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Healthcare design to improve safe doffing of personal protective equipment for care of patients with COVID-19

October 2022
The Center For Health Design

Why does this study matter?
In the early days of the pandemic, infection prevention protocols were focused on the possibility of contact transmission, including intensive efforts to provide and keep personal protective equipment (PPE) clean. Now, more than two years into the COVID-19 pandemic, we have a clear understanding that the main mode of transmission happens via airborne droplets and particles. But contact transmission is still possible, and healthcare leadership must consider how to address contact transmission possibilities from all types of infectious disease.


How was the study done?
This study took place about a year after the start of the COVID-19 pandemic at three different hospitals.

The researchers started with a literature review and interviews with experts to understand the evidence around risky behaviors that lead to self- and cross contamination during doffing procedures. Then, they observed donning/doffing activities, gave healthcare workers two surveys focused on their perceptions of doffing tasks, and held focus groups with nurses and infection perfectionists.
Then, they used a method called pattern matching to create a framework where they organized the results from each method into summaries of the doffing challenges in the context of the physical environment.

Finally, they used the framework to lead a virtual design-focused workshop with nine healthcare experts. The workshop resulted in a set of design goals, guidelines, and strategies to better support safe doffing, which are organized in a handy and visually appealing table that you can access in the full paper.


So what do we learn from the study?
First we’ll focus on highlights from the study itself, but I’ll also mention how the findings informed the work in the design workshop. 

First of all: Lots of Variation. The researchers noticed big differences in the ways doffing was handled (i.e., the number of steps, how long it took, cleaning, storage, and hand hygiene). There was also variation in the design of the storage and cleaning stations. The paper includes photos of several cluttered spaces, with seven different PPE storage configurations, four different types of trash disposal, three types of PPE cleaning stations, and two ways staff were hanging items to dry. 

When these results were addressed in the design workshop, they focused on the importance of standardization in the doffing process and in the design of doffing station. 

The second main finding had to do with Inadequacies in the environment. The healthcare workers explained their perception that the environment increased the risk of contamination during doffing. At times, staff had to stretch to reach a hand sanitizer or to toss their gown into the trash, and all sinks were at least 15 feet from the patient room door. Staff described having to walk around to find a gown or other supplies. Researchers observed PPE being left in the wrong place in clean/dirty storage, staff touching contaminated PPE, and using overfull trash bins.
(In the workshop they focused on: considerations for easy access to PPE supplies, transparent storage, delineated space for clean/dirty, carts on wheels for flexible locations, and visual cues for cleaning and hand hygiene protocols.)
These clinicians were a year into the pandemic, and they were quite used to donning and doffing at this point; however, they still rated gown removal as the most demanding part of the process overall, and PPE cleaning as the most mentally demanding. Hand-hygiene was rated as the least demanding task overall, and least mentally demanding part of the routine as well. Researchers noticed that the majority of handwashing events (69%) took less than ten seconds. 

(In the workshop they focused on: Improve standardization, visual cues, automatic touchless designs, organize corridor layout according to sequence of safe doffing procedure.)


Can we say the results are definitive?
Much of the article focused on storage, cleaning, and donning/doffing of gowns and gloves, but less so on face masks. Early in the pandemic, at the time of this study, there was intense focus on contact transmission. Design for safe donning and doffing must also include considerations for infection prevention protocols for airborne transmission, whether we’re talking about COVID-19 or other infectious disease.


What’s the takeaway?
Every healthcare organization goes into the design process wanting to do things better, which means trying new things. We have the right intentions when we do things differently, but unfortunately this leads to so much variation among healthcare facilities. A new and different design means new and different spaces for healthcare workers to adjust to. And when we are faced with each new and different disaster that comes our way – like COVID 19 – all that variation appears to increase the cognitive load on staff, the likelihood of contact transmission, and ultimately, the risk of adverse events. This study gives us good reason to consider standardization, with room for flexibility, in order to support efficient and safe behavior. 


Interested in the topic? Visit The Center for Health Design Knowledge Repository for more.


Summary of:
Machry, H., Z. Matić, Y. Oh, J. R. DuBose, J. S. Morgan, K. L. Love, J. T. Jacob, and C. M. Zimring. “Healthcare Design to Improve Safe Doffing of Personal Protective Equipment for Care of Patients with COVID-19.” Infection Control & Hospital Epidemiology, 2022, 1–10. https://doi.org/10.1017/ice.2021.526


Our slidecasts are an outcome of the popular Research Matters presentations at the annual Healthcare Design Expo & Conference. Our research team picks papers that have some significance to the healthcare design community and distill the study down into a 5-minute summary of how the study was done, what was learned, the limitations and the takeaway. The slidecasts bring research to you in digestible format. Just five minutes, and you’ll know more.