Personal Protective Equipment: The Safe and Effective Use in the Hospital

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Introduction Background Safeguarding the health of the people within the community is one of the most important functions of the Health Authority. In case of an outbreak of communicable diseases such as influenza pandemic, Ebola Virus Disease (EVD) and Middle East Respiratory Syndrome leading to public health emergencies, each hospital will soon activate departmental contingency plan and response measures according to the corresponding Government’s preparedness and response plans. Thus, all nursing staff should be vigilant and well prepared to take actions in alignment with departmental policy.

In case of public health emergencies, both medical and nursing employees take up high responsibilities in triage and patient care at medical or health surveillance points of different clinical settings on top of the hospital setting. These clinical settings include outpatient clinics, quarantine camps, ground crossings, harbour boundary control points and airports. As there are opportunities for direct or close contact with patients with suspected or confirmed communicable diseases, they should be particularly alert and well equipped with effective practices in infection prevention and control. Risk management Direct or close contact with patients with suspected or confirmed infectious diseases at different medical or health surveillance points is usually inevitable. Risks of human-to-human transmission exist, for instance, during healthcare delivery in the current Ebola outbreak in West Africa. According to several overseas reports, healthcare providers were infected while treating patients with suspected or confirmed EVD. In addition, these reports have determined that proper infection prevention and control practices in personal protective equipment (PPE) donning and doffing was the most effective in reducing or eliminating risks of EVD infection. PPE may include items such as facemasks, respirators, goggles, face shields, caps, gowns, gloves, boots and shoe covers among others. They constitute parts of equipment used to protect healthcare providers from exposure to or contact with infectious materials, and to protect against transmission of communicable diseases. However, PPE may fail to prevent transmission and spread the infection if all the PPEs are not safely designed, fit and/or not removed properly. To prepare staff to handle case of communicable diseases outbreaks effectively, a series of risk management measures had been implemented from June to November 2014. These measures were specially organised by the Infection Control Branch (ICB) and the Central Nursing Division (CND) for staff to enhance knowledge on infection prevention and control and to strengthen skills in donning and doffing of full PPE. The notable risk management measures taken covered all departments, and they were delivered through distribution of relevant protocols and modified procedures, staff training seminars, and individual based measures such as regular mandatory self-training and self-assessment. The ICB prepared a “Personal Protective Equipment (PPE) Donning/Doffing and Hand Hygiene (HH) Assessment Checklist” for staff to carry out mandatory training and practice in June 2014. These checklists were subsequently revised in October 2014 and November 2014 in response to the most up-to-date recommendations from the World Health Organisation. Further, posters on PPE donning and doffing were issued in November 2014. Both checklists and posters had provided practical guidelines on proper techniques for performing full PPE donning and doffing and HH throughout the procedures. The CND initiated a variety of promotion activities accordingly. First, internal assessments of staff performance in PPE donning and doffing based on the ICB checklists were conducted from April to August 2014. Second, dozens of similar infection control seminars mandatory for all nursing staff were organised in November 2014. Third, the CND advised all Department Operation Managers (DOMs) of respective service units to ensure that all updated information regarding current communicable disease outbreak and related infection control be accessible to all frontline staff. Finally, all DOMs were reminded to strengthen staff training on infection prevention and control practices, and skills in donning and doffing of full PPE as recommended by the ICB. e

However, both monitoring of and evaluation on safe and effective use of PPE in the hospital had not been in place after the implementation of all risk management measures. This programme, led by the CND, was conducted to give a comprehensive evaluation of infection prevention and control practices and recommendations for improvement in PPE donning and doffing in the hospital/clinics. Aim and objectives The aim of the programme was to improve infection prevention and control practices in PPE donning and doffing during the provision of care for patients with suspected or confirmed infectious diseases in clinical and ward settings. The objectives were: To assess the level of practices in supporting safe and effective use of PPE in clinics or wards; To assess the level of staff competency in practising infection prevention and control during donning and doffing of full PPE; and To identify areas for further improvement and make recommendations for sustaining good practices and enhancing improvement Method Formation of the Evaluation Team The Evaluation Team was formed by the end of October 2014. The Team consisted of 19 nursing staff from different service units of the hospital. Of whom, 10 were Advance Practice Nurses (APN) and nine were Registered Nurses (RN). They all had received training on either quality assurance or quality management. At the first team meeting, members got a thorough understanding of the aim and objectives of the programme. They reviewed the existing guidelines and visual references related to PPE donning and doffing. In addition, the Team identified main areas for assessment by brainstorming. Finally, members drafted action plans for the programme, including the evaluation and continuous improvement. Sampling The evaluation was conducted in all service units within the hospital with nursing staff posted, and 23 service units were identified. Fifty clinics/wards were selected from all service units. In which, 35 were selected from ward settings while 15 were chosen from clinical settings. Each clinic/ward was visited once for the evaluation. During the evaluation visit, two or three nurses would be selected to take part in individual assessment. The selection of these staff was assigned by the APN in-charge of the selected clinic/ward on the spot.

Checklist development Three checklists were used to collect data during the evaluation visits at wards/centres. The assessors would rate the evaluation finding of each checking item under one of three options: ‘Yes’, ‘No’ and ‘Not-applicable’. The checklists were: Clinic/Ward Checklist (Appendix A) Staff Assessment Checklist 1: PPE donning (Appendix B) Staff Assessment Checklist 2: PPE doffing (Appendix C) The Clinic/Ward Checklist was formulated by the Evaluation Team with reference to the “Guidelines on Infection Control Practice in Clinical Setting” (Infection Control Committee, DH, HKSARG, 2011) and the “Audit Tools for Monitoring Infection Control Guidelines within the Community Setting” (Infection Control Nurses Association, DH, England, 2005). It comprised of 23 checking items. Item no. 1 to Items no. 7 consisted of structure criteria to measure the standard of current mechanism that delivered updated knowledge on the use of PPE and proper HH. On the other hand, Item no. 8 to Item no. 23 consisted of process criteria to check the existence of evidence that showed the principles of donning and doffing of PPE were followed. Staff Assessment Checklists were used to assess staff competency in performing the procedures of PPE donning and doffing. These two checklists were designed by the Evaluation Team based on the updated “Personal Protective Equipment (PPE) Donning/Doffing and HH Assessment Checklists” issued by the ICB on 12 November 2014 (ICB, CHP, HKSARG, 2014). To facilitate the evaluation process, key elements of effective use of mask and proper HH were also incorporated into the checklists. These key elements were retrieved from pamphlets of “Use Mask properly to protect ourselves and protect others” (CHP, HKSARG, 2010) and “HH: an easy way to prevent infection” (CHP, HKSARG, 2010). Pilot evaluation A pilot visit was conducted on 27 November 2014 in one of the selected clinics/wards. Immediately after the pilot visit, the Evaluation Team met to streamline the evaluation process and to get ready for conducting a full-fledged evaluation. In addition, members went through details of all assessment checklists and success criteria (Appendix D) and any other relevant report forms. Data analysis The data analysis was performed using Microsoft Excel. Spreadsheets were designed for data entry, data cleaning and sorting. Summary statistics on categories of staff recruited and clinics/wards involved were reviewed. Compliance rate was calculated by the number of “Yes” and divided by the total number of “Yes” and “No”, which had been set in the spreadsheets while each question in the checklist was equally weighted. The total compliance and individual compliance rate on different categories of checking items were calculated. Bar charts on different compliance rates were displayed for comparison. Findings The evaluation was performed in selected clinics/wards through surprise visits. At each clinic/ward visit, performance of both individual clinic/ward and selected staff in safe and effective use of PPE while providing care for patients with suspected or confirmed communicable diseases was assessed. Clinic/Ward performance was assessed against the standard of structure and process criteria (Appendix A). On the other hand, staff performance was assessed against the Staff Assessment Checklist 1: PPE donning (Appendix B) and Staff Assessment Checklist 2: PPE doffing (Appendix C).

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Results of the evaluation below were presented and analysed into three categories, including clinic/ward performance, staff performance in PPE donning procedures and staff performance in PPE doffing procedures. Summary of the evaluation visits Fifty clinics/wards under 23 service units in the hospital were visited during the evaluation period. Apart from the assessment on practice of selected clinic/ward, performance of 110 staff was assessed. Table 1 shows details of the visits. Table 1: Details of the evaluation visits Period of evaluation : 27/11/2014 – 18/12/2014 No. of assessors : 19 No. of assessment teams : 7 No. of staff assessed : 110 (APN : 22, RN: 80, EN: 8) No. of clinic/ward assessed : 50 (35 of ward settings and 15 of clinic settings) No. of Service Unit assessed : 23 Evaluation results As observed, the overall clinic/ward performance was the highest (97.3% compliance), followed by the overall staff performance in PPE donning procedures (89.4% compliance) and finally, the overall staff performance in PPE doffing procedures (80.9% compliance). Centre performance Performance of clinic/ward practice in supporting safe and effective use of PPE was assessed against the standard of 23 checking items in structure criteria and process criteria. Structure criteria are standards for evaluating the practices in delivering updated knowledge on the use of PPE and proper HH. Conversely, process criteria are standards of assessing practices in supporting and following principles of donning and doffing of PPE. As shown in Table 2, 86.0% of clinics/wards visited (that is 43 out of 50 clinics/wards) had full compliance (100.0%) with both structure and process criteria. On the other hand, one clinic did not have any evidences that showed practices of delivering updated knowledge in the clinic (0.0% compliance). Table 2: Clinic/Ward performance in individual items of structure and process criteria Compliance Rate on items (Structure + Process) Clinic/Ward (N=50) n (%) 100% (Full compliance) 43 86.0 ? 90% 45 90.0 ? 80% 47 94.0 ? 70% 48 96.0 ? 60% 48 96.0 ? 50% 49 98.0 ?40% 49 98.0 ?30% 49 98.0 ?20% 49 98.0 ?10% 49 98.0 >0% 49 98.0 0% (Nil compliance) 1 2.0 The range of compliance rates was 90.3% to 100.0%. Full compliance (100.0%) was attained in seven items, including Item no. 1, no. 5, no. 8, no. 9, no. 10, no. 11 and no. 13). Non-compliance practices observed in clinics/wards were summarised in Table 3. As shown, the incident rates of clinics/wards found to have these non-compliance practices in structure criteria (that is Item no. 1 to Item no.7) were 1/50 to 2/50; and in process criteria (that is Item no. 8 to Item no. 23) were 1/35 to 3/35. Table 3: Summary of non-compliance practices observed in clinics/wards Item Standard Requirement Non-compliance Practice Observed No. of centres involved 2 Mechanism exists that all staff read and sign the guidelines/protocols on IC practice quarterly. No clinic record documented the practice of circulating IC related guidelines/protocols to clinic staff every 3 months. 1 3 The IC refresher training is provided to all staff every two years. Neither the clinic record nor individual staff records documented the IC refresher training of clinic staff. 1 4 PPE donning and doffing and proper HH are integral part of mandatory IC training for all staff. Neither the clinic record nor individual staff records documented the assessment of PPE donning and doffing and effective HH of clinic staff. 2 6 An internal audit on HH practice is carried out yearly. Records of annual Internal Audit on HH Practice were not found in clinic/office. 1 7 Fit testing on respirators for staff is provided. Either individual staff records or clinic summary record of fit testing on respirators was not found in the clinic/office 2 12 Either a mirror or a trained observer is available for checking visually if all PPE has been donned properly. Neither mirror nor a trained observer was available in PPE donning area for checking visually if all PPE has been donned properly 1 14 Disposable or clean face shields are available (at least 5 pieces). The number of disposable or clean face shields in PPE donning area was less than 5. 1 15 Disposable caps pieces are available (at least 10). The number of disposable caps in PPE donning area was less than 10. 1 16 Disposable gowns pieces are available (at least 10). The number of disposable gowns in PPE donning area was less than 10. 1 17 Disposable shoe covers are available (at least 10 pairs). The stock of disposable shoe covers was less than 10 pairs. 1 18 Disposable latex gloves, either powdered or powder-free are available (at least one box of each size; large, medium and small). One box of each size (including large, medium and small) of disposable latex gloves was not available in the PPE donning area. 1 19 A designated area for doffing is in proximity to the Isolation Room (e.g. Hallway outside the Isolation Room or anteroom). The doffing area was not in proximity to the Isolation Room (e.g. Hallway outside the Isolation Room or anteroom room) 2 20 An updated list of correct steps in PPE doffing is on display for quick reference. Neither the poster “Out: Removing PPE Step by Step” nor the poster “Donning procedures with shoe covers” (26/8/2014 version 3) was on display in the PPE doffing area. 1 21 An updated list of correct steps of HH is on display for quick reference. The poster “HH technique, rub hands for 20 seconds” was not on display in the PPE doffing area. 3 22 HH facility is available for performing HH. Neither ABHR nor hand washing facilities was available in the PPE doffing area. 1 23 A pedal dustbin lined with a leak-proof disposable plastic bag is available for collection of all potentially contaminated waste. A pedal dustbin lined with a leak-proof disposable plastic bag was not available in the PPE doffing area. 2 Remarks: ABHR=Alcohol based handrub; HH=Hand hygiene; IC=Infection control; and PPE=Personal protective equipment. The compliance rates of individual staff in PPE donning procedures were shown in Table 4. in which 23.6% (that is 26 out of 110) of staff assessed achieved 100.0% compliance in all donning steps. Table 4: Staff performance in all checking steps during PPE donning Compliance Rate Staff (N=110) n (%) 100% 26 23.6 ?90% 64 58.2 ?80% 87 79.1 ?70% 107 97.3 ?60% 109 99.1 ?50% 110 100.0 As shown in Table 5, the overall compliance rate of all PPE donning procedures among staff was 89.4%. However, the compliance rate was raised to 93.8% when all HH steps in donning were excluded. The compliance rate of all HH checking steps in PPE donning among staff was 72.4%. In all these HH checking steps, the compliance rate of the “7 steps and duration of hand rubbing” was only 45.9% (Table 5). Table 5: Compliance rates of PPE donning procedures among staff Procedure Compliance Rate All donning 89.4% Donning excluding HH 93.8% HH in donning 72.4% ABHR coverage during HH 88.6% 7 steps and duration of hand rubbing 45.9% The individual steps included donning of surgical mask, donning of face shield, donning of cap, donning of gown, donning of shoe covers, donning of gloves and all HH steps. Among these checking steps, the compliance rate of all HH steps was the lowest (72.4%) while the compliance of donning of surgical mask was the highest (97.9%). Table 6 displayed compliance rates of individual steps in PPE donning among staff. Table 6: Staff performance in individual steps during PPE donning Individual steps during donning procedure? Compliance Rate Donning of surgical mask 97.9% Donning of face shield 96.8% Donning of cap 90.9% Donning of gown 90.9% Donning of shoe covers 87.3% Donning of gloves 93.6% All HH steps 72.4% Table 7 summarised the observed non-compliance practices during the evaluation of staff performance during PPE donning procedures. Table 7: Summary of non-compliance practice observed during PPE donning Action Standard Requirement Non-compliance Practice Put on Surgical Mask Choose the appropriate size of mask The folds facing downwards on the outside and with the metallic clip uppermost Position the ear-loops around ears Fit metallic clip over nose bridge Extend the mask to cover the chin so that it fits snugly over the face Check the mask for proper coverage either by viewing the image in a mirror or by the help of a trained observer Putting on the face mask with the wrong side (the outer side) touching the face. The metallic clip not properly fitted over the nose bridge Left a space between the metallic clip and the nose bridge and the metallic clip is put before Put on Face Shield Slightly tighten the band to fit snugly against forehead Check the face shield for proper coverage (including all forehead, extend below chin and wrap around side of face) either by viewing the image in a mirror or by the help of a trained observer The face shield did not fit snugly against the forehead as the headband of the selected face shield was not adjustable. No fitness checks by the use of mirror or a trained observer. Put on disposable Cap Check the cap for proper coverage (including all hair, both ears and the headband of the face shield) either by viewing the image in a mirror or by help of a trained observer Did not fully cover hair, ears or the headband of the face shield. Put on disposable gown Unfold the gown without causing the strings to touch the floor Slide hands and arms down the sleeves Fasten neck strings at the back of the neck: the string is secure enough and not loose Overlap the gown at the back as much as possible Fasten waist strings at side Check the gown for proper coverage (including the front and back of body) either by viewing the image in a mirror or by the help of a trained observer Strings touched on the floor when unfolding the gown. The back was not fully covered as the staff did not try to overlap the gown at the back as much as possible. Fastened waist strings at the back. No fitness checks by the use of mirror or a trained observer. Put on shoe covers Put on shoe covers properly over shoes so that the sides, front and rear of the shoes are covered and not loosely hanging around Did not cover over the sides, front or rear of the shoe. Put on latex gloves Select the correct size of gloves Extend gloves over gown cuffs Wore gloves of inappropriate size Did not extend gloves over gown cuffs Perform hand hygiene Apply a palmful of ABHR which is enough to cover all surfaces Carry out 7 steps of hand hygiene for 20 seconds Did not apply sufficient amount of ABHR to cover all surfaces. The duration of hand rubbing was less than 20 seconds. The 7 steps of HH were not fully carried out Remarks: ABHR=Alcohol based handrub; HH=Hand hygiene; IC=Infection control; and PPE=Personal protective equipment. Staff performance in PPE doffing The compliance rates of individual staff in PPE doffing were shown in Table 8. Only 8.2% (9 out of 110 staff) of staff assessed achieved 100% compliance in all doffing steps. Table 8: Staff performance in all checking steps during PPE doffing Compliance Staff (N=110) n (%) 100% 9 8.2 ?90% 41 37.3 ?80% 61 55.5 ?70% 83 75.5 ?60% 99 90.0 ?50% 109 99.1 The compliance rate of all doffing procedure among staff was 80.9% (Table 9). However, the compliance rate was raised to 86.1% when all HH steps in doffing were excluded. The compliance rate of all HH checking steps in PPE doffing among staff was 68.4%. In all these HH checking steps, the compliance rate of the “7 steps and duration of hand rubbing” was only 48.9% (Table 9). Table 9: Compliance rates of PPE doffing procedures among staff Procedure Compliance Rate All doffing 80.9% Doffing excluding HH 86.1% HH in doffing 68.4% ABHR coverage during HH 87.8% 7 steps and duration of hand rubbing 48.9% Compliance rates of individual steps in PPE doffing among staff were summarised in Table 10. The individual steps included removal of shoe covers, removal of gloves, removal of gown, removal of cap, removal of face shield, removal of surgical mask and all HH steps. Among these checking steps, the compliance rate of all HH steps was the lowest (68.4%) while the compliance rate of removal of surgical mask was the highest (94.5%). Table 10: Staff performance in individual steps of PPE doffing Individual steps during doffing procedures Compliance Rate Removal of shoe covers 77.6% Removal of gloves 94.1% Removal of grown 86.7% Removal of cap 71.8% Removal of face shield 87.3% Removal of surgical mask 94.5% All HH steps 68.4% The non-compliance practices observed in the evaluation of staff performance in PPE doffing were shown in Table 11. Table 11: Summary of non-compliance practices observed during PPE doffing Action Standard Requirement Non-compliance Practice Remove shoe covers Touch the highest part of one shoe cover behind ankle only Take off the shoe cover of the first shoe Discard the cover into lidded rubbish bin, and step on to designated area Touch the highest part of another shoe cover behind ankle only Take off the shoe cover of the second shoe Discard the cover into lidded rubbish bin, and step on to designated area The shoe was contaminated as the staff slid the gloved fingers into the inner side of the shoe cover when taking off the shoe cover. Staff did not step on to designated area after removing off the shoe covers. Staff nearly fell down while removing the shoe cover, and thus the observer touched the contaminated PPE when giving a hand to maintain the staff’s balance. Remove disposable gloves Grasp one glove at outside edge near the wrist Peel the glove off the hand by turning it inside-out Grasp the removed glove in the still-gloved hand Slide ungloved finger(s) underneath the wrist of the remaining gloved hand Peel the glove off the hand from inside, creating a bag for both gloves Discard the gloves into lidded rubbish bin Gloved fingers slid underneath the wrist. Ungloved fingers touched the outside of the remaining glove when peeling the glove off the hand. Adopted an inappropriate HH method. The staff performed hand rubbing with ABHR rather than hand washing after removal of powdered gloves. Remove disposable gown Unfasten neck strings, and then waist strings Pull away from neck and shoulders Remove the gown gently Turn the outer “contaminated” side inward and then roll it into a bundle Discard the gown into lidded rubbish bin Placed the removed gown close to the body of the staff while rolling it into a bundle. Either the fingers or the outer “contaminated” side touched their own clothing while removing the gown Staff did not roll the gown in a bundle before discarding the gown into the dustbin Remove disposable cap Grasp behind head at the top, and then gently lift it off from the head Discard the cap into lidded rubbish bin Tucked fingers of two hands in the cap, and then grasped the rim to lift it off the head. The cap touched the shoulder, neck or face when removing it Remove face shield Hold the head band with both hands and lift the face shield forward gently Discard the face shield into lidded rubbish bin Hair and the shoulder were contaminated as the face shield was lift backward. The face shield was accidentally lifted off while removing the cap because the face shield was not donned properly. During donning, the staff might not adjust the headband to fit or adopt a type of face shield without an adjustable head band. Remove surgical mask Hold both ear loops and gently lift Remove the mask from face by holding the ear loops Discard the surgical mask into lidded rubbish bin Staff removed the mask by holding one side of ear loop, and thus the mask contaminated the face and ear. Perform hand hygiene Apply a palmful of ABHR which is enough to cover all surfaces Carry out 7 steps of hand hygiene for 20 seconds Did not apply sufficient amount of ABHR to cover all surfaces. The duration of hand rubbing was less than 20 seconds. The 7 steps of HH were not fully carried out. Remarks: ABHR=Alcohol based handrub; HH=Hand hygiene; IC=Infection control; and PPE=Personal protective equipment. Discussion The Evaluation Team had assessed the current practices in supporting safe and effective use of PPE as well as individual staff competency in performing donning/ doffing of full PPE and HH in selected clinics/wards among the service units within the hospital. Based on collected data and field observation, both best practices and areas for improvement were identified. Clinic/Ward practice High performance (overall compliance rate of 97.3%) was achieved in clinics/wards. Forty-three out of 50 clinics/wards achieved full compliance based on the standards of structure and process criteria. The high achievement in structure criteria indicated a positive supportive infrastructure for practicing effective infection prevention and control. Best practices in the following areas were observed: Continuous staff training was provided to enhance knowledge on infection prevention and control and related risk management, and strengthen skills in safe and effective use of PPE. Updated guidelines and information regarding infection control practices were accessible to all staff in their workplace. Internal audits on HH and infection control practices were conducted on a regular basis to monitor and review the performance. Fit testing on N95 respirators was provided to all staff to ensure optimal protection for staff during emergencies. The attainment of good compliance in process criteria reflected the high-level of staff preparedness for practicing infection control precautions in PPE donning and doffing in their workplaces. The following best practices were observed: Two separated areas were specially assigned for PPE donning and PPE doffing. The donning area was fully furnished to facilitate the donning procedures. All types of commonly used PPE items required in the checklist were available for use. HH facility such as alcohol based handrub (ABHR) or hand washing facility was easily accessible for performing HH. A mirror was available for checking visually if all PPE had been donned properly. Visual references including the poster of updated correct steps in PPE donning and the poster of updated correct procedures of HH were on display. These posters were quick and practical guide that avoided relying on memory leading to missed steps due to human factors such as stress, anxiety or fatigue. The doffing area was fully furnished to facilitate the doffing procedures. A pedal dustbin lined with a leakproof plastic bag was available for collecting all potentially contaminated waste while HH facility such as ABHR or hand washing facility was also easily accessible for performing HH. In addition, visual references including the poster of updated correct steps in PPE doffing and the poster of updated correct steps of HH were on display. These posters were quick and practical guidelines that reduced relying on memory leading to missed steps due to human factors such as stress, anxiety or fatigue. The process of the evaluation visits were smooth as most clinics/wards were well prepared for the evaluation according to instructions given by the Evaluation Team. Prior to the evaluation visits, all Service DOMs were well informed of details of the evaluation and relevant documents including assessment checklists and success criteria. In addition, they received the “clinic preparation checklist” and “samples of record forms on infection control practice” for their preparation in clinics/wards. This arrangement aimed to facilitate individual clinics/wards to have a good preparation for the assessment, and thus might promote their compliance in structure and process standards. The overall clinic/ward performance was satisfactory, although there were non-compliance practices observed in a few clinics/wards. Staff performance Staff performance in all PPE donning and doffing procedures was not ideal. In particular, the performance of all HH procedures was the lowest (compliance rate of 72.4% in donning and of 68.4% in doffing). By an analysis of performance in individual steps of HH procedures, the substandard performance in “7 steps and duration of hand rubbing” was found (compliance rate of 45.9% in donning and 48.9% in doffing). HH is one effective way to prevent the spread of many types of infectious microorganisms while providing care for patients with infectious diseases. Proper HH is vital to infection prevention and control in the PPE donning and doffing procedures. The low performance in PPE donning and doffing procedures might be related to the following causes: Lack of self-practice in donning and doffing of full PPE The opportunities for nursing staff to adopt the full set of PPE in daily healthcare are rare. Instead, they are familiar with the use of gloves and surgical mask in regular process of healthcare. As a result, the relevant experience in real practice was limited. Nurses had carried out a course of self-practice for the mandatory internal assessment on PPE donning and doffing in June 2014. However, healthcare providers did not perform further self-practice subsequent to revised guidelines and instructions in most of clinics/wards. Low awareness of updated guidelines and checklists on PPE donning and doffing Although the updated guidelines and checklists were in place, staff did not notice important differences between PPE donning and doffing compared to the preceding checklists. The assessment checklist on PPE donning and doffing was fir

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