Personal Protective Equipment (PPE)

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Introduction

This guide covers the donning (putting on) and doffing (taking off) of personal protective equipment (PPE) when dealing with patients who are suspected or confirmed to have COVID-19. This article is based on the latest guidance from the UK Government. ^1,2,3

The article provides PPE guidance for both aerosol-generating procedures (AGPs)¹ and non-aerosol generating procedures (non-AGPs).²

The highest risk of transmission of respiratory viruses is during AGPs of the respiratory tract, and use of enhanced respiratory protective equipment is indicated for health and social care workers performing or assisting in such procedures.³

The UK Government has defined aerosol-generating procedures (AGPs) as any of the following:³

• intubation, extubation and related procedures, for example, manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
• tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)
• bronchoscopy and upper ENT airway procedures that involve suctioning
• upper gastrointestinal endoscopy where there is open suctioning of the upper respiratory tract
• surgery and post mortem procedures involving high-speed devices
• some dental procedures (for example, high-speed drilling)
• non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
• induction of sputum
• high flow nasal oxygen (HFNO)
• high-frequency oscillatory ventilation (HFOV)

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PPE for non-aerosol generating procedures (NAGP)²

Equipment

PPE required for NAGPs includes the following:

• Alcohol hand rub
• Gloves
• Eye protection (if a risk assessment indicates that these are required to prevent eye splashes)
• Fluid resistant surgical face mask

Before putting on PPE

Ensure you are hydrated to minimise the risk of fainting.

Tie your hair back and remove any jewellery.

Ensure the PPE you have chosen is the correct size for you.

Wash your hands with alcohol hand gel or rub (see our video guide here).

Putting on PPE (donning)

Don an apron

Put on the disposable apron and ensure the ties are securely tied at the back of the apron.

Don a surgical face mask

Putting on a surgical face mask (elastic type):

1. Secure the mask around your ears with the pieces of elastic

2. Mould the mask around each side of the nose, ensuring it is flat against your cheeks

3. Extend the mask down to fully cover your chin

Putting on a surgical face mask (with ties):

1. Position the straps of the mask on the crown of your head and tie the bow above your ears

2. Tie the lower straps at the nape of your neck

3. Mould the mask around each side of your nose, ensuring it is flat against your cheeks

4. Extend the mask down to fully cover your chin

Don eye protection

Eye protection must be worn if a risk assessment indicates the need for it.

Regular spectacles are NOT considered adequate eye protection.

Don some gloves

Put on disposable non-sterile gloves (there is no requirement for double gloving).

Final check

Before entering the patient room, you need to perform a final check that:

• the apron ties at the neck and waist are secure
• the surgical mask is correctly fitted
• eye protection is being worn if appropriate
• gloves are worn

Once you are confident all steps have been completed, you can enter the patient area. After entering the patient’s room, remain vigilant of both your own and your colleague’s PPE integrity.

Taking off PPE (Doffing)

PPE should be removed in an order that minimises the potential for self-contamination.

Remove your gloves

1. Grasp the outside of your glove with your opposite gloved hand and peel off

2. Hold the removed glove in your gloved hand

3. Slide the fingers of your ungloved hand under your remaining glove at the wrist and peel the remaining glove off over the first glove

4. Dispose of both gloves into the clinical waste bin

5. Clean your hands with alcohol hand gel or rub (if not available, use soap and water)

Remove your disposable apron

1. Unfasten or break the apron ties at the neck and let the apron fold down on itself

2. Unfasten or break the ties at the waist and fold the apron in on itself (DO NOT touch the outside, as this will be contaminated)

3. Discard into a clinical waste bin

Remove your eye protection

1. Hold onto both arms of the eye protection, then lift and then pull away from your face

2. Discard after use into a clinical waste bin

3. Clean your hands with alcohol hand gel or rub (if not available, use soap and water)

Remove your surgical face mask

This should be performed OUTSIDE of the patient area.

Removing a surgical face mask (elastic type):

1. Using both hands, grasp the elastic ties around your ears, stretch them and carefully pull away from your face

2. Dispose of the mask into a clinical waste bin immediately

3. Wash your hands with soap and water

Removing a surgical face mask (ties):

1. Using both hands unfasten the lower neck strap

2. Then unfasten the strap above your ears and lift the mask forwards (do not touch the front of the mask, as this is contaminated)

3. Dispose of the mask into a clinical waste bin immediately

4. Wash your hands with soap and water

Taking off PPE for Non-AGPs video demonstration

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PPE for aerosol-generating procedures (AGPs)¹

General points

Keep your hands away from your face and the PPE you are wearing.

Change your gloves when torn or heavily contaminated.

Minimise the surfaces you touch within the patient environment.

Regularly perform hand hygiene.

Always clean your hands after removing gloves.

Equipment

PPE required for AGPs includes the following:

• Surgical gown (long, rear-fastening, fluid-resistant, long-sleeved)
• Coverall (an alternative to a surgical gown)
• Alcohol hand rub
• Gloves
• Disposable full-face visor or goggles
• Respirator (a fit-tested FFP3 respirator)

Before putting on PPE

Ensure you are hydrated to minimise the risk of fainting.

Tie your hair back and remove any jewellery.

Ensure the PPE you have chosen is the correct size for you.

Wash your hands with alcohol hand rub (see our video guide here).

Putting on PPE (donning)

All PPE should be put on OUTSIDE of the patient’s room and where possible should be supervised by a buddy at a distance of 2 metres.

A buddy is a member of staff also trained and competent in the use of PPE.

Don a surgical gown or coveralls

You should have access to either a surgical gown or a coverall.

Gown:

1. Put on the disposable gown

2. Do not use the inside tie

3. Fasten the necktie/velcro and waist ties securely

Coveralls:

1. Step into the coveralls

2. Pull the coveralls up to your waist

3. Insert your arms into the sleeves:

• If thumb hoops are available then hoop these over your thumbs
• Ensure the sleeves are long enough to reach the glove cuffs to avoid skin exposure

4. Pull the coveralls up over your shoulders

5. Fasten the zip all the way to the top

Don a respirator

The respirator you use MUST be one you have already been fit-tested for:

1. Position the upper straps of the respirator on your head, above your ears.

2. Position the lower strap at the nape of your neck.

3. Ensure the respirator is positioned flat against your cheeks.

4. Mould the nose piece, using both hands, pressing down both sides of your nose with your fingers until you have a good facial fit.

5. Perform a fit-check (the technique differs depending on the respirator model, follow the manufacturer instructions):

• For an unvalved product, exhale sharply to test
• For a valved product, inhale sharply to test
• If air flows around the nose, readjust the nose piece
• If air flows around the edges of the respirator, readjust the headbands
• If an adequate fit cannot be achieved, you should NOT PROCEED

Don eye protection

1. Place the eye protection over your face and eyes:

• a disposable full-face visor is preferred
• goggles may be used if a visor is not available
• if using a visor, ensure it covers all of your face including your chin

2. Adjust the headband to achieve a secure fit

3. If a buddy is not available, you will need visible confirmation that the visor is in the correct position

Don gloves

1. Put on a pair of non-sterile, nitrile gloves

2. Choose gloves that are the appropriate size to ensure they fit you correctly

3. Pull each glove cuff to cover the cuff of each gown sleeve (to avoid skin exposure)

Final check

Before entering the patient room, you need to perform a final check that:

• the gown ties at the neck and waist are secure
• the respirator is correctly fitted
• the visor is in the correct position
• the gloves are covering the cuffs of the gown/coverall

Once you are confident all steps have been completed, you can enter the patient area. After entering the patient’s room, remain vigilant of both your own and your colleague’s PPE integrity.

In the event of a high exposure episode (e.g. projectile vomiting) or if there are concerns about PPE integrity, LEAVE THE ROOM at the earliest opportunity and inform your buddy prior to removing any PPE.

Putting on PPE for AGPs video demonstration

Taking off PPE (Doffing)

Where possible, the process of removing PPE should be supervised by a buddy at a distance of two metres.

The buddy can assist you when removing your PPE to reduce the risk of you contaminating yourself.

DO NOT step into the clean area whilst wearing contaminated PPE.

If you become aware of a potential PPE breach or high-exposure contamination (e.g. projectile vomiting), inform your buddy before removing your PPE.

Remove your gloves

1. Grasp the outside of your glove with your opposite gloved hand and peel off

2. Hold the removed glove in your gloved hand

3. Slide the fingers of your ungloved hand under your remaining glove at the wrist and peel the remaining glove off over the first glove

4. Dispose of both gloves into the clinical waste bin

5. Clean your hands with alcohol hand gel or rub (if not available, use soap and water)

Remove your surgical gown

The surgical gown should be removed slowly and carefully:

1. Undo the necktie

2. Undo the waist tie

3. Pull the surgical gown away from your neck and shoulders (touching the inside of the gown only) using a peeling motion, as the outside of the gown will be contaminated

4. Turn the gown inside out, fold into a bundle and discard immediately into a clinical waste bin

Remove your visor

1. To remove the visor, ensure you are standing straight and not bending forward (as this brings the bottom of the visor in contact with the clean upper body)

2. Reach for the elastic strap at the back of your head, close your eyes and lift the strap upwards and then over your head using both hands

3. Place the visor into the clinical waste bin immediately

4. Leave the patient’s room whilst still wearing your respirator

5. Clean your hands with alcohol gel or rub

Remove your respirator

1. Carefully remove the FFP3 respirator without touching the front of the device which is contaminated

2. Reach to the back of your head with both hands to find the bottom strap and bring it up to the top strap

3. Lift both straps over the top of your head

4. Let the respirator fall away from your face and drop it into the clinical waste bin

5. You can now leave the designated doffing area and immediately wash your hands with soap and water

Taking off PPE for AGPs video demonstration

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References

1. UK Government. Guidance: COVID-19: personal protective equipment use for aerosol-generating procedures. Published 10th January 2020. Last updated 10th April 2020. Accessed 15th April 2020. Available from: [LINK]
2. UK Government. Guidance: COVID-19: personal protective equipment use for non-aerosol generating procedures. Published 10th January 2020. Last updated 8th April 2020. Accessed 15th April 2020. Available from: [LINK]
3. UK Government. Guidance: Personal Protective Equipment (PPE). Last updated 12th April 2020. Accessed 15th April 2020. Available from: [LINK]

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