Clinical Editor's Corner: Kern

“The D’Officer” – Tips on Donning and Doffing PPE

Morton J. Kern, MD, MSCAI, FACC, FAHA

Clinical Editor; Chief of Medicine, Long Beach VA Medical Center, Long Beach, California; Associate Chief Cardiology, University of California, Irvine Medical Center, Orange, California 

Morton J. Kern, MD, MSCAI, FACC, FAHA

Clinical Editor; Chief of Medicine, Long Beach VA Medical Center, Long Beach, California; Associate Chief Cardiology, University of California, Irvine Medical Center, Orange, California 

Our cardiac cath labs will be taking care of patients with COVID-19 (C19) for at least a couple years. Some hospitals with several labs can designate one lab as a C19 lab, and isolate the area and establish protocols for working in the lab safely. If you are a small hospital with only one lab, you may have to perform the C19 procedure at the end of the day, followed by a terminal cleaning and withholding further procedures for C19-negative patients until the next day (if possible). In our hospital, we are reactivating one of the operating rooms we had used for cardiac cath while remodeling the current lab. In planning for C19-positive cases, we changed the patient flow through the lab to enter from a side hallway door, curtained the corridor with plastic seal sheeting, and created a pass-through from non-COVID space to COVID space for supplies. We will reduce the number of team members in the lab caring for the patient and of course, we will require full personal protective equipment (PPE).  

In practicing for the C19 emergent cath case, it became apparent that although we thought we knew what the instructions were for proper donning and doffing of PPE, the actual steps we needed to take were not automatically understood. We needed a “D’Officer” (doffing observer) to help. Here’s what we heard (Figure 1) on my first attempts: “Let’s see, first the N95, then the gown, then the booties, then the gloves?? Oh, da*&%n, I got dirty taking off my hat, then the mask…No? I’m glad you caught me!” We found the D’Officer extremely helpful. I thought I would share some of the recommendations for the proper and safe way of donning and doffing PPE for the C19 cath lab.1,2 Keep in mind there is more than one way to accomplish safe donning and doffing of PPE. The protocols must fit into your hospital work flow for the cath patients. 

First Principle  

The first principle is awareness that when coming out of a C19 procedure, the front surface of face masks, gowns, and other PPE are contaminated once used, and should be carefully taken off and disposed of safely.1

Donning of PPE

1. Wear surgical scrubs and change after each C19-positive case is treated or if there is any clothing soiling. Remove jewelry. Tuck scrub top into scrub pants. Wear a scrub hat that covers both ears.

2. Wash your hands thoroughly for at least 20 seconds (as long as singing 2 rounds of ‘Happy Birthday’) prior to initiating the donning process.

3. Put on your usual radiation protection equipment as used for the regular procedures.

4. Don booties (shoe covers). 

5. Don the N95 respirator mask. Some hospital teams are using a second disposable paper surgical mask to protect the N95 from direct exposure and contamination. N95 respirator masks should have been fit-tested and the correct size respirator mask for the individual should be used.

6. Don a disposable paper gown over your lead apron. Take care to ensure that gown sleeves do not go beyond wrists as it is put on. Ensure that the top of the gown covers as much of the exposed neck area as possible. Non-sterile gloves are put on and then ‘washed’ with topical disinfecting gel before going into the cath lab in order to put on the sterile gown in the lab. The second set of gloves (sterile) is put on in the cath lab. (This is the two-glove method.)

7. Additional face protection (eg, plastic shield) should be used, and worn over the N95 respirator and scrub cap. Plastic helmet-type face shields can be reused if cleaned properly. Surgical safety goggles can be used as an alternative, but will need to be sterilized after each case. The shield visor should adequately cover both eyes and provide some protection to the sides of the face. Tip: Put the face shield on after the first gown, as the gown needs to be pulled over one’s head.

8. Prescription glasses or lead glasses are not enough for face protection. 

9. If you’re using the two-glove technique, ensure that both gloves fit snugly and cover the sleeves of the gown.

Doffing of PPE

Doffing carries the highest risk of contamination. Therefore, another individual should watch you doffing the PPE and alert you to any possibility of contamination (ie, our “D’Officer”). Steps to safe doffing are the following:

1. At the end of the case, the control room reminds everyone to take C19 precautions.

2. Exit cath lab to anteroom.

3. Remove shoe covers and discard (you’ll need some balance point, eg, a chair). 

4. There is a question as to whether one should wash hands/gloves with alcohol during each step of doffing. Some institutions recommend cleaning hands between every step of the procedure.

Gowns and Gloves (Figure 2)

Remember: the gown front and sleeves, and the outside of gloves are contaminated! If your hands get contaminated during gown or glove removal, immediately wash your hands or use an alcohol-based hand sanitizer. 

5. Grasp the gown in the front (near the shoulders) and pull away from your body so that the ties break, touching outside of gown only with gloved hands. 

6. While removing the gown, fold or roll the gown inside-out, into a bundle. 

7. As you are removing the gown, peel off your gloves at the same time, only touching the inside of the gloves and gown with your bare hands (or if using two-glove method, your inner pair of gloves). Place the gown and gloves into a waste container. 

Goggles or Face Shield

8. Remember: the outside of your goggles or face shield is contaminated! If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer.

9. Remove goggles or face shield from the back, by lifting head band and without touching the front of the goggles or face shield. 

10. If the item is reusable, wipe with sanitizer and place in designated receptacle (paper bag) for reprocessing. Otherwise, discard in a waste container.

Mask or Respirator 

11. Remember front of mask/respirator may be contaminated — DO NOT TOUCH! 

12. If your hands get contaminated during mask/respirator removal, immediately wash your hands.

13. Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front.

14. Discard in a waste container. 

15. Remove scrub cap.

16. For two-glove method, remove internal pair of gloves, wash hands. 

17. Remove radiation protection (and wash your hands). 

Radiation protection equipment should be cleaned with an alcohol scrub. Surgical scrubs should be washed. The chair used during doffing of booties should be cleaned with an alcohol scrub. There is a recommendation that you then take a shower, but many operators elect to shower only before leaving the hospital (Figure 3).

All supplies and equipment that cannot be effectively cleaned at the end of each case should be removed if possible, so as to avoid the potential for cross-contamination. In addition, frequent wipe downs of commonly touched objects in the control rooms (ie, keyboards, mouse, door handles) should be performed. Recommendations on how to safely clean cell phones using 70% isopropyl alcohol wipes have been issued by different vendors. 

To minimize personnel exposure in the cath lab, the number of staff and clinicians in the cath and control rooms should be kept to a safe minimum. No visitors for the moment, as well. Control room personnel should adhere to social distancing if possible and of course, continue to use face masks.  

The Bottom Line

For the protection of all healthcare workers, we can minimize contagion by safe donning and doffing. Using a D’Officer is helpful. Good practices to reduce contamination must be actively renewed and carried out daily (Figure 4). As I mentioned in a previous editor’s page, we will meet this challenge with the professionalism that defines the cath lab life. Moreover, you should be very proud to be protecting and serving our patients, families and co-workers over this pandemic time.

Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, Opsens Inc., and Heartflow Inc. 

Dr. Kern can be contacted at mortonkern2007@gmail.com.

On Twitter: @drmortkern

References
  1. John TJ, Hassan K, Weich H. Donning and doffing of personal protective equipment (PPE) for angiography during the COVID-19 crisis. Eur Heart J. 2020 May; 41(19): 1786-1787.
  2. Szerlip M, Anwaruddin S, Aronow HD, et al. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates [published online ahead of print, 2020 Mar 25]. Catheter Cardiovasc Interv. 2020;10.1002/ccd.28887. doi:10.1002/ccd.28887.