Attachment 1 FM Donning and Doffing CleanRoom Suites.pptx

Hazardous Drug (HD) Buffer Room: Steps for Doffing Inside HD Buffer Room Clean Side of Ante-Room

VHA BHHCS PHARMACY

11/2021

Remove outer pair of sterile gloves while inside the hood. If not compounding, remove outer pair of sterile gloves before doffing line. Dispose in yellow sharps container.

Remove outer most shoe covers one at a time, sit on a stool placed at the doffing line. Beginning with the foot closest to the doffing line, remove the outer shoe cover, put this foot across the line and into the doffing area. Discard the shoe cover in yellow chemo bin. Repeat with other outer most shoe cover.

Remove the HD gown by pulling from the waist/hips until it releases from the shoulders. Do NOT touch your collar or loosen the Velcro with gloved hands. Slowly remove the gown, turning it inside out and balling it up. Discard in the yellow chemo bin.

Remove your inner gloves by grasping the first glove by the palm, removing it, and placing it in the palm of the hand with the remaining glove. Slide your index finger under the remaining glove, pulling it off to make an inside-out pouch of the used gloves. Discard in yellow chemo bin.

Exit the buffer room.

If you are leaving the compounding suite, do this:

Remove the non-HD gown and hang it on hook. OR if end of shift: Remove the non-HD gown and discard.

Since HDs are water-soluble, always wash hands and wrists with soap and water.

Walk to the dirty side of the ante-room or exit ante-room and remove the remainder of the garb (bouffant cap, Respirator/PAPR hood if applicable, mask, and inner shoe covers).*

* Provided that coated gowns and second set of shoe covers are used AND doffing is performed correctly, these items are not considered contaminated with HD residue.

If you need to enter the non-HD buffer room, do this:

Remove the non-HD gown. Hang it on a hook.

Perform hand hygiene per SOP (lathering 30 seconds) to remove any HD residue present from gaps in proper doffing, as well as reduce the microbial load on hands.

Redon the gown on the hook.

Enter the non-HD buffer room and don sterile gloves.

HD Doff

Hazardous Drug (HD) Buffer Room: Steps for Garbing Dirty Side Ante-Room Clean Side Ante-Room

HD

Buffer Room

VHA BHHCS PHARMACY

11/2021

Don Facemask and head cover (bouffant cap) Facemask: bend nose bar; pull down under chin, no gaps; beard cover over mask if goatee and full head cover if beard.

Head Cover: ensure ears are covered If monthly cleaning with peridox, cleaning underneath HD BSC or CACI bench, don respirator or PAPR instead of facemask.

If cleaning above eye level, don wrap-around eye googles unless wearing full-face respirator/PAPR hood

2. Don 2 pairs of shoe covers on each foot, one foot at a time crossing over the line of demarcation(LOD).

3. Perform hand hygiene, including a 30 second lather to the elbows after using nail pick on wet, soap lathered hands.

4. Dry hands with low-lint wipes.

Don a non-HD gown then don an HD gown over the non-HD gown. Do not put thumb loops in place. Pull the sleeves of the HD gown up to mid-forearm. Enter the buffer room.

6. Obtain 2 pairs of sterile chemo gloves. Remove both from their outer packages at counter surface.

7. Apply alcohol-based hand rub to nails, hands, and wrists.

When hands are dry, put the non-HD gown’s thumb loops in place and don the 1st pair of gloves, ensuring the cuff of this pair is placed over the non-HD gown’s sleeve. gloves to pull the HD gown sleeves down over the cuffs of the 1st pair of gloves without contaminating the gloves.

Use the sterile paper from the 1st pair of Don the 2nd pair of gloves (cuffs over HD gown sleeves) Sanitize gloves with sIPA.

HD

Garb

Non-Hazardous (Non-HD) Buffer Room: Steps for Garbing

Ante-Room Clean Side Ante-Room Non-HD Buffer Room

VHA BHHCS PHARMACY

11/2021

Don Facemask and head cover (bouffant cap) Facemask: bend nose bar; pull down under chin, no gaps; beard cover over mask if goatee and full head cover if beard.

Head Cover: ensure ears are covered If monthly cleaning with peridox, cleaning underneath HD BSC or CACI bench, don respirator or PAPR instead of facemask.

If cleaning above eye level, don wrap-around eye googles unless wearing full-face respirator/PAPR hood

2. Don 1 pairs of shoe covers on each foot, one foot at a time crossing over the line of demarcation(LOD).

3. Perform hand hygiene, including a 30 second lather to the elbows after using nail pick on wet, soap lathered hands.

4. Dry hands with low-lint wipes.

5. Don a non-HD gown. Enter the buffer room.

6. Obtain 1 pair of sterile gloves. Remove from their outer packages at counter surface.

7. Apply alcohol-based hand rub to nails, hands, and wrists.

8. When hands are dry, put thumb loops in place and don gloves, ensuring the cuff is placed over the non-HD gown’s sleeve.

9. Sanitize gloves with sIPA.

Non-HD Garb

Non-Hazardous Drug (Non-HD) Buffer Room: Steps for Doffing Inside Non-HD buffer room Clean Side of Ante-Room

VHA BHHCS PHARMACY

11/2021

Exit the buffer room.

If you are leaving compounding suite, do this:

Remove gloves.

Remove gown. Gown maybe hung on hook and reused during shift by same employee. Discard at end of shift.

Wash hands and wrists with soap and water.

Walk to the dirty side of the ante-room or exit ante-room and remove the remainder of the garb (bouffant cap, Respirator/PAPR hood if applicable, mask, and inner shoe covers).

If you need to enter the HD buffer room, do this:

Sitting on the clean side of the bench in ante-room place second pair of shoe covers on each foot.

Doff gloves.

Then don a HD gown over the non-HD gown. Do not put thumb loops in place. Pull the sleeves of the HD gown up to mid-forearm.

Enter the buffer room and follow HD buffer room: steps 7-12 for garbing ISO 7 HD Buffer room.

Non-HD Doff

EMS ONLY -> Cleaning: Steps for Garbing

Ante-Room Clean Side Ante-Room

Non-HD Buffer Room

VHA BHHCS PHARMACY

11/2021

1. Don Facemask and head cover (bouffant cap) Facemask: bend nose bar; pull down under chin, no gaps; beard cover over mask if goatee and full head cover if beard.

Head Cover: ensure ears are covered If monthly cleaning with peridox, cleaning underneath HD BSC or CACI bench, don respirator or PAPR instead of facemask.

If cleaning above eye level, don wrap-around eye googles unless wearing full-face respirator/PAPR hood

2. Don 2 pairs of shoe covers on each foot, one foot at a time crossing over the line of demarcation(LOD).

3. Perform hand hygiene, including a 30 second lather to the elbows after using nail pick on wet, soap lathered hands.

Dry hands with low-lint wipes.

Don a non-HD gown then don an HD (chemo) gown over the non-HD gown.

Do not put thumb loops in place. Pull the sleeves of the HD gown up to mid-forearm.

6. Enter the Non-HD buffer room.

7. Obtain 2 pairs of chemo grade exam gloves or sterile gloves.

Apply alcohol-based hand rub to nails, hands, and wrists.

When hands are dry, put the non-HD gown’s thumb loops in place and don the 1st pair of gloves, ensuring the cuff of this pair is placed over the non-HD gown’s sleeve.

Pull the HD gown sleeves down over the cuffs of the 1st pair of gloves.

Don the 2nd pair of gloves. (cuffs over HD gown’s sleeves)

EMS ONLY -> Cleaning: Moving from Non-HD Buffer to HD-Buffer and working out of IV room suites Inside Non-HD buffer room Clean Side of Ante-Room

VHA BHHCS PHARMACY

11/2021 Exit the Non-HD buffer room and proceed to the HD buffer room. Enter HD buffer room.

6. Wash hands with soap and water. Dry with low lint wipes. Put the gown’s thumb loops in place.

Obtain 2 pairs of chemo grade exam or sterile gloves and don.

Continue cleaning the Ante-Room, cleaning self out of the room.

Exit Ante-Room, remove PPE and wash hands with soap and water.

Exiting HD Buffer Room:

1. Remove outer pair of gloves before doffing line. Dispose in yellow sharps container in trolley.

Remove outer most shoe covers one at a time, sit on a stool placed at the doffing line.

Beginning with the foot closest to the doffing line, remove the outer shoe cover, put this foot across the line and into the doffing area. Discard the shoe cover in yellow chemo bin. Repeat with other outer most shoe cover.

Remove the HD gown by pulling from the waist/hips until it releases from the shoulders. Do NOT touch your collar or loosen the Velcro with gloved hands. Slowly remove the gown, turning it inside out and balling it up. Discard in the yellow chemo bin.

Remove your inner gloves by grasping the first glove by the palm, removing it, and placing it in the palm of the hand with the remaining glove. Slide your index finger under the remaining glove, pulling it off to make an inside-out pouch of the used gloves. Discard in yellow chemo bin.

Exit the buffer room to the clean-side of the ante room.

Inside HD buffer room

Remove make-up, jewelry, and extra clothing; tie up hair Clean personal glasses with glass cleaner and kimtech wipes on frames and lenses Don 1 pair of bootie covers Wash hands Enter the ante-room Before Entering Ante-Room image1.jpeg image2.jpeg image3.jpeg image4.jpeg image5.jpeg image6.png image7.svg

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