CDC guide to PPE: Remove gloves first

Work practices, sequence are important

There is a right way to put on and remove personal protective equipment (PPE). Now there’s a step-by-step guide to teach health care workers how to do it.

The Centers for Disease Control and Prevention (CDC) has considered all the elements needed to safely treat patients in isolation and released a fact sheet on the correct use of PPE.

Improper use of PPE could cause health care workers to become infected. In Toronto last year, about 15 health care workers became infected with severe acute respiratory syndrome (SARS) despite wearing respirators and other protective gear. That could have resulted from loosely fitted masks, inadequate respirators, breaches in infection control, or other factors.

"We don’t really know exactly what happened in all of those circumstances," explains Linda Chiarello, RN, MS, of CDC’s Division of Healthcare Quality Promotion. "It’s clear that very rigorous infection control measures need to be taken during those [high-risk, aerosolizing] procedures."

The guide uses a common-sense approach to working with PPE, and it emphasizes the need for good work practices while wearing PPE. It applies to TB, SARS, and any other infectious disease that requires patients to be in a negative-pressure room.

Here are some key points:

Make sure the PPE fits properly.

Health care workers wearing a respirator should conduct a fit check and make sure it fits snugly to their face and below their chin. Gloves should fit snugly at the wrist and extend over the wrist of the gown. For example, vinyl gloves that don’t have that snug fit would not be recommended, Chiarello says. Double-gloving and sterile gloves are not recommended for working with patients in isolation, she notes.

Use good work practices.

Safe work practices are essential to maintaining the integrity of the PPE, Chiarello adds. "There’s been so much emphasis on the ritual of donning and removing PPE, I worry that when people get into a room, they aren’t thinking about how they might contaminate themselves or spread greater contamination in the environment," she says.

If health care workers have a sudden urge to scratch their noses or adjust their glasses, they would need to remove their gloves, make the adjustment, wash their hands, then put on clean gloves.

Health care workers also need to touch as few surfaces as possible in the patient’s room to avoid spreading the infectious disease. (TB is not spread through surface contamination, as is SARS and other diseases.)

Remove PPE in proper sequence.

The CDC recommends removing all PPE except the respirator at the doorway or anteroom of the patient’s room. The respirator should be removed after leaving the patient room and closing the door.

The gloves should be removed first and discarded. "Sequence is important," says Chiarello. "The gloves are generally the most contaminated part of the isolation garb. When you’re removing the isolation garb, you need to bring your hands up around the face and the neck. We recommend removing the gloves first."

The goggles should then be removed, handling them by touching the earpieces or headband. Untie the gown, then handle it from the inside. The respirator should be handled by touching the top ties or elastics.

"Perform hand hygiene immediately after removing all PPE," CDC advises.

If the employee is wearing a powered air-purifying respirator or elastomeric respirator that covers the entire head, that must be removed before the gown — in the ante room, Chiarello explains.

(Editor’s note: A copy of the poster is available on-line at