training review feedback

>> hi. i'm peter pronovost, the johnhopkins medicine senior vice president for patient safety and quality and thedirector of the armstrong institute. one of the most important ways you cankeep yourself safe in caring for patients with ebola is to make surethat you learn to put on and take off personal protectiveequipment in the most appropriate way. now the centers for disease control hasprovided us detailed guidance for how to do that, but we need to train modules. so we partnered with the cdc to do that. we pulled together our infectious diseaseexperts, human factors and systems engineers,

psychologists, instructionaldesigners, and technology experts to come together to produce this content. we've been here a week workinglong hours to make modules for you, and now what you'll see are threekey modules-number 1, how to put on or don personal protectiveequipment, number 2, how to take off or doff personal protective equipment, andnumber 3, how the observer can work together to help ensure your safety using teamworkbehaviors that were developed by the agency for healthcare research and quality. now we know these are anxiety-filled times.

believe me, i'm a critical care physician. i'm right with you, but we alsoknow that with proper training and when we ensure your competency inputting on and taking off this equipment, we could safely care for these patients. so we hope you enjoy the training and from ourcolleagues at the centers for disease control and our colleagues at john hopkins medicine,we thank you for all you do for patients. >> this training module discusses the rolesand responsibilities of trained donning and doffing observers called trained observers. a trained observer is a clinician, most likelyan infection prevention professional nurse

or physician whose sole responsibility isto guide healthcare providers as they don and doff personal protective equipment or ppe. when acting as a trained observer, you willnot be delivering care directly to patients. instead you will focus on ensuring thesafety of healthcare providers and, in some circumstances, their doffing assistants. you may directly assist yourcare delivery colleagues as they don their personal protective equipment. you will need to walk through the care processesand equipment usage patterns of your institution to understand when and if adoffing assistant is required.

if your institution determines that thereare circumstances where you, as the observer, will also offer doffing assistance, youshould strictly minimize physical contact. when you work with a healthcare provider anddoffing assistant, you will not assist at all. you are a proactive risk monitor, protector,and guide who calmly leads healthcare providers through the routine aspects of donningand doffing personal protective equipment. remember, an effective observeris vigilant in spotting breaches, is proactive in identifying upcoming risks, usesthe checklist but focuses on the big picture, is informative, supportive, and wellpaced in issuing instructions or advice, always washes immediatelyafter providing assistance.

the broader goal is to minimize the amountof direct contact assistance you provide. if you do provide assistance in doffing,remember always to disinfect your gloves. this hand hygiene step must be followed everytime you touch possibly contaminated equipment. hand hygiene is time consuming,but is critical for safety and a good method of pacing the doffing process. as an observer, you will ensure the safetyof the healthcare provider by helping them to manage the complexity of thecritical donning and doffing tasks. you will also provide psychological supportduring an inherently stressful experience. observers are responsible for monitoringto maximize safety by ensuring compliance

with personal protective equipment protocols,guiding, correcting, and assisting colleagues as they work through the process ofdonning and doffing, protecting yourself through proper personal protective equipmentuse during doffing, promoting mindful and steady adherence to protocols,anticipating and planning for risks. to achieve this, you mustbe a leader, a protector, and a guide who calmly coaches team members through the routine aspectsof donning and doffing. as an observer you will do muchmore than watch and record. you will be an active participantin protecting the healthcare worker.

to do so, you need to customizeyour participation according to your facility's resources,equipment, and physical layout. you need to understand your local process. for example healthcare providers will requiremore intensive assistance doffing certain types of personal protective equipment. how will you balance your role as observerand leader with the need for physical contact? will you require a doffing assistant? you will also actively lead andsupport your colleagues' actions. only use the checklist as a guide.

it is a memory aid, not a tick box. use it to direct action and sensitizeyourself and your team members to risks and adhere to safe practices. as a trained observer, you will be a teamleader and responsible for maintaining accurate, complete, and up to date situational awareness. to do this you will need to keep thebig picture in mind, manage details, and help healthcare providers identifyand avoid any potential protocol breaches. first, keep the big picture in mind. this includes understanding and managingthe entire donning and doffing processes

where the healthcare worker currently is inthe process, what your team members need, and any possible safety risks thathave or could arise in a situation. don't hesitate to give the teammembers an update on the big picture. it is critical to ensureeveryone is on the same page. second, manage details. this includes the effectivecompletion of each step in the process. monitoring adherence to protocolsis central to the observer role but be an active participantand use the checklist as a tool. third, help clinicians identify andavoid potential protocol breaches

by understanding the situation,thinking ahead, being sensitive to risks, and proactively communicatingwith your team members. you should remain vigilant about fourfactors while leading the donning or doffing process-the situation, team members,environment, and progress towards your goal. be aware of the situationincluding preparing needed equipment and ensuring the work areais properly configured. always ask, "do we have needed supplies and personal protective equipmentin the correct sizes? is the equipment functioning properly?

do we have waste disposal containers available? are they full?" be aware of your team members' statusand their needs in order to support them. you should ask, "are they fatigued?" proactively warn them during criticalsteps where fatigue may cause error. for example when taking off a hood, warn themnot to touch their face or wipe their brow. are they overly anxious? in a calming tone, refocusthem on the task at hand. reassure them they will get through this.

when beginning doffing, willyou need a doffing assistant? think through your local process and equipment. if you will need an assistant during doffing,make sure you have identified that person and that they will be available in the properpersonal protective equipment before beginning the doffing process. be aware of the environmentand any risks it may pose. ask, "is there contamination ofany areas, surfaces, or equipment? are donning and doffing areasclearly designated? are there any hazards in the environment?"

be aware of progress towards your goal. you will be coaching the healthcareworker through donning and doffing. you guide the process, and you set the pace. letting your healthcare worker know howfar they are in the process can be calming and support a steady and measured pace. where are we in the process,and what comes next? pacing. are we moving too fast? do we need to slow down? the observer is much likea team leader or coach.

it is your job to set the stage for safecompletion of the donning and doffing processes. you will lead the process. this includes conducting briefingsto establish role clarity. who will be responsible forassisting if it is required? it is your responsibility to ensure you havethe right people available at the right time and that they are adequately protected withappropriate personal protective equipment. additionally you will need to anticipatechallenges your healthcare worker may experience along the way. is there new personal protectiveequipment in use?

have our processes changed recently? are there any hazards in theenvironment that can be managed? this also includes asserting yourleadership to manage distractions and guide the clinician through the process. you will facilitate effective communication. as the support system for your healthcareworker, you can employ several tactics to ensure communication isclear, accurate, and timely. establish red flag wordsto immediately stop action. ensure understanding by having alldirections verbally repeated by the clinician.

red flag words or stop the line phrases areverbal shorthand for important information or protocol steps, phrases thatwill be quickly understood. red flag words improve the efficiency ofcommunication and reduce the amount of effort and time you spend gettingacross critical information. in healthcare cus words are commonly used. "i'm concerned." "i'm uncomfortable." "this is a safety issue." these are easy phrases that requireeveryone to stop and pay attention.

it is up to you to define andreinforce the red flag words. use words that have a consistentmeaning in your organization. you should have red flag words defined fora breach in protocol requiring a full stop but no immediate hazard, a breachin protocol and immediate hazard. closed loop communication helpsensure information is received and interpreted as intended. here messages that are sentare acknowledged and verified. closed loop communication shouldbe verbal and explicit instructions that are repeated by the healthcare provider.

repeating instructions iscritical in this situation. your healthcare provider will likely befatigued and stressed, known contributors to communication slips and lapses. additional some of the personalprotective equipment can degrade hearing. to address these challenges use closed loopcommunication for each instruction given. closed loop communicationshould be verbal and explicit. it should be used for each step of the protocolat both the beginning and ending of each step. specifically you should verbalizethe next step of the process. the healthcare worker should repeat this backto you and subsequently you should verbalize

when that step has been completed successfully. this pattern of communication not only ensuresgood information exchange, it helps control and slow the pace of the process. while your primary role is a leader and coach, your healthcare providermay need physical assistance at points during the donningand doffing processes. during donning you may assist at anypoint as this is performed in a clean area with clean personal protective equipment. during doffing, you should remember 5key principles-minimize physical contact;

plan for when you will need a doffing assistant;anticipate where you may need to assist; protect yourself when you do assist; onceyou assist, you are now contaminated. discuss these points in your pre-briefingwhere you review the process and clarify roles and determine who will be steppingat what points of the process. for example, in the doffing process, youmay need to help the healthcare worker to remove respirator, gown, or jumpsuit. the points requiring assistance shouldbe decided during the pre-briefing and process walkthrough and aplan established at that point. the trained observer should not enter theroom of a patient with ebola but will be

in the personal protective equipment doffingarea to observe and assist with removal of specific components of personalprotective equipment as outlined below. the observer should not participate inany ebola patient care activities while conducting observations. the following personal protective equipmentare recommended for trained observers. single use, disposable, fluid-resistant,or impermeable gown that extends to at least mid-calf or acoverall without integrated hood. single use, disposable, fluid-resistance,or impermeable gown that extends single use, disposable full facial,

single use disposable night trialexamination gloves with extended cuffs. two pairs of gloves should be worn. at a minimum outer glovesshould have extended cuffs. single use, disposable, fluidresistant, or impermeable shoe covers. shoe covers should allow for ease of movementand not present a slip hazard to the worker. trained observers should don and doff selectedpersonal protective equipment according to the same procedures outlinedfor the healthcare worker. if the trained observer assists withpersonal protective equipment doffing, then the trained observer shoulddisinfect outer-gloved hands

with an epa registered disinfectant wipe oralcohol based hand rub immediately after contact with healthcare workers'personal protective equipment. the trained observer's role in thedonning process has 3 major components. one, guide the healthcare provider throughthe donning process using the checklist; two, assist the healthcare provider in donning theirpersonal protective equipment as necessary; three, continually scan yourcolleague's personal protective equipment and the environment for possiblecontamination risks during donning. the checklist is a memory aid thatstructures the donning process. its details are important, butthey are not your only focus.

the big picture here is keeping yourcolleague and yourself safe by identifying and avoiding contamination risks. all instructions from the checklist need to be verbally confirmed closing thecommunications loop before they are acted on. assuring successful completion of eachdonning step is one of your major roles. remember to use verbal andexplicit closed looped communication for each step in the process. ideally as the observer, you tell thehealthcare provider what step to perform. they verbalize back the task toensure they understood, and you,

as the observer, verbalize completion. completion means a thoroughcheck that every part of the healthcare worker's personal protectiveequipment is in place, in tact, fits properly, allows freedom of motion so yourcolleague can do their work, is positioned to ensure allskin and hair is covered. completion also means a thoroughcheck to ensure no part of the personal protectiveequipment is ripped, torn. as an observer you are guidingand protecting your colleagues. the foundation of your role is communication.

the first step here is to agree ona system of engagement so that you and your healthcare provider colleaguecan signal one another that the donning and doffing process needs to begin. will you use call bells orhand signs or verbal signals? will you as the observeralways be in a certain location or available on a certain pager or phone? the donning process begins when you andthe healthcare provider engage one another and verbally review the protocol. this time out or pre-briefing will involveconfirming all necessary supplies are available,

conveniently located, correctly sized, and ingood working order including no rips or tears, running through the order of activitieson the checklist, setting expectations about the timeline, and a slow, steadypace for completing the donning process, establishing a common understanding of whatyou will do if something unexpected happens. acting as a guide and protector means thatyou are proactive about identifying breaches of protocol and possiblepoints of contamination. as examples when you and yourcolleague begin the donning process, you may notice that they are stillwearing jewelry or id badges. draw items like cellphones, jewelry,

and id badges to your colleague'sattention well before they don any personal protective equipment. a good time may be when they changeinto their fresh surgical scrubs. other examples of proactive risk monitoringduring doffing might include identifying issues with equipment. >> i'm looking at your gloves. do they seem to fit? they look a little big. let's get you a different size.

>> identifying placement and fit issueswith personal protective equipment. >> now we're going to verifythat the ppe was placed properly. we're going to make sure thatall your skin is covered. >> controlling the pace of the donning process. >> we're going to do this safely. we're going to do everythingslowly and methodically. i'm here to help you if youhave any kind of questions. >> these are only some examples. your role is to protect not byjust reading from the checklist

but by proactively monitoringfor contamination risks. the trained observer's role in the doffingprocess has three major components-one, guide the healthcare provider andin some cases the doffing assistant, through the doffing process using the checklist;two, ensure doffing proceeds at a slow, deliberate pace; three, continually scan yourcolleague's personal protective equipment and the environment for possiblecontamination risks during doffing. a major part of your role as an observer is toensure safety by proceeding at a measured pace. always engage in confirmatory, closed-loopedcommunications with the healthcare providers and doffing assistants you are guiding.

you should assure successfulcompletion of each doffing step, remembering that completion means a removeditem is in tact and has not touched clean areas, has been disposed of properly inthe available waste container, and has not contaminated any staff members. the doffing process begins when youacknowledge your colleague's need to exit the patient care space. before you approve theirexit from the patient space, you must ensure you are wearingappropriate personal protective equipment. if you are not already wearing personalprotective equipment, follow the protocols

in place at your institution for donningobserver level protection to ensure your safety. as the observer, it is part ofyour role to maintain awareness of the situation and anticipate needs. once you are wearing personal protectiveequipment, you should inspect the doffing area to ensure that an appropriately maintained and not overfilled medical infectiouswaste container is available. all other equipment necessary for doffing shouldalso be available and in good working order. also at this time determine ifyou will need a doffing assistant to help safely remove personalprotective equipment.

you will need one if the healthcareworker is using a paper or a coverall. once in the doffing area, remind thehealthcare provider or the healthcare provider and doffing assistant to wait for your instructions beforebeginning the doffing protocol. >> i'm here to help you throughthe doffing process. you'll hear me give you directionsthat aren't part of standard process, but they're designed to keep you safe. >> it is important to remindthe healthcare provider not to touch their face during the process.

>> remember, go slowly anddo not touch your face. >> appropriate communications willhelp you keep the healthcare provider and any doffing assistant safe. take the time to go through the orderand the activities on the checklist. set expectations for a slow and steady pacefor safely completing the doffing process. prompted by the checklist, provide step-by-stepinstructions to the healthcare provider. use closed loop communicationthroughout the process. each step should be acknowledge by thehealthcare provider, the action taken, and then re-acknowledged bythe observer as completed.

only then should you move on to the next step. be familiar with the checklist but rememberyour focus is on the bigger picture. in cases where you will be assisting a colleaguewearing a paper or an n95 respirator combined with a coverall, a third person will be needed. it is your role as the observer to ensure thisperson called a doffing assistant is available and wearing appropriate personalprotective equipment. be sure the doffing assistantis trained on the protocols. remaining outside the doffingarea, you will observe and guide as a doffing assistant inspects the healthcareprovider for any signs of contamination.

any areas that are identified as contaminatedshould be disinfected using an epa approved disinfectant wipe. remember, for safety the doffingassistant is to provide a minimum of direct assistance to the healthcare provider. if they do assist the healthcareprovider directly, it is your job to ensure theyimmediately perform and hygiene. in cases where you'll be assisting a colleaguewearing an n95 respirator combined with a gown, your role as the observeris to guide their doffing, minimally assisting themif absolutely necessary.

unless assistance is necessary, you will remainoutside the doffing area, guiding and pacing without coming into contact with your colleague. if you do provide assistance, youmust immediately perform hand hygiene. your role as an observer goesbeyond reading the checklist. you should proactively sensitizethe healthcare provider to risks at different steps of the process. for example, when a healthcare provider removestheir protective headgear, they may be likely to inadvertently wipe theirbrow or push their hair back. when providing directions for these steps youcan offer supportive comments and reminders

to be careful not to make those slips.