Personal protective equipment (PPE) doffing errors were common in a study of healthcare workers treating patients under contact isolation for multidrug-resistant organisms (MDROs), researchers report.1

Healthcare workers (HCWs) have been infected and colonized with MDROs, but the primary threat in the study scenario is cross transmission of pathogens from patient to patient. However, the study has implications for worker safety as well, as the type of doffing errors described could lead to occupational infections with much more dangerous pathogens like Ebola.

Researchers at Rush University Medical Center in Chicago studied 125 healthcare workers treating ICU patients who were on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

The workers’ hands, gloves, and other PPE and equipment were sampled before and after each patient interaction. Researchers also observed removal of PPE and coded errors based on CDC recommendations.

Of 5,093 cultures of workers, patients, and the environment, 652 (14.7%) yielded the target MDRO, the study found.1

“Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including four (3.2%) on hands and 38 (30.4%) on PPE,” the authors reported. “Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing.”

Hospital Employee Health sought further comment on the study from lead author Koh Okamoto, MD, in the following interview, which has been edited for length and clarity.

HEH: You found that more than one-third of healthcare workers were contaminated with multidrug-resistant organisms after caring for patients colonized or infected with the bacteria. Would the contamination observed with MRSA and VRE predict similar results with other bacteria and viruses like Ebola?

Okamoto: We think our finding shows that the contamination with multidrug-resistant organisms and lapses in donning and doffing of PPE are not uncommon in busy clinical settings. However, different bacteria or viruses have different characteristics, such as infectious inocula, how long they are viable in environments, to what degree patients can be contaminated with those organisms, how easily organisms can be transmitted, and how easily organisms can be detected by current testing methods.

Although we are cautious about concluding that our findings would be similar with other organisms, certainly our findings provide an important message that our measures of protection against organisms are far from perfect and we need improvement, especially for highly virulent organisms such as Ebola.

HEH: Self-contamination when doffing PPE was a common finding during the 2014 Ebola epidemic. Given your similar findings, do you recommend methods like having a trained observer assist during PPE removal?

Okamoto: An intervention as simple as reinforcing the preferred order of doffing may reduce healthcare worker contamination with multidrug-resistant organisms. Having a trained observer assist could be another practical method in case of highly virulent organisms like Ebola.

HEH: You observed that 72% of workers who used a “gloves-first” removal approach made PPE errors. Is this one of the methods recommended by the CDC, and do you think that should be reconsidered in light of your findings?

Okamoto: Yes, it was one of the CDC recommended methods. Based on our finding, we believe additional study of doffing approaches is needed, and in the meantime, extra caution might be required when removing gloves first.


  1. Okamoto K, Rhee Y, Schoeny M, et al. Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions. Infect Control Hosp Epidemiol 2019;20:1-7.