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This skill is based fully upon material take from the CDC recommendations for EMS personnel^[1] and reflects up to date COVID-19 compliant instructions^[2] for the donning and doffing of a full set of PPE including respiratory, eye and hand protection with a full isolation gown. For most prehospital patient encounters the isolation gown is not required, but you should be familiar with its use.

How to Put On (Don) PPE Gear

Annotations:

• 1:35 Donning N95 Respirator
• 2:12 N95 Seal Check
• 2:43 Donning Facemask
• 3:08 Donning Face Shield or Goggles
• 3:23 Donning non-sterile gloves

More than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical.

1. Identify and gather the proper PPE to don.
2. Perform hand hygiene using hand sanitizer.
3. Put on correctly sized isolation gown (if using). Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel.
4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. 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.
   • Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.
   • Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now initiate patient contact.

Tips and Tricks

• Think about your situation before you enter; does your patient have significant bleeding? Are they in cardiac arrest and require CPR? Situations with significant chances for contamination or exertion may require different PPE requirements in addition to the normal gloves, goggles, and mask (for COVID times). Consider gowning or double gloving.
• Keep a spare gown and N95 in an easily accessible place along with one or two pairs of gloves. Even if your patient does not initially look like they may require full contact and respiratory precautions, oftentimes patients will forget to mention clinically significant findings that require changes to PPE and sometimes the situation changes rapidly or in unexpected ways (think projectile vomiting from a patient with moderate abdominal pain). Having easily accessible PPE means that you do not have to potentially reach over your now vomiting patient to the PPE cabinet to grab a gown.

How to Take Off (Doff) PPE Gear

Annotations:

• 0:31 Remove Gloves
• 1:25 Remove Gown
• 2:02 Hand Hygiene
• 2:15 Remove face shield or goggle
• 2:27 Remove Respirator or facemask
• 3:00 Final hand hygiene

More than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing.

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.
   • Respirator: 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.
   • Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.

Self Assessment

Self-assessment

• When donning, perform the respirator check at 2:12 in the video to verify proper fit
• For doffing, practice removing gloves contaminated with ketchup or other non-infectious contaminant to verify glove removal technique.

References