average in their riskiness at each hospital. At all hospitals, hand hygiene, removal of the outermost garment, and removal of boot covers were above average in their overall riskiness. Measurements of workload revealed that doffing steps were often mentally demanding, and this facet of workload correlated most strongly with the effortfulness of a doffing step. Conclusions: We systematically identified common points of concern in protocols for doffing high-level PPE. Addressing FMs related to hand hygiene and the removal of the outermost garment, boot covers, and PAPR hood could improve HCW safety when doffing high-level PPE. We identified ways that doffing protocols for high-level personal protective equipment may fail to protect healthcare workers. Hand hygiene, removing the outermost garment, boot covers, and respirator hood harbored the greatest risk and failed in similar ways across different hospitals.