Discussion

We designed and operationalised PPE donning and doffing areas for a COVID-19 care facility within a span of 1 week. The biggest challenge was to train the housekeeping staff and environmental service personnel who had no experience in PPE and to translate the training into practice within a short span of time.

There was considerable awareness and interest in COVID-19 among staff due to social media coverage. However, apprehensions related to the disease were also huge. Focus groups, lectures, picture-guided posters, online training videos and demonstrations on donning and doffing were conducted by infection preventionists. Evidence shows that traditional learning methods (eg, watching educational videos and learning PPE guidelines) are inferior to immersive learning methods, including audiovisual devices and active learning involvement using simulation training that includes feedback on performance in guiding the PPE procedures.22–24 Hands-on practical training should be provided to allow HCWs to develop muscle memory.6 Though instructional videos were circulated to all HCWs, most did not go through the videos on their own unless under supervised persuasion. The anticipated PPE shortage restricted the staff to practise using PPE extensively. We did a literature review to line list all identified donning and doffing errors and used this as a tool to strengthen training and improvise HCW donning and doffing. Repeated PDSA cycles minimised protocol violations during donning and doffing.

The PDSA cycles also enabled us to identify practical issues that every healthcare facility must address while operationalising donning and doffing areas in its facility. Limited hospital layouts disrupt space management for PPE use. Since it was not possible to construct an ideal doffing facility or even make major alterations due to constraints of space, time and raw material supply chain logistics due to national lockdown, the identified available space within the ward and the isolation facility was reconfigured optimally.

Initially, items were frequently moved and placed in inconsistent locations when design did not provide standard, convenient locations, leading to errors, frustration and risky behaviours such as retracing into contaminated area to use alcohol-based hand rubs (ABHRs). However, if items such as bins were immovably fixed at identified locations in the doffing room, then this impaired cleaning. Therefore, the floor was marked with coloured tapes to indicate the placement of bins and stools.

Donning was dissected into nine sequential objective steps to reduce cognitive effort. Nine sequential unidirectional stations were created in the donning room. A poster corresponding to each step of donning was pasted on the wall at each station in sequence along with supply of the relevant PPE on tables at that station. Similarly, 11 sequential stations were created in the doffing room corresponding to each step of doffing. At each station, a poster corresponding to the step was pasted on the wall. Automatic no-touch dispensers were provided in each zone (red, yellow and green) in the doffing room to eliminate the risk of contamination and to prevent wastage of ABHRs, which were being used indiscriminately otherwise.

Apart from the errors recognised in literature, the most frequent behaviour was touching the front part of the mask to adjust the positioning of mask at intervals. Individualised seal checks were not possible due to supply of universal size N95 masks. Fogging of goggles occurred often due to poor fit of masks. HCWs used surgical tapes to seal the masks on the face. This carried a risk of contamination during doffing. However, Bell et al reported that taping may not present significant contamination risk.25 HCWs who used prescription glasses perceived risk of contamination of glasses while doffing.

Engineering staff (plumbers and electricians) were required to enter patient isolation rooms to rectify emergency complaints such as seepage of water and faulty drains. Others such as phlebotomists, physiotherapists, radiographers, dieticians, ambulance drivers, laundry personnel and kitchen stewards also required training in PPE use. These were big challenges as it is known that personnel donning and doffing PPE that they are unfamiliar with or have not received training on during emergency situations increase the likelihood of a doffing error.8 Just-in-time training was provided to them. However, some of these staff doffed expeditiously with less regard to safety and required explicit verbal instructions and prompts by a trained observer on all occasions.

After a few days of regular usage of PPE, some staff exhibited automaticity and reduced compliance to doffing sequence even after being explicitly guided by an observer. The presence of a peer guiding the process may have contributed to their reduced compliance. However, in the presence of a senior supervisor, compliance improved. The mean time spent by HCWs in PPE in the wards or isolation facility was 2.4 (±0.04) hours. Some staff (5%) needed to doff within 2 hours of donning PPE due to extreme discomfort or dizziness.

PPE kits should not be changed frequently to minimise errors during donning and doffing.26 However, PPE supplies changed on four occasions due to unavoidable supply chain logistics and apprehensions regarding the quality of PPE among resident doctors due to a few instances of PPE getting torn while donning. The initial PPE ensemble earlier was replaced with an assembled set consisting of a category III protection level tychem coverall, an N95 respirator, a pair of knee length shoe covers and one pair of goggles due to exhausted supplies. Gloves and hood caps had to be obtained separately. This was followed by a supply of two different kinds of coveralls made of spun bound fabric with one layer of microfilm, which differed in their breathability. The other accessories of PPE were separately obtained and assembled. Non-availability of extra-large size gowns or coveralls was an issue of concern for some HCWs due to exposure of the uncovered areas. Due to change in PPE ensemble, the sequence of donning and doffing of shoe covers had to be altered, which led to confusion and errors among HCWs. This required just-in-time training on multiple occasions. Face shields were preferred compared with goggles. However, evidence is limited about the effectiveness of goggles versus face shields.27

Another managerial issue that required monitoring was sustaining the practice of discarding used N95 masks, goggles, face shields and coveralls in separate containers in the doffing room by HCWs for reuse after disinfection. Ensuring round-the-clock availability of supplies in the doffing room and postdoffing bathroom was another issue. Direct supervision of the doffing room was comparatively less due to perception of high risk of room contamination and required fresh donning to go inside to check and replenish supplies carefully without contamination. The next issue was to ensure that goggles and face shields were disinfected as per the protocol and transported out from the doffing room safely by the nursing assistants. Ensuring availability of supplies such as towels and scrubs in the lockers always required constant monitoring. A checklist (table 4) was created for the supervisor of environmental service personnel who was made accountable to address these issues in the donning and doffing rooms in every shift.

The availability of all supplies within doffing room, visual prompts and affordances were not sufficient to ensure full compliance with doffing protocols. Fogging of goggles hindered reading doffing posters on the wall for some HCWs. Fatigue also contributed to lack of attention by the HCW during doffing. The presence of a trained observer who provided verbal prompts to the doffing HCW promoted compliance the most. However, some HCWs reported hearing difficulty while in PPE due to which the vocal prompts provided by the doffing assistant during doffing were not heard. This led to the idea of prompting instructions by an observer using a microphone from outside while being able to visualise the doffing process through a glass screen. However, since HCWs doffed at random intervals, ensuring the presence of a doffing assistant always was resource intensive.

Biomedical waste bins for coveralls got filled up faster due to the size of the coveralls. This required more frequent inspection and proactive initiative by environmental service personnel who needed supervisory nudging.

Our experience recommends that water or oral rehydrating solutions should be provided to HCWs at the time of donning and after doffing. There must be space designated for the HCW to sit before entering the doffing room, if the HCW needed to take rest. It was also important to make it known to all the HCWs that these were available for them.

Donning and doffing by different HCWs occurred multiple times due to random arrivals of patients. This caused overcrowding in the doffing room, at times, leading to prolonged waits for other HCW. Some HCWs doffed simultaneously without waiting, which would lead to one of these HCW waiting in the doffing room to enter the bathroom that was already occupied. The waiting in the doffing room without PPE caused apprehensions of exposure to the coronavirus. This was circumvented by preventing simultaneous doffing and by using a set of two rooms, one room to doff and the other room with an attached bathroom to wait if required. Initially, overcrowding happened due to uniform shift timings of staff. We, therefore, staggered the staff duty timings so that at least any one category of staff always remained donned inside the isolation facility at any time, PPEs were not used unnecessarily and doffing of all staff at the end of a shift did not occur en masse.