PPE donning and doffing order, the CDC sequence

Infection Control and Safety is 15 of the 150 scored items on the NHA CCMA exam, and the order you put on and take off personal protective equipment is one of its most reliable sequence questions. The order is not arbitrary. Every step exists to keep the dirtiest surface away from your skin and face, and once you see that logic the sequence stops being a list to memorize. This post follows the infection control unit of the NHA CCMA exam prep course and uses the CDC sequence. It is a study aid, not clinical guidance; facility policy, the provider and your training decide practice.

Drill the order before or after reading with the PPE donning and doffing order quiz, which shuffles the steps and checks your sequence.

Donning: putting PPE on

Perform hand hygiene first. Then:

1. Gown. Fully cover the torso from neck to knees and the arms to the end of the wrists. Wrap it around the back and fasten at the back of the neck and waist.
2. Mask or respirator. Secure the ties or elastic at the middle of the head and the neck. Fit the flexible band to the nose bridge, snug to the face and below the chin. If it is a respirator, do a user seal check.
3. Goggles or face shield. Place over the face and eyes and adjust to fit.
4. Gloves. Last, and pulled up to cover the wrist (cuff) of the gown.

Gloves go on last because they are the item most likely to touch the patient and the environment, and you want them covering the gown cuff so no skin shows at the wrist. While wearing PPE, keep your hands away from your face, limit the surfaces you touch, and change gloves when they tear or become heavily contaminated.

Doffing: taking PPE off

Remember one principle and the sequence follows: the outside of the gloves, the outside of the goggles, the front and sleeves of the gown and the front of the mask are all contaminated. The inside surfaces and the ties are clean. You peel from dirtiest to least dirty, touching only clean parts, and you protect your face until the very end.

The CDC sequence:

1. Gloves. Grasp the palm of one glove with the other gloved hand and peel it off. Hold it in the still-gloved hand. Slide the bare fingers under the remaining glove at the wrist and peel it off over the first glove, so the two end up inside out together.
2. Goggles or face shield. Remove from the back by lifting the headband or earpieces. Do not touch the front. Reusable eyewear goes in the reprocessing receptacle.
3. Gown. Unfasten the ties, pull the gown away from the neck and shoulders touching only the inside, turn it inside out, and fold or roll it into a bundle to discard.
4. Mask or respirator. Grasp the bottom ties or elastics first, then the top, and remove without touching the front.
5. Hand hygiene immediately after all PPE is off.

CDC also publishes a second poster in which the gown and gloves come off together as a single first step, the gown pulled away so the ties break and rolled inside out with the gloves peeled off inside it, followed by goggles, mask and hand hygiene. In both versions the gloves come off first and the mask comes off last, because the glove surface is the dirtiest and the face is the most protected area. On an exam item, work from that principle and you will pick the right option.

If your hands become contaminated at any step, stop and perform hand hygiene before continuing, then again at the end.

Where you take it off

All PPE comes off before leaving the patient room, with one exception: a respirator stays on until you have left the room and closed the door. The reason is the same one that puts it last in the doffing order. In an airborne isolation room the air itself is the hazard, so the respirator is the last barrier to drop and it drops outside.

OSHA's bloodborne pathogens standard adds the workplace rules. A garment penetrated by blood or other potentially infectious material is removed as soon as feasible, all PPE comes off before leaving the work area, and the employer provides, launders, repairs and replaces PPE at no cost to the employee. Disposable gloves are never washed or reused; utility gloves may be decontaminated and reused if they are not cracked, peeling or torn.

Matching PPE to the situation

Donning everything for every patient is wrong on the exam and wasteful in practice. PPE is chosen by the expected exposure under standard precautions, plus whatever the transmission-based category requires.

A surgical mask is for droplet precautions and splash protection. An N95 respirator is for airborne precautions, and under OSHA it requires a medical evaluation, a fit test before first use and at least annually, and a seal check every time it is worn. The broader precaution categories, and the chain they interrupt, are in chain of infection and medical asepsis.

Hand hygiene, the step on both ends

Hand hygiene is the single most important measure in standard precautions, and gloves do not replace it. The exam tests when and how.

When: immediately before touching a patient; before an aseptic task; before moving from a soiled site to a clean site on the same patient; after touching a patient or the patient's surroundings; after contact with blood, body fluids or contaminated surfaces; and immediately after removing gloves.

How: in most clinical situations CDC prefers alcohol-based hand sanitizer, because it kills germs better than soap and is gentler on skin. Use a product with at least 60 percent alcohol, cover all surfaces of the hands and fingers, and rub until dry, about 20 seconds. Wiping it off early defeats it. Use soap and water instead when hands are visibly soiled, before eating, after using the restroom, and when caring for a patient with suspected or confirmed C. difficile or norovirus during an outbreak. Alcohol does not kill bacterial spores, so spores have to be physically washed off.

Washing: wet the hands, apply soap, rub vigorously for at least 20 seconds over all surfaces, rinse, dry with a disposable towel, and use the towel to turn off the faucet, because the handle is considered contaminated. Avoid hot water, which increases dermatitis. Natural nails stay short of the fingertip, artificial nails are discouraged for high-risk care, and only facility-approved lotions are used because some lotions interfere with sanitizers or gloves.

Common mistakes on exam items

• Putting gloves on before the gown, which leaves the gown cuff over the glove and bare skin exposed when the glove slips.
• Removing the mask first because it feels like the most uncomfortable item. It comes off last.
• Touching the front of the mask or goggles during removal. Handle ties, elastics, earpieces and headbands only.
• Taking a respirator off inside an airborne isolation room.
• Skipping hand hygiene after doffing because gloves were worn.
• Picking an answer that says to wash and reuse disposable gloves.
• Reaching for alcohol rub for a C. difficile patient. Soap and water.

Studying sequences

Sequence questions reward retrieval practice more than rereading. Shuffle the steps and order them cold, check, and repeat tomorrow. That is the testing effect in its simplest form, and the quiz above is built for it. Phlebotomy students meet the same PPE rules in the Safety and Compliance domain, which the NHA CPT exam: what's on it describes, so if you plan to hold both credentials the chapter does double duty; CCMA vs CPT compares the two tests. Within the CCMA itself, infection control also governs injection sites and needle handling and the specimen work in CLIA-waived tests for medical assistants. For the full domain weights, see NHA CCMA exam: what's on it.