Rapid ramp-up of powered air-purifying respirator (PAPR) training for infection prevention and control during the COVID-19 pandemic

Editor—Singapore's first coronavirus disease 2019 (COVID-19) patient was diagnosed on January 23, 2020. This triggered an urgent ramp-up of just-in-time (JIT) training to expedite development of infection prevention and control capabilities in the Department of Anaesthesiology, Intensive Care, and Pain Medicine of Tan Tock Seng Hospital in anticipation of a rapidly escalating COVID-19 pandemic.

Frequent involvement in aerosol-generating procedures (AGPs) such as tracheal intubation, extubation, and open airway procedures including tracheostomy and bronchoscopy¹ exposes our staff to high risk of contamination. Proper use of a hooded powered air-purifying respirator (PAPR) offers better protection against respiratory pathogens during AGPs, with an assigned protection factor (APF) of up to 1000 compared with an APF of 10 for a N95 respirator.² Our hospital uses two types of PAPRs: the 3M™ Jupiter™ with 3M™ HT-101 Lightweight Hood (Fig 1 ) and the 3M™ Versaflo™ TR-300 with 3M™ Hood Assembly S-855. In the initial phase of our pandemic response plan, our department prioritised JIT resources for infection prevention and control measures against AGP, with a focus on PAPR training, as these are infrequently used, and their effectiveness requires a high level of staff involvement.

Fig 1.

Jupiter™ PAPR donning, doffing, and decontamination training guide. PAPR, powered air-purifying respirator; PPE, personal preventive equipment.

Development of a PAPR training programme

Pre-requisites

All staff had been N95 mask-fitted and had undergone two PAPR training sessions with competency checks, one each for Jupiter™ and Versaflo™ PAPRs. These covered the basic operation and donning and doffing of the PAPRs.

Timeline

Our department's infection prevention and control team was formed on January 28, 2020 and aimed to complete departmental PAPR training before Singapore progressed to a heightened risk. We allocated 2 weeks each for the training of Jupiter™ and Versaflo™ PAPR, and this allowed comprehensive one-on-one training for all 96 anaesthetists within February 2020.

Focus

The Infection Prevention and Control team developed a concise JIT training programme with the highly specific focus of safe donning, doffing, and decontamination of PAPR, managing PAPR failure, and performing procedures while wearing PAPR.

Training design

Immersive learning and pre-training interventions³ were used to optimise capability development within the limited time we had. We produced a preparatory instructional video to enhance pre-learning and expedite the practical session. Pictograms and cognitive aids were displayed in the operating rooms (ORs) and Emergency Airway Management Response (EAMR) kit. Educational materials were uploaded on the Intranet and shared via an online platform. Trainees had the option of video recording their training performance for subsequent reflection.

Training scenarios

We prioritised infection prevention and control training for AGPs in two clinical settings: EAMR and the conduct of general anaesthesia (GA) in a COVID-19 patient in the OR. The training placed emphasis on the expected role of the anaesthetist: senior doctors performed tracheal intubation while wearing the PAPR, whereas junior doctors focused on OR preparation and assisting the senior doctor.

Trainee scheduling

We prioritised doctors who may encounter clinical scenarios with minimal logistical support. This included registrars who provide EAMR after hours. We collaborated with the roster maker to assign PAPR-competent anaesthetists to the ORs designated for contagious pathogens.

Principles behind respiratory protection

As a prescriptive model may not always fit unpredictable clinical circumstances, we assisted doctors in developing thought processes that enable them to make safe infection prevention and control decisions independently. Although PAPR may be used for AGPs, the anaesthetist should rely on their best judgement based on patient and medical team safety, bearing in mind that the acuity of the situation, for example critical patient conditions requiring urgent intubation, may preclude safe donning, doffing, and decontamination of a PAPR.

Logistics

We coordinated with the OR director for manpower deployment as training had to be prioritised, and doctors had to be released from routine clinical work. We were able to locate two ORs to conduct training as business-as-usual workload gradually reduced. We liaised with the nursing officer to obtain PAPR units for training, while maintaining sufficient operational units for clinical use.

Training—individual level

For a realistic learning experience, in situ simulation was used. This allowed doctors to familiarise themselves with the actual OR set-up and identify possible barriers with the use of PAPR during patient care. The agenda of each session included:

• •Clinical scenario of a COVID-19 patient requiring urgent surgery under GA or requiring intubation in the general ward as part of an EAMR.
• •A discussion on the thought process of choosing appropriate PPE for different clinical scenarios.
• •OR or ward preparation with focus on infection prevention and control measures.
• •Checking and donning of PAPR.
• •Conduct of GA in OR or urgent intubation in the general ward.
• •
  Capabilities to counter drawbacks of PAPR use:

  • o
    Safe doffing and decontamination of PAPR.
  • o
    PAPR failure drill.

Thought processes and step-by-step instructions are detailed in Fig 1, which includes practical pointers to achieve maximal protection. Figure 1 is tailored to the use of Jupiter™ PAPR in the OR, but the same principles can be applied to the use of any PAPR in a variety of clinical settings.

Training—team level

To validate and improve our processes, a multidisciplinary OR drill was organised for an elective tracheostomy, which is a high-risk AGP requiring robust infection prevention and control measures for staff protection. Participants' proficiency in PAPR use was supervised and evaluated by our infection prevention and control team. An inter-professional debrief was conducted to refine our processes further. For example, we observed that our standard isolation gown with back ties may inadvertently expose one's back and risk contamination of the PAPR; hence the wrap-around surgical gown is now recommended when a PAPR is used.

Training—hospital level

Workflow for use of PAPR in an EAMR and for emergency OR cases was tested in the broader context of a hospital-level drill, where a manikin-simulated COVID-19 patient was intubated in the general ward and subsequently transferred for scans and procedures. This drill led to further improvements to the EAMR logistical support by providing a trained OR nurse to bring the Jupiter™ PAPR to the anaesthetist at the EAMR location, assist in safe donning and doffing, and set up of a doffing area.

With rigorous infection prevention and control measures and PAPR training, we managed to keep patient-to-doctor transmission at 0% from January to March 2020, while providing seamless care for the majority of COVID-19 patients in Singapore.

Declarations of interests

The authors declare that they have no conflicts of interest.