Reducing Contamination: Enhanced Training for Effective Donning and Doffing of Personal Protective Equipment

Donning and Doffing

In the midst of the COVID-19 pandemic, healthcare workers had to take many precautions to avoid being infected, and ineffective use of personal protective equipment (PPE) was a significant hazard. In the Department of Anesthesiology, an initiative was launched to train residents in effective techniques for putting on and removing PPE. Led by Cameron Smith, M.D., Ph.D., and Brenda Fahy, M.D., the training was implemented in 2020 and documented in an article published in the Journal of Clinical Anesthesia’s June 2023 issue entitled “Staying Proper with Your Personal Protective Equipment: How to Don and Doff.” Along with Dr. Smith and Dr. Fahy, co-authors included Terrie Vasilopoulos, Ph.D., Amanda Frantz, M.D., Thomas LeMaster, MSN, M.Ed., R.N., Ramon Martinez, and Amy Gunnett, R.N.

“Dr. Fahy and Dr. Smith started out by asking if the residents knew how to don and doff their PPE,” said Gunnett. “They soon realized there wasn’t any formal training. The assumption was everyone knew how.” Previous experience with a deadly coronavirus outbreak in Canada supported Dr. Smith’s interest in effective improvement efforts. “I was in Toronto during the height of the first SARS epidemic in 2003, which had an 11% fatality rate,” said Smith. “Many of my colleagues got sick, so we had a lot of formal training.” Smith brought this training to bear in helping develop the donning and doffing instruction for anesthesiology residents. “Across the board, people are not good at this stuff when they don’t have formal education. A little bit of training goes a long way.”

Donning and Doffing

A multi-step approach was used to train first- and second-year anesthesiology residents, which was administered through the Center for Experiential Learning & Simulation (CELS) with assistance from LeMaster, the director of education and training programs. First, prior to formal instruction the participants were asked to put on PPE in the way they considered appropriate for caring for a COVID-19–positive patient. To simulate exposure to the virus, they were then sprayed with a fluorescent marker and filmed under a blacklight before removing their PPE. Afterwards, contaminated areas were identified. “You should expect the outside of any PPE you’ve used during aerosol-generating procedures to be contaminated,” said Smith. “Data show that people are far more likely to contaminate themselves while taking off their equipment.”

After that initial stage, participants were shown a video demonstration illustrating the proper donning and doffing techniques for PPE. This was followed by a face-to-face demonstration and practice, with participants outfitting themselves using the techniques they had learned and then repeating the simulated exposure, filming, and PPE removal steps. They were checked again for areas of contamination and received feedback.

Amy Gunnett, RN

“I think the biggest lesson that Dr. Smith and Dr. Fahy were trying to get across to the residents is that we’re always wanting to move quicker, but you need to take the time to make sure you’re protecting yourself.”

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“We definitely saw an improvement in the ways they put on their PPE,” said Gunnett. “It was interesting to them that they thought they were doing the right things but they would find contamination on their hands, in their hair, or on their necks. The residents wanted to learn, which was nice, and so we saw improvement.”

As a result of the training, participants’ donning and doffing techniques were significantly improved. Overall contamination decreased by nearly 30%, and contamination across multiple areas decreased to only 6%. “I thought it was fantastic,” said Smith. “We were able to demonstrate very nicely with the short intervention that people were able to put PPE on and take it off properly.”

Donning and Doffing

To evaluate the long-term effectiveness of the training, a follow-up session was held six months later. The results indicated a decline in skills retention, data which the research team is using to improve future efforts. One area they are evaluating is the inclusion of a trained observer in the process. “In studies related to Ebola, recommendations from CDC are that there should be someone else whose whole job should be watching you [don and doff PPE],” said Smith. “If they observe you making mistakes, they will point them out so you can correct them.”

Due to their effectiveness, trainings on properly donning and doffing PPE continue to be delivered. “During Intern Education Month they do a workshop over at the sim center,” said Gunnett. “I think the plan is to continue this because it’s something that previously hasn’t been formally taught.”

Gunnett continued, “I think the biggest lesson that Dr. Smith and Dr. Fahy were trying to get across to the residents is that we’re always wanting to move quicker, but you need to take the time to make sure you’re protecting yourself. It’s the same when you’re removing the PPE: take the time to make sure you’re doing it properly. There tends to be a ‘we have to hurry up’ mentality, that’s just the nature of medicine, but sometimes you have to stop and take the time to take care of yourself.”