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Stay Safe! What is the correct order for donning (putting on) and doffing (removing) PPE?

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What is PPE?

Personal protective equipment (PPE) is equipment designed to protect the wearer from injury or the spread of infection or illness, e.g. protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators.

When used properly, PPE acts as a barrier between infectious materials such as viral and bacterial contaminants and your skin, mouth, nose, or eyes (mucous membranes). The barrier has the potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. When used properly and with other infection control practices such as hand-washing, using alcohol-based hand sanitizers, and covering coughs and sneezes, it minimizes the spread of infection from one person to another1.

 

How does this relate to COVID-19?

The current outbreak of COVID-19 comes from a virus belonging to the family of Coronaviridae (SARS-CoV-2, genus: Betacoronavirus), a large family of enveloped, positive-sense single-stranded RNA viruses2.

Coronaviruses are usually transmitted through large respiratory droplets and direct contact, but other modes of transmission (i.e. airborne and faeco-oral) may also occur3.  The average incubation period is estimated at 5 to 6 days, but it can range overall from 0 to 14 days4,5.

SARS-CoV-2 (causing COVID-19 disease) is spread mainly from person-to-person through respiratory droplets produced when an infected person coughs, sneezes, or talks6. Infectious droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Respiratory droplets can land on hands, objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching hands, objects or surfaces with droplets and then touching their eyes, nose, or mouth7. The virus is spread between people who are in close contact with one another (within 1.5 meters/6 feet); and, may be spread by people who are not showing symptoms. These individuals may never exhibit symptoms, or may days after actually contracting the virus8.

 

For the general public, when you should wear and remove a mask?

Masks offer some protection to you and are also meant to protect those around you, in case you are unknowingly infected with the virus that causes COVID-199.

Ideally, you have been socially distancing and not exposed to individuals with COVID-19 and you’re staying at home most of the time. Masks may not be necessary when you are outside by yourself away from others, or with other people who live in your household. However, you should wear a mask even at your home if you are caring for someone who is sick with COVID-19 (whether at home or in a non-healthcare setting), or if you are sick with COVID-19 or think you may have COVID-19.

Also, it is especially important to wear a mask when you go outside, when you are unable to stay at least 6 feet apart from others since COVID-19 spreads mainly among people who are in close contact with one another (within about 6 feet). Some localities may have mask mandates while out in public and these mandates should always be followed.

In these cases, you should wear a mask, even if you do not feel sick. This is because several studies have found that people with COVID-19 who never develop symptoms (asymptomatic) and those who are not yet showing symptoms (pre-symptomatic) can still spread the virus to other people. The main function of wearing a mask is to protect those around you, in case you are infected but not showing symptoms. Your mask offers some protection to you.

In general, you should wear a mask that fits properly (snugly around the nose and chin with no large gaps around the sides of the face). How well a mask protects you from breathing in the virus likely depends on the fabrics used and how your mask is made (e.g. the type of material or fabric, the number of layers of fabric, how well the mask fits)9.

If you need to remove your mask after you have finished your trip, errand or work shift or temporarily need to remove your mask to eat, avoid removing your mask near other people and remove your mask facing away from others, thereafter maintain at least 6ft of space between you and others. You can also remove it outside, once you are away from others, or in your car on your way home.

When you're ready to take the mask off, clean your hands with soap and water or use hand sanitizer before touching the mask. Avoid touching the outside of the mask, which may be contaminated or dirty. Only touch the ear loops and hold both of the ear loops to gently lift and remove the mask. If you want to take your mask off in your car, have a paper bag waiting to place the mask in so that you can throw it in the trash later. Clean your hands with soap and water or hand sanitizer after removing your mask.

 

For Healthcare workers, what types of PPE should be worn?

In order to manage suspected or confirmed cases of COVID-19, it’s crucial healthcare professionals and managers working in multidisciplinary areas, are educated in the correct usage of Personal Protective Equipment (PPE). This protects not only themselves, but their patients as well.

The US Centers for Disease Control and Prevention (CDC) and the European Centre for Disease Prevention and Control (ECDPC) both suggest a minimal PPE set for the management of suspected or confirmed cases of COVID- 19 to mitigate contact, droplet and airborne transmission that includes respiratory protection, eye protection (googles or face shield), body protection and hand protection,10. For respiratory protection, the ECDPC recommends FFP2 or FFP3 respirators while the CDC recommends using a surgical/medical mask or a fitted respirator mask (N95 respirators, FFP2 or equivalent) when performing aerosol generating procedures. For Body protection, the CDC recommends wearing a clean, non-sterile, long-sleeve gown, while the ECDPC recommends along-sleeved water-resistant gown or a single-use plastic apron worn over a non-water-resistant gown7,10.

The agencies and regulators warn that most PPE components come in different sizes, and stress that PPE does not follow a one-size-fits- all principle. A proper PPE fit is essential to obtain protection; a size too large or too small will fail to provide adequate protection10,11.

 

What order should you use when wearing (donning) PPE?

Putting on and removing PPE is a critical process and requires significant care. Specifically the removal and disposal of contaminated PPE is considered a highly important step in limiting exposure to SARS-CoV-2.

The CDC, ECDPC and WHO suggest the following procedure for safe donning and doffing10,11,12,13.

Before wearing the PPE for managing a suspected or confirmed COVID-19 case, proper hand hygiene should be performed following international recommendations14. This is a critical aspect in this setting and should be performed using an alcohol-based solution, with at least 70% alcohol10,15.

The first PPE to be donned is the long-sleeved water-resistant gown (when using a gown with back closure, a second person should help by securing the back). Ensure that the choice of gown size is correct (based on training).

After the gown, proceed with the respirator to protect from the inhalation of droplets and particles. The metal nose clip needs to be adjusted to fit the nose using both hands and not be bent or tented, and the top respirator strap should be placed on the crown of the head and the bottom strap on the based of the neck or if using a respirator with an earloop design, ensure the straps fit tightly to have a firm and comfortable fit.

Perform a user seal check each time you put on the respirator. If you cannot achieve a proper fit, position the straps crosswise. If a face mask (surgical mask) is worn as substitution for a respirator, it is still important to correctly position it on the face, and adjust with the metal nose clip to achieve a proper fit. The Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.

Once the respirator has been properly positioned, put on the goggles for eye protection. When wearing a respirator, make sure that the respirator does not interfere with the correct positioning of eye protection and that eye protection does not affect the fit or seal of the respirator. Place the goggles over the mask’s straps and ensure that the textile elastic strap fits snugly – but not too tightly.

After the goggles, the gloves are next. It is important to extend the glove to cover the wrist over the gown’s cuffs. For individuals allergic to latex gloves, an alternative option, for example nitrile gloves, should be available.

 

Which PPE should you remove first and which should you remove last?

After the patient has been examined, the removal (doffing) of the PPE is a critical because of the possibility it’s now contaminated. This makes it an important step that needs to be carefully carried out to avoid self-contamination.

The gloves are removed first because they have a high likelihood of heavy contamination. Use of alcohol-based hand disinfectant should be considered before removing the gloves. The gloves should be removed following eight steps, according to Fig.1. Always dispose of the gloves in a biohazard bin.

Fig.1 – Removal of contaminated gloves10

Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove. If your hands get contaminated during glove removal, immediately wash your hands or use an alcohol-based hand sanitizer. Discard gloves in a waste container. After the removal of gloves, proper hand washing and sanitizing should be performed, and a new pair of gloves should be worn to further continue the doffing procedure. Using a new pair of gloves will prevent self-contamination.

The gown is removed next with the new pair of clean gloves (Back closure gowns will require help from another person, who needs to wear gloves and a surgical mask. They should be removed after opening the gown). After the gloves of the assistant are removed, hand hygiene should be performed using an alcoholic solution.

 

Untie all ties or unsnap all buttons on the gown taking care that sleeves don’t contact your body. (Some gown ties can be broken rather than untied.) After the gown has been unbuttoned or untied, remove gently by reaching up to the shoulders and carefully grabbing the back of the gown and pulling it away from the neck and shoulders, touching inside of gown only and keeping the contaminated front part inside the gown rolled inside out. Fold or Roll into a bundle. Single-use gowns should be disposed of immediately. Reusable gowns have to be placed in a bag or container for disinfection. If your hands get contaminated during gown removal, immediately

wash your hands or use an alcohol-based hand sanitizer.

After the gown, the goggles or face shield should be carefully removed by handling the earpieces or headband without touching the front of the googles or face shield be disposed if they are single-use, or placed in a bag or container for disinfection if they’re reusable. Touching the front part of the googles or face shield should be avoided, due to possible contamination. If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer. If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container.

The respirator should be removed next by placing a finger or thumb under the straps in the back and removing from the face. Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. The respirator (or the surgical mask) should be disposed of after removal. It is important to avoid touching the front of the respirator with the gloves (except for the elastic straps) during its removal.

The last PPE item to remove are the gloves, which should be rubbed in an alcohol-based solution before removal (procedure described above in Fig.1). After glove removal, hand hygiene should be performed.

 

References:

1          FDA. (ed U.S. Food and Drug Administration) (FDA, https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control, 2020).

2          Huang, R., Xia, J., Chen, Y., Shan, C. & Wu, C. A family cluster of SARS-CoV-2 infection involving 11 patients in Nanjing, China. The Lancet Infectious Diseases, doi:10.1016/S1473-3099(20)30147-X (2020).

3          Kang, S. et al. Recent Progress in understanding 2019 Novel Coronavirus associated with Human Respiratory Disease: Detection, Mechanism and Treatment. Int J Antimicrob Agents, 105950-105950, doi:10.1016/j.ijantimicag.2020.105950 (2020).

4          WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 73. (World Health Organization, https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-19.pdf?sfvrsn=5ae25bc7_2, 2020).

5          Yu, P., Zhu, J., Zhang, Z., Han, Y. & Huang, L. A familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period. J Infect Dis, jiaa077, doi:10.1093/infdis/jiaa077 (2020).

6          Alwan, N. A. et al. Scientific consensus on the COVID-19 pandemic: we need to act now. The Lancet 396, e71-e72, doi:10.1016/S0140-6736(20)32153-X (2020).

7          CDC.    (ed USA Centers for Disease Control and Prevention) (CDC, https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#PPE, 2020).

8          The Lancet Respiratory, M. COVID-19 transmission: up in the air. The Lancet Respiratory Medicine, doi:10.1016/S2213-2600(20)30514-2.

9          CDC.    (ed USA Centers for Disease Control and Prevention) (CDC, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html#anchor_1604967124156, 2020).10           ECDPC.  Vol. Stockholm  (ed European Centre for Disease Prevention and Control) (ECDPC, https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-guidance-wearing-and-removing-personal-protective-equipment-healthcare-settings-updated.pdf, 2020).

11        WHO. COVID-19: How to put on and remove personal protective equipment (PPE), 2020).

12        CDC.    (ed USA Centers for Disease Control and Prevention) (CDC, https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, 2020).

13        CDC.    (ed USA Centers for Disease Control and Prevention) (CDC, https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf, 2020).

14        WHO.    (ed World Health Organization) (https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessionid=3D5B6AF129FA5FA0F98F7D80DF80EC2D?sequence=1, 2009).

15        CDC.    (ed USA Centers for Disease Control and Prevention) (CDC, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html, 2020).

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