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PPE Doffing Dilemmas
Observer: Watch or Assist?
Questions have arisen about the role of the "trained observer" during doffing. Some hospitals, such as the Nebraska Biocontainment Unit, allow the observer to assist with some elements of the doffing procedure. CDC, however, recommends that the trained observer should not actively participate in doffing or touch the HCW in any way.
"In our guidance, the observer really should only be observing," explains Dr Srinivasan. "The observer should not be participating in any part of the removal of the PPE. We want that person to be exclusively focused on watching and guiding the HCW to remove PPE safely."
Staff at the Nebraska Biocontainment Unit use a different approach. Rather than a "trained observer," they use a "doffing partner," to actively assist with doffing. "It's almost impossible to avoid contaminating yourself if you try to doff without assistance," says Boulter.
Another common question is, "After doffing, who watches the trained observer remove his or her PPE?" Dr Srinivasan replies, "We have heard about different ways people are handling this. Remember, the observer is standing at a distance. He or she does not touch the HCW during doffing, or any of the HCW's PPE, so the risk for contamination of the observer is very low. Nonetheless, there is risk, so a reasonable way of accomplishing this is that after the HCW who has exited the patient's room finishes doffing, he or she watches the observer remove his or her PPE, before they both leave the doffing area."
The situation is different in Nebraska, where the doffing partner does touch the HCW while removing the HCW's PPE. Boulter explains how they doff the last doffing partner. "We have a doffing partner in full PPE 24/7 while there is a nurse in the room with the patient and when the room is being cleaned after the patient is removed. Each time a new doffing partner is ready to take over, that person assists the old doffing partner to doff. After the patient has had two consecutive negative Ebola tests, the final doffing partner doffs with minimal assistance from a staff member in standard isolation gear. At that point in time, the Ebola viral load is exceedingly low, so the risk for exposure to the final doffing partner is minimal." Nebraska has used this approach successfully with Ebola patients in their care.
How Do You Keep the Floor Clean?
One of the trickiest aspects of doffing is avoiding contamination of the floor after leaving the patient room and during doffing of PPE. You have just left the room, and the bottoms of your boot covers are now contaminated from walking around the isolation room. How do you avoid contaminating the floor of the doffing area?
Several different methods are used in special biocontainment units to prevent contamination of the floor. CDC recommends using clearly marked "clean chairs" and "dirty chairs" to sit in when removing boot covers and cleaning shoes, but many people have expressed concern that contamination of the floor, and then recontamination of the HCW's shoes, is still possible while the HCW is doffing the remainder of the PPE.
CDC's advice on this is to consider the layout or configuration of the patient care area that you will be using, and develop a method that works in your setting, keeping the basic principle in mind that boot covers are removed, then shoes are bleach-wiped before the HCW steps onto a "clean" area of the floor. The "dirty" area of the floor must then be cleaned.
Any of the methods used by experienced biocontainment units would be appropriate if they work for you. Here are the methods used by biocontainment units to address this problem:
Emory.In the Serious Communicable Disease Unit, an anteroom connected to the patient room is used as the doffing area. Within a specially marked area of the anteroom floor, immediately adjacent to the door to the patient's room, the anteroom nurse prepares a "chemical mat" for the "dirty" HCW to step on when exiting the patient room. First, a disposable chux-type pad is placed in the marked area. A solution of water (600 mL) mixed with disinfectant (300 mL) is carefully poured onto the pad to create a chemical mat. The HCW leaving the room first removes one shoe cover and steps onto the chemical mat. The second shoe cover is then removed, and the HCW steps onto the mat with the other foot. The bottoms of the HCW's shoes are now decontaminated, and he or she can step onto the floor of the anteroom without contaminating the floor.
Nebraska.The doffing protocol at the Biocontainment Unit uses a dry doffing pad to prevent contamination of the floor before the boot covers are removed and the shoes are cleaned. The doffing pad is divided in half, into "clean" and "dirty" areas. The HCW leaving the room steps onto the dirty half of the pad. One boot cover is removed, and the HCW then places that foot onto the clean side of the pad. This is repeated with the other foot. Before stepping off of the doffing pad onto the floor, the assistant cleans the tops, sides, and bottoms of each shoe with bleach wipes.
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