2.3 PPE Selection & Donning/Doffing Protocols

2.3 PPE Selection & Donning/Doffing Protocols

Quick Answer: Personal Protective Equipment (PPE) creates a physical barrier between the healthcare worker and infectious materials. The CDC Donning Sequence is: 1. Gown -> 2. Mask/Respirator -> 3. Goggles/Face Shield -> 4. Gloves (over gown cuffs). The CDC Doffing Sequence is: 1. Gloves (most contaminated) -> 2. Goggles/Face Shield -> 3. Gown -> 4. Mask/Respirator -> 5. Immediate Hand Hygiene. Particulate respirators (N95) require positive and negative pressure user seal checks before every entry. Prescription eyeglasses are NOT OSHA-approved eye protection. Powder-free nitrile gloves are standard to eliminate Type I (IgE anaphylactic) and Type IV (cell-mediated delayed) latex hypersensitivity risks.

In healthcare environments, blood collection exposes phlebotomists to percutaneous inoculation, splash hazards, and airborne pathogens. Selecting appropriate PPE and executing error-free donning and doffing sequences prevents occupational exposure and stops cross-contamination between containment areas and general wards.

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PPE Categories & Selection Standards

PPE selection is governed by the anticipated level of exposure to blood, body fluids, secretions, excretions, and airborne infectious agents.

+-------------------------------------------------------------------------+
|                        CORE PPE CATEGORIES & USES                       |
+-------------------------------------------------------------------------+
| PPE Item           | Primary Protection / Clinical Standard             |
+--------------------+----------------------------------------------------+
| Examination Gloves | Barrier for hands against blood, OPIM, chemicals   |
| Fluid-Resist. Gown | Protects skin and clothing from splashes and sprays|
| Surgical Mask      | Fluid barrier against large respiratory droplets   |
| N95 Respirator     | Filters >=95% of airborne particles (down to 0.3um)|
| Goggles / Shield   | Protects ocular conjunctiva and mucous membranes   |
+-------------------------------------------------------------------------+

1. Medical Examination Gloves

Gloves provide barrier protection for the hands against bloodborne pathogens, chemicals, and infectious body substances. Gloves must be worn during all vascular access procedures, handling specimen tubes, processing blood, and cleaning biohazard spills.

• Material Options: Nitrile (synthetic copolymer with high puncture and chemical resistance; clinical standard), Neoprene/Chloroprene, Vinyl (polyvinyl chloride; looser fit, lower barrier integrity, suitable for low-risk non-blood tasks), and Latex (natural rubber; high elasticity but carries severe allergy risks).

2. Isolation Gowns and Laboratory Coats

Fluid-resistant or impermeable isolation gowns protect the phlebotomist's clothing and exposed arm/torso skin from blood splashes, sprays, and direct contact with colonized patient environments.

• Requirements: Must cover the body from neck to knees and arms to the end of wrists. Gowns must fasten securely at both the neck and waist. In outpatient drawing rooms, fluid-resistant lab coats with cuffed sleeves and front closures are standard.

3. Surgical and Procedure Masks

Fluid-resistant surgical masks cover the nose and mouth, providing a physical barrier against large respiratory droplets (>5 µm), blood splatters, and aerosol sprays generated during specimen centrifugation or tube unstopping.

• Fit: Must fit snugly over the nose, mouth, and chin, with the pliable metal strip molded firmly across the nasal bridge.

4. Particulate Respirators (N95, N99, PAPR)

National Institute for Occupational Safety and Health (NIOSH)-certified particulate respirators are designed to protect healthcare personnel from airborne droplet nuclei (≤5 µm) that remain suspended in room air.

• N95 Respirator: Filters at least 95% of airborne particles as small as 0.3 microns under standard test flow rates. It does not provide protection against gases, chemical vapors, or oil-based aerosols.
• Powered Air-Purifying Respirator (PAPR): Uses a battery-powered blower to pull air through HEPA filters into a full hood; used by individuals with facial hair or facial anatomical features that prevent an airtight N95 seal.

5. Eye and Face Protection (Goggles & Face Shields)

Protects the mucous membranes of the eyes (conjunctiva) from infectious blood splatters, droplet sprays, and aerosol generation.

• OSHA Eye Protection Standard: Standard personal prescription eyeglasses do NOT constitute protective eye equipment. Prescription lenses lack side shields, top brow guards, and peripheral impact/splash resistance. Healthcare workers who wear prescription glasses must use full wrap-around safety goggles fitted over their glasses, OSHA-compliant prescription safety glasses with permanent side shields, or a full-face shield.

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Strict CDC Donning & Doffing Protocols

Contamination of healthcare workers frequently occurs during the removal (doffing) of PPE rather than during clinical care. Adhering to standardized sequences ensures that clean hands never touch contaminated outer PPE surfaces.

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|                  CDC DONNING & DOFFING STEP SEQUENCES                   |
+-------------------------------------------------------------------------+
| DONNING SEQUENCE (Clean to On)     | DOFFING SEQUENCE (Dirty to Off)    |
+------------------------------------+------------------------------------+
| 1. Gown (fasten neck & waist)      | 1. Gloves (glove-in-glove method)  |
| 2. Mask or N95 Respirator          | 2. Goggles or Face Shield          |
| 3. Goggles or Full-Face Shield     | 3. Isolation Gown (peel away)      |
| 4. Gloves (pull over gown cuffs)   | 4. Mask or Respirator (ear loops)  |
|                                    | 5. Immediate Hand Hygiene          |
+------------------------------------+------------------------------------+

CDC Donning Sequence (Putting On PPE)

Donning must take place outside the patient isolation room or before engaging in high-risk blood collection.

1. Step 1: Gown
   • Select the appropriate size and fluid resistance level.
   • Slip arms into sleeves, ensuring full torso coverage from neck to mid-thigh.
   • Fasten ties securely at the back of the neck and around the waist. Ensure no clothing is exposed at the back.
2. Step 2: Mask or Respirator
   • Position the mask over the nose, mouth, and chin.
   • Secure elastic loops behind the ears or tie upper straps at the crown of the head and lower straps behind the nape of the neck.
   • For an N95 respirator: place the bottom strap around the neck below the ears and the top strap over the crown of the head.
   • Mold the flexible metallic nosepiece firmly over the bridge of the nose using fingertips from both hands.
   • Perform mandatory User Seal Checks (positive and negative pressure).
3. Step 3: Goggles or Face Shield
   • Place goggles over the eyes or face shield over the face.
   • Adjust headbands to ensure a secure, comfortable fit without disturbing the mask seal.
4. Step 4: Gloves
   • Don gloves last.
   • Extend the glove cuffs over the knitted or elastic wrist cuffs of the isolation gown to eliminate any exposed skin at the wrists.

CDC Doffing Sequence (Removing PPE)

Doffing must occur at the doorway of the isolation room or in a designated anteroom. Respirators and masks are always removed outside the patient room after closing the door.

1. Step 1: Gloves (Most Contaminated Item)
   • Glove-in-Glove Technique: a. Pinch the outside exterior of one glove near the wrist with the other gloved hand. Avoid touching bare skin. b. Peel the glove downward away from the wrist, turning it inside out, and hold the removed glove crumpled in the palm of the remaining gloved hand. c. Slide an un-gloved bare finger under the interior wrist cuff of the remaining glove without touching its outer surface. d. Peel the second glove downward over the first glove, creating an enclosed inside-out bundle with all contaminated surfaces contained within. e. Discard the bundled gloves immediately into a designated biohazard receptacle.
2. Step 2: Goggles or Face Shield
   • The outside of eye protection is heavily contaminated.
   • Grasp the clean elastic headband or side earpieces with bare, clean hands.
   • Lift the goggles or face shield up and away from the face without touching the front visor.
   • Discard in biohazard waste or place into a dedicated container for reprocessing.
3. Step 3: Isolation Gown
   • The gown front and sleeves are contaminated.
   • Unfasten or break neck and waist ties without touching the front surface of the gown.
   • Peel the gown downward away from the neck and shoulders, touching only the clean interior lining.
   • Turn the gown inside out as it is removed from the arms, roll it into a compact bundle with contaminated exterior folded inward, and discard.
4. Step 4: Mask or Respirator
   • Step outside the patient room and close the door before removing respiratory protection.
   • The front of the mask/respirator is contaminated; do not touch it.
   • Grasp the bottom elastic strap or ties first, lift over the back of the head, then grasp the top strap/ties and lift away from the face.
   • Discard the mask/respirator directly into the waste receptacle.
5. Step 5: Immediate Hand Hygiene
   • Perform thorough hand hygiene immediately with alcohol-based hand rub or soap and water to decontaminate any transient microflora acquired during doffing.

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Respirator Fit Testing & User Seal Checks

A particulate respirator cannot protect healthcare personnel if air leaks around the perimeter. OSHA mandates a strict respiratory protection protocol.

• Medical Evaluation & Annual Fit Testing: Before wearing an N95 respirator clinically, workers must undergo medical clearance and an annual quantitative or qualitative Fit Test to determine the specific brand, model, and size (Small, Medium, Regular) that forms an airtight seal against their facial structure.
• User Seal Checks (Every Single Use): A fit test is conducted annually, but a User Seal Check must be performed by the phlebotomist every time the respirator is donned:
  1. Positive Pressure Seal Check: Gently exhale into the respirator while cupping hands lightly over the front surface (without collapsing it). A slight positive pressure should build inside the facepiece without any air escaping along the nose bridge, cheeks, or chin perimeter. If air escapes, readjust the nosepiece and straps.
  2. Negative Pressure Seal Check: Inhale sharply while cupping hands over the respirator. The facepiece should collapse slightly inward toward the face without inward air leaking around the perimeter edges.

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Latex Allergies & Nitrile Alternatives

Latex hypersensitivity stems from allergenic proteins found in the sap of the Brazilian rubber tree (Hevea brasiliensis). With repeated occupational exposure, sensitized individuals can develop severe immunological reactions.

+-------------------------------------------------------------------------+
|                    LATEX REACTION CLASSIFICATION                        |
+-------------------------------------------------------------------------+
| Type                | Mechanism         | Clinical Manifestations       |
+---------------------+-------------------+-------------------------------+
| Type I (Immediate)  | IgE-Mediated      | Urticaria, bronchospasm,      |
| Hypersensitivity    | Immune Response   | angioedema, anaphylactic shock|
+---------------------+-------------------+-------------------------------+
| Type IV (Delayed)   | T-Cell Mediated   | Erythema, pruritus, vesicles, |
| Hypersensitivity    | Cellular Response | scaling (peaks in 24-48 hrs)  |
+---------------------+-------------------+-------------------------------+
| Irritant Contact    | Non-Immunological | Dry, chapped, cracked, red    |
| Dermatitis          | Chemical Friction | skin (not an allergic reaction|
+-------------------------------------------------------------------------+

1. Type I Immediate Latex Allergy (IgE-Mediated)

• Pathophysiology: Sensitization stimulates the production of specific Immunoglobulin E (IgE) antibodies. Upon subsequent exposure to natural rubber latex proteins, mast cells and basophils rapidly degranulate, releasing histamine, leukotrienes, and prostaglandins.
• Clinical Manifestations: Symptoms develop within minutes: localized hives (urticaria), generalized flushing, rhinoconjunctivitis, swelling of lips and eyelids (angioedema), wheezing, severe laryngeal edema, acute bronchospasm, profound hypotension, and life-threatening anaphylactic shock.
• Management: Immediate administration of intramuscular epinephrine (1:1,000), airway management, high-flow oxygen, antihistamines, and systemic corticosteroids. Patients and workers with Type I latex allergy must have zero contact with natural rubber products.

2. Type IV Delayed Contact Dermatitis (Cell-Mediated)

• Pathophysiology: A T-cell-mediated delayed hypersensitivity reaction triggered primarily by chemical accelerators (thiurams, carbamates, mercaptobenzothiazoles) added during rubber vulcanization.
• Clinical Manifestations: Manifests 24 to 48 hours post-exposure with localized erythema, intense itching (pruritus), vesicular eruptions, weeping skin lesions, and subsequent chronic lichenification, scaling, and skin cracking.

3. Irritant Contact Dermatitis (Non-Allergic)

• Pathophysiology: Non-immunological mechanical and chemical irritation caused by friction, glove powder (cornstarch), frequent handwashing, occluded sweat, or harsh soaps.
• Clinical Manifestations: Dry, rough, chapped, red, and irritated skin limited to the hands, without immune system involvement.

Clinical Standard: Powder-Free Nitrile

To eliminate latex sensitization and airborne latex protein dissemination via powdered cornstarch, clinical facilities mandate powder-free nitrile gloves. Nitrile provides superior tensile strength, solvent resistance, and barrier protection without latex allergens.