Table 7

Lessons learnt from literature review used as a strategic tool to refine our PDSA cycles27 37–40

Potential issues identified in literature reviewAction taken
Limited hospital layouts disrupted space management for PPE use.Space was maximally optimised within the available alternatives.
Even when PPE is used, errors in technique may reduce or negate its intended effects.The right technique of donning was emphasised repeatedly during training and assistance was provided in actual practice.
HCPs were reported to make changed mistakes while avoiding previous mistakes, even after receiving feedback on their PPE contaminations.Multiple reiterations and trainings were planned and provided.
Lack of assessment of infection control competencies may suggest to learners that these aspects of clinical competency are less valuable than others.Every training was assessed. Compliance was sought using Hawthorne effect.
Women’s experiences wearing PPE found the coverall to be among the worst-fitting PPE types.Feedback was taken from female HCWs after doffing to improvise the process, if required.
Taping over gaps between hood and coverallGaps could not be avoided as it depended on the PPE provided.
With more PPE items, the doffing order became complicated and confusing.Doffing assistants and observers provided guidance at every step.
Since sitting increases the risk of spreading contamination to other parts of the PPE, installing built-in grab bars was suggestedHandrails were installed at the location where shoe covers are removed.
Layout of the doffing area increases the risk of contamination.Layout was designed based on best practices cited in literature.
When HCWs are potentially fatigued after hours of providing patient care, removal of PPE has been identified as a high-risk activity for self-contamination and potential acquisition of pathogens.
An HCW who is uncomfortable and tired may make mistakes while removing the PPE hastily.
Prolonged donning and doffing time may be an issue.
Donning was initiated only based on requirement. Activities were planned in advance before donning to maximise available time after donning. HCW was recommended to take a rest inside the ward/isolation facility at intervals in case of discomfort, uneasiness or heavy sweating. Doffing was initiated only after the HCW was relaxed. Gentle reassurance was provided to them.
In an environment where urgency is evident and employee safety is critical, complex procedures are more accurately followed when written procedures are coupled with visual images to provide guidance to staff. Compliance of staff to the procedure outlined is enhanced when staff can visualise each step as they are completing the process.Visual posters were put up alongside each instruction in the donning and doffing room.
Some protocols (NC and MSF) recommend rubber boots without boot covers.We found this recommendation suitable for engineering staff such as plumbers who complained of feet getting soiled or wet during repairs of faulty drains and sewage lines.
Picture-guided posters or visual images enhance staff compliance to donning and doffing procedures when staff is able to visualise each step as they are completing the process.Full-length posters were made available in the donning and doffing rooms.
Defining specific roles and responsibilities and training the participants to practise core teamwork skills such as closed-loop communication, mutual support, situational awareness and speaking up about safety concernsPDSA cycles tried to address these issues
HCWs should be given just-in-time training if their standard PPE is replaced with a new style during shortages or vendor changes.PPE protocols were defined. 5S tool was used to standardise and sustain PPE protocols.
Regardless of PPE type, increased access and training to published donning/ doffing guidelines improves HCW ability to don or doff without protocol deviations.
PPE protocols must be clear and unambiguous.
  • HCP, healthcare personnel; HCW, healthcare worker; MSF, Médecins Sans Frontières; NC, North Carolina; PDSA, plan–do–study–act; PPE, personal protective equipment.