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Table 3 Recommendations used in the Delphi rounds, median and interquartile (IQR) ratings of participants, and proportion of participants providing a rating of 7, 8 or 9. Legend: Bold numbers indicate recommendations on which consensus was reached. See Supplement 2 for more details

From: How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application

Recommendation to improve processes illustrated in the video Delphi round 1 Delphi round 2
Median IQR 7–8-9 percentage Median IQR 7–8-9 percentage
Preparation and team roles
 1. To prevent excessive donning and doffing associated with leaving and re-entering the room, assign someone outside the room to act as a runner. For example, to receive blood samples to send to the lab or to obtain extra equipment if needed. 9 2 82    
 2. Use role identifiers for staff wearing PPE. For example, staff should wear stickers or laminated photos. 7 3 61 8 2 81
 3. Have pre-defined key roles for staff during each emergency and allocate these to a specific team at the start of each shift with a buddy system. For example, in the event of a PPH, one staff member’s role would be to prepare the PPH medication in the room. 7 4 59 7 4 63
Donning of PPE
 4. Clarify correct sequence for donning gloves and entering room. 9 2 80    
 5. To avoid contamination, ensure appropriate glove use: wear double gloves, do not open doors with gloved hands, and wear the gloves over the long-sleeved gowns. 8 2 72    
 6. Perform hand hygiene prior to donning PPE. 9 3 72 9 1 86
 7. Have a person to assist with donning of PPE if possible. For example, the third team member should receive assistance from the second team member with donning. 7 3 69 8 2 86
 8. Secure and fix hair away from face to protect hair and face from contamination. For example, use disposable hats, caps or tie hair back. 8 3 68 9 2 84
 9. A woman with suspected or confirmed COVID-19 should be cared for by staff wearing full protective PPE using a visor and not just a simple mask. 7 4 56 9 4 67
 10. Improve gown and apron cover for both the woman and the doctor. For example, tie gown at the side rather than at the back. 6 3 44 7 2 39
 11. Avoid giving masks to patients during an emergency (as it compromises breathing and reduces ability to assess). 5 3 32 6 3 47
 12. Include more time and instruction on the correct doffing order. For example, doff the majority of PPE (gloves and gown) inside the room and doff masks outside of the room. 9 2 76    
 13. Perform hand hygiene at each stage of the doffing process. For example, perform hand hygiene before or after doffing the gown, before or after doffing gloves, and before doffing the mask or eye protection. 7 4 53 9 3 68
Layout and design – application of human factors
 14. Apply human factors principles to the design of the PPE donning station. For example, items in sequence of use, standardised layout. 9 2 86    
 15. Improve grab bag design. For example, indicate contents, use a box and standardised layout. 9 2 85    
 16. Provide a clear demarcation of dirty/clean zones to indicate moving in and out of a potential ‘contamination’ zone. For example, mark a red area outside of room for doffing, to ensure potentially contaminated equipment is doffed in a controlled area. 8 2 80    
 17. Improve bin design to allow easy PPE disposal. For example, wider aperture and a fully opening lid. 8 2 79    
 18. Provide instructions to explain correct processes of donning and doffing. For example, a poster on the wall. 9 2 87    
 19. Provide opportunity for debrief and feedback for the team involved. 9 1 87    
 20. The importance of communicating with the woman and/or partner should be emphasised. For example, when wearing masks, staff should have awareness of eye contact, tone of voice and body language between the team and towards the woman and partner. 8 2 80    
 21. Review the design of the algorithm (step-by-step guide). For example, optimise text size and contrast for legibility and provide a hard surface for writing on. 7 2 76    
 22. Use alternative methods of communication with others outside the room, for example, mobile phones or intercoms. 7 3 61 8 2 68