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Infect Control Hosp Epidemiol. 2018 Aug;39(8):961-967. doi: 10.1017/ice.2018.125. Epub 2018 Jun 18.

Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.

Author information

1SimTigrate Design Lab,School of Architecture,Georgia Institute of Technology,Atlanta,Georgia.
3School of Psychology,Georgia Institute of Technology,Atlanta,Georgia.
4Department of Pathology and Laboratory Medicine,Emory University School of Medicine,Atlanta,Georgia.
6Division of Environmental Health,School of Public Health,Georgia State University,Atlanta,Georgia.
5Division of Infectious Diseases,Department of Medicine,Emory University School of Medicine,Atlanta,Georgia.



To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU).


We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises.


The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.ParticipantsA total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study.


In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements.


Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.

[Indexed for MEDLINE]

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