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Despite guidelines, more than 100 ways PPE doffing process can fail

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December 15, 2018

Ayse P. Gurses, PhD, MPH
Ayes P. Gurses

Experts at Johns Hopkins Hospital identified more than 100 ways that health care workers can potentially self-contaminate while doffing personal protective equipment, despite the existence of detailed guidelines.

The CDC developed recommendations to reduce the risk for self-contamination while doffing personal protective equipment (PPE) after more than 600 health care workers died while caring for patients during the West African Ebola epidemic.

However, guidelines by themselves do not always lead to “consistent adherence with best practices,” Ayse P. Gurses, PhD, MPH, associate professor of anesthesiology and critical care medicine in the Johns Hopkins University School of Medicine and director of the Armstrong Institute Center for Health Care Human Factors, told Infection Disease News.

“The scientific discipline of human factors engineering can help [us] understand how and why guidelines may not be consistently followed,” Gurses said. “Human factors engineers develop scientific, data-based recommendations on how to improve patient and health care worker performance, such as how to improve the safety of enhanced PPE doffing tasks.”

For the study, two infection prevention experts reviewed CDC guidelines and the web-based training for a respirator/PPE combination and observed seven simulated doffing sessions. Other experts collaborated in focus group sessions and by recording, reviewing and validating data.

The experts identified 103 ways the doffing process failed. According to Gurses and colleagues, the riskiest steps for self-contamination were associated with movement between clean and contaminated areas, glove and apron removal and self-inspection while preparing to doff. Gurses noted several factors that contributed to the failure of guideline adherence, including inadequate technical or teamwork competency, undetected PPE contamination, PPE design characteristics, inadequate space for doffing and inadequate emphasis and resources dedicated to training and preparation for outbreaks.

Gurses said there is an “urgent need” to develop a competency assessment system for PPE doffing. Moreover, human factors experts should be consulted to evaluate guidelines, she said.

“Our analyses clearly revealed that for safe doffing of enhanced PPE, the team should include three members — the health care worker, the buddy and the trained observer,” Gurses said. “Since safe doffing relies heavily on effective teamwork, in addition to technical skill development, training and simulation programs must incorporate content on developing specific team skills, such as closed-loop communication and mutual performance monitoring.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

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