>> Hi I'm Peter Pronovost, the Johns Hopkins Medicine Senior Vice President
for Patient Safety and Quality, and the Director of the Armstrong Institute.
One of the most important ways you can keep yourself safe in caring for patients
with Ebola is to make sure that you learn to put
and take off personal protective equipment in the most appropriate way.
Now, the Centers for Disease Control has provided us detailed guidance for how
to do that, but we needed training modules so we partnered with the CDC to do that.
We pulled together our infectious disease experts, human factors and systems engineers,
psychologists, instructional designers, and technology experts
to come together to produce this content.
We've been here a week working long hours to make modules for you,
and now what you'll see are three key modules.
Number one, how to put on, or don, personal protective equipment.
Number two, how to take off, or doff, personal protective equipment.
And number three, how the observer can work together
to help ensure your safety using teamwork behaviors 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 also know that with proper training and when we ensure your competency in putting on
and taking off this equipment, we could safely care for these patients.
So we hope you enjoy the training and from our colleagues at the Centers for Disease Control
and our colleagues at Johns Hopkins Medicine, we thank you for all you do for patients.
>> This donning procedure assumes the facility has elected to us an N95 respirator with a gown.
An established protocol facilitates training and compliance.
Use a trained observer to verify successful compliance with the protocol.
The trained observer will read aloud to the healthcare worker each step
in the donning procedural checklist, and visually confirm and document
that the step has been completed correctly.
The trained observer in the donning process is a dedicated individual
with the sole responsibility of ensuring adherence to the entire donning procedure.
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The donning process is conducted under the guidance and supervision of a trained observer
who confirms visually that all personal protective equipment is serviceable
and has been donned successfully.
The trained observer should suggest to the healthcare worker that he or she attend
to personal needs such as using the restroom and hydration prior
to donning personal protective equipment.
The trained observer uses verbal commands and a written checklist to confirm each step
in donning personal protective equipment, and can assist with ensuring
and verifying the integrity of the ensemble.
No exposed skin or hair should be visible at the conclusion of the donning process.
>> We're now going to work together, carefully, to put on your personal protective equipment.
I'm going to be here with you.
I'm going to help you and guide you.
We're going to do everything slowly and methodically.
If you have any issues or questions just stop and feel free to ask me whatever you need to.
I'm going to give you verbal instructions and you're going to acknowledge them back to me.
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>> Before starting the donning procedure change into clean surgical scrubs
or provided disposable garments and dedicated washable footwear, such as plastic
or rubber materials, in a suitable, clean area.
All footwear should be closed toe and closed heel with no holes.
No personal items such as jewelry, watches, cellphones, pagers,
or pens should be brought into the patient room.
Ensure hair is pulled back, away from the face and off the neck and back.
Ensure that your nails are no longer than a quarter of an inch
so they do not puncture the gloves.
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>> Now we're going to look at your PPE to make sure that everything is here and intact.
>> Visually inspect the personal protective equipment ensemble to be worn to ensure
that it is in serviceable condition, and that all required personal protective equipment
and supplies are available, and that the sizes selected are correct
for the healthcare provider.
The trained observer reviews the donning sequence with the healthcare worker,
before the healthcare worker begins the donning process, and reads it to the healthcare worker
in a step-by-step fashion using a checklist.
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>> First, before any procedure, we need to perform proper hand hygiene.
Make sure that you get in between your fingers, the backs of your hands, and your wrist.
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>> Now we're going to put on your boot covers.
For safety go ahead and sit in the chair and take your time.
>> Make sure that all areas of the foot are covered
and the boot covers are snug over your ankle and calf.
If your boot covers have a strap, wrap the strap around for a comfortable fit.
Try not to touch the floor or other areas with your hands while putting the boot cover on.
If you do, disinfect your hands before putting your inner gloves on.
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>> Now we're going to put on our first pair of gloves.
Do this as you normally would.
It does not need to be done in a sterile fashion.
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>> Make sure that the cuffs of the gloves go as far up your arm as possible.
These are going to be called your inner gloves.
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>> Now I'm going to want you to put on your gown.
Go ahead and look at it to make sure there are no holes or tears.
Take your time.
Put the gown on slowly and methodically.
>> Ensure the gown is sized properly and large enough
to allow unrestricted freedom of movement.
If available, a gown with thumb hooks helps to secure the cuff of the gown over the inner glove
to help ensure there is not a gap between the glove and the cuff.
Tie the gown securely, but in a manner that it can be easily untied
when you begin the doffing process.
Leave some length of the tie so that it can be pulled and untied without much effort.
Ensure cuffs of the inner gloves are tucked under the sleeve of the gown.
>> We're going to tie the gown on the side, carefully, snug, but not too tight.
>> If your gown does not have thumb hooks, some facilities may consider taping the sleeve
of the gown over the inner glove to prevent potential skin exposure from separation
between the sleeve and inner glove during activity.
If taping is used a tab should be created by folding the tape over at the end.
This tab will help facilitate easy removal during the doffing process.
Care must be taken to remove tape gently.
Experience from some facilities suggests that taping may increase risk
by making the doffing process more difficult.
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>> Now we're going to go ahead and put on the N95 respirator.
>> Hold the respirator in the palm of your hand with the straps facing the floor.
Place the N95 respirator on your face, covering your nose and mouth.
Pull the bottom strap up and over the top of your head,
and put it behind your head below your ears.
Take the upper strap and put it behind your head towards the crown of your head.
Mold the nose piece of the respirator over the bridge of your nose to obtain a tight seal.
Always follow the manufacturer's instructions for wearing a respirator.
Perform a fit check to ensure there is a good seal against the skin.
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>> Now you're going to put on your surgical hood.
First you need to inspect it.
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>> You're going to put on the surgical hood so that the opening is in the front.
Slowly pull the hood over your head and your shoulders.
>> The trained observer should give a check once the hood is in place to ensure that all parts
of the skin are covered, no hair is hanging down, and the hood extends to the shoulders.
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>> If the patient is vomiting or has diarrhea, put on a single use, fluid resistant,
or impermeable apron that covers the torso to the level of the mid-calf.
The apron provides an additional layer of protection to the front of the body
against exposure to body fluids or excrement from the patient.
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>> Now you're going to put on your outer gloves.
If you need help with this, just let me know.
>> Double gloving provides an extra layer of safety during direct patient care
and during the personal protective equipment removal process.
>> When putting on these gloves make sure that the cuffs extend as far up your arm as possible
and are over the cuff of your gown.
>> Some facilities have found that using different colored gloves
for the outer gloves is beneficial.
Utilizing different colored gloves for each layer helps
to rapidly identify any breaches in glove integrity.
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>> Next you're going to put on your face shield.
Do this by placing the elastic strap behind your head,
making sure that the foam is resting on your forehead.
>> Put on a full face shield over the N95 respirator and surgical hood
to provide additional protection to the front and sides of the face, including skin and eyes.
Bending forward, hold on to the face shield with both hands.
Expand the elastic with your thumbs and place the elastic behind your head
so that the foam rests on your forehead.
Once the shield is situated check to make sure it covers the front and sides
of the face and no areas are left uncovered.
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>> Can you please hold your arms out to your side and turn around for me?
I'm going to check to make sure that all of your skin is covered
and you are able to move comfortably.
>> The healthcare worker should be comfortable, and able to extend the arms, bend at the waist,
and go through a range of motions to ensure there is sufficient range
of movement while all areas of the body remain covered.
A mirror in the room can be useful
for the healthcare worker while donning personal protective equipment.
>> Okay. Everything looks great!