1.2 Personal Protective Equipment (PPE) Protocols

Personal Protective Equipment (PPE) Protocols

Personal Protective Equipment (PPE) encompasses specialized physical barriers designed to shield healthcare personnel from exposure to infectious agents, bloodborne pathogens, and hazardous chemical or biological materials. When used in conjunction with rigorous hand hygiene, PPE forms an indispensable defense that protects both the clinician and the patient from cross-contamination.

Selecting, donning, operating within, and doffing PPE demands strict procedural discipline. An error during removal (doffing) represents one of the most common mechanisms by which healthcare workers inadvertently contaminate their own skin, mucous membranes, and personal clothing.

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1. PPE Components & Clinical Selection Rationale

Under OSHA Bloodborne Pathogens Standards and CDC infection control directives, employers must provide appropriate PPE at no cost to healthcare workers, and personnel must select equipment matched to the anticipated clinical exposure.

Examination Gloves

• Clinical Purpose: Protects hands from direct contact with blood, infectious materials, mucous membranes, non-intact skin, and contaminated surfaces; reduces the risk of transmitting the worker's endogenous flora to the patient.
• Material Selection: Nitrile gloves are the preferred standard across most acute healthcare settings due to superior puncture resistance, chemical durability, and complete avoidance of Type I latex allergy risks. Latex gloves offer excellent elasticity and tactile sensitivity but present significant allergic sensitization hazards. Vinyl gloves are loose-fitting with lower tensile strength and higher failure rates; their use is restricted to brief, non-invasive, low-risk procedures with zero potential for blood or bodily fluid contact.
• Critical Practice Rules: Disposable examination gloves must never be washed, disinfected with alcohol rub, or reused. Washing causes "wicking" (enhanced penetration of liquids through microscopic pinholes), and alcohol degrades glove integrity. Gloves must be changed immediately if punctured, torn, or heavily contaminated.

Isolation Gowns

• Clinical Purpose: Shields the healthcare worker's arms, torso, and clothing from blood, wound exudates, bodily fluids, splashing liquids, and direct physical contact with uncontained infectious lesions or contaminated patient environments.
• Design & Fluid Resistance: Gowns must open in the back, provide full coverage from the neck to the mid-calf, feature long sleeves with snug elastic or knit cuffs, and possess secure fastenings at both the neck and waist. Fluid-resistant or fluid-impermeable materials are mandated whenever splashing, copious wound irrigation, or large-volume body fluids are anticipated.

Surgical / Procedure Masks

• Clinical Purpose: Protects the oral and nasal mucous membranes from large respiratory droplets (> 5 microns) generated by patient coughing, sneezing, or vocalization, as well as blood or bodily fluid splashes. Masks simultaneously serve as "source control," filtering the exhaled droplets of the wearer.
• Design Features: Pleated fluid-resistant synthetic material with a flexible aluminum or plastic nosepiece and attachment ties or elastic ear loops. Masks do not seal tightly against the facial contours and do not filter tiny airborne particles.

Eye Protection: Goggles & Face Shields

• Clinical Purpose: Shields the ocular conjunctiva from infectious droplets, sprays, splatters, and respiratory aerosols.
• Goggles: Must fit snugly over and around the eyes with dedicated side and top shields to prevent splash entry. Personal prescription eyeglasses are strictly prohibited as a substitute for safety goggles because they leave wide gaps above, below, and to the sides of the orbits.
• Face Shields: Provide comprehensive coverage extending from the forehead down past the chin and wrapping around the temples. Face shields protect the eyes, nose, mouth, and the external surface of masks or respirators from high-velocity fluid impacts.

Particulate Respirators (N95, N99, N100, PAPR)

• Clinical Purpose: Tight-fitting respiratory protective devices certified by the National Institute for Occupational Safety and Health (NIOSH) to filter at least 95% of airborne particulate matter down to 0.3 microns. Mandated for Airborne Precautions against pathogens like Mycobacterium tuberculosis, measles (rubeola), and varicella (chickenpox).
• Powered Air-Purifying Respirators (PAPR): Utilize battery-operated blowers that draw ambient air through high-efficiency particulate air (HEPA) filters and supply positive-pressure purified air into a loose-fitting hood or helmet. Indicated for personnel who cannot achieve an adequate facial seal with an N95 respirator due to facial hair, deep facial scars, or non-conforming bone structure.

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2. CDC Standard Donning Sequence

PPE must be donned systematically before entering the patient room or clinical procedure area (typically in a clean anteroom or immediate hallway staging area). Complete donning prior to contact ensures zero unprotected exposure.

1. Isolation Gown  --->  2. Mask or Respirator  --->  3. Goggles or Face Shield  --->  4. Gloves
(Fasten neck & waist)    (Mold nosepiece, seal)       (Secure over eyes/face)      (Pull cuffs over gown)

Step 1: Isolation Gown

• Select a gown of appropriate size and fluid-barrier rating.
• Slip arms through the sleeves, ensuring full coverage from the neck to the knees and wrists.
• Wrap the gown fully around the back of the uniform so no underlying clothing is exposed.
• Fasten the neck ties securely, then tie the waist ties firmly. Leaving ties loose or unfastened allows the gown to sag, exposing scrubs to contaminated bedding and surfaces.

Step 2: Mask or Respirator

• Surgical Mask: Position over the nose, mouth, and chin. Fit the flexible metal band over the bridge of the nose. Tie the upper ties at the crown of the head and the lower ties behind the nape of the neck (or loop elastics over ears). Pull the bottom edge securely beneath the chin.
• N95 Respirator: Cup the respirator in one hand with the nosepiece resting at the fingertips. Position the respirator against the face covering nose and chin. Pull the top strap over the head to rest high on the crown. Pull the bottom strap over the head and position it around the neck below the ears. Use both hands to mold the malleable metal nosepiece firmly against the nasal bridge from the center outward. (Never pinch the nosepiece with one hand, as this creates a sharp peak and a prominent air gap).
• Perform the mandatory User Seal Check (detailed in Section 4).

Step 3: Goggles or Face Shield

• Place the goggles or face shield over the eyes and face.
• Adjust the headband or earpieces so the protective shield rests comfortably and firmly without displacing or compromising the facial seal of the mask or respirator.

Step 4: Gloves

• Don clean, non-sterile examination gloves last.
• Pull the glove gauntlets up and over the knit or elastic wrist cuffs of the isolation gown.
• Ensure complete overlap so that no bare skin is visible between the gown sleeve and the glove cuff during clinical movement.

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3. CDC Doffing Sequences & Contamination Rationale

When removing PPE, healthcare personnel must recognize which surfaces are contaminated and which remain clean:

• Contaminated Zones (DO NOT TOUCH WITH BARE HANDS): The outside front and sleeves of the gown, the exterior surfaces of gloves, and the front and sides of goggles, face shields, and masks.
• Clean Zones: The interior surfaces of the gown, the gown ties at the neck and waist, the earpieces and headband of goggles/face shields, the ties and elastic straps of masks/respirators, and the interior surfaces of gloves.

Method 1: Component-by-Component Sequence

This standard sequence prioritizes early removal of the most heavily contaminated articles, minimizing the hazard of secondary self-inoculation.

1. Gloves First (Highest Bioburden)

• Gloves harbor the heaviest concentration of pathogens and bodily fluids. Removing them first prevents spreading contaminants to gown ties, eye protection, and the face.
• Glove-in-Glove Technique:
  1. Grasp the exterior edge of one glove near the wrist cuff using the opposite gloved hand. Do not touch bare skin.
  2. Peel the glove downward and away from the body, turning it inside out as it is removed. Hold the removed inside-out glove balled up in the palm of the remaining gloved hand.
  3. Slide the bare index or middle finger of the ungloved hand under the interior wrist cuff of the remaining glove, touching only clean skin on the inside of the wrist.
  4. Peel the second glove downward over the first glove, turning it inside out to create a contained, inside-out bundle containing both gloves.
  5. Discard the bundled gloves immediately into the appropriate waste receptacle.

2. Goggles or Face Shield

• The front of the eye protection is contaminated.
• Reach around with clean, bare hands to grasp the clean headband or earpieces from the back of the head.
• Lift the goggles or face shield up, forward, and away from the face without touching the front surface.
• Place in a designated reprocessing container or discard into the waste bin.

3. Isolation Gown

• The front and sleeves are heavily contaminated.
• Unfasten the neck ties, then unfasten the waist ties (or break breakaway ties by pulling forward).
• Grasp the gown by the inside neck and shoulder seams using clean bare hands.
• Peel the gown downward and away from the neck and shoulders, touching only the clean inside.
• Turn the gown inside out as it slides down the arms.
• Roll the gown into a neat, contained bundle with the contaminated exterior facing inward, and discard.

4. Mask or Respirator

• The front surface of the mask is heavily contaminated with filtered droplets or aerosols.
• Critical Rule: Never touch the front of the mask or respirator.
• Untie or grasp the bottom strap/ties first, then untie or grasp the top strap/ties behind the crown of the head.
• Lift the mask forward and away from the face by the straps, and discard directly into the trash.
• Location Note: A surgical mask or respirator used for Contact or Droplet precautions may be removed inside the patient room near the exit door. However, an N95 respirator used for Airborne Precautions must NEVER be removed inside the patient room; it must be removed in the anteroom or hallway only after exiting the room and closing the door.

5. Immediate Hand Hygiene

• Perform immediate hand hygiene using an alcohol-based hand rub or soap and water immediately following the removal of all PPE, as microscopic contamination during doffing is well documented.

Method 2: Combined Gown and Glove Removal

In this approved alternative method, the isolation gown and gloves are removed simultaneously:

1. Grasp the gown front at chest level with gloved hands and pull firmly forward to snap breakaway ties.
2. Roll the gown forward and downward into a ball, simultaneously peeling the gloves off inside-out within the sleeves of the gown.
3. Discard the combined ball of gown and gloves into the waste receptacle.
4. Remove goggles/face shield by the rear straps.
5. Remove mask/respirator by the rear straps.
6. Perform immediate hand hygiene.

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4. N95 Respirator: Fit Testing vs. User Seal Check

A critical distinction tested on clinical certification examinations is the difference between formal annual fit testing and the mandatory point-of-use user seal check.

Performing the User Seal Check (Positive & Negative Pressure)

Every healthcare worker must perform both checks immediately upon donning an N95 respirator:

1. Positive Pressure Seal Check:
   • Place both hands gently over the surface of the respirator, taking care not to disturb its position against the face.
   • Exhale gently into the facepiece.
   • Passing Result: The facepiece should bulge outward slightly with a positive pressure sensation, and no air should leak around the nasal bridge, cheeks, or chin.
   • Corrective Action: If air escapes along the top edge, remold the nosepiece. If air escapes at the sides or bottom, readjust the position of the elastic head straps.
2. Negative Pressure Seal Check:
   • Place both hands over the surface of the respirator.
   • Inhale sharply and deeply.
   • Passing Result: The facepiece should collapse inward slightly against the face, and no air should enter around the facial perimeter.
   • Corrective Action: If air enters around the perimeter, readjust the tension and position of the straps and repeat both tests. If an airtight seal cannot be achieved, the worker must not enter the airborne isolation environment and must be re-fitted with an alternate size or a PAPR.

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5. Preventing Cross-Contamination During Patient Care

Wearing PPE does not grant immunity from spreading microorganisms if clinical discipline is violated during routine tasks.

• Clean to Dirty Progression: When planning multiple patient care activities, always perform the cleanest tasks first before proceeding to dirtier procedures. For example, obtain oral vital signs and examine eyes before performing wound care or emptying a urinary drainage bag.
• Glove Changes on the Same Patient: Gloves must be removed, hands decontaminated, and fresh gloves donned whenever moving from a contaminated anatomical site (e.g., managing incontinence, changing a soiled sacral dressing, tracheostomy care) to a clean anatomical site (e.g., adjusting an IV line, administering oral care, drawing blood).
• Environmental Discipline: Never touch clean environmental surfaces (charts, medical supply cabinets, clean linen carts, door handles, computer keyboards, mobile phones) with contaminated gloves. Remove gloves and perform hand hygiene before accessing clean workspaces.