Creating a Safety Officer Program to Enhance Staff Safety During the Care of COVID-19 Patients

Abstract

Staff safety is paramount when managing an infectious disease event. However, early data from the COVID-19 pandemic suggested that staff compliance with personal protective equipment and other safety protocols was poor. In response to patient surges, many hospitals created dedicated “biomode” units to provide care for patients infected with SARS-CoV-2, the virus that causes COVID-19. To enhance staff safety on biomode units and during patient transports, our hospital created a safety officer/transport safety officer (SO/TSO) program. The first SOs/TSOs were nurses, clinical technicians, and other support staff who were redeployed from their home units when the units closed during the initial surge. During subsequent COVID-19 surges, dedicated SOs/TSOs were hired to maintain the program. SOs/TSOs provided just-in-time personal protective equipment training and helped staff safely enter and exit COVID-19 clinical units. SOs/TSOs participated in the transport of over 1,000 COVID-19 patients with no safety incidents reported. SOs/TSOs conducted safety audits throughout the hospital and observed 86% compliance with COVID-19 precautions across 32,500 activities. During contact tracing of frontline staff who became infected with SARS-CoV-2, potential deviations from COVID-19 precautions were identified in only 7.7% of cases. The SO/TSO program contributed to a culture of safety in the biomode units and helped to enhance infection prevention throughout the hospital. This program can serve as a model for other health systems during the response to the current pandemic and during future infectious disease threats.

Introduction

During an infectious disease outbreak, ensuring the safety of frontline healthcare workers is of paramount importance. Following the 2014-2016 Ebola outbreak in West Africa, the Office of the Assistant Secretary for Preparedness and Response, within the US Department of Health and Human Services, created 10 Regional Emerging Special Pathogen Treatment Centers (RESPTCs) to help prepare for the next infectious disease threat.^1,2 These centers (1) helped to establish staff protocols for the safe donning and doffing of personal protective equipment (PPE) when caring for patients with high-consequence pathogens,^3,4 (2) designed and validated waste handling procedures,⁵ (3) explored the interaction of human behavior and the built environment to enhance safety,^6-8 and (4) developed training programs to educate frontline healthcare workers about how to safely provide care to patients infected with high-consequence pathogens.^9,10 Many of the RESPTCs were called upon to care for the first cases of COVID-19 in their regions in the winter of 2020. In addition to frontline care, the RESPTCs were intimately involved in preparing their health systems to augment capacity to care for COVID-19 patients once the individual RESPTC exceeded their capacities.⁹

Many institutions rapidly created “biomode” units to safely care for patients infected with SARS-CoV-2, the virus that causes COVID-19. Biomode units were retrofitted with negative pressure air-handling systems, dedicated donning and doffing areas, and often had unidirectional flow of staff to minimize the risk of infection.^11-13 In addition to creating a safe physical space, facilities needed to rapidly train staff on how to safely navigate these new clinical units while wearing enhanced PPE. The 2014-2016 Ebola outbreak highlighted the potential dangers of self-contamination during PPE doffing, a multistep process with dozens of potential failure points.^14-20 Despite lessons learned, errors in PPE donning and doffing during the early part of the COVID-19 pandemic were alarmingly common, and occurred in as many as 40% to 60% of observed episodes.^21,22 Donning and doffing errors were largely due to user inexperience and unfamiliarity with PPE items (particularly airborne PPE) coupled with the high-stress environment of increased clinical burden and fear of exposure. Experienced healthcare workers were more likely to adhere to PPE protocols than less experienced personnel, but errors in the proper wearing of respirators were common among both groups.²³ COVID-19 PPE ensembles were not as complicated as PPE ensembles designed for special pathogens like viral hemorrhagic fevers. However, infection control measures like hand hygiene on gloves and careful, deliberate doffing techniques for gown and gloves were incorporated into practice to reduce self-contamination. Transportation of COVID-19 patients is also fraught with risks to healthcare workers and staff as the patient care environment becomes mobile. Planning (eg, using predetermined, less trafficked routes to and from biomode units and designated dirty and clean patient elevators) was key to minimizing the risk of environmental contamination and unintentional exposure of passersby.²⁴

To address these challenges, The Johns Hopkins Hospital created a program to train a core group of individuals to function as safety officers on biomode units and during patient intrafacility transports during the COVID-19 pandemic. As a highly resourced academic medical institution with an existing RESPTC, The Johns Hopkins Hospital was uniquely positioned to develop and implement the safety officer program.

Developing a Sustainable SO/TSO Training Model

Defining SO and TSO Roles

Biomode units at The Johns Hopkins Hospital were identified by hospital leadership with input from infection control staff based on the number and acuity of COVID-19 patients during pandemic surges. Bed capacity per biomode unit was dependent on the original structure of the inpatient unit for single-patient rooms. No beds were added to inpatient biomode units. However, 1 to 2 rooms were closed on each biomode unit due to staffing, patient acuity, and/or the need for additional space for waste storage. Between March and May 2020, redeployed clinical staff including nurses and clinical technicians from pediatric, outpatient, and procedural areas fulfilled SO and TSO roles and staffed biomode units continuously on 12-hour shifts. The primary goal of SOs/TSOs was to ensure PPE safety and reduce environmental contamination and healthcare worker self-contamination within and outside of biomode units. SOs/TSOs also served as infection control ambassadors by addressing knowledge and awareness gaps for bedside clinician teams in the midst of an evolving situation where practice, operation, and workflow changes occurred daily.

SO duties included delivering just-in-time PPE donning and doffing training, coaching clinicians through proper donning and doffing of airborne and contact isolation equipment, decontaminating durable equipment, maintaining biomode unit unidirectional flow, and monitoring biomode unit negative air-pressure systems. The duties of a TSO during the transport of COVID-19 patients were adapted from current practices used by the Johns Hopkins Lifeline Special Operations Response Team. The Special Operations Response Team is the clinical team responsible for retrieval and transport of patients with suspected or confirmed high-consequence infectious diseases for the Johns Hopkins RESPTC. The TSO fulfilled a mobile safety role by ensuring safe PPE practices of healthcare workers, reducing and preventing contamination of the hospital environment during patient movement, and safeguarding other staff and visitors as a traffic controller by escorting the transport team on predetermined routes to and from biomode units.²⁴

Standardized Training for SO and TSOs

Between March and May 2020, redeployed clinical staff from pediatric, outpatient, and procedural areas staffed 12-hour SO/TSO shifts on biomode units because their primary units were either closed or had fewer patients due to the pandemic. Initial training for redeployed clinical staff was provided through a brief 30-minute presentation and question-and-answer session that detailed COVID-19 isolation precautions and the SO and TSO duties. The presentation was followed by a 15-minute, in-person, just-in-time PPE return demonstration in which the participant observed and then performed the procedure. A checklist overview led by infection control preventionists and nurse educators further enforced PPE skills for SO/TSOs. The curriculum was based mostly on the “see one, do one, teach one” framework that is popular in large academic medical centers for just-in-time training.²⁵ Preliminary checklists were drafted to ensure consistent training objectives were met, including an overview of COVID-19 PPE components, donning and doffing procedures, and best practices for equipment decontamination.

Sustainable SO and TSO Model

As the first COVID-19 surge subsided in the summer of 2020, redeployed clinicians returned to their regular clinical duties. There was an immediate need to recruit nonclinicians and furloughed staff to maintain the SO/TSO model for subsequent surges and address the continued activation of biomode units. By June 24, 2020, the coordination of SO/TSOs transitioned from the Department of Nursing to the newly created Safety Officer Department under Hospital Epidemiology and Infection Control. The Safety Officer Department managed newly hired SO/TSOs and continued to respond to the COVID-19 needs of frontline staff. Per 12-hour shift, 1 to 4 SOs per biomode unit were assigned to support ongoing unit operations and patient care. The number of SOs per shift was based on the number of hospitalized COVID-19 patients and number of donning and doffing areas to monitor (ie, 1 unit staffed by a minimum of 2 SO/TSOs per 12-hour shift). The influx of nonclinical staff filling the role of SO/TSO required an updated, standardized, and more robust training curriculum.

The development of this new curriculum was based on the 6-step approach to medical education in which the identified problem of “poor PPE donning and doffing practices” was followed by a needs assessment that emphasized the vital function of SO/TSO observation and coaching.²⁶ The educational strategy of demonstration and return demonstration was again used as the backbone of the curriculum.

The new 8-hour training curriculum was launched in August 2020. The first hour consisted of a didactic overview of the Safety Officer Department structure and a presentation of COVID-19 isolation precautions, including identification and discussion of the airborne and contact PPE ensemble (eg, respirators, face shields, gowns, and gloves). The remainder of the training emphasized hands-on PPE proficiency and communication skills through repetitive simulation on an inactive inpatient unit. Simulations consisted of role-playing scenarios in which SO/TSO trainees practiced coaching clinicians through COVID-19 PPE donning and doffing procedures. Scenarios like poor hand hygiene, PPE breaches, and self-contamination enabled trainees to practice risk mitigation through engagement and instruction.

The training took place in the Johns Hopkins Biocontainment Unit. Training in a clinical space was important to help newly hired nonclinical staff familiarize themselves with medical equipment, such as hospital beds and cardiac monitors, and to help them feel safe functioning in the hospital environment.¹⁰ It was equally crucial to tour the active biomode units and patient transport routes to help SO/TSOs navigate the vast hospital footprint. See Supplemental Materials for the agenda, goals, and objectives for the SO training program (www.liebertpub.com/doi/suppl/10.1089/hs.2021.0182).

COVID-19 PPE donning and doffing videos were filmed and posted to an online central repository along with other biomode unit resources to supplement ad hoc just-in-time PPE training, including signage and fast fact sheets.

Safety Audits and Contact Tracing

Beginning in October 2020, SO/TSOs incorporated safety audits of all clinical units throughout the hospital into their workflow. SO/TSOs used a secret shopper approach to identify deviations from accepted COVID-19 precautions including physical distancing, maximum room occupancy requirements, eye protection, and mask use. When deviations were identified, SO/TSOs would provide instructions in real time to prevent future errors. Data from the safety audits were entered into IP-360, a custom web-based system created by the data architect for The Johns Hopkins Hospital to improve infection prevention. Unit-based infection preventionists used the data from IP-360 to enhance compliance with COVID-19 precautions.²⁷ See Supplemental Materials for the checklist used by the SO/TSOs in the safety audits (www.liebertpub.com/doi/suppl/10.1089/hs.2021.0182).

In addition to the safety audits, a contact tracing team interviewed any staff member who tested positive for SARS-CoV-2 or was diagnosed with COVID-19. The team conducted standardized interviews to determine potential risk factors in the hospital that may have contributed to the staff members testing positive, including failure to wear proper PPE during aerosol-generating procedures, failure to wear eye protection during patient encounters, or failure to wear recommended PPE during a COVID-19 patient encounter. These data were entered into IP-360 and used by unit-based infection preventionists in quality improvement initiatives.

Infection control leadership selected categories of noncompliance according to their likelihood of contributing to staff exposure. For example, mask-wearing noncompliance was defined as lack of a mask or improper mask wearing (ie, mask worn below the nose). SOs were trained by infection control staff on the categories of compliance and what types of behaviors or observations constituted noncompliance.

Posttraining Results

A total of 202 redeployed clinical staff were trained as SO/TSOs. An additional 30 SO/TSOs were hired once clinical staff returned to their home units. From September 2020 through July 2021, SO/TSOs worked over 1,200 shifts totaling 14,000 hours. During that time the SO/TSOs supported 8 biomode units and other clinical areas that collectively cared for 1,582 patients with COVID-19, and countless more individuals under investigation for COVID-19. SO/TSOs also assisted with more than 1,000 transports during which no healthcare worker exposures were reported.²⁸ In addition to having SO/TSOs work with their staff on biomode units, all departments—including labor and delivery, the adult emergency department, pediatrics, and surgery—incorporated safe COVID-19 PPE practices into unit-specific training by using the standardized and enduring training resources from the Safety Officer Department.

Safety Audits

From September 2020 through July 2021, over 32,500 individuals were observed performing more than 53,500 activities as part of the SO/TSO safety audit program. Overall compliance with hospital COVID-19 precautions observed through these audits was 86%. Staff were over 90% compliant with mask-wearing guidance but were less compliant with wearing eye protection, particularly during encounters with non-COVID-19 patients (Table 1). Compliance also differed by location, with near universal compliance in outpatient clinical areas and lower compliance in ancillary areas (eg, cafeterias, nonpatient unit hallways) (Table 2).

Table 1.

COVID-19 Precaution Compliance Observations by Category

Category Description	Total Observations	Compliant Observations	Category Compliance
Staff mask compliance	31,972	29,816	93%
Staff max room occupancy compliance	5,478	4,722	86%
Staff physical distance compliance	9,160	7,106	78%
Staff eye protection compliance in patient room	6,997	4,676	67%

Table 2.

Compliance with COVID-19 Guidance by Location

Hospital Area	Total Observations	Compliant Observations	Compliance by Hospital Area
Outpatient	304	300	99%
Inpatient	43,223	38,748	90%
Procedure	3,640	2,929	80%
Ancillary^a	6,418	4,329	67%

Nonclinical spaces such as restaurants, cafeterias, nonclinical hallways, and common spaces.

Contact Tracing

From March 2020 through August 2021, thousands of frontline staff cared for approximately 2,683 COVID-19 patients and many more individuals under investigation for COVID-19 in biomode units or in dedicated airborne isolation rooms. Of the 1,251 staff members who contracted SARS-CoV-2 during that period, only 96 (7.7%) reported improper PPE use during the care of a confirmed COVID-19 patient as a potential risk factor during their contact tracing interview. The staff members who tested positive worked in both outpatient and inpatient locations, and included both bedside and ancillary/support roles, such as food service and security personnel. However, not all staff who tested positive entered biomode units.

Discussion

Staff safety during the COVID-19 pandemic is one of the most important issues facing healthcare systems. Our hospital developed an SO/TSO program to assist frontline COVID-19 providers to don and doff PPE, navigate the clinical environment of new biomode units, and transport COVID-19 patients to and from clinical units. Hundreds of clinical staff were reassigned from their home clinical units to become SO/TSOs for dedicated biomode units during the early part of the pandemic. Dozens more were hired to sustain the program once clinical operations resumed in other parts of the hospital for non-COVID-19 care. Data from contact tracing and safety audits on clinical units suggest that the SO/TSO program contributed to a culture of safety in which staff were consistently compliant with COVID-19 precautions and the incidence of work-based transmission of COVID-19 from contact with COVID-19 patients was low.

In addition to their immediate value to frontline COVID-19 staff, redeployed clinicians who were trained as SO/TSOs served as infection prevention resources for their colleagues once they returned to their home units. The standardized training package with didactic presentation, skills competencies, and simulation checklists could be delivered by these unit-based educators to enhance overall unit performance in infection prevention for COVID-19 and non-COVID-19 patients alike. The curriculum and central repository for COVID-19 resources such as PPE videos also contributed to the long-term goal of increasing unit self-sufficiency to maintain PPE competency during COVID-19 and regular clinical operations.

The challenges of implementing a sustainable SO/TSO model included recruiting individuals for a temporary role, frequent and rapid changes in protocols and responsibilities, maintaining 24-hour staffing coverage, and the uncertain role of SO/TSOs in hospital operations beyond the COVID-19 response. It is difficult to quantify the benefit of the SO/TSO program since it was not possible to gather baseline data on COVID-19 PPE and infection prevention compliance before the pandemic. It was not ethically acceptable to assign SO/TSOs to specific units to compare outcomes, given the concerns for staff safety that prompted the creation of the program. Overall compliance rate with COVID-19 precautions was much higher than previously reported in other institutions. For example, compliance with eye protection was 67% in our safety audits compared with 33% in a prior study by Wotherspoon and Conroy.²¹ This suggests that the SO/TSO program likely played an important role in promoting a culture of safety on biomode units and throughout the hospital. The lack of any reported safety incidents such as staff exposure or environmental contamination during more than 1,000 COVID-19 patient transports also speaks to the value of the TSO in creating a safe environment for frontline providers.

Conclusion

The development of a safety officer program enhanced staff safety during COVID-19 frontline care, improved the transport process of patients infected with highly infectious diseases, and provided a framework for individual hospital units to improve their infection prevention practices. The SO/TSO program can serve as a model for other healthcare institutions looking to build a flexible and durable solution to improve staff safety in biomode units during the COVID-19 pandemic and to bolster infection prevention for future infectious disease threats.

Footnotes

Acknowledgments

The authors would like to thank the staff of The Johns Hopkins Hospital for all of their efforts to care for patients and each other during the pandemic. We would also like to thank the Maryland Department of Health, the US Office of the Assistant Secretary for Preparedness and Response, and the National Emerging Special Pathogens Training and Education Center for their continued support of high-level isolation unit preparedness. Part of this work was funded by the COVID-19 Administrative Supplement for the US Department of Health and Human Services Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.

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