Donning and Removing PPE for Infection Prevention

The demands on healthcare personnel (HCP) are extraordinary, but the importance of attention to personal protection cannot be underestimated. By way of example, a cluster of 17 SARS (severe acute respiratory syndrome) cases among Canadian HCP in 2003 was studied. Among their findings – 13 of those who fell ill (87 percent) were unsure of the proper order in which personal protective equipment (PPE) should be donned and removed.

The authors concluded that multiple factors were involved in the development of SARS in the HCP studied. Among those factors: high-risk patient-care procedures, inconsistent use of PPE, fatigue and lack of adequate infection control training.¹

Infection preventionists are encouraged to remind HCP of the need for vigilance when using PPE.  Assessing compliance is a basic, but essential duty. This article reviews the role of Standard Precautions and offers specific guidance on donning and removal of PPE. 

The Role of Standard Precautions

According to CDC’s 2004 Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings, “Standard Precautions are intended to prevent the transmission of common infectious agents to healthcare personnel, patients and visitors in any healthcare setting.” In caring for a patient, Standard Precautions require HCP to assume the presence of an infectious agent in the patient’s blood or body fluids and excretions, other than sweat.⁴

As a result of that assumption, appropriate precautions should be taken. These include: hand hygiene; and proper donning, use and removal of gloves, gown, mask, eye protection or face shield. Also required is proper handling of equipment or items in the patient environment. 

Examples are: wearing gloves during direct patient contact; containing heavily soiled equipment; and properly cleaning and disinfecting or sterilizing reusable equipment before using it on another patient.³

A component of Standard Precautions, PPE is one of a hierarchy of controls aimed at removing or eliminating hazards to HCP from infectious disease exposures.² The hierarchy is as follows:

• Training and administrative controls (i.e., isolation policies and procedures).

• Engineering controls (i.e., negative-pressure rooms for airborne diseases). 

• Work practice controls (i.e., not recapping needles).

• PPE (i.e., gown, mask or respirator, goggles or face shield, gloves).

Donning Basics

General CDC recommendations for the appropriate use of PPE include:³

• Don PPE before patient contact and generally before entering the patient room.

• Once it is on, use PPE carefully to avoid contamination. Follow general safe-work practices including:

-- Keep hands away from face.

-- Work from clean to dirty.

-- Limit surfaces touched.

-- Change PPE when torn or heavily contaminated.

The recommended donning sequence is as follows:

To don a gown:

• Select the appropriate type and size.

• With the opening in the back, secure the gown at the neck and waist.

• If the gown is too small for full coverage, use two; the first with the opening in the front, and the second placed over it with the opening in the back.

To don a mask:

• Place it over the nose, mouth and chin.

• Fit the flexible nose piece over the bridge of the nose.

• Secure it on the head with ties or elastic.

• Adjust it to fit.

If the mask has two elastic head bands, these should be separated.  With the mask over the nose, mouth and chin, stretch the bands over the head and secure them comfortably – one on the upper back of the head and one below the ears at the base of the neck.

To don goggles and face shield:

• Position goggles over the eyes and secure to the head using the ear pieces or headband.

• Position the face shield over the face and secure on brow with the headband.

• Adjust for comfort.

Putting on a particulate respirator (like an N95, N99 or N100) is similar to donning a pre-formed mask with elastic head bands. Check manufacturers’ instructions for any model-specific precautions and fit testing requirements. 

To don gloves:

Gloves are the last element of PPE to be applied.

• Extend the hands into the gloves and extend the gloves to cover the wrist of the isolation gown. 

• Tuck the cuffs of the gown securely under each glove. 

• Adjust for comfort and dexterity.  

Removal Basics

Once patient-care tasks are complete, carefully remove PPE and discard it in the receptacles provided.³ Immediately perform hand hygiene. During removal, the goal is to avoid contamination of self or the environment with the contaminated equipment.  Generally, the outside front and sleeves of a gown, the outside front of face protection and the outside of gloves are considered contaminated regardless of the appearance of visible soil. 

The location for removing PPE will depend on the amount and type of PPE worn as well as the category of patient isolation. For instance, if only gloves are worn, they may be removed and discarded in the patient room. When a gown or full PPE is worn, PPE should be removed at the doorway to a patient room or in an anteroom. Respirators should always be taken off outside a patient room, once the door is closed.²                      

To remove a gown:

• Unfasten the ties.

• Peel the gown away from the neck and shoulder.

• Turn the contaminated side (the outside) toward the inside.

• Fold or roll the gown into a bundle.

• Discard in designated receptacle.

To remove a mask, note that the front is considered contaminated and should not be touched. Follow these steps:

• First untie the bottom, then the top tie.

• Lift the mask away from the face.

• Discard in designated receptacle.

To remove a respirator:

• Lift the bottom elastic over the head first.

• Lift the top elastic slowly to avoid “snapping.”

• Discard in designated receptacle.

To remove gloves:

• Grasp the outside edge near the wrist. 

• Peel the glove away from the hand, turning the glove inside out.  Hold it in the opposite gloved hand.

• Slide an ungloved finger under the wrist of the remaining glove, then peel it off from the inside, creating a “bag” for both used gloves.

• Discard in designated receptacle.

Again, remember to perform hand hygiene after using and discarding PPE.        

Role of Safety Culture

Proper donning and removal of PPE is one basic step in a safety culture. A safety culture refers to a work environment where there is a shared commitment to safety on the part of management and employees.Several hospital studies have linked this shared commitment to safety with healthcare personnel adherence to safe work practices and reduced exposure to potentially infectious blood and body fluids.³Building a strong safety culture is a means to enhance your infection prevention program. 

Conclusion

Compliance with the basics, including proper donning and removal of PPE,  can significantly impact the ability of  healthcare facilities to reduce the risk of healthcare-associated infections (HAIs). Are you doing all you can to create and advocate for a culture of safety? Is your infection control program doing all it should to engage employees in training, provide proper PPE and encourage adherence?

Kathleen B. Stoessel, RN, BSN, MS, is senior manager of clinical education for Kimberly-Clark Health Care.

References:

1. Ofner-Agostini M, Gravel D, McDonald L. C, Lem M, Sarwal, S, McGreer A, Green K, Vearncombe M, Roth V, Paton S, Loeb M, Simor A, Cluster of Cases of Severe Acute Respiratory Syndrome Among Toronto Healthcare Workers After Implementation of Infection Control Precautions:  A Case Series.  Hospital Control & Hospital Epidemiology, April 26, 2006.

2. Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings, Centers for Disease Control and Prevention, May 2004.

3. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf