Researchers’ Guidelines Could Keep Healthcare Workers Safe

SimTigrate researchers test design layouts in a biocontainment unit mockup on the Georgia Tech campus.
SimTigrate researchers test design layouts in a biocontainment unit mockup on the Georgia Tech campus.

Guidelines that could help protect health care workers as they test and treat COVID-19 patients have been issued by researchers at Georgia Tech's SimTigrate Design Lab.

The recommendations are contained in a white paper that looks at ways to design biocontainment units so health care workers don’t contaminate themselves when they remove their personal protective equipment (PPE). 

The paper was borne out of research following the 2014 Ebola outbreak and was published in early February 2020 -- just as the novel coronavirus, which causes COVID-19, was being transmitted around the world. 

“We started this long before the coronavirus was the specific threat," said Jennifer DuBose, associate director of SimTigrate in Georgia Tech’s College of Design. 

"There was always this fear that there's going to be something else, there was going to be something like SARS that was going to come," she said. “I guess it was great timing.”

DuBose co-authored the white paper, which has already been translated into ChineseFarsiKorean, and Portuguese.

While the paper is aimed at architects who design hospital biocontainment units, it could also help inform the design, construction, and use of temporary facilities during the novel coronavirus crisis, DuBose said. 

Researchers and health care workers refer to the process of putting on and taking off PPE as donning and doffing. 

“Given our current crisis, there's going to be a lot of pop-up treatment areas,” she said. “These guidelines can even be used in temporary treatment setups. If you're putting a tent up in a parking lot, this could inform how to set up the doffing area.”

Removing PPE is risky to doctors’ and nurses’ health. During the Ebola outbreak, DuBose said, nurses spent a good deal of time cleaning up patients’ body fluids, which would get on their PPE.

“You've worn something to protect yourself. The suit has effectively protected you. And now you have to get it off without touching the outside of it,” she said.

With COVID-19, the evidence is less visceral, but the issue is the same, said DuBose. 

“Clearly it's being transmitted through air droplets,” she said. “Once somebody sneezes or coughs, if those droplets land on your PPE, presumably, when you're taking off your PPE, if you touch that with your bare skin, and then touch your eyes or your face, you can get it.”

A matter of inches

That’s where the design of the biocontainment unit (BCU) comes in. Through charts and graphics, SimTigrate’s paper shows how best to lay out a proposed BCU’s space by placing a large doffing area between two private patient rooms. 

Based on SimTigrate’s evaluation and testing of many BCU designs, the proposed “optimized design” allows health care workers to move in one direction, from clean to dirty areas, without backtracking. It also provides an efficient use of space, reducing the burden on healthcare workers and making it easier for “trained observers,” who guide health care workers step-by-step through their doffing procedure, to perform their duties. 

The SimTigrate team studied every movement and item, down to the location of trash cans, mirrors, clocks, grab bars – even where to mount hand sanitizer dispensers, said Zorana Matić, a Ph.D. student in Georgia Tech’s School of Architecture and a co-author of the white paper. (The third co-author of the white paper was Benton Humphreys, a graduate research assistant at SimTigrate and an MS candidate in Human-Computer Interaction.)

“It’s really a matter of detail, like inches,” said Matić. “This is the place in the biocontainment unit where health care workers are doffing their personal protective equipment after hours of providing direct patient care.

“They are very tired, sometimes they are spending eight or 10 hours in that suit. It’s an incredibly hot suit, they’re sweating inside, they haven’t used the restroom,” she said. “They’re not focused on every step, and every step is very important.”

Matić said many of the recommended strategies are low-cost and can be implemented immediately, such as placing colored tape on the floor to mark clean and contaminated areas, or hanging a mirror so health care workers can inspect themselves while removing their PPE suits.

“I think that’s the high value of our work,” she said. “Most of our strategies do not require millions of dollars to retrofit BCUs, but they can be applied – today. Anything that can reduce that risk of a single healthcare worker being infected is like a small victory that we can achieve.

“Those people are really modern heroes. They don’t wear capes, they wear PPEs. That’s why the doffing area is very important.”

Reducing the risk of error

SimTigrate issued the white paper after publishing a series of journal articles in Clinical Infectious Diseases and Infection Control and Hospital Epidemiology, several of which were compiled in a special supplement from the Centers for Disease Control and Prevention (CDC).

Those articles represent years of research that involved working with hospitals, helping design full-scale mockups of BCUs and videotaping dozens of health care workers doffing their PPEs. 

In journal articles, researchers spell out the steps they take to test their hypotheses, and then present their findings as data. But such articles aren’t the place for subjective recommendations such as those offered in the white paper, DuBose said. 

Also, architects – even healthcare architects – aren’t likely to read scientific journals in the areas of disease and epidemiology, she said.

“So that was the idea of the white paper: How can we get something out there to architects and designers and nurses and the frontline people, to say, ‘If you’re going to pay attention to something, here’s what you need to do.’

“It’s taken us years to develop the expertise,” DuBose said. “Now we need to share this so any architecture firm could get it. Knowing that not every architecture firm or hospital designing a biocontainment unit has a direct relationship with us, how can we help all of the projects going up be better?”

Since its publication, the white paper has been translated into Mandarin by Hui Cai, a SimTigrate alumna and an associate professor at the University of Kansas; Farsi by Fatemeh Raha Rastegar, a Ph.D. student at SimTigrate; Korean by Yeinn Oh, a graduate research assistant at SimTigrate, and Lisa Lim, another SimTigrate alumna and assistant professor at Texas Tech University; and Portuguese by Herminia Machry, a postdoctoral fellow at SimTigrate. 

The Korean translation has been published in the Journal of the Korea Institute of Healthcare Architecture (KIHA), Matić said. And the Portuguese translation has been shared with two Brazilian organizations --  Instituto de Pesquisas Hospitalares (IPH) and Associação Brasileira para o Desenvolvimento do Edificio Hospitalar (ABDEH) -- for wider distribution, Machry said. Matić said there have been discussions about translating the white paper into Italian.

“We’re trying to target those high-impacted areas in the world right now,” she said.