Guidance on Personal Protective Equipment To Be Used by Healthcare WorkersDuring Management of Patients with Ebola Virus Disease in U.S. Hospitals,Including Procedures for Putting On (Donning) and Removing (Doffing)

This guidance iscurrent as of October 20, 2014

The following procedures providedetailed guidance on the types of personal protective equipment (PPE) to be usedand on the processes for donning and doffing (i.e., putting on and removing)PPE for all healthcare workers entering the room of a patient hospitalized withEbola virus disease (Ebola). The guidance in this document reflects lessonslearned from the recent experiences of U.S. hospitals caring for Ebola patientsand emphasizes the importance of training, practice, competence, andobservation of healthcare workers in correct donning and doffing of PPEselected by the facility.

This guidance contains the followingkey principles:

1 Prior to working with Ebola patients, all healthcareworkers involved in the care of Ebola patients must have received repeatedtraining and have demonstrated competency in performing all Ebola-relatedinfection control practices and procedures, and specifically in donning/doffingproper PPE.

2 While working in PPE, healthcare workers caring for Ebolapatients should have no skin exposed.

3 The overall safe care of Ebola patients in a facilitymust be overseen by an onsite manager at all times, and each step of every PPEdonning/doffing procedure must be supervised by a trained observer to ensureproper completion of established PPE protocols.

In healthcare settings, Ebola isspread through direct contact (e.g., throughbroken skin or through mucous membranes of the eyes, nose, or mouth) with bloodor body fluids of a person who is sick with Ebola or with objects (e.g.,needles, syringes) that have been contaminated with the virus. For allhealthcare workers caring for Ebola patients, PPE with full body coverage isrecommended to further reduce the risk of self-contamination.

External (Non-CDC) Resources onPPE

•   EmoryHealthcare: Ebola Preparedness Protocols

•   University of Nebraska Medical Center: PPE for Ebola

•   Médecins Sans Frontières (Doctors without Borders): FilovirusHaemorrhagic Fever Guideline, 2008[PDF - 134pages]

•   World Health Organization (WHO): Infection prevention and controlguidance for care of patients in health-care settings, with focus on Ebola

To protect healthcare workersduring care of an Ebola patient, healthcare facilities must provide onsitemanagement and oversight on the safe use of PPE and implement administrativeand environmental controls with continuous safety checks through directobservation of healthcare workers during the PPE donning and doffing processes.

Recommended Administrative andEnvironmental Controls for Healthcare Facilities

Protecting healthcare workersand preventing spread of Ebola requires that proper administrative proceduresand safe work practices be carried out in appropriate physical settings. Thesecontrols include the following:

•   At an administrative level, the facility’s infectionprevention management system, in collaboration with the facility’s occupationalhealth department, should

◦                     Establish and implement triage protocols to effectivelyidentify patients who may have Ebola and institute the precautions detailed inthis document.

◦                     Designate individuals as site managers responsible foroverseeing the implementation of precautions for healthcare workers and patientsafety. A site manager’s sole responsibility is to ensure the safe andeffective delivery of Ebola treatment. These individuals are responsible forall aspects of Ebola infection control including supply monitoring andevaluation with direct observation of care before, during, and after staffenter an isolation and treatment area.

▪                                       At least one site manager should be on-site at all timesin the location where the Ebola patient is being cared for.

◦                     Identify critical patient care functions and essentialhealthcare workers for care of Ebola patients, for collection of laboratoryspecimens, and for management of the environment and waste ahead of time.

◦                     Ensure healthcare workers have been trained in allrecommended protocols for safe care of Ebola patients before they enter thepatient care area.

◦                     Train healthcare workers on all PPE recommended in thefacility’s protocols. Healthcare workers should practice donning and doffingprocedures and must demonstrate during the training process competency throughtesting and assessment before caring for Ebola patients.

▪                                       Use trained observers to monitor for correct PPE use andadherence to protocols for donning and doffing PPE, and guide healthcareworkers at each point of use using a checklist for every donning and doffingprocedure.

◦                     Document training of observers and healthcare workers forproficiency and competency in donning and doffing PPE, and in performing allnecessary care-related duties while wearing PPE.

◦                     Designate spaces so that PPE can be donned and doffed inseparate areas.

•   Key safe work practices include the following:

◦                     Identify and isolate the Ebola patient in a singlepatient room with a closed door and a private bathroom as soon as possible.

◦                     Limit the number of healthcare workers who come intocontact with the Ebola patient (e.g., avoid short shifts), and restrictnon-essential personnel and visitors from the patient care area.

◦                     Monitor the patient care area at all times, and log at aminimum entry and exit of all healthcare workers who enter the room of an Ebolapatient.

◦                     Ensure that a trained observer watches closely eachdonning and each doffing procedure, and provides supervisory assurance thatdonning and doffing protocols are followed.

◦                     Ensure that healthcare workers have sufficient time todon and doff PPE correctly without disturbances.

◦                     Ensure that practical precautions are taken duringpatient care, such as keeping hands away from the face, limiting touch ofsurfaces and body fluids, preventing needlestick and sharps injuries, andperforming frequent disinfection of gloved hands using an alcohol-based handrub (ABHR), particularly after handling body fluids.

◦                     Disinfect immediately any visibly contaminated PPEsurfaces, equipment, or patient care area surfaces using an *EPA-registereddisinfectant wipe.

◦                     Perform regular cleaning and disinfection of patient carearea surfaces, even absent visible contamination.

▪                                       This should be performed only by nurses or physicians aspart of patient care activities in order to limit the number of additionalhealthcare workers who enter the room.

◦                     Implement observation of healthcare workers in thepatient room, if possible (e.g., glass-walled intensive care unit [ICU] room,video link).

◦                     Establish a facility exposure management plan thataddresses decontamination and follow-up of an affected healthcare worker incase of any unprotected exposure. Training on this plan and follow-up should bepart of the healthcare worker training.

Top of Page

Principles of PPE

Healthcare workers mustunderstand the following basic principles to ensure safe and effective PPE use,which include that no skin may be exposed while working in PPE:

•   Donning

◦                     PPE must be donned correctly in proper order before entryinto the patient care area and not be later modified while in the patient carearea. The donning activities must be directly observed by a trained observer.

•   During Patient Care

◦                     PPE must remain in place and be worn correctly for theduration of exposure to potentially contaminated areas. PPE should not beadjusted during patient care.

◦                     Healthcare workers should perform frequent disinfectionof gloved hands using an ABHR, particularly after handling body fluids.

◦                     If during patient care a partial or total breach in PPE (e.g.,gloves separate from sleeves leaving exposed skin, a tear develops in an outerglove, a needlestick) occurs, the healthcare worker must move immediately tothe doffing area to assess the exposure. Implement the facility exposure plan,if indicated by assessment.

•   Doffing

◦                     The removal of used PPE is a high-risk process thatrequires a structured procedure, a trained observer, and a designated area forremoval to ensure protection

◦                     PPE must be removed slowly and deliberately in thecorrect sequence to reduce the possibility of self-contamination or otherexposure to Ebola virus

◦                     A stepwise process should be developed and used duringtraining and daily practice

Double gloving provides an extralayer of safety during direct patient care and during the PPE removal process.Beyond this, more layers of PPE may make it more difficult to perform patientcare duties and put healthcare workers at greater risk for percutaneous injury(e.g., needlesticks), self-contamination during care or doffing, or other exposuresto Ebola. If healthcare facilities decide to add additional PPE or modify thisPPE guidance, they must consider the risk/benefit of any modification, andtrain healthcare workers on correct donning and doffing in the modifiedprocedures.

Top of Page

Training on Correct Use of PPE

Training ensures that healthcareworkers are knowledgeable and proficient in the donning and doffing of PPEprior to engaging in management of an Ebola patient. Comfort and proficiencywhen donning and doffing are only achieved through repeated practice on thecorrect use of PPE. Healthcare workers should be required to demonstratecompetency in the use of PPE, including donning and doffing while beingobserved by a trained observer, before working with Ebola patients. In addition,during practice, healthcare workers and their trainers should assess theirproficiency and comfort with performing required duties while wearing PPE.Training should be available in formats accessible to individuals withdisabilities or limited English proficiency. Target training to the educationallevel of the intended audience.

Top of Page

Use of a Trained Observer

Because the sequence and actionsinvolved in each donning and doffing step are critical to avoiding exposure, atrained observer will read aloud to the healthcare worker each step in theprocedure checklist and visually confirm and document that the step has beencompleted correctly. The trained observer is a dedicated individual with thesole responsibility of ensuring adherence to the entire donning and doffingprocess. The trained observer will be knowledgeable about all PPE recommendedin the facility’s protocol and the correct donning and doffing procedures,including disposal of used PPE, and will be qualified to provide guidance andtechnique recommendations to the healthcare worker. The trained observer willmonitor and document successful donning and doffing procedures, providingimmediate corrective instruction if the healthcare worker is not following therecommended steps. The trained observer should know the exposure managementplan in the event of an unintentional break in procedure.

Top of Page

Designating Areas for PPEDonning and Doffing

Facilities should ensure thatspace and layout allow for clear separation between clean and potentiallycontaminated areas. It is critical that physical barriers (e.g., plasticenclosures) be used where necessary, along with visible signage, to separatedistinct areas and ensure a one-way flow of care moving from clean areas (e.g.,area where PPE is donned and unused equipment is stored) to the patient roomand to the PPE removal area (area where PPE is removed and discarded).

Post signage to highlight keyaspects of PPE donning and doffing, including

•   Designating clean areas vs. potentially contaminatedareas

•   Reminding healthcare workers to wait for a trainedobserver before removing PPE

•   Reinforcing need for slow and deliberate removal of PPEto prevent self-contamination

•   Reminding healthcare workers to perform disinfection ofgloved hands in between steps of the doffing procedure, as indicated below.

Designate the following areaswith appropriate signage:

1 PPE Storage and Donning Area

2 This is an area outside the Ebola patient room (e.g., anearby vacant patient room, a marked area in the hallway outside the patientroom) where clean PPE is stored and where healthcare workers can don PPE beforeentering the patient’s room. Do not store potentially contaminated equipment,used PPE, or waste removed from the patient’s room in this area. If waste mustpass through this area, it must be properly contained.

3 Patient Room

4 This is a single-patient room. The door is kept closed.Any item or healthcare worker exiting this room should be consideredpotentially contaminated.

5 PPE Removal Area

6 This is an area in proximity to the patient’s room (e.g.,anteroom or adjacent vacant patient room that is separate from the clean area)where healthcare workers leaving the patient’s room can doff and discard theirPPE. Alternatively, some steps of the PPE removal process may be performed in aclearly designated area of the patient’s room near the door, provided thesesteps can be seen and supervised by a trained observer (e.g., through a windowsuch that the healthcare worker doffing PPE can still hear the instructions ofthe trained observer). Do not use this clearly designated area within thepatient room for any other purpose. Stock gloves in a clean section of the PPEremoval area accessible to the healthcare worker while doffing.

7

8 In the PPE removal area, provide supplies fordisinfection of PPE and for performing hand hygiene and space to remove PPE,including a place for sitting that can be easily cleaned and disinfected, wherethe healthcare workers can remove boot covers. Provide leak-proof infectiouswaste containers for discarding used PPE. Perform frequent environmentalcleaning and disinfection of the PPE removal area, including upon completion ofdoffing procedure by healthcare workers.

9

10          If a facility must use the hallway outside the patientroom as the PPE removal area, construct physical barriers to close the hallwayto through traffic and thereby create an anteroom. In so doing, the facilityshould make sure that this hallway space complies with fire-codes. Restrictaccess to this hallway to essential personnel who are properly trained onrecommended infection prevention practices for the care of Ebola patients.

Facilities should considermaking showers available for use by healthcare workers after doffing of PPE.

Top of Page

Selection of PPE for HealthcareWorkers during Management of Ebola patients

This section outlines severalPPE combinations and how they should be correctly worn. The key to all PPE isconsistent implementation through repeated training and practice. A facilityshould select and standardize the PPE to be used by all essential healthcareworkers directly interacting with Ebola patients and provide a written protocoloutlining procedures for donning and doffing of this PPE, which will bereviewed and monitored by the trained observer.

CDC recommends facilities use apowered air-purifying respirator (PAPR) or an N95 or higher respirator in theevent of an unexpected aerosol-generating procedure.

For healthcare workers who mayspend extended periods of time in PPE while caring for Ebola patients, safetyand comfort are critical. Standardizing attire under PPE (e.g., surgical scrubsor disposable garments and dedicated washable footwear) facilitates the donningand doffing process and eliminates concerns of contamination of personalclothing.

If facilities elect to usedifferent PPE from what is outlined below (e.g., coveralls with either anintegrated hood or a surgical hood with integrated full face shield), they musttrain healthcare workers in this use and ensure that donning and doffingprocedures are adjusted and practiced accordingly.

Top of Page

Recommended Personal ProtectiveEquipment

•   PAPR or N95 Respirator. If a NIOSH-certified PAPR and aNIOSH-certified fit-tested disposable N95 respirator is used in facilityprotocols, ensure compliance with all elements of the OSHA Respiratory Protection Standard, 29 CFR 1910.134,including fit testing, medical evaluation, and training of the healthcareworker.

◦                     PAPR: A PAPR with a full face shield, helmet, orheadpiece. Any reusable helmet or headpiece must be covered with a single-use(disposable) hood that extends to the shoulders and fully covers the neck andis compatible with the selected PAPR. The facility should follow manufacturer’sinstructions for decontamination of all reusable components and, based uponthose instructions, develop facility protocols that include the designation ofresponsible personnel who assure that the equipment is appropriatelyreprocessed and that batteries are fully charged before reuse.

▪                                       A PAPR with a self-contained filter and blower unitintegrated inside the helmet is preferred.

▪                                       A PAPR with external belt-mounted blower unit requiresadjustment of the sequence for donning and doffing, as described below.

◦                     N95 Respirator: Single-use (disposable) N95 respirator incombination with single-use (disposable) surgical hood extending to shouldersand single-use (disposable) full face shield.** If N95 respirators are usedinstead of PAPRs, careful observation is required to ensure healthcare workersare not inadvertently touching their faces under the face shield during patientcare.

•   Single-use (disposable) fluid-resistant or impermeablegown that extends to at least mid-calf or coverall without integrated hood.Coveralls with or without integrated socks are acceptable.

•   Consideration should be given to selecting gowns orcoveralls with thumb hooks to secure sleeves over inner glove. If gowns orcoveralls with thumb hooks are not available, personnel may consider taping thesleeve of the gown or coverall over the inner glove to prevent potential skinexposure from separation between sleeve and inner glove during activity.However, if taping is used, care must be taken to remove tape gently.Experience in some facilities suggests that taping may increase risk by makingthe doffing process more difficult and cumbersome.

•   Single-use (disposable) nitrile examination gloves withextended cuffs. Two pairs of gloves should be worn. At a minimum, outer glovesshould have extended cuffs.

•   Single-use (disposable), fluid-resistant or impermeableboot covers that extend to at least mid-calf or single-use (disposable) shoecovers. Boot and shoe covers should allow for ease of movement and not presenta slip hazard to the worker.

◦                     Single-use (disposable) fluid-resistant or impermeableshoe covers are acceptable only if they will be used in combination with acoverall with integrated socks.

•   Single-use (disposable), fluid-resistant or impermeableapron that covers the torso to the level of the mid-calf should be used if Ebolapatients have vomiting or diarrhea. An apron provides additional protectionagainst exposure of the front of the body to body fluids or excrement. If aPAPR will be worn, consider selecting an apron that ties behind the neck tofacilitate easier removal during the doffing procedure.

Top of Page

Recommended PPE for TrainedObserver during Observations of PPE Doffing

The trained observer should notenter the room of a patient with Ebola, but will be in the PPE removal area toobserve and assist with removal of specific components of PPE, as outlinedbelow. The observer should not participate in any Ebola patient care activitieswhile conducting observations. The following PPE are recommended for trainedobservers:

•   Single-use (disposable) fluid-resistant or impermeablegown that extends to at least mid-calf or coverall without integrated hood.

•   Single-use (disposable) full face shield.

•   Single-use (disposable) nitrile examination gloves withextended cuffs. Two pairs of gloves should be worn. At a minimum, outer glovesshould have extended cuffs.

•   Single-use (disposable) fluid-resistant or impermeableshoe covers. Shoe covers should allow for ease of movement and not present aslip hazard to the worker.

Trained observers should don anddoff selected PPE according to same procedures outlined below. Of note, if thetrained observer assists with PPE doffing, then the trained observer shoulddisinfect outer-gloved hands with an *EPA-registered disinfectant wipe or ABHRimmediately after contact with healthcare worker’s PPE.

Donning PPE, PAPR Option – Thisdonning procedure assumes the facility has elected to use PAPRs. An establishedprotocol facilitates training and compliance. Use a trained observer to verifysuccessful compliance with the protocol.

1 Engage Trained Observer: The donning process is conductedunder the guidance and supervision of a trained observer, who confirms visuallythat all PPE is serviceable and has been donned successfully. The trainedobserver uses a written checklist to confirm each step in donning PPE and canassist with ensuring and verifying the integrity of the ensemble. No exposedskin or hair of the healthcare worker should be visible at the conclusion ofthe donning process.

2 Remove Personal Clothing and Items: Change into surgicalscrubs (or disposable garments) and dedicated washable (plastic or rubber)footwear in a suitable clean area. No personal items (e.g., jewelry, watches,cell phones, pagers, pens) should be brought into patient room.

3 Inspect PPE Prior to Donning: Visually inspect the PPEensemble to be worn to ensure that it is in serviceable condition, that allrequired PPE and supplies are available, and that the sizes selected arecorrect for the healthcare worker. The trained observer reviews the donningsequence with the healthcare worker before the healthcare worker begins thedonning process and reads it to the healthcare worker in a step-by-stepfashion.

4 Perform Hand Hygiene: Perform hand hygiene with ABHR.When using ABHR, allow hands to dry before moving to next step.

5 Put on Inner Gloves: Put on first pair of gloves.

6 Put on Boot or Shoe Covers.

7 Put on Gown or Coverall: Put on gown orcoverall. Ensure gown or coverall is large enough to allow unrestricted freedomof movement. Ensure cuffs of inner gloves are tucked under the sleeve of thegown or coverall

a                   If a PAPR with a self-contained filter and blower unitthat is integrated inside the helmet is used, then the belt and battery unitmust be put on prior to donning the impermeable gown or coverall so thatthe belt and battery unit are contained under the gown or coverall.

b                   If a PAPR with external belt-mounted blower is used, thenthe blower and tubing must be on the outside of gown or coverall toensure proper airflow.

8 Put on Outer Gloves: Put on second pair of gloves (withextended cuffs). Ensure the cuffs are pulled over the sleeves of the gown orcoverall

9 Put on Respirator: Put on PAPR with a full face-shield,helmet, or headpiece

a                   If a PAPR with a self-contained filter and blower unitintegrated inside the helmet is used, then a single-use (disposable) hood thatextends to the shoulders and fully covers the neck must also be used. Be surethat the hood covers all of the hair and the ears, and that it extends past theneck to the shoulders.

b                   If a PAPR with external belt-mounted blower unit andattached reusable headpiece is used, then a single-use (disposable) hood thatextends to the shoulders and fully covers the neck must also be used. Be surethat the hood covers all of the hair and the ears, and that it extends past theneck to the shoulders.

10          Put on Outer Apron (if used): Put on full-body apron toprovide additional protection to the front of the body against exposure to bodyfluids or excrement from the patient.

11          Verify: After completing the donning process, theintegrity of the ensemble is verified by the trained observer. The healthcareworker should be comfortable and able to extend the arms, bend at the waist,and go through a range of motions to ensure there is sufficient range ofmovement while all areas of the body remain covered. A mirror in the room canbe useful for the healthcare worker while donning PPE.

12          Disinfect Outer Gloves: Disinfect outer-gloved hands withABHR. Allow to dry prior to patient contact.

Donning PPE, N95 RespiratorOption – This donning procedure assumes the facility has elected to use N95respirators. An established protocol facilitates training and compliance. Use atrained observer to verify successful compliance with the protocol.

1 Engage Trained Observer: The donning process is conductedunder the guidance and supervision of a trained observer who confirms visuallythat all PPE is serviceable and has been donned successfully. The trainedobserver will use a written checklist to confirm each step in donning PPE andcan assist with ensuring and verifying the integrity of the ensemble. Noexposed skin or hair of the healthcare worker should be visible at theconclusion of the donning process.

2 Remove Personal Clothing and Items: Change into surgicalscrubs (or disposable garments) and dedicated washable (plastic or rubber)footwear in a suitable, clean area. No personal items (e.g., jewelry, watches,cell phones, pagers, pens) should be brought into patient room.

3 Inspect PPE Prior to Donning: Visually inspect the PPE ensembleto be worn to ensure it is in serviceable condition, all required PPE andsupplies are available, and that the sizes selected are correct for thehealthcare worker. The trained observer reviews the donning sequence with thehealthcare worker before the healthcare worker begins and reads it to thehealthcare worker in a step-by-step fashion.

4 Perform Hand Hygiene: Perform hand hygiene with ABHR.When using ABHR, allow hands to dry before moving to next step.

5 Put on Inner Gloves: Put on first pair of gloves.

6 Put on Boot or Shoe Covers.

7 Put on Gown or Coverall: Put on gown orcoverall. Ensure gown or coverall is large enough to allow unrestrictedfreedom of movement. Ensure cuffs of inner gloves are tucked under the sleeveof the gown or coverall.

8 Put on N95 Respirator: Put on N95 respirator. Complete auser seal check.

9 Put on Surgical Hood: Over the N95 respirator, place asurgical hood that covers all of the hair and the ears, and ensure that itextends past the neck to the shoulders. Be certain that hood completely coversthe ears and neck.

10          Put on Outer Apron (if used): Put on full-body apron toprovide additional protection to the front of the body against exposure to bodyfluids or excrement from the patient.

11          Put on Outer Gloves: Put on second pair of gloves (withextended cuffs). Ensure the cuffs are pulled over the sleeves of the gown orcoverall.

12          Put on Face Shield: Put on full face shield over the N95respirator and surgical hood to provide additional protection to the front andsides of the face, including skin and eyes.

13          Verify: After completing the donning process, theintegrity of the ensemble is verified by the trained observer. The healthcareworker should be comfortable and able to extend the arms, bend at the waist andgo through a range of motions to ensure there is sufficient range of movementwhile all areas of the body remain covered. A mirror in the room can be usefulfor the healthcare worker while donning PPE.

14          Disinfect Outer Gloves: Disinfect outer-gloved hands withABHR. Allow to dry prior to patient contact.

Top of Page

Preparing for Doffing

The purpose of this step is toprepare for the removal of PPE. Before entering the PPE removal area, inspectand disinfect (using an *EPA-registered disinfectant wipe) any visiblecontamination on the PPE. As a final step, disinfect outer-gloved hands witheither an *EPA-registered disinfectant wipe or ABHR, and allow to dry. Verifythat the trained observer is available in the PPE removal area before enteringand beginning the PPE removal process.

Doffing PPE, PAPR Option – PPEdoffing should be performed in the designated PPE removal area. Place all PPEwaste in a leak-proof infectious waste container.

1 Engage Trained Observer: The doffing process is conductedunder the supervision of a trained observer, who reads aloud each step of theprocedure and confirms visually that the PPE is removed properly. Prior todoffing PPE, the trained observer must remind the healthcare worker to avoidreflexive actions that may put them at risk, such as touching their face. Postthis instruction and repeat it verbally during doffing. Although the trainedobserver should minimize touching the healthcare worker or the healthcareworker’s PPE during the doffing process, the trained observer may assist withremoval of specific components of PPE, as outlined below. The trained observerdisinfects the outer-gloved hands immediately after handling any healthcareworker PPE.

2 Inspect: Inspect the PPE to assess for visiblecontamination, cuts, or tears before starting to remove. If any PPE ispotentially contaminated, then disinfect using an *EPA-registered disinfectantwipe. If the facility conditions permit and appropriate regulations arefollowed, an *EPA-registered disinfectant spray can be used, particularly oncontaminated areas.

3 Disinfect Outer Gloves: Disinfect outer-gloved hands witheither an *EPA-registered disinfectant wipe or ABHR, and allow to dry.

4 Remove Apron (if used): Remove and discard apron takingcare to avoid contaminating gloves by rolling the apron from inside to outside.

5 Inspect: Following apron removal, inspect the PPE ensembleto assess for visible contamination or cuts or tears. If visibly contaminated,then disinfect affected PPE using an *EPA-registered disinfectant wipe.

6 Disinfect Outer Gloves: Disinfect outer-gloved hands witheither an *EPA-registered disinfectant wipe or ABHR.

7 Remove Boot or Shoe Covers: While sitting down,remove and discard boot or shoe covers.

8 Disinfect and Remove Outer Gloves: Disinfect outer-glovedhands with either an *EPA-registered disinfectant wipe or ABHR. Remove anddiscard outer gloves, taking care not to contaminate inner glove during removalprocess.

9 Inspect and Disinfect Inner Gloves: Inspect the innergloves’ outer surfaces for visible contamination, cuts, or tears. If an innerglove is visibly soiled, cut, or torn, then disinfect the glove with either an*EPA-registered disinfectant wipe or ABHR. Then remove the inner gloves,perform hand hygiene with ABHR on bare hands, and don a clean pair of gloves.If no visible contamination, cuts, or tears are identified on the inner gloves,then disinfect the inner-gloved hands with either an *EPA-registereddisinfectant wipe or ABHR.

10          Remove Respirator (PAPR)***:

a                   If a PAPR with a self-contained filter and blower unitintegrated inside the helmet is used, then wait until Step 15 for removal andgo to Step 11.

b                   If a PAPR with an external belt-mounted blower unit isused, then all components must be removed at this step.

i                                       Remove and discard disposable hood.

ii                                      Disinfect inner gloves with either an *EPA-registereddisinfectant wipe or ABHR.

iii                                    Remove headpiece, blower, tubing, and the belt andbattery unit. This step might require assistance from the trainedobserver.

iv                                     Disinfect inner gloves with either an *EPA-registereddisinfectant wipe or ABHR.

v                                      Place all reusable PAPR components in an area orcontainer designated for the collection of PAPR components for disinfection.

11          Remove Gown or Coverall: Remove and discard.

a                   Depending on gown design and location of fasteners, thehealthcare worker can either untie fasteners, receive assistance by the trainedobserver to unfasten the gown, or gently break fasteners. Avoid contact ofscrubs or disposable garments with outer surface of gown during removal. Pullgown away from body, rolling inside out and touching only the inside of thegown.

b                   To remove coverall, tilt head back and reach under thePAPR hood to reach zipper or fasteners. Use a mirror to help avoid touching theskin. Unzip or unfasten coverall completely before rolling down and turninginside out. Avoid contact of scrubs with outer surface of coverall duringremoval, touching only the inside of the coverall.

12          Disinfect Inner Gloves: Disinfect inner gloves witheither an *EPA-registered disinfectant wipe or ABHR

13          Disinfect Washable Shoes: Sitting on a new clean surface(e.g., second clean chair, clean side of a bench) use an *EPA-registereddisinfectant wipe to wipe down every external surface of the washable shoes.

14          Disinfect Inner Gloves: Disinfect inner gloves witheither an *EPA-registered disinfectant wipe or ABHR.

15          Remove Respirator (if not already removed): If a PAPRwith a self-contained filter and blower unit that is integrated inside helmetis used, then remove all components.

a                   Remove and discard disposable hood

b                   Disinfect inner gloves with either an *EPA-registereddisinfectant wipe or ABHR

c                    Remove and discard inner gloves taking care not tocontaminate bare hands during removal process

d                   Perform hand hygiene with ABHR

e                   Don a new pair of inner gloves

f                     Remove helmet and the belt and battery unit. This stepmight require assistance from the trained observer.

16          Disinfect and Remove Inner Gloves: Disinfect inner-glovedhands with either an *EPA-registered disinfectant wipe or ABHR. Remove anddiscard gloves taking care not to contaminate bare hands during removalprocess.

17          Perform Hand Hygiene: Perform hand hygiene with ABHR.

18          Inspect: Perform a final inspection of healthcare workerfor any indication of contamination of the surgical scrubs or disposablegarments. If contamination is identified, immediately inform infectionpreventionist or occupational safety and health coordinator or their designeebefore exiting PPE removal area.

19          Scrubs: Healthcare worker can leave PPE removal areawearing dedicated washable footwear and surgical scrubs or disposable garments.

20          Shower: Showers are recommended at each shift’s end forhealthcare workers performing high-risk patient care (e.g., exposed to largequantities of blood, body fluids, or excreta). Showers are also suggested forhealthcare workers spending extended periods of time in the Ebola patient room.

21          Protocol Evaluation/Medical Assessment: Either theinfection preventionist or occupational safety and health coordinator or theirdesignee on the unit at the time should meet with the healthcare worker toreview the patient care activities performed to identify any concerns aboutcare protocols and to record healthcare worker’s level of fatigue.

Doffing PPE, N95 RespiratorOption – PPE doffing is performed in the designated PPE removal area. Place allPPE waste in a leak-proof infectious waste container.

1 Engage Trained Observer: The doffing process is conductedunder the supervision of a trained observer, who reads aloud each step of theprocedure and confirms visually that the PPE has been removed properly. Priorto doffing PPE, the trained observer must remind healthcare workers to avoidreflexive actions that may put them at risk, such as touching their face. Postthis instruction and repeat it verbally during doffing. Although the trainedobserver should minimize touching healthcare workers or their PPE during thedoffing process, the trained observer may assist with removal of specificcomponents of PPE as outlined below. The trained observer disinfects theouter-gloved hands immediately after handling any healthcare worker PPE.

2 Inspect: Inspect the PPE to assess for visiblecontamination, cuts, or tears before starting to remove. If any PPE is visiblycontaminated, then disinfect using an *EPA-registered disinfectant wipe. If thefacility conditions permit and appropriate regulations are followed, an*EPA-registered disinfectant spray can be used, particularly on contaminatedareas.

3 Disinfect Outer Gloves: Disinfect outer-gloved hands witheither an *EPA-registered disinfectant wipe or ABHR.

4 Remove Apron (if used): Remove and discard apron takingcare to avoid contaminating gloves by rolling the apron from inside to outside.

5 Inspect: Following apron removal, inspect the PPEensemble to assess for visible contamination or cuts or tears. If visiblycontaminated, then disinfect affected PPE using an *EPA-registered disinfectantwipe.

6 Disinfect Outer Gloves: Disinfect outer-gloved hands witheither an *EPA-registered disinfectant wipe or ABHR.

7 Remove Boot or Shoe Covers: While sitting down,remove and discard boot or shoe covers.

8 Disinfect and Remove Outer Gloves: Disinfect outer-glovedhands with either an *EPA-registered disinfectant wipe or ABHR. Remove anddiscard outer gloves taking care not to contaminate inner gloves during removalprocess.

9 Inspect and Disinfect Inner Gloves: Inspect the innergloves’ outer surfaces for visible contamination, cuts, or tears. If an innerglove is visibly soiled, cut, or torn, then disinfect the glove with either an*EPA-registered disinfectant wipe or ABHR. Then remove the inner gloves,perform hand hygiene with ABHR on bare hands, and don a clean pair of gloves.If no visible contamination, cuts, or tears are identified on the inner gloves,then disinfect the inner-gloved hands with either an *EPA-registereddisinfectant wipe or ABHR.

10          Remove Face Shield: Remove the full face shield bytilting the head slightly forward, grabbing the rear strap and pulling it overthe head, gently allowing the face shield to fall forward and discard. Avoidtouching the front surface of the face shield.

11          Disinfect Inner Gloves: Disinfect inner gloves witheither an *EPA-registered disinfectant wipe or ABHR.

12          Remove Surgical Hood: Unfasten (if applicable) surgicalhood, gently remove, and discard. The trained observer may assist with unfasteninghood.

13          Disinfect Inner Gloves: Disinfect inner gloves witheither an *EPA-registered disinfectant wipe or ABHR.

14          Remove Gown or Coverall: Remove and discard.

a                   Depending on gown design and location of fasteners, thehealthcare worker can either untie fasteners, receive assistance by the trainedobserver to unfasten to gown, or gently break fasteners. Avoid contact ofscrubs or disposable garments with outer surface of gown during removal. Pullgown away from body, rolling inside out and touching only the inside of thegown.

b                   To remove coverall, tilt head back to reach zipper orfasteners. Unzip or unfasten coverall completely before rolling down andturning inside out. Avoid contact of scrubs with outer surface of coverallduring removal, touching only the inside of the coverall.

15          Disinfect and Change Inner Gloves: Disinfect inner gloveswith either an *EPA-registered disinfectant wipe or ABHR. Remove and discardgloves taking care not to contaminate bare hands during removal process. Performhand hygiene with ABHR. Don a new pair of inner gloves.

16          Remove N95 Respirator: Remove the N95 respirator bytilting the head slightly forward, grasping first the bottom tie or elasticstrap, then the top tie or elastic strap, and remove without touching the frontof the N95 respirator. Discard N95 respirator.

17          Disinfect Inner Gloves: Disinfect inner gloves witheither an *EPA-registered disinfectant wipe or ABHR

18          Disinfect Washable Shoes: Sitting on a new clean surface(e.g., second clean chair, clean side of a bench) use an *EPA-registereddisinfectant wipe to wipe down every external surface of the washable shoes.

19          Disinfect and Remove Inner Gloves: Disinfect inner-glovedhands with either an *EPA-registered disinfectant wipe or ABHR. Remove anddiscard gloves taking care not to contaminate bare hands during removalprocess.

20          Perform Hand Hygiene: Perform hand hygiene with ABHR.

21          Inspect: Perform a final inspection of healthcare workerfor any indication of contamination of the surgical scrubs or disposablegarments. If contamination is identified, immediately inform infectionpreventionist or occupational safety and health coordinator or their designeebefore exiting PPE removal area.

22          Scrubs: Healthcare worker can leave PPE removal areawearing dedicated washable footwear and surgical scrubs or disposable garments.

23          Shower: Showers are recommended at each shift’s end forhealthcare workers performing high risk patient care (e.g., exposed to largequantities of blood, body fluids, or excreta). Showers are also suggested forhealthcare workers spending extended periods of time in the Ebola patient room.

Protocol Evaluation/Medical Assessment: Either the infection preventionistor occupational health safety and health coordinator or their designee on theunit at the time should meet with the healthcare worker to review the patientcare activities performed to identify any concerns about care protocols and torecord healthcare worker’s level of fatigue.