Video Section-Operative Nuances: Step by Step – Donning and Doffing in Neurosurgical Operating Room
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.293436
Source of Support: None, Conflict of Interest: None
Keywords: COVID-19, doffing, donning, neurosurgical procedure, operating room, personal protective equipments, scrubbing
Donning and doffing of personal protective equipments (PPE) has become relevant specially during COVID-19 pandemic and neurosurgeons operating upon COVID-19 positive or suspect patients should be aware of proper method and sequence of PPE donning and doffing. This is essential for prevention of transmission of infection during surgical procedures to health care workers. Surgeries involving direct exposure of anterior nasal spaces/ paranasal sinuses carry significantly more risk of infection and it may be prudent to use PPE while operating all such cases.
To demonstrate the protocol of donning and doffing of PPE which we have devised for our operating room.
Donning and doffing require proper designated spaces.,, We have created such spaces by extensive modifications of the space available in the OR complex and ensured one-way traffic for the entire procedure. In the doffing area, we marked separate dirty and clean areas for sequential doffing. This video shows the detailed procedure of donning and scrubbing at the designated donning-cum-scrubbing area and proper sequential doffing at the designated doffing area. The video also shows the cleaning and sterilisation of the goggles, that authors follow at their institute. The detailed steps of procedure are described in the following transcript.
00-0.26 seconds: Titles and music
0.26-0.57 seconds: The following video demonstrates our protocol for donning and doffing in OR. It is important to have a separate donning area. Since most of the ORs have not been structured to have a separate donning area, a small station may be placed just adjacent to the scrubbing area as we have done. A chair should be place to allow the surgeon to sit comfortably and put on the shoe covers. The first step is putting on the shoe covers.
0.57 seconds-1.18 minutes: It is important to first wash hands thoroughly before placing surgical cap and mask. So, one should first wear the surgical cap, followed by N95 mask. Another 3-ply surgical mask is placed over the N95 mask.
1.18-1.36 minutes: The next step is to wear goggles. A good quality goggles should be worn which has an air tight seal all around. We prefer to use the Black and Dekker goggles, but any good quality goggles with a complete air seal may be used.
1.36-2.00 minutes: The next step is to wear the coverall. We prefer a level 3 suit (light weight, gsm 80-100). One needs to sit down to wear this coverall. This is not a sterile suit.
2.00- 2.34 minutes: The next step is to wear gum boots. We prefer to wear gum boots as these provide adequate protection from splashes. Some surgeons may find this difficult to wear this, but we have been wearing this since several years and have become accustomed to the same.
2.34-2.53 minutes: The next step is scrubbing. This may be done by pulling up the coverall sleeves. A through scrubbing is done as is for all elective surgeries followed by drying using a sterile towel.
2.53-3.09 minutes: The next step is wearing a sterile surgical gown. We use a standard surgical gown with anti-viral barrier along with double gloves.
3.09-3.20 minutes: Following complete donning, the surgeon has to follow the direction markers placed on the floor to enter the OR after which the doors are closed.
3.20-4.01 minutes: It is important that once the operating room personnel enter the OT, they cannot come out of the same entry route. The follow a different exit route which takes them to the doffing area. In our case, we have converted a complete OR room into a doffing area. It is important to keep the doffing area, unlike a donning area in a separate room with all doors closed with separate ventilation. During the COVID pandemic, we have increased the air exchanges in OR to more than 25/ hour and also created a negative pressure OR. Prior to doffing, it is important to first clean the gloves with alcohol and remove the face shield first.
4.01-4.47 minutes: To clean gloves again, and then remove the gown as shown here with slow movements, invert it and slowly bundle it into a small ball and then dispose it off. It is important to have an assistant who is wearing full coverall in the room. One should imagine while doffing that the infective material may be sticking on the outer surgical gown like a powder and hence slow movements are necessary while removing the gown. A 2 layered suit is necessary as the inner suit will take most of the infective spill form the outer gown. One should undertake demonstration exercises in every OR before starting or streamlining surgeries, as most of the infections take place while doffing.
4.47-5.29 minutes: The next step is to remove the shoe covers. As may be seen here, the shoe covers should be removed by the surgeon by sitting on the 'dirty chair'. In doffing room, we have kept two chairs, one is a contaminated chair used by the surgeon to sit down while the coverall is still on and the other a 'clean chair' used while removing the coveralls. The clean chair procedure will be shown shortly. As you may have noticed we have also kept linen sheets soaked with sodium hypochlorite on the floor for the surgeon to walk during the procedure of doffing. One may now see that the doffing procedure is more complex than donning.
5.29-6.08 minutes: The next procedure is to clean the gum boots with alcohol thoroughly. Even though the gum boots are left inside the OR, we advise the boots to cleaned at this stage to reduce the infection risk.
6.08 -6.27 minutes: The gum boots are removed next. One may notice that once the gum boots are removed, the inner pair of shoe covers protect the feet. In addition, the surgeon also stands on the sodium hypochlorite-soaked linen to allow further sanitization of the feet.
6.27-7.36 minutes: These steps show the procedure of removal of coverall which includes sanitization of hands and wearing a fresh pair of gloves. Then the surgeon walks to the 'clean chair' and then removes the coveralls by slowly inverting it. As it can be seen, it does require some amount of skill as there is danger of tripping or slipping. To avoid such accidents, the surgeon must slowly invert the coverall, and then use the chair when the coverall comes to the knee level. All movements must be slow, without hurry as any accident like; falling on ground, touching the face could be dangerous or risky.
7.36- 8.00 minutes: The inner shoe covers are removed next. As shown here, again they should be removed slowly, and then a clean pair of foot wear must be worn.
8.00-8.52 minutes: The next step is to remove the gloves, sanitize and wear a fresh pair of sterile gloves before removing face apparatus. Note the method of removing gloves. While removing the face apparatus, the cap must be removed first, followed by goggles, which should be kept in a plastic box filled with sodium hypochlorite solution. Next the 3-ply mask should be removed. As shown here, hand sanitization must done between each step. In addition, while, removing the face mask, one must bend the head forward, and then gently remove the face mask.
8.52-9.00 minutes: The surgeon will now walk away from the doffing area, wear a fresh cap, mask and gloves.
9.00-9.26 minutes: The following steps show how to clean the goggles and then place them back in the cleaned plastic box. This is important so that the surgeon immediately cleans and take the goggles with him or her as leaving them behind in OR will have a risk of mix up of goggles. Hence, the following procedure shows how to clean the goggles and take them out of OR.
9.26-9.41 minutes: Once the goggle is cleaned and dried with linen, we prefer to keep the goggles in a UV oven for 4 minutes and then place it in a sterile plastic. Once this is done, the goggle is taken by surgeon to be kept carefully for the next case.
9.41-9.59- References and disclaimer.
Video link: https://youtu.be/bb1fS3BgbWs
Outcome: As this is not a surgical procedure, there are no specific outcomes.
Designated spaces for donning and doffing should be earmarked and strict protocol for donning and doffing should be followed. Donning should be done with due care keeping in mind that none of the part of body is exposed directly to the environment after donning is completed. During doffing, one should keep in mind that it must be done gradually and in such a manner that there is minimum aerosolization of any contaminants over the PPE. Inverting and slowly removing all possible items while proper doffing is the key that must be inculcated by all health care workers. Proper sanitisation of the gloved hands should be done after every step. Sudden and jerky movements must be avoided during doffing. Proper shower should be taken after the doffing is completed.
At our centre, the challenge was to convert the existing operating rooms into mutually exclusive donning and doffing areas. To create such mandatory spaces was challenging due to limited space in the operating room complex. Most of the operating rooms across the world were not planned as per the requirements imposed by this pandemic. However, the present COVID crisis has necessitated to create such spaces., At our centre we have created a donning area adjacent to the scrub station and this is immediately outside the entry gate of operating rooms. Earlier, routine donning used to be done inside the operating room after scrubbing. For doffing, we have created a dedicated space adjacent to every operating room and for this purpose we utilised the space of adjacent operating room. It may seem too radical and may appear as a waste of precious OR space, but one must realize the paramount importance of doffing and the adequate space it demands. Our ORs were planned in such a manner that there was a common scrub station outside and in-between two adjacent ORs and the two ORs were connected through a separate passage [Figure 1]. We modified our ORs by combining two adjacent ORs, converted one of the ORs exclusively into doffing area and thus we created mutually exclusive donning and doffing areas [Figure 2]. By this arrangement, we also ensured one-way traffic from the donning area to OR and from OR to doffing area through the passage between the two ORs [Figure 2]. In the doffing area, we have marked areas for sequential doffing - part of doffing area near its entry is designated as the most contaminated zone and area near the exit of doffing area is considered as relatively less contaminated zone. As shown in the video, the surgeon removes the face-shield, outer shoe-covers, surgical gown and gloves in the most contaminated zone while sitting on a dirty chair. Whereas the coverall, inner shoe covers, cap and masks are removed in the relatively less contaminated zone, sitting on a clean chair. The basic idea behind the donning and doffing for COVID-19 suspect or confirmed cases is that one should be extremely careful during each and every step and ensure that after donning there are no parts exposed directly to the environment and that has to be checked by another person with gross visual inspection. During doffing, one should keep in mind that it must be done gradually and in such a manner that there is minimum aerosolization of any contaminants over the PPE. Inverting and slowly removing all possible items while proper doffing is the key behavioral concept that must be inculcated by all health care workers. Proper sanitisation of the gloved hands should be done after every step. The overall purpose of doing such an extensive procedure is to ensure safety of health care workers and patients.
We present a video demonstrating donning and doffing protocol we devised for our operating rooms during the COVID pandemic. In brief we also described the necessary logistical modifications done in the OR. Proper donning and doffing is extremely important during the current COVID pandemic to prevent infection to the health care workers and allow safe surgery for the patients.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]