PPE Protocol — Perform proper PPE donning and doffing

Historical Context & Motivation

The evolution of personal protective equipment (PPE) in healthcare represents one of the most consequential developments in infection control history. Long before the germ theory of disease was established, clinicians observed that physical barriers between the caregiver and the patient could reduce the spread of illness, though the mechanisms remained poorly understood. The formalization of PPE protocols emerged gradually through centuries of epidemiological observation, catastrophic outbreaks, and paradigm-shifting discoveries in microbiology. Understanding this history provides essential context for why modern donning and doffing sequences are performed in a specific, evidence-based order—deviations from which have been directly linked to healthcare-associated infections (HAIs) and occupational exposures.

The recurring lesson across these milestones is clear: PPE is only as effective as the protocol governing its use. A properly fitted N95 respirator offers negligible protection if a clinician touches its outer surface during removal and then touches the face. The central question this lesson addresses is therefore not merely what PPE to wear, but how to don and doff it in the correct sequence to maintain an unbroken chain of infection prevention.

Core Principles of PPE Use

Before examining specific donning and doffing sequences, it is essential to internalize the foundational principles that govern all PPE protocols. These principles are derived from the chain of infection model and the CDC's hierarchy of controls. Each principle directly informs why certain steps must occur in a fixed order—omitting or rearranging steps creates vulnerabilities through which pathogens can breach the barrier between the contaminated environment and the healthcare worker's skin, mucous membranes, or clothing.

Visual Guide — The Donning Sequence

The following diagram illustrates the complete CDC-recommended donning sequence. Notice that the order proceeds from items that cover the largest body surface area (gown) to items that cover the smallest and most vulnerable exposure points (gloves, which seal the gown cuffs). Each step builds upon the previous one, creating an integrated barrier system.

As illustrated above, the donning sequence terminates with glove application because gloves serve a dual purpose: they protect the hands from direct contact with pathogens, and they mechanically seal the gown's wrist cuffs, preventing fluid from wicking underneath the gown during patient care activities. If a clinician were to don gloves before the gown, the cuff-seal would be compromised, and any fluid contacting the wrist area could penetrate to the underlying skin. This seemingly minor deviation has been implicated in documented cases of healthcare worker infection during high-risk procedures such as wound debridement and airway suctioning.

The Doffing Sequence — Where Contamination Risk Is Greatest

Research consistently demonstrates that the doffing (removal) phase poses a substantially greater contamination risk than donning. A landmark simulation study published in the American Journal of Infection Control (2015) found that approximately 46% of healthcare workers self-contaminated during doffing when not following standardized protocols, compared to less than 5% during donning. The reason is straightforward: after patient care, the outer surfaces of all PPE are presumed contaminated. Every removal action creates an opportunity for contaminated surfaces to contact the healthcare worker's skin, hair, or underlying clothing.

CDC Standard Doffing Sequence

1. Step 1 — Remove Gloves: Using the glove-in-glove technique, grasp the outside of one glove near the wrist and peel it away, turning it inside out. Hold the removed glove in the still-gloved hand, then slide an ungloved finger under the wrist of the remaining glove and peel it off over the first glove, creating a contained 'bag' of contaminated surfaces. Discard immediately into biohazard waste.
2. Step 2 — Perform Hand Hygiene: Apply ABHR generously, covering all surfaces of the hands. This step is critical because micro-perforations in gloves—invisible to the naked eye—may have allowed pathogen transfer during patient care.
3. Step 3 — Remove Goggles/Face Shield: Grasp the earpieces, headband, or temples—these are considered 'clean' zones because they were not facing the patient. Lift away from the face without touching the front surface. Place in a designated receptacle for reprocessing or disposal.
4. Step 4 — Remove Gown: Unfasten ties. Pull the gown away from the body at the shoulders, touching only the inside. Turn the gown inside out as it is removed, folding the contaminated outside inward, and roll it into a bundle. Discard into biohazard waste.
5. Step 5 — Perform Hand Hygiene: Repeat hand hygiene after gown removal, as gown ties or inner surfaces may have had incidental contact with contaminants.
6. Step 6 — Remove Mask/Respirator: Without touching the front of the mask, grasp the bottom ties or elastics first, then the top ties or elastics. Remove by pulling forward, away from the face. Discard. The mask is removed last because it protects the airway—the most critical exposure route—and should remain in place while other contaminated items are handled.
7. Step 7 — Final Hand Hygiene: Perform one final round of hand hygiene before leaving the doffing area or touching any clean surfaces.

PPE Types & Transmission-Based Precaution Levels

The specific combination of PPE a clinical medical assistant dons depends on the type of transmission-based precautions indicated for the patient. The CDC defines three categories—contact, droplet, and airborne—each requiring a distinct PPE ensemble in addition to the baseline Standard Precautions applied to every patient encounter. Understanding which PPE components are required under each precaution category ensures that neither under-protection (risking exposure) nor over-protection (wasting resources) occurs.

A critical distinction for CCMAs to understand is the difference between a standard surgical mask and an N95 filtering facepiece respirator. Surgical masks are loose-fitting and primarily block large-particle droplets and splashes from reaching the wearer's mouth and nose; they do not provide a reliable seal against aerosolized particles smaller than 5 μm. N95 respirators, by contrast, filter at least 95% of airborne particles down to 0.3 μm when properly fitted. The donning of an N95 requires an additional user seal check after placement: the wearer covers the respirator with both hands, inhales sharply to test for negative-pressure seal (the respirator should collapse slightly toward the face), and exhales forcefully to check for leaks around the edges. Annual fit testing is required under OSHA regulations for all personnel who may need to use N95 respirators.

Worked Example — Full Donning and Doffing Scenario

The following scenario walks through a complete PPE cycle for a CCMA entering a patient room under contact and droplet precautions. The patient has been diagnosed with influenza and is also colonized with MRSA. The CCMA must obtain vital signs and assist the patient with a specimen collection.

Common Errors & Best Practices

Observational studies conducted in hospital settings have cataloged the most frequent PPE protocol violations. The table below contrasts common errors with the corresponding best practice, along with the clinical consequence of each error. Awareness of these pitfalls is essential for CCMAs because many violations are habitual and unconscious—they occur not from ignorance but from time pressure, fatigue, or muscle memory developed through incorrect repetition.

Connection to Advanced Infection Control & Regulatory Standards

The PPE donning and doffing protocols discussed in this lesson represent the foundational layer of a broader infection prevention and control (IPC) framework. As CCMAs advance in their careers—potentially pursuing certifications in infection control (CIC) or moving into supervisory roles—they will encounter more complex regulatory and evidence-based layers that build upon these core skills. The table below situates PPE protocols within the larger ecosystem of IPC standards and advanced practices.

From a regulatory standpoint, PPE use in clinical settings is governed by multiple overlapping authorities. OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) mandates that employers provide and ensure the use of appropriate PPE at no cost to the employee. The Joint Commission (TJC) evaluates PPE compliance during accreditation surveys under its National Patient Safety Goals. State health departments may impose additional requirements, and individual facilities establish policies that meet or exceed these regulatory floors. As a CCMA, understanding that your PPE practices are not merely best practices but legally mandated obligations underscores the seriousness with which this competency must be maintained.

Practice Problems

Summary — PPE Protocol: Donning and Doffing