Editor's Note: Medscape collaborated with experts from the Centers for Disease Control and Prevention (CDC) to prepare this video for healthcare professionals, offering step-by-step guidance regarding the new personal protective equipment (PPE) recommendations for patients with suspected or confirmed Ebola virus disease. We worked directly with Arjun Srinivasan, MD (CAPT, USPHS), Associate Director of CDC's Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases,; Bryan Christensen, PhD, Epidemiologist, CDC Domestic Infection Control Team for the Ebola Response; and Barbara A. Smith, BSN, MPA, of the Division of Infection Control and Epidemiology at Mount Sinai St. Luke's Hospital and Mount Sinai Roosevelt Hospital, New York, New York.
This video is based on CDC Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing), as of October 20, 2014. This video demonstrates one methodology for putting on and taking off personal protective equipment safely. Healthcare facilities may need to adapt this protocol to their needs. Healthcare providers should be well trained on the protocol they are going to follow, practice rigorously in advance, and utilize a trained observer to ensure oversight and safety. The names of any commercial products that appear in this video are for information purposes only, and the use of these names does not represent an endorsement of those products by the Centers for Disease Control and Prevention or Medscape.
Arjun Srinivasan, MD: I'm Dr Arjun Srinivasan, associate director for healthcare-associated infection prevention programs at the Centers for Disease Control and Prevention. I'm pleased to bring you this video, produced in collaboration with CDC and Medscape, where Dr Bryan Christensen and infection preventionist Barbara Smith will walk you through the sequence for putting on and taking off PPE, recommended in the new CDC guidance for providing care of patients hospitalized with Ebola virus disease.
Preparing the Equipment
Bryan Christensen, PhD: Today, as part of the CDC Commentary series on Medscape, we're going to be demonstrating PPE as part of the enhanced guidelines for healthcare workers wearing PPE as they care for patients with Ebola. Barbara Smith, an infection preventionist from Mount Sinai, is going to be assisting me today.
Today I'll be acting as the trained observer, which is why I already have on a surgical gown that's fluid resistant, nitrile gloves, and boot covers that cover my legs and feet up to mid-calf. I will also be putting on a face shield to protect my eyes and my mouth.
The first thing we're going to do is inspect our PPE, to make sure that we have everything we need and that it is laid out in proper order. This includes nitrile gloves; shoe and leg covers that go to the mid-calf; a gown that is large enough to allow free movement and is fluid resistant; an N95 respirator; surgical hood that covers all of the hair, ears, and neck; outer gloves that have an extended cuff; and a face shield that provides additional protection to the face, including skin and eyes.
The Role of a Trained Observer
Next, Barbara is going to make sure that someone is supervising her. The person in that role should be trained on all aspects of PPE and infection control, and I will be representing the trained observer in this case.
As her trainer, I'm going to make sure that she's wearing scrubs and washable footwear, and that she has removed all personal items such as jewelry, phones, and pens.
The PPE Donning Process
Next, Barbara's going to clean her hands with alcohol-based hand sanitizer, which I will also refer to as hand hygiene. Then she's going to put on the first pair of gloves after ensuring that her hands are dry.
Next, she's going to sit in a clean chair and put on the shoe covers and pull them up to her mid-calf.
Barbara is now going to put on the gown and make sure that the inner gloves are tucked under the sleeves of the gown. And as the trained observer, I can assist with the gown.
Next, Barbara is going to put on the N95 respirator and put the top strap first over her head and keep it above her ears. The bottom strap goes along the back of the neck. Barbara is going to then check to make sure that there's a seal.
Barbara is now going to put on the hood and pull it down to cover her hair and ears.
Next, she's going to put on the second pair of gloves and make sure that the cuffs are pulled over the sleeves of the gown.
The last item that Barbara's going to put on is a face shield, to protect the front and sides of her face.
Barbara will now turn around so I can inspect her and go through range-of-motion assessment, to make sure that she can move freely and comfortably. I'm also going to make sure that all areas of the body are covered.
Now, before Barbara goes to see a patient, we're going to disinfect her hands.
Doffing PPE Equipment After Patient Care
Now, let's pretend that Barbara goes to see a patient. When she is done, we need to remove the PPE and make sure that she doesn't get exposed, which is the role of the trained observer—to ensure that this occurs safely and carefully.
Now that Barbara is done providing patient care, her trained observer needs to be there to help her get the PPE off safely and discard it in an appropriate waste container.
Barbara is first going to turn around, and I'm going to inspect the PPE to see if it has visible contamination, cuts, or tears. And while I'm doing this, I'm at a safe distance from her. Everything looks fine.
First, we're going to disinfect her outer-gloved hands. Notice that we perform hand hygiene after each step of removing PPE.
Barbara now is going to sit down and carefully remove the shoe covers in a chair specified for removing booties or shoe covers. We also have a second chair to clean shoes, which will remain clean. It is important to note that these chairs have proper signage.
Next, she's going to disinfect and remove her outer gloves. And it's important to carefully remove them.
Now, we're going to inspect her inner gloves to see if there's any visible contamination, cuts, or tears, and she will also perform hand hygiene.
Now, Barbara is going to remove the face shield by tilting her head forward, grabbing the rear strap, and pulling it over her head without touching the front of the face shield. Again, she will perform hand hygiene.
In a similar fashion, she's going to tilt her head forward and carefully remove the surgical hood, grabbing from behind the head. Again, hand hygiene.
Now, Barbara is going to slowly and carefully remove the gown. She's going to pull the gown away from the body, rolling it inside out, only touching the inside of the gown. But if removing the gown poses a problem, the trained observer can help with this.
A good trick that Barbara is going to show is to step on the inside of the gown to help remove it, as her shoes are clean and the inside of the gown is as well.
Again, we're going to perform hand hygiene. And we're going to remove the inner pair of gloves.
We're going to perform hand hygiene on the bare hands.
After they are dry, we're going to put on a new pair of gloves. This new pair of gloves is helpful to add another layer of protection. We're now bringing your hands close to your face to remove the respirator. You don't want to touch your face or head with gloves that may be contaminated.
Barbara is now going to remove the N95 mask by tilting her head forward, pulling the bottom strap over her head, followed by the top strap, without touching the front of the respirator. Again, we're going to perform hand hygiene.
Now, Barbara is going to sit on a clean chair and use a disinfectant wipe to clean her shoes.
Barbara's going to do hand hygiene again with the gloves on. And now Barbara is going to carefully remove her gloves. It's important to note that for the first one, she only grabs the outside of the glove and slowly pulls it off. For the second glove, while she holds that glove with the gloved hand, she slides her finger underneath the cuff and slowly pulls it off without touching the outside of the glove. And then she'll discard the gloves and perform hand hygiene on the bare hands.
And now, we'll do a final inspection of her scrubs to make sure that there's no visible contamination.
Correct PPE Requires Slow Pace, Much Practice
We'd like to make a few statements about the importance of this process. Donning and doffing requires a very deliberate pace, so be careful when you put everything on to make sure everything is properly in place. And when you take it off, you want to take it off slowly and to ensure that you do not contaminate yourself or expose yourself to bodily fluids or anything else you may have been in contact with in the patient's room.
This requires a lot of training. It's very important to train putting on and taking off the PPE, as well as working in it, to make sure you're fully comfortable with the PPE.
Dr Srinivasan: As you can see, this is a detailed procedure. It takes time. But it can be done well with practice. We hope that this video will help you as you practice putting on and taking off PPE.
CDC and our public health partners will continue to work 24/7 to ensure that you have the information you need to provide safe care for patients with Ebola.
Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)