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Healthcare workers (HCWs) spend a lot of time up working in close proximity to their patients, which is a high-risk activity. Standard Personal Protective Equipment (PPE) have been recommended for the healthcare setting, but donning and doffing of the PPE has its own challenges. Clinicians and their assistants need to be careful while removing the PPE so that they can minimize cross-contamination. Dr Ankit Desai (Periodontist, Surat) suggests a small modification in the PPE design that can significantly reduce this risk.
In healthcare settings, the virus spreads through direct contact with blood, body fluids or via infected person's aerosols and splatter that contaminate the surfaces and objects in the clinic. This infection can enter the HCW's body through broken skin or unprotected mucous membranes eg. the eyes, nose, or mouth1.
The anxiety of knowing that you are at risk when you’re doing your job can be very challenging for all healthcare workers including the Dental Surgeons, Ophthalmologists, ENT surgeons as their area of work contains maximum viral load, technically they can’t practice social distancing while treating and the emergency procedure carried out by them generates aerosols as well as splatter.2
To ensure occupational safety, the HCW must find ways to reduce the viral load and the cross-contamination in the clinic as much as possible. By ensuring all the standard infection control protocols, use of PPEs and understanding the errors in removing the PPE would reduce the risk of contamination to some extent.
Here I would like to bring a fact to your attention which could probably demand a change in coverall design. In the fluorescent dye experiment, the author found that spatter tended to travel like a tornado upward in a vertical, expanding, funnel-shaped, circular pattern, striking the operator’s chest, shoulders and face and falling in heavy rain on the lower arms. (Fig 1)
Dye spatter was clearly and immediately evident on the filter paper disks on the upper surfaces of the operator’s arms, on the chest and lower neck region, and around the manikin.3 It means the microbial load will be much higher on this “red zones of PPE” and which also means the backside of PPE is relatively less contaminated as it doesn’t get directly exposed to the aerosols and splatter. The operator would want to avoid contaminating himself by “not touching these red zones of PPE” as much as possible.
As per the current doffing protocols, the operator is asked to use the alcohol-based sanitizer on each step of removing the PPE components. While doffing, the probability of errors are higher especially when clinicians are tired and cognitively overloaded and it is associated with the greatest risk of contamination. Even after sanitizing the hand, while unzipping the coverall, the doctor has to touch the red zone of PPE as the zip is on the front side of all the coveralls currently available in the market.
Why not simply change the design in such a manner that would skip touching the red zone of the coverall!
With this hypothesis, I propose a new design which shifts the PPE zip to the backside of the coverall which may have minimum contamination possible. (Fig 2) Of course, we need assistance to unzip which can be managed well by the helper by first spraying 70% isopropyl alcohol on the back and also by following good hand hygiene. I could see another advantage of this design is that it becomes very convenient for the operator to turn the coverall inside out which actually eliminates touching the outer surface of the gown.
Based on this rationality, we should reevaluate the design and the strategies for removing personal protective equipment, as well as how often healthcare workers are trained on these methods. Considering it as the most critical step in infection control, of course donning and doffing of PPE should be practised and when performed clinically, the recommendations are to remove it under supervision to ensure its meticulous performance in accordance with checklists.
One must not misinterpret the proposed changes in the PPE as it doesn’t ease up the doffing protocols. Utmost care is needed, cycles of thorough hand disinfection must be undertaken and supervised, and meticulous waste disposal must be completed.4
Doctor’s work is physically and mentally draining. The aim here is to make doffing stress-free by reducing the risk of contamination. I would appeal to the government, CDC and the industries to consider this change as the important safety feature to protect those who are fighting against corona pandemic. Sometimes a small change makes a huge impact on our lives. By reducing the risk to the frontliners, we would certainly benefit society.
1) Centres for Disease Control and Prevention. Ebola (Ebola virus disease): transmission. Updated February 12, 2015 (http://www.cdc.gov/vhf/ebola/transmission/index.html. opens in new tab).
2) Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. Harrel SK, Molinari J. J Am Dent Assoc. 2004 Apr;135(4):429-37.
3) Evaluating spatter and aerosol contamination during dental procedures. Bentley CD, Burkhart NW, Crawford JJ. J Am Dent Assoc. 1994 May;125(5):579-84.
4) Putting On and Removing Personal Protective Equipment. Ortega R, Obanor O, Yu P. N Engl J Med. 2015 Jun 18;372(25):2464-5.
Dr Ankit J Desai (MDS, Periodontics)
Dr Ankit completed his MDS in Periodontics from Bapuji Dental College & Hospital, Davangere with a University Rank at the Rajiv Gandhi University of Health Sciences. He maintains his private practice with special emphasis on periodontics and implant rehabilitation.
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