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

Abstract

Objective: Understand how the built environment can affect safety and efficiency outcomes during doffing of personal protective equipment (PPE) in the context of coronavirus disease 2019 (COVID-19) patient care.

Study design: We conducted (1) field observations and surveys administered to healthcare workers (HCWs) performing PPE doffing, (2) focus groups with HCWs and infection prevention experts, and (3) a with healthcare design experts.

Settings: This study was conducted in 4 inpatient units treating patients with COVID-19, in 3 hospitals of a single healthcare system.

Participants: The study included 24 nurses, 2 physicians, 1 respiratory therapist, and 2 infection preventionists.

Results: The doffing task sequence and the layout of doffing spaces varied considerably across sites, with field observations showing most doffing tasks occurring around the patient room door and PPE support stations. Behaviors perceived as most risky included touching contaminated items and inadequate hand hygiene. Doffing space layout and types of PPE storage and work surfaces were often associated with inadequate cleaning and improper storage of PPE. Focus groups and the design charrette provided insights on how design affording standardization, accessibility, and flexibility can support PPE doffing safety and efficiency in this context.

Conclusions: There is a need to define, organize and standardize PPE doffing spaces in healthcare settings and to understand the environmental implications of COVID-19-specific issues related to supply shortage and staff workload. Low-effort and low-cost design adaptations of the layout and design of PPE doffing spaces may improve HCW safety and efficiency in existing healthcare facilities.

Keywords: COVID-19; PPE; built environment; doffing; healthcare design; infectious diseases.

Fig. 1.

Overview of four study settings, with sites 2a and 2b being different units in the same hospital. Settings varied in layout and configuration of spaces allocated for doffing.

Fig. 2.

Number and location of doffing tasks in each site based on observations (16 donning-doffing events). The color intensity of each circle is proportionate to the number of doffing tasks done at that specific area.

Fig. 3.

Different types of PPE storage, work/cleaning surfaces, hangers, and disposals observed across sites: there were various wall-mounted or cart storage and disposal solutions depending on local practices and available wall space and floor space.

Fig. 4.

Summary of design goals, guidelines, and strategies for PPE doffing design.