PlanвЂ“doвЂ“studyвЂ“act (PDSA) cycles were done to further improvise the structure and process of the areas. This tool addresses planning in a structured way: sort, set in order, shine, standardise and sustain. The tool, 5S, 20 was used to set up and sustain the structure and process of donning and doffing areas. The hospital provided surgical scrubs and slippers to HCWs before donning PPE. Ankle-length shoe covers, another pair of gloves, one face shield and one N95 respirator were added separately to complete the full-body PPE. Initial training in PPE was done with a commercial PPE ensemble that comprised an impermeable surgical gown, a hood cap, a pair of goggles and a pair each of gloves, arm guards and knee-length impermeable leggings. Physical distancing was maintained between participants during group trainings. Training of trainers was done who later trained HCWs in small groups every day. 19 This was used as a tool to strategise planning and training. Our initial literature review identified all issues pertaining to donning and doffing in terms of DonabedianвЂ™s structure, process and outcome. Inputs were taken from infectious disease specialists as well as the apprehensions, suggestions, comments and feedback of resident doctors throughout. The team comprised hospital administrators, infection preventionists, and supervisors of nursing assistants and environmental service personnel. A rapid QI event was conducted for 6 weeks. Care was provided to more than 2358 patients for 12 weeks out of which more than 90% had mild to moderate symptoms. The initiative was undertaken at an acute cancer hospital that was converted into a COVID-19 care facility with 400 isolation rooms, 400 beds in wards and 25 beds in ICU. The objectives were to define the structure (size, layout and design) of an ideal donning and doffing room, identify the process issues pertaining to donning and doffing and take systemic measures to improve the same. The aim of our quality improvement (QI) initiative was to rapidly set up PPE donning and doffing areas in a hospital. Also, literature is limited on the ideal size for a donning and doffing room and managerial issues of donning and doffing areas. 15вЂ“18 The coronavirus is not transmitted in the same way and it is not clear if these recommendations translate to COVID-19. Studies describing the layout and design for doffing rooms specific to Clostridium difficile and Ebola virus have established that the space and design of built environment for donning and doffing improves HCW safety, influences compliance and has a measurable impact on HCW contamination risk while doffing PPE. 12вЂ“14 Routine breaches in PPE use do not generally result in highly visible disease outbreaks but may contribute to ongoing transmission of nosocomial infection. 10 11 Comparatively, despite wearing PPE, 1 in 10 HCWs contracted Ebola during the epidemic. However, SARS-CoV-2 contamination of common objects in the intensive care unit (ICU) and wards, virus aerosolisation in a confined space or spread from asymptomatic infected persons is documented, implying a potentially high infection risk for medical staff and other close contacts even though the amount of viable virus could not be determined. 1вЂ“6 Quantitatively, the amount of self-contamination that is clinically meaningful to transmit SARS-CoV-2 during doffing is not yet known. 9 However, deviations from recommended doffing protocol are common with self-contamination rates ranging from 13% to 90%. 7 It is a high-risk process 8 that requires a structured procedure and a designated area for removal to ensure protection. Doffing is a physically rigorous task that demands flexibility, balance and constant vigilance. HCWs endure extreme heat, long periods of standing during patient care and then remove PPE, which requires patience, attention and some unusual movements. Risks of contamination during doffing can be due to an incorrect removal technique, improper handling and disposal of PPE, or by damaging PPE to expose HCWs. 2 Contamination of HCWs can occur during patient care if PPE is damaged, has design flaws or if HCWs circumvent protection. 1 Incorrect technique or sequence in donning can expose HCWs during patient care or sets HCW up for a doffing failure. Issues during any of these phases can lead to a risk of contamination to the healthcare worker (HCW). Personal protective equipment (PPE) use in healthcare involves three phases: donning, while providing patient care, and doffing.

N95 donning and doffing pdf