Donning and Doffing PPE for High-Consequence Infectious Disease Treatment

Jill Morgan, RN, BSN, site manager, SCDU, Emory University Hospital, works in their Serious Communicable Diseases Unit (SCDU), which was the first healthcare institution in the US to treat patients with Ebola.

She provided an overview of donning (putting on PPE) and doffing (taking off) PPE when caring for patients with high-consequence infectious disease. Here is an edited transcript of her explanation.

Morgan: For high-consequence infectious diseases like Ebola or Marburg, we aim to use a personal protective equipment (PPE) ensemble that provides what we call total skin coverage. This means there are no openings that could allow pathogens to reach the skin.

We start with respiratory and eye protection, which in this case is provided by a powered air-purifying respirator (PAPR). This is a helmet-based system with a battery-powered blower that filters incoming air and delivers clean air across the face. This airflow helps prevent fogging and provides a much wider field of view than standard safety glasses. The entire hood covering is disposable and single-use.

This is a complex PPE ensemble with multiple protective layers. We know that some layers become more contaminated than others, so we use a fluid-resistant gown on the outside. This creates a smoother, more wipeable surface for contact with things like wet beds or patients.

We also wear 2 layers of gloves. The inner gloves are extended-cuff, chemo-rated gloves that are more chemically resistant. These are taped to the coverall and essentially become our “skin.” We do not remove them inside the room. Instead, we sanitize over the gloves and tape if needed. The outer gloves are standard extended-cuff gloves that can be changed if they become contaminated during care.

Underneath everything is a full-body coverall zipped up the front. This coverall is tested for resistance to artificial blood and viral-sized particles, providing an additional protective barrier. On our feet, we wear shoe covers. Since the floor is considered the dirtiest surface in the room, these can be changed inside the room if needed while still maintaining protection.

All of these components must be put on in a specific order to ensure total skin coverage. Just as important is removing them in the correct order. Each piece we take off is an opportunity to leave contamination where it belongs—inside the patient care room.

We focus on keeping our PPE as clean as possible during care. Rather than assuming everything is contaminated, we actively clean visible contamination to make doffing safer. The full doffing process takes about 40 steps and roughly 20 minutes. It must be done slowly and methodically. While our trained team at Emory can do it faster, speed is never the priority—accuracy and safety are.

When we exit the patient care room, we keep our respiratory protection on and remove it carefully in the anteroom.

This total skin coverage ensemble can be adapted. For example, some facilities may use a Level 4 gown instead of a coverall or omit the outer gown. However, we believe the extra layer provides added protection.

We also conducted research at Emory to evaluate our PPE design. Previously, we used an apron that left part of the respirator hood uncovered. In our study, volunteers were exposed to a harmless bacteriophage and then tested for contamination. We found that using a gown over the ensemble provided better protection and reduced the risk of self-contamination when removing the hood.

In the final episode of the Emory series, Morgan discusses how providers sanitize themselves after doffing, disposal of supplies, and if someone has a potential pathogen exposure.