Table 3 Highest impact and highest frequency outcomes

1. Theme: Safe doffing (removal of PPE safely and in correct order)

People/teams/tasks;

Tools/technology

Key outcomes

Cross monitor team members during doffing

Use and IPAC poster as a cognitive aid

Ensure “1 to 1” doffing to avoid breaches observed when too many doffing at once (e.g., getting ahead or behind in doffing sequence)

Consistent role of a “PPE Coach” to support safe doffing-ensure focus and intention with every step

Implement “just-in-time” review of safe doffing to reduce cognitive load during long stressful periods in PPE.

2. Theme: Conducting environmental scans of care areas is crucial in anticipating, planning ahead, and developing area processes

Environment;

Tools/technology;

People/Teams/Tasks

Key outcomes

Remove visitor chairs, extra equipment and linens from room to avoid waste, and additional cleaning between patients

Keep transport routes

Post signage for direction and decrease of clutter

Creation of supply restocking checklist white this

Creation of COVID-19 specific cart of required supplies

Creation of small, labeled packages of specific supplies, or medications for fast grab and go

Ensure team members are aware of the responsibilities required to maintain the space

Ensure cleaning processes for removal of equipment leaving COVID-19 rooms (e.g., stretchers, wheelchairs)

3. Theme: Conduct inter-departmental/inter-hospital transport routes to establish communication and process between departments and professions

People/teams/tasks;

Environment;

Tools/technology

Key outcomes

Test and walk through the route

Use signage if COVID-19 routes differ from the usual process

Clean hallways of clutter and reduce traffic if possible

Consider dedicating elevator banks for COVID-19 patients, staff and carts

Establish a designated clean person on transports to ensure surfaces are cleaned (e.g., floors, elevator buttons, stretchers, and wheel chairs)

Emergency medical services should use a common Stem in communication and pages: This line is supposed to be with the one below to read: "Emergency medical services should 

“Possible/Confirmed COVID-19 patient” this goes afte the word "pages" in line above

Upon arrival of out of external hospital emergency medical services, ensure transport is ready and routes are prepared. white this Should read; Upon arrival of externa;l hospital emergency medical services, ensure transport is ready and routes are prepared.

4. Theme: Maintenance of isolation environment/prevention of contamination

Tools/technology;

People/teams/tasks

Key outcomes

Removal of stethoscopes, phones, ID badges, lanyards, watches, and earrings from person prior to donning.

When items are on person, reinforce learnings re: do not reach below gown for ID badge/pager/mobile phone; or under visor to adjust goggles/mask.

Creation of bins on an external cart in donning area for dropping items into

Keep numbers of staff in the room low when possible

Ensure cleaning process for roving items such as clipboards, ultrasound machines, etc.

5. Theme: Roles and responsibilities

People/teams/tasks;

Environment

Key outcomes

A runner role is needed across multi areas: Operating Room, Emergency Department, Labor and Delivery Unit, Intensive Care Unit (team member to bring supplies between isolated COVID-19 care area and non-isolated area)

Consider the involvement of HCAs and Unit Clerks to bring necessary equipment required for teams

Establish “clean” and “dirty” sides between rooms and within rooms by taping the floors for a visual cue

Establish CODE COVID-19 team to attend to all rapid deteriorating patients

6. Theme: Innovative approaches to communication

Tools/technology;

People/teams/tasks

Key outcomes

Use of dry erase markers on the shared glass wall of isolation to ante room

Use of a laminated page that can be flipped back and forth

Use of white boards to communicate key messages to outside team members

Use of two-way radios (e.g., walkie talkies) and baby monitors

Limit the use of negative pressure rooms and use ante rooms where available

Use of speaker phone setting

Use of tape on floor to communicate ‘clean versus dirty’ zones

Check that monitors and speakers on phones (especially with PPE on) can be heard

Include name/role tag stickers on outer PPE to ensure role clarity and effective communication

Reduce noise and ensure use of closed-loop communication (additional communication challenges with PPE on)

Use of trigger scripts on pagers to signal a priority response. Scripts like “COVID airway” or “COVID transport” to alert a team and get the right people and the right equipment to the right place.

7. Theme: Psychological safety and speaking up

People/teams/tasks

Key outcomes

Use critical language when breeches in PPE or when overcrowding in rooms occur

Encourage all team members to speak up when they see breaches in safe PPE practices

Removing hierarchical barriers can be challenging; promoting psychology safety is important for a cohesive team

Go beyond your professional role to cross teach about PPE

8. Theme: Critical care medicine pre-intubation cognitive aid

People/teams/tasks;

Tools/technology;

Organization

Key outcomes

Communicate a plan ahead to ensure staff know their roles

Double-check proper PPE during intubation

Most experienced practitioner should perform the intubation

Ensure the ventilator and video laryngoscopy device are in the room prior to start

Consider back-up plan depending on available resources

Ensure correct bagger filter is attached

9. Theme: Use of cognitive aids and checklists

Tools/technology

Key outcomes

Consider human factors science in the development of new COVID-19 cognitive aids and checklists

Cognitive aids can be made into posters, use larger font, central point of reference white this

They should be clear, easy to use adaptable to context, trained prior to implement, and pilot tested prior to use on a real patient

Examples: COVID-19 airway pause checklist, checklists for buckets, and carts/bins, IPAC donning and doffing poster white this