17 Donning and Doffing


Emerging pathogens are defined as novel etiological agents that have been recently introduced in a population. The most recent emerging novel virus is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which created a global pandemic. SARS-CoV, a member of the coronaviridae family, is known to infect the horseshoe bat and in late 2019 “jumped” into a human host, thus resulting in a worldwide pandemic. In the human population, SARS-CoV causes a respiratory disease called coronavirus disease 19 (COVID-19). Many viruses such as influenza viruses and SARS-CoV-2 affect the respiratory tract and are transmitted by respiratory secretions and aerosol droplets. Effective measures for preventing their transmission in a health care setting include following infection prevention practices. As the virus evolves in the human population, so do the science, diagnostic measures, treatment modalities, and prevention strategies. Sharing updated information regarding the various aspects of the disease caused by the virus will help in managing and controlling emerging viral infections better.1

A multipronged approach is needed in decreasing the transmission of SARS-CoV-2. This approach in health care includes universal masking, social distancing, use of personal protective equipment (PPE), implementation of isolation precautions, hand hygiene, and vaccination. This chapter will focus on the use of infection prevention measures to prevent the transmission of infection to patients and health care providers (HCPs).

General Infection and Prevention Practice in an Acute Care Setting

General Infection Prevention Practices

During the SARS-CoV-2 pandemic, the Centers for Disease Control and Prevention (CDC) recommends using standard precautions with additional infection prevention and control practices in the care of all patients. Some additional practices include screening for symptoms of COVID-19, adherence to source control of respiratory secretions with the use of a mask, and social distancing.2

Entrances of the Facility

Screening of persons entering the facility is an important strategy to identify persons with symptomatic disease. Persons need to be screened by asking for the presence of the following symptoms: fever, cough, shortness of breath (SOB), chills, myalgia, headache, congestion, ageusia, and anosmia. Persons entering the building should also be queried if they have been diagnosed with COVID-19 in the past 10 days or exposed to a person with COVID-19 in the past 14 days. Persons who respond positively to any of the questions should be restricted from access and referred for evaluation.3

Hospital-Wide Locations

Signage regarding infection prevention practices, facemask, screening, hand hygiene, respiratory etiquette, and social distancing should be visible at the entrances and strategic locations such as waiting areas, dining areas, and elevators. Limiting the number of persons in elevators should be posted to ensure proper distancing.

Social distancing is a vital strategy to prevent the transmission of COVID-19. Reminders such as markings should be placed on the floor, indicating 6-feet separation when anticipated waiting for lines. Seating in waiting areas should spatially be separated by 6 feet. Strategically place alcohol-based hand sanitizers (ABHRs) with 60 to 95% alcohol throughout the building. In attempts to decrease transmission of COVID-19, visitors and unnecessary personnel should be restricted or limited during high prevalence of transmission.3

General Guidelines for the Use of Masks

Studies reveal that asymptomatic patients can transmit the infection to others due to the presence of high viral loads in the upper respiratory tract.46 Therefore, masks are essential in the strategy for the source control of respiratory secretions from persons who are speaking, sneezing, or coughing. Well-fitting facemasks are required to be worn by all persons older than 2 years within the health care facility and by all HCPs.

To limit the potential for contamination, the HCP should consider wearing the same mask and eye protection throughout their work shift. If the HCP needs to remove the mask or eye protection, perform hand hygiene before and after removing PPE.

Breakroom Areas

The potential for exposure to SARS-CoV-2 can also occur from other employees as well as patients. Maintaining social distancing as well as source control of respiratory secretion during meal and break time is essential. Signage with the appropriate number of persons should be posted inside the breakroom and meeting rooms. The use of plastic barriers is an additional measure to decrease potential exposure to respiratory secretions during mealtime. High-efficiency particulate air (HEPA) filters in breakrooms and eating locations are an added measure in decreasing the transmission of infection.

Routine Care for Patients Not Diagnosed with SARS-CoV-2

Facemasks covering the patient’s nose and mouth should be worn at all times to manage source control of respiratory secretions. During mealtime, the facemask may be removed and replaced as soon as possible. Patients may remove their mask when alone in their rooms but the mask should be donned as soon as other persons are in the room or upon leaving the room.

As part of the daily and ongoing assessment of the patient, the HCP should include screening for symptoms of COVID-19 and monitor temperature and oxygen saturation. Transmission-based precautions (TBPs) should be implemented for any unexplained fever or symptoms of COVID-19. HCPs should wear an N95 respirator or a well-fitting facemask with a nosepiece. When donning the facemask, the HCP must conform the nosepiece to the face in a smooth fashion and secure the mask tight to the face and ensure that there are no gaps on either side of the mask. Eye protection from respiratory secretions should be worn during all patient encounters.

Patients with Suspected/Confirmed SARS-CoV-2 Infection

Patient Placement and Isolation Precautions

Those persons who have been in close contact with someone who has COVID-19 need to be quarantined for 14 days from the last exposure. Persons who have mild-to-moderate illness and are stable may be quarantined at home in a private room. Persons who have tested positive for COVID-19 in the previous 3 months do not need to quarantine.7

Hospitalization is required for COVID-19-positive persons who are acutely ill or are decompensating. Patients with suspected or confirmed COVID-19 should be admitted in a private room with a bathroom; the door should be closed, and the patient should be placed on transmission-based isolation precautions. Patients may be grouped together in a semiprivate room if they have lab-confirmed COVID-19 infection and no other infectious disease or respiratory pathogen is identified. Designating patient care units for confirmed or suspected SARS-CoV-2 patients with assigned staff is a strategy to limit HCPs’ exposures and conserve PPE.2

Patients should wear their masks at all times, except when eating or drinking. Maintain a barrier between patients by using a privacy curtain or plastic barrier. Patients should be kept alone if they cannot keep their facemask on or are symptomatic despite negative SARS-CoV-2 tests. Ideally, aerosol-generating procedures (AGPs) should take place in a negative pressure room.2 Aerosol-generating procedures are considered; “open suctioning of airways, sputum induction, cardiopulmonary resuscitation, endotracheal intubation and extubations, bronchoscopy, manual ventilation and non-invasive ventilation” such as bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP). Other procedures that may create aerosolization are nebulizer administration and high-flow oxygen delivery.8

Transmission-Based Precautions

TBPs are based upon the routes transmission of a suspected or confirmed pathogen to another person. The transmission of a pathogen depends on many factors such as the infectiousness of the pathogen, the type of care the HCP is providing, the proximity of the HCP and the patient, use of PPE, and compliance with hand hygiene.

The SARS-CoV-2 virus is approximately 0.1 µm in diameter. Respiratory droplets produced by speaking, coughing, and sneezing are divided into two sizes; large droplets (>5 µm in diameter) and small droplets (≤5 µm in diameter). Large respiratory droplets fall to the ground rapidly, are transmitted over short distances, and settle onto surfaces and contaminate the environment or patient room. Patients with infectious diseases that produce large droplets are placed on droplet precautions. Small respiratory droplets can remain suspended in the air for a significant period of time as droplet nuclei. These droplet nuclei can be inhaled. Aerosolized particles (<5 µm in diameter) may be generated from infected patients, especially during AGPs. Therefore, the implementation of airborne isolation precautions is recommended. N95 masks are manufactured to remove more than 95% of all particles that are at least 0.3 µm in diameter. Measurements of particle filtration of N95 masks reveal they are efficacious in filtering approximately 99.8% of particles with a diameter of approximately 0.1 µm.9

HCPs can contaminate themselves by touching contaminated surfaces with their hands and subsequently touching their mucous membranes (eyes, nose, and mouth) during doffing PPE or if hand hygiene is not performed when indicated. SARS-CoV-2 pathogen has been recovered from surfaces several weeks after contact.10 The remaining stability of the infectious virions on surfaces varies depending on the type of surface, the temperature, and the humidity of the environment. Note that the stability of the virus on plastic is greater than that on copper or steel.11 Due to the potential for the environment to become contaminated, contact precautions are also recommended.

Negative Pressure Rooms and Airborne Isolation Precautions

Airborne isolation refers to the isolation of patients infected with organisms spread by airborne droplet nuclei less than 5 μm in diameter. Negative pressure rooms are required to be designed using the single-pass approach bringing clean air from a clean area to the contaminated area. Several factors impact the actual negative pressure level, such as the differences in the supply air volume and the exhaust air volume, airflow paths, and airflow openings as well as room size. To maintain negative pressure in a room, the exhaust air volume needs to be 10% larger than the supply air volume. Six to twelve air changes per hour are needed to ensure the room is under negative pressure, so airflow direction is from the adjacent outside space such as the hallway into the room.12 The air in the negative pressure room is preferably exhausted to the outside 25 feet away from intake areas but may be recirculated, provided that the return air is filtered through a HEPA filter.13

Negative pressure rooms should be prioritized for a suspected or confirmed COVID-19 patients receiving AGPs. A complete list of AGPs has not been determined for two primary reasons: limited data from studies supporting which procedures would generate infectious aerosols and difficulty in determining if transmissions during AGPs are due to the aerosolization of infectious particles. In general, coughing, sneezing, talking, and breathing can create aerosolization of respiratory particles, but some procedures may create uncontrolled respiratory secretions and place HCPs at an increased risk of exposure to respiratory pathogens. These procedures include open suctioning, sputum induction, cardiopulmonary resuscitation, intubation and extubation, supplemental oxygenation using BiPAP or CPAP, bronchoscopy, and manual ventilation. There are limited studies to confirm if aerosolized particles from medications administered through a nebulizer or high-flow oxygen delivery are infectious.14,15

General Care

All persons entering a patient’s room with suspected or confirmed COVID-19 are to practice TBPs, perform hand hygiene, and wear the appropriate PPE. Persons at the most significant risk of infection are those who have prolonged, unprotected close contact, defined as within 6 feet for 15 minutes or longer, with a confirmed SARS-CoV-2-infected symptomatic or asymptomatic person. This risk can be reduced by practicing social distancing, performing hand hygiene, and wearing appropriate PPE.8

To decrease the exposure of employees to suspected or confirmed cases of SAR-CoV-2, bundling of care should be implemented when feasible. Reallocating duties such as surface cleaning of the patient room or dietary tray distribution to a few personnel also helps decrease HCPs’ exposure. Dedicated equipment should be used for a suspected or confirmed SARS-CoV-2 patients. If dedicated equipment is not available, all equipment needs to be cleaned and disinfected according to the manufacturer’s recommendations. When delivering care to a patient, limit exposure to the environment as much as possible and limit the traffic into the patient’s room.

Use routine care for linens and dietary items; no additional precautions are needed. Waste generated from a patient should be contained in strong bags and entirely closed before disposal. Tissues or other respiratory care items used by the patient to manage source control of sneezes or coughs should be immediately disposed of in the trash, followed immediately by hand hygiene.

Measures should be implemented to limit the movement of the patient throughout the facility. Transporting or transferring patients outside of their room should be limited to medically necessary procedures. If the patient needs to be transported to another department, the HCP in the receiving department should be notified in advance to prevent any delays and to facilitate immediate entrance into the exam room, expedited exam, and a quick turnaround to bring the patient back to his room. During transport, the patient should have a facemask and a clean sheet covering the stretcher or wheelchair. The transport vehicle needs to be cleaned after use.3

There is insufficient evidence to determine if the following additional measures impact the risk of transmission, but some HCPs may implement the following:

  • Donning headwear.

  • Removing clothing and immediately washing items worn at work.

  • Showering upon entering the home environment.

  • Dedicating shoes specific for work.

Cleaning and Disinfection

Environmental surfaces can become contaminated with infectious organisms. The virus can be detected on surfaces such as bedrails and floors for a prolonged period of time. The survival time of the virus depends on several factors, including the initial virus concentration, type and smoothness of the surface, temperature, and relative humidity.16,17 The transmission of pathogens usually occurs due to contamination of the hands of the HCP from the patient or their environment. The HCP can then contaminate other patients, employees, equipment, or themselves unless strict adherence to donning and doffing, isolation precautions, and hand hygiene are performed.

Cleaning and disinfection and hand hygiene are integral components of reducing the incidence of all health care–acquired infections. Cleaning may be a one-step or two-step process depending upon the product’s Environmental Protection Agency (EPA) registration. A multistep process requires the surface to be first cleaned and then disinfected. Inactivation of the SARS-CoV-2 virus could be achieved within 1 minute using common disinfectants, such as 70% ethanol or 0.1% sodium hypochlorite.18 The EPA List N is a compilation of all agents with activity against SAR-CoV-2.19

Cleaning is an essential first step because it lowers the number of organisms and bioburden from surfaces, but it does not kill the organisms. Cleaning is done with soap or detergent and water with the physical act of removing the organisms from surfaces or decreasing the bioburden on the surface. Disinfecting is the second step and is carried out using chemicals to eliminate or kill germs on surfaces or objects. This process does not necessarily clean dirty surfaces or remove germs, but killing germs on a surface after cleaning can further lower the risk of spreading infection. All surfaces must be thoroughly cleaned before disinfection can occur.8,20,21

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Jun 23, 2022 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 17 Donning and Doffing
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