Donning and Doffing PPE Correctly

Amidst the global COVID-19 pandemic, it is now especially crucial that healthcare professionals working in multidisciplinary areas are educated in the correct application and removal of personal protective equipment in order to protect both themselves and their patients.

Personal protective equipment (PPE) donning and doffing is a critical process that requires significant care.

This process, particularly the removal and disposal of contaminated PPE, is considered a highly important step in limiting exposure to pathogens (CEC 2020).

Healthcare organisations should uphold appropriate infection control and prevention measures as per the NSQHS Preventing and Controlling Healthcare-Associated Infection Standard.

What is PPE?

The term personal protective equipment refers to anything used to decrease the risk of harm to the health and safety of workers (Safe Work Australia 2017).

In healthcare settings, PPE is used to create a barrier between the worker and any infectious agents (spread through airborne, contact or droplet modes) they may come into contact with. The aim is to reduce the risk of touching, transmitting or being exposed to pathogens (MedlinePlus 2019).

PPE includes:

• Clothing (gowns, aprons, head covering, shoe covers);
• Gloves;
• Masks; and
• Eye protection (face shields, goggles).

(MedlinePlus 2019)

Using PPE Effectively

• Healthcare workers must be thoroughly informed about any infections and updated on the current policies, procedures and protocols of their organisation.
• Workers must have access to the necessary equipment to carry out the specified task correctly and safely.
• You may consider having a second clinician present to supervise the donning and doffing process and ensure it is performed correctly.
• Healthcare organisations must apply both standard and transmission-based precautions as they are applied individually.
• Workers must have a thorough understanding of contact, droplet and airborne precautions.
• Strict hand hygiene must be performed.

(CEC 2020; WHO 2014; ACSQH 2019)

Sequence for Donning and Doffing PPE

Note: The above video details the procedure for donning and doffing PPE for combined contact and droplet precautions.

If you are dealing with aerosol-generating procedures, you should refer to the combined contact, droplet and airborne precautions video instead.

Donning

1. Perform hand hygiene.


2. Put on gown.
   • Fully cover your torso from your neck to knees and your arms to the end of your wrists, then tie at the back.
   • The gown should be large enough to allow unrestricted movement without gaping.
   • Fasten at the back of the neck and waist.


3. Put on surgical mask or P2/N5 respirator.
   • Secure the ties or elastic bands at the middle of the head and neck.
   • Fit flexible band to the nose bridge.
   • Fit mask snug to face and below the chin.
   • Fit-check respirator according to manufacturer instructions.


4. Put on protective eyewear or face shield.
   • Place over eyes/face and adjust to fit.


5. Put on gloves.
   • Extend the gloves to cover the wrist of the gown.

(Adapted from diagrams by Queensland DoH 2020; CDC 2014)

If at any point your gloves become contaminated, you must dispose of them, perform hand hygiene and then replace them with new gloves (CEC 2020).

Remember to always refer to WHO’s ‘5 Moments for Hand Hygiene’.

Doffing

Following a correct doffing procedure is especially crucial in the control and prevention of infection. It is the most important step of preventing infection transmission (CEC 2020).

The doffing of PPE should protect your clothing, skin and mucous membranes from contamination (CDC 2014).

Remember that all PPE is contaminated after use. Perform hand hygiene immediately after each step of doffing (Queensland DoH 2020).

Your gloves and gown should be removed before exiting the patient’s room (CDC 2014).

1. Remove gloves.
   • Using one hand, grasp the palm of the other hand and peel off the first glove.
   • Hold the removed glove in the gloved hand.
   • Slide fingers of the ungloved hand under the remaining glove at the wrist and peel it off over the first glove.
   • Discard gloves in a waster container.


2. Perform hand hygiene.


3. Remove gown.
   • Unfasten the ties, ensuring the sleeves don’t make contact with your body.
   • Pull the gown away from the neck and shoulders, touching the inside only.
   • Turn the gown inside out.
   • Fold or roll the gown into a bundle and discard in the waste container.
   
   
4. Perform hand hygiene.


5. Exit the patient’s room and close the door.


6. Remove goggles/face shield.
   • Remove from the back of the head by lifting headband or ear pieces.
   • If reusable, place in the designated reprocessing receptacle. If not, discard in waste container.


7. Perform hand hygiene.


8. Remove mask/respirator.
   • Grasp the bottom ties/elastics, then the top ones, and remove without touching the front of the mask.
   • Discard in the waste container.


9. Immediately perform hand hygiene.

(Queensland DoH 2020; CEC 2020)

Note: PPE must be disposed of after use unless it is marked as reusable. Reusable PPE must be reprocessed before being used again (DoH 2020).

Appropriate PPE for Exposure to COVID-19 Patients

Transmission-based precautions should be used when dealing with confirmed or suspected COVID-19 patients.

• Contact and droplet precautions should be used for routine care of COVID-19 patients.
• Contact, droplet and airborne precautions should be used for:
  • Performing aerosol-generating procedures on COVID-19 patients; and
  • Caring for critically ill COVID-19 patients in ICU.

(DoH 2020)

Other Considerations

• If PPE is not worn correctly, there is a high risk of contamination (Pyrek 2018). Always follow hospital protocol and notify your supervisor if necessary.
• If goggles and masks are worn for too long, they may cause pressure injuries to the face. Ensure you protect bony prominences and/or change PPE frequently if possible.
• Always remember to engage with the patient, as it can be quite confronting for them not to see the healthcare worker’s face.
• Take regular breaks if you can.

Conclusion

Correct PPE use is crucial to infection control and prevention. You must always ensure correct procedures for donning and doffing are followed, and that staff are well-trained and competent (Pyrek 2018).

Always refer to your organisation’s policies and procedures.

Additional Resources

• Clinical Excellence Commission, Application of PPE in Response to COVID-19 Pandemic, http://cec.health.nsw.gov.au/__data/assets/pdf_file/0006/572883/Application-of-PPE-in-Response-to-COVID-19-19-March-2020-V1.4.pdf
• Clinical Excellence Commission, PPE Guidance for COVID-19, http://cec.health.nsw.gov.au/keep-patients-safe/COVID-19/Personal-Protective-Equipment-PPE
• Queensland Government Department of Health 2020, PPE Quick Reference Guide, https://www.health.qld.gov.au/__data/assets/pdf_file/0037/949960/covid-19-ppe-quick-reference.pdf
• Australian Government Department of Health 2020, Interim Recommendations for the use of Personal Protective Equipment (PPE) During Hospital Care of People with Coronavirus disease (COVID-19), https://www.health.gov.au/sites/default/files/documents/2020/03/interim-recommendations-for-the-use-of-personal-protective-equipment-ppe-during-hospital-care-of-people-with-coronavirus-disease-2019-covid-19.pdf
• Hand Hygiene 101, https://www.ausmed.com.au/cpd/articles/hand-hygiene-101
• Infectious Diseases: How Do You Break the Chain?, https://www.ausmed.com.au/cpd/articles/infectious-diseases

References

• Australian Commission on Safety and Quality in Health Care 2019, Action 3.5, Australian Commission on Safety and Quality in Health Care, viewed 23 April 2020, https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare-associated-infection-standard/infection-prevention-and-control-systems/action-35
• Australian Government Department of Health 2020, Interim Recommendations for the use of Personal Protective Equipment (PPE) During Hospital Care of People with Coronavirus disease (COVID-19), Australian Government Department of Health, viewed 23 April 2020, https://www.health.gov.au/sites/default/files/documents/2020/03/interim-recommendations-for-the-use-of-personal-protective-equipment-ppe-during-hospital-care-of-people-with-coronavirus-disease-2019-covid-19.pdf
• Centers for Disease Control and Prevention 2014, Sequence for Putting on Personal Protective Equipment (PPE), Centers for Disease Control and Prevention, viewed 23 April 2020, https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
• New South Wales Government Clinical Excellence Commission 2020, PPE Training for Individual Transmission-based Precautions, New South Wales Government Clinical Excellence Commission, viewed 23 April 2020, http://cec.health.nsw.gov.au/keep-patients-safe/COVID-19/Basic-PPE-training
• Safe Work Australia 2017, Personal Protective Equipment, Safe Work Australia, viewed 23 April 2020, https://www.safeworkaustralia.gov.au/ppe
• MedlinePlus 2019, Personal Protective Equipment, MedlinePlus, viewed 23 April 2020, https://medlineplus.gov/ency/patientinstructions/000447.htm
• Pyrek, K M 2018, ‘PPE Donning and Doffing Reveals Gaps in Knowledge and Practice’, Infection Control Today, 13 July, viewed 23 April 2020, https://www.infectioncontroltoday.com/personal-protective-equipment/ppe-donning-and-doffing-reveals-gaps-knowledge-and-practice
• Queensland Government Department of Health 2020, PPE Quick Reference Guide, Queensland Government Department of Health, viewed 23 April 2020, https://www.health.qld.gov.au/__data/assets/pdf_file/0037/949960/covid-19-ppe-quick-reference.pdf
• World Health Organisation 2014, Steps to Put on Personal Protective Equipment, World Health Organisation, viewed 23 April 2020, https://www.ncbi.nlm.nih.gov/books/NBK269628/bin/algorithm.pdf