Effects of Safety Zone Implementation on Perceptions of Safety and Well-Being When Caring for COVID-19 Patients

Claudia Skinner, DNP, RN, CIC, CCRN-K, NE-BC; Lilian Ablir, MSN, RN, CIC; Todd Bloom, MPH, CHES; Stacie Fujimoto, MSN, RN, PCCN-K; Yelena Rozenfeld, MPH; Peggy Leung, MSN, RN


Am J Crit Care. 2022;31(2):104-110. 

In This Article

Abstract and Introduction


Background: In March 2020, the caseload of patients positive for COVID-19 in hospitals began increasing rapidly, creating fear and anxiety among health care workers and concern about supplies of personal protective equipment.

Objectives: To determine if implementing safety zones improves the perceptions of safety, well-being, workflow, and teamwork among hospital staff caring for patients during a pandemic.

Methods: A safety zone process was implemented to designate levels of contamination risk and appropriate activities for certain areas. Zones were designated as hot (highest risk), warm (moderate risk), or cold (lowest risk). Caregivers working in the safety zones were invited to complete a survey regarding their perceptions of safety, caregiver well-being, workflow, and teamwork. Each question was asked twice to obtain caregiver opinions for the periods before and after implementation of the zones.

Results: Significant improvements were seen in perceptions of caregiver safety (P < .001) and collaboration within a multidisciplinary staff (P < .001). Significant reductions in perceived staff fatigue (P = .03), perceived cross contamination (P < .001), anxiety (P < .001), and fear of exposure (P < .001) were also seen. Teamwork (P = .23) and workflow (P = .69) were not significantly affected.

Conclusions: Safety zone implementation improved caregivers' perceptions of their safety, their well-being, and collaboration within the multidisciplinary staff but did not improve their perceptions of teamwork or workflow.


SARS-CoV-2 is a single-stranded RNA virus that can spread quickly.[1] Despite growing awareness of the risk of COVID-19 infection to health care workers (HCWs), conflicting evidence and conflicting expert opinions from policy makers on this risk persist.[2] Health care workers are at risk for exposure to many infectious diseases, particularly when caring for patients undergoing aerosol-generating procedures (AGPs).

Aerosol-generating procedures include handheld nebulizer treatments, oral/tracheal suction, intubation, and mechanical ventilation. However, the risk of transmission to HCWs through AGPs has not been well studied.[3] Indirect evidence suggests that noninvasive ventilation and invasive mechanical ventilation may increase the risk of COVID-19 transmission.[4] Aerosol-generating procedures and noninvasive ventilation quickly became part of the standard of care for patients hospitalized for COVID-19 infections, increasing the fear of viral spread to the frontline HCWs.

The first case of COVID-19 at the study facility was confirmed on March 9, 2020. Before the pandemic, approximately 360 isolation gowns and fewer than 100 N95 masks were used per month. By the middle of June 2020, more than 1900 gowns and 150 N95 masks were being used each day. Similar increases in the use of gloves, face shields, and surgical masks were identified. Supplies of alcohol-based hand sanitizer and disinfectant wipes were at a critical shortage by the middle of June 2020. Concern over the shortage grew as the number of positive cases rapidly increased. Caregivers expressed concerns over their safety.

Surge planning became a priority, as did strategies for personal protective equipment (PPE) conservation. The situation was changing daily, requiring close tracking of PPE resources and increased efforts to obtain PPE through unfamiliar suppliers. Staff were required to use unfamiliar PPE and other supplies. Anxiety among HCWs increased as the standard protocols to minimize risk were modified.[5]

As in many medical centers throughout the country, exposure to and transmission of COVID-19 to caregivers began to increase in the study facility. At that time, compared with workers in other professions, HCWs were more likely to become infected with COVID-19.[6] By June 2020, the Centers for Disease Control and Prevention reported that 19% of patients with confirmed COVID-19 in the United States were HCWs.[7] (The figure was based on patients with confirmed COVID-19 whose occupations were on record.) At that time, hundreds of HCWs had been exposed to patients with COVID-19 at the study facility. Several HCWs had tested positive, creating additional fear and stress. As the acuity level of patients increased, so did the use of AGPs and other supportive respiratory therapies. The magnitude of the risk of acquiring an infectious disease through patient care and procedures is not clearly understood.[8] The scarcity of information regarding protection provided by PPE remained a concern.[9]

Within months, the study hospital had a critical shortage of supplies of PPE, disinfectants, and hand sanitizer.

As case counts began to climb, we began grouping patients into cohorts. This gave us an opportunity to develop a team of caregivers with additional training and competency in safely caring for patients with COVID-19. With the rapid decline of the PPE supply, we focused on slowing the rate of PPE use, protecting caregivers, reducing fatigue from donning and doffing PPE, and providing the best possible care for our patients.

Doffing an isolation gown that has been worn in a room with aerosolized respiratory secretions is considered a high-risk procedure.[10] The doffing process may aerosolize contamination on the gown; the HCW, no longer protected by the gown, would then be at risk for direct contamination of the skin. The potential for inhaling aerosolized particles exists; however, continued use of N95 masks protected caregivers from this risk.

Through our search, we discovered a process that would meet our needs to conserve PPE, conserve staff energy during donning and doffing, and reduce HCWs' risk of exposure to COVID-19. In the Environmental Protection Agency's (EPA) emergency response plan, a safety zone process is described.[11] This process had been used successfully in other health care organizations to care for patients with highly infectious, highly virulent diseases.[12] After a thorough review of the safety zone process, we decided to implement it in the step-down/critical care unit and medical/surgical units which were providing care only for patients with COVID-19.