How to Contain the Ebola Virus in the Hospital: Lessons From Nebraska

Nebraska Biocontainment Unit Provides Illustrated Instructions

Laura A. Stokowski, RN, MS


October 17, 2014

In This Article

The Art of Donning and Doffing PPE

If you are the nurse involved in the care of a patient with Ebola virus infection on the Biocontainment Unit at Nebraska Medical Center, you don't wear your own scrubs, socks, or shoes at work. You don't use your own elastic tie to pull back your hair. You don't even wear your own underwear.

Wait a minute—what level of isolation is hazmat underwear? Actually, it is just one detail of the entire package of protection provided for staff members working in the Biocontainment Unit. Supplying everything down to the underwear means that staff members don't have to take home any potentially contaminated items that might transmit Ebola (or any other infectious disease) to family members.

It all makes sense when you understand how seriously protection is taken in the Biocontainment Unit. The nurse enters the unit through a locker room where she exchanges street clothes for hospital-provided underclothing, scrubs, socks, and plastic Croc-type shoes. She then dons standard precaution-level "contact" isolation gear: isolation gown, gloves, and mask, all of which are worn by everyone who enters the Biocontainment Unit, even to sit at the desk and answer the phone. If the nurse is assigned to any patient care role, additional PPE is applied in a clean staging area before entering the patient's room, according to a specific "donning" protocol. A line on the floor before the entrance to the hallway where the patient room is located reminds staff that no one crosses the line without donning full PPE (nor does anyone who is "dirty" cross the line in the other direction without following the doffing protocol.)

Assisted by a second staff member (Figure), the nurse dons the following items of PPE:

Surgical boot covers (knee-high)

Surgical gown (impermeable, level 4, according to Association for the Advancement of Medical Instrumentation [AAMI])

Hood (covering the hair, ears, neck, and shoulders, tucked underneath the gown)

Three pairs of gloves: standard (under the cuffs of the gown), purple nitrile KC500 gloves (cuffs are taped to the gown using duct tape to prevent slippage), and another pair of standard gloves over the KC500 gloves

N95 mask (1870 white trifold style)

Optional eye protection

Face shield

An apron is applied in the room if procedures are to be performed that might generate splashing or droplets (removed immediately following the procedure)

Figure. Alicia Parker, RN, assists Drew Molacek, RN, in donning PPE in the Nebraska Biocontainment Unit. Courtesy of the Biocontainment Unit at Nebraska Medical Center.

Tyvek suits (coveralls) and powered, air-purifying respirators are not worn routinely but are available if patient condition and care procedures warrant additional protection. Every staff member working in the patient room, the autoclave room, the on-site lab, or functioning as the "doffer" wears PPE as described above.

The illustrated Nebraska Biocontainment Unit PPE Donning Protocol for Ebola Patients is available here.

Leaving the patient area is even more critical. No one simply walks out the door of the patient room, tearing off their PPE and tossing it into a red trash can. Leaving is a strictly controlled process that begins with alerting the doffer of the intent to leave, and waiting for the doffer to signal that it is safe to enter the "dirty staging area." In preparation, the doffer places a "doffing pad" on the floor that is divided into two zones, and a trash can lined with an autoclave bag into which PPE will be discarded.

Before even leaving the room, the nurse first removes the top pair of gloves and wipes the outside of her purple gloves with bleach. She then opens the door and steps onto the doffing pad. The doffer peels the duct tape from the purple gloves, which are then removed using glove-in-glove technique. The nurse turns around, and the doffer unties her gown, gently flipping it forward for the nurse to remove it carefully by gathering it and turning it inside-out into a ball. Nothing contaminated is ever allowed to touch the nurse's skin. Boot covers are removed one at a time by the doffer, and as each cover is removed, the nurse steps onto zone 2 of the doffing pad. Before removing her face shield, the nurse removes the last pair of standard patient gloves, cleans her hands with hand sanitizer, and applies a new pair of gloves. The face shield is removed, and then the hood is untied and removed carefully, along with the N95 mask. The gloves are removed and the nurse sanitizes her hands again, and applies a clean mask and gloves. Finally, the doffer uses a bleach wipe to clean the top, sides, and bottom of each of the nurse's shoes, and as each shoe is cleaned, the nurse steps off of the doffing pad with the cleaned foot.

The nurse is not finished yet. She proceeds to the sink, removes her gloves, and washes her hands with soap and water before applying another pair of gloves. She then stands at "the line" until the shower is ready, and then she showers and gets dressed in clean scrubs. Everything but her scrubs and shoes go in the trash.

The illustrated Nebraska Biocontainment Unit PPE Doffing Protocol for Ebola Patients is available here.

It is a lot to remember, and it seems as though the doffing procedure, especially, would take a long time, but it doesn't. Although it is never rushed, the staff members have practiced it so often and become so adept at each step, that the protocol is ingrained as a habit.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.