Overview
Given the
threat of coronavirus disease 2019, or Covid-19, it is important to emphasize
the use of proper precautions for infection control in health care settings.
Severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, is the virus
that causes Covid-19.1 The routes of SARS-CoV-2 transmission include
direct contact — that is, contact with the respiratory droplets and aerosols
from an affected person — and indirect contact, such as contact with
contaminated surfaces or supplies.2
The best
way for health care workers to prevent infection with SARS-CoV-2 is through
training and demonstrated competency in putting on and removing, also known as
donning and doffing, personal protective equipment (PPE). Various methods of
putting on and removing PPE may be acceptable; you should follow the guidelines
of the Centers for Disease Control and Prevention (or CDC) and your
institution.
This
video demonstrates a procedure for putting on and removing one type of PPE that
has been recommended by the CDC for use in U.S. hospitals to minimize the risk
of exposure to infectious material during the care of patients with Covid-19.3
Equipment
Protection
against exposure to SARS-CoV-2 includes both standard and transmission-based
precautions. The PPE used to prevent exposure includes gloves, a gown, a
respirator with a rating of N95 or higher, and a full face shield or goggles.
When respirators are not available, face masks are an acceptable alternative.
These recommendations may be updated during the Covid-19 pandemic as decisions
about best practices change.
You will
need a fluid-resistant gown or coveralls that should cover the body at least
from the neck to the mid-calf and medical gloves that extend to cover the
wrists of the gown. Gowns with integrated thumb hooks may help to secure the
sleeves under the gloves.
If
disposable N95 respirators are worn, they must be certified by the National
Institute for Occupational Safety and Health (NIOSH) and fit-tested by
occupational health officials. The respirator should be used along with a full
face shield that protects the face and neck. Alternatively, a NIOSH-certified,
powered air-purifying respirator (PAPR) can be used.
Procedure for Putting on PPE
Because
you may be wearing PPE for an extended period of time, make sure that you are
well hydrated and use the restroom before putting on PPE. If you wear
prescription eyeglasses, make sure that they are positioned securely on your
face. Prescription eyeglasses alone do not suffice as eye protection.
Put on
the PPE when you are near the patient’s room. Before donning PPE, it is
advisable to change into scrubs, secure long hair, and remove personal items
such as jewelry.
Before
handling any PPE, wash your hands with soap and water or clean your hands with
an alcohol-based hand sanitizer. Visually check the integrity of the equipment.
If possible, have an observer watch you as you put on the PPE to make sure
there are no breaches in technique.
If the
gown has an opening for your head, pull the gown over your head through the
opening. If the gown does not have such an opening, fasten it behind your neck.
When using a respirator, cup the outside of the respirator in your dominant
hand, holding the pliable nasal strip with your fingertips and letting the two
straps hang freely around your hand. Bring the respirator to your face. Secure
the lower strap around the back of your neck, and then secure the upper strap
behind your head. Mold the pliable nasal strip around the bridge of your nose
with both hands, without tenting it. Do not pinch the nosepiece with one hand.
Figure 1.
Testing for Air
Leaks.
Testing for Air
Leaks.
Check the
seal of the respirator. Begin by covering the respirator with your hands and
inhaling deeply and quickly several times. The respirator should collapse
slightly against your face when you inhale. Next, place your hands around the
edges of the respirator and exhale to determine whether there are any air leaks
(Figure 1). If the respirator fails to collapse or if air
leaks from the sides, remold the nasal strip and adjust the positioning of the
respirator on your face. If you are still unable to obtain a complete seal,
consider using a PAPR.
Put on
the face shield, letting it rest on your forehead and securing the strap on the
back of your head. If your hair is tied in a bun, make sure the strap is
positioned in a manner that ensures that the strap will not slide up or down.
Adjust the elastic strap if necessary, to ensure a snug fit. If you are wearing
eyeglasses, make sure they are secure to minimize the need to readjust them
during patient care.
Disinfect
your hands with an alcohol-based hand sanitizer. Put on the gloves and extend
the cuffs over the sleeves of the gown. You are now ready to enter the
patient’s room.
Procedure for Removing PPE
Proper
removal and disposal of contaminated PPE is the most difficult challenge in
preventing exposure to pathogens. Careful attention is required. Whenever
possible, have an observer watch you as you take off the PPE to make sure there
are no breaches in technique. Removal of PPE should begin in the patient’s
room.
Figure 2.
Removal of Second
Glove.
Removal of Second
Glove.
There is
more than one technique for removing gloves. We describe the glove-in-glove technique
(Figure 2). First, remove your gloves by grasping the glove
on one hand with the other hand. Grasping the exterior of the glove at the
wrist, pull the glove off your hand, with the contaminated exterior folded
inside. Hold the removed glove in your gloved hand. Slide a finger under the
wristband of the remaining glove. Gently pull off the glove so that it is now
inside-out, forming a bag for the other glove, and discard. Disinfect your
hands.
Remove
your gown by first undoing the fastening at the waist. Someone may assist you
in undoing the fastenings at the neck and the back of the gown. Grasp the
shoulder area and peel the gown away from your body, turning the gown
inside-out and wrapping it into a bundle. Only the interior of the gown should
remain visible. Discard the gown and disinfect your hands.
You are
now ready to leave the patient’s room. Disinfect your hands again.
Figure 3.
Removal of Face
Shield.
Removal of Face
Shield.
Once you
have left the patient’s room, remove the face shield (Figure 3). It is particularly important to avoid
contamination of the eyes and mucous membranes when removing facial PPE. Tilt
your head forward and lift the shield by the strap. Lift it above and away from
your head without touching the shield itself. If you wear prescription
eyeglasses, make sure the glasses are not contaminated when you remove the PPE.
If you
have used a nondisposable face shield, place it in the appropriate container
for decontamination, following the guidelines at your institution. If you have
used a disposable face shield, a waste receptacle should be available to
discard such equipment.
Figure 4.
Removal of
Respirator.
Removal of
Respirator.
Remove
the N95 respirator (Figure 4). To minimize the possibility of contamination,
avoid contact with the respirator itself, touching only the straps. Tilt your
head forward, grab the strap that is around your neck, and lift it over your
head, allowing it to hang freely. Then bring the top strap over your head and
use it to remove the respirator from your face. Discard the respirator or
return it to a designated location for recycling, following the guidelines at
your institution. Disinfect your hands.
Summary
When PPE
is properly worn, removed, and discarded, it is effective in protecting both
the person who wears it and those with whom that person comes into contact.
Disclosure forms provided by the authors are available
with this video at NEJM.org.
No
potential conflict of interest relevant to this video was reported.
This
video was published on May 19, 2020, at NEJM.org.
Author Affiliations
From the
Department of Anesthesiology, Boston Medical Center, Boston.
Address
reprint requests to Dr. Ortega at the Department of Anesthesiology, Boston
Medical Center, 750 Albany St., Boston, MA 02118, or at rafael.ortega@bmc.org.
