Many HCWs don't know correct PPE sequence

Train on selecting, removing PPE

Your annual training in the use of personal protective equipment may not be good enough. According to a study of PPE use during the H1N1 pandemic in Canada, most health care workers don't know how to choose the right items or how to put them on or take them off correctly.

In observations of 110 health care workers, only 6 (6%) performed all the steps correctly in a study by the Public Health Agency of Canada in Ottawa, which was presented at the spring conference of the Society for Healthcare Epidemiology of America (SHEA). The researchers observed health care workers at seven hospitals in Ontario and Manitoba during the second wave of H1N1, between February and April of 2010.

Only 29% of the health care workers selected the appropriate PPE and 29% removed it in the correct sequence. (See sequence box, below.) The performance varied by unit. Fewer people removed their PPE correctly in the intensive care unit and emergency department than in pediatrics.

These findings, which have not yet been published, raise questions about the effectiveness of the training that health care workers receive. In the United States, the Occupational Safety and Health Administration requires annual training along with respirator fit-testing.

Training isn't sufficient, says David Weissman, MD, director of the Division of Respiratory Disease Studies at the National Institute for Occupational Safety and Health (NIOSH) in Morgantown, WV.

"To get high levels of adherence requires real dedication to develop a safety climate," he says. "You have to develop an atmosphere of adherence. It's a challenge and it requires continuous effort. It isn't something you can fix and then it's fixed permanently. You achieve high levels by exerting a lot of energy and then maintaining it over time."

The Centers for Disease Control and Prevention provides posters to remind health care workers how to don and doff PPE. (

Health care workers may not realize why the order of removing PPE is so important, says Weissman. "If equipment isn't removed properly and in the proper sequence with attention to detail, the worker could potentially contaminate their hands and create the risk of infecting themselves or infecting or colonizing others," he says.

Sequence for donning PPE

1. Gown: Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist.

2. Mask or respirator: Secure ties or elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit-check respirator.

3. Goggles or face shield: Place over face and eyes and adjust to fit.

4. Gloves: Extend to cover wrist of isolation gown.

Sequence for removing PPE

1. Gloves: Outside of gloves is contaminated! Grasp outside of glove with opposite gloved hand; peel off. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Peel glove off over first glove. Discard gloves in waste container.

2. Goggles or face shield: Outside of goggles or face shield is contaminated! To remove, handle by head band or ear pieces. Place in designated receptacle for reprocessing or in waste container.

3. Gown: Gown front and sleeves are contaminated! Unfasten ties. Pull away from neck and shoulders, touching inside of gown only. Turn gown inside out. Fold or roll into a bundle and discard.

4. Mask or respirator: Front of mask/respirator is contaminated — DO NOT TOUCH! Grasp bottom, then top ties or elastics and remove. Discard in waste container.

Source: Centers for Disease Control and Prevention: