4.3 PPE Selection, Donning, Doffing, & Safety

4.3 PPE Selection, Donning, Doffing, & Safety

Quick Answer: Personal Protective Equipment (PPE) includes specialized clothing or equipment worn by healthcare personnel to protect against infectious hazards. Regulated by the Occupational Safety and Health Administration (OSHA) under the Bloodborne Pathogens (29 CFR 1910.1030) and Respiratory Protection (29 CFR 1910.134) standards, PPE must be selected based on anticipated exposure risk. Adherence to exact donning (putting on) and doffing (taking off) sequences is essential to prevent self-contamination.

While engineering controls (such as negative pressure rooms) and work practice controls (such as needle safety devices) form higher levels of hierarchy in hazard controls, PPE provides indispensable individual barrier protection. Infection Preventionists are responsible for training staff, auditing compliance, and ensuring appropriate PPE selection across clinical departments.

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Regulatory Framework: OSHA Mandates

OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030)

The OSHA BBP Standard protects employees from occupational exposure to blood and other potentially infectious materials (OPIM). Key employer obligations include:

• Written Exposure Control Plan: Annual review and updating of the facility's exposure control plan.
• Provision of PPE: Employers must provide appropriate PPE (gloves, gowns, masks, eye protection) in suitable sizes at no cost to employees.
• Cleaning & Maintenance: Employers must clean, launder, repair, or dispose of PPE at no cost.
• Hepatitis B Vaccination: Free Hepatitis B vaccination must be offered to all employees with occupational exposure risk within 10 working days of initial assignment.
• Post-Exposure Evaluation: Immediate, confidential medical evaluation and follow-up after an exposure incident.

OSHA Respiratory Protection Standard (29 CFR 1910.134)

When healthcare workers require respiratory protection (e.g., against M. tuberculosis, measles, SARS-CoV-2), OSHA mandates a comprehensive respiratory protection program featuring:

1. Medical Clearance: Medical evaluation by a physician or licensed healthcare professional before fit testing or respirator use to ensure the employee is physically able to wear a respirator.
2. Annual Fit Testing: Qualitative (pass/fail based on taste/smell threshold detection, e.g., saccharin or Bitrex) or quantitative (numerical measurement of face seal leakage using instruments like a PortaCount) fit testing performed initially and annually thereafter, or whenever face structure changes.
3. User Seal Check: Required every single time a user dons a tight-fitting filtering facepiece respirator (N95) before entering a contaminated environment (positive and negative pressure checks).

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Overview of PPE Components

N95 Filtering Facepiece Respirator vs. Powered Air-Purifying Respirator (PAPR)

• N95 Respirator: Tight-fitting negative-pressure respirator that filters at least 95% of airborne particles down to 0.3 micrometers. Requires medical clearance, initial/annual fit testing, and user seal checks.
• PAPR: Positive-pressure device equipped with a blower unit, HEPA filter, battery, and loose-fitting hood/helmet. Offers an Assigned Protection Factor (APF) of 25 (compared to APF 10 for N95). PAPRs are ideal for personnel with facial hair, facial deformities, or those who fail N95 fit testing.

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Step-by-Step Donning Sequence (Putting On PPE)

Donning must occur outside the patient room or in an anteroom prior to entering the patient care area.

   DONNING SEQUENCE (CDC Guidelines)
   ┌─────────────────────────────────────────────────────────┐
   │  STEP 1: Perform Hand Hygiene                           │
   └───────────────────────────┬─────────────────────────────┘
                               │
   ┌───────────────────────────▼─────────────────────────────┐
   │  STEP 2: Put on Gown                                    │
   │  (Cover torso neck-to-knees, fasten in back)            │
   └───────────────────────────┬─────────────────────────────┘
                               │
   ┌───────────────────────────▼─────────────────────────────┐
   │  STEP 3: Put on Mask or Respirator                      │
   │  (Secure ties/straps, fit nosepiece, user seal check)   │
   └───────────────────────────┬─────────────────────────────┘
                               │
   ┌───────────────────────────▼─────────────────────────────┐
   │  STEP 4: Put on Goggles or Face Shield                  │
   │  (Adjust headband to fit comfortably)                   │
   └───────────────────────────┬─────────────────────────────┘
                               │
   ┌───────────────────────────▼─────────────────────────────┐
   │  STEP 5: Put on Gloves                                  │
   │  (Extend gloves over wrist cuffs of gown)               │
   └─────────────────────────────────────────────────────────┘

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Step-by-Step Doffing Sequence (Taking Off PPE)

Doffing is the high-risk phase for self-contamination. Doffing must be performed slowly and deliberately. Except for the respirator/mask, all PPE should be removed at the doorway or in the anteroom.

Key Principle: Contaminated vs. Clean Areas

• Contaminated Areas (Outside/Front): Outside front and sleeves of gown, front of face shield/goggles, outside of gloves, front of mask/respirator.
• Clean Areas (Inside/Back/Straps): Inside of gloves, inside of gown, gown ties at back, ear loops/straps of mask/goggles.

Standard Doffing Sequence (CDC Preferred)

1. REMOVE GLOVES: Grasp outside edge of opposite glove near wrist. Peel away from hand, turning glove inside out. Hold removed glove in gloved hand. Slide fingers of ungloved hand under wrist of remaining glove and peel off, creating a "glove-in-glove" bundle. Discard in waste container.
2. REMOVE GOGGLES / FACE SHIELD: Remove from back by lifting headband or ear pieces. Touch only headband/ear pieces, not the contaminated front surface. Discard or place in designated container for reprocessing.
3. REMOVE GOWN: Unfasten gown ties at neck and waist (taking care not to touch front). Allow gown to fall away from shoulders. Touching inside of gown only, turn gown inside out, roll into a bundle, and discard.
4. PERFORM HAND HYGIENE: Decontaminate hands with ABHR or soap and water immediately after removing gown.
5. REMOVE MASK OR RESPIRATOR: Perform AFTER exiting the patient room and closing the door. Grasp bottom ties or elastics, then top ties/elastics, and pull away from face without touching the front. Discard in waste receptacle.
6. PERFORM HAND HYGIENE: Decontaminate hands again after mask removal.

Alternative Doffing Sequence (Combined Gown and Glove Removal)

Grasp gown front and peel away from body so ties break. Roll gown inside out while peeling off gloves simultaneously into a single bundle, followed by eye protection, hand hygiene, mask removal outside room, and hand hygiene.