Nursing Practice
equipment/Infection prevention/Safety/
Practice educator
Infection prevention
Protecting staff and patients from infection is vital so all staff who may have to use
personal protective equipment must know how to use and remove it correctly
How to use personal
protective equipment
Learning points...
 etails of different types of personal protective equipment
D
When PPE should be used
How to safely remove PPE
Author Vicky Pang is clinical lead nurse;
Yvonne Carter is deputy director of
infection prevention and control; Janice
Scott is clinical nurse specialist; Glenn
Salazar and Velor Johnson are practice
educators (infection prevention and
control, all at the Royal Free Hospital,
London.
Abstract Pang V et al (2014) How to use
personal protective equipment. Nursing
Times; 110, 51: 14-16.
This article offers a refresher on what
personal protective equipment (PPE) is,
how to choose the right PPE and how to
wear and remove it safely. PPE aims to
improve staff and patient safety, but
self-contamination commonly occurs
during its removal; failure to remove PPE
carefully can lead to contamination of the
user’s skin, own clothes, uniform or scrubs,
hair, face and hands. The importance of
correct PPE use has been highlighted by
the ebola crisis and NHS preparations to
deal with patients who are infected.
T
he aim of using personal protec-
tive equipment (PPE) is to protect
against health or safety risks at
work. The epic3 (Loveday et al,
2014) evidence-based guidelines on infec-
tion prevention and control state that
selection of PPE should be based on an
assessment of the:
» Risk of transmission of micro-
organisms to the patient or carer;
» Risk of contamination of the health
professional’s clothing or skin by the
patient’s blood or body fluid or respired
aerosols or droplets;
» Suitability of the equipment for the
proposed use – does it fit, is it CE
marked, do PPE items fit together?
14 Nursing Times 17.12.14/ Vol 110 No 51 / www.nursingtimes.net
Keywords: Personal protective
Contamination
●This article has been double-blind
peer reviewed
5 practice
points
1 Health profes-
sionals must use
personal protective
equipment (PPE)
when undertaking
Before using PPE, staff should be edu- any procedure
cated and their competence assessed in the that carries an
assessment of risk, and selection and use infection risk
of PPE, as well as the use of standard pre-
cautions. It is important to assess whether
the selected PPE will be effective – for
2 PPE is only as
effective as the
user’s skill in use
example, staff using respirators will need and removal
to be “fit tested” to ensure masks are a cor-
rect and safe fit (NHS England and Public
Health England, 2013a).
3 PPE can
protect staff
from infection risks,
Using unfamiliar PPE can increase the and vulnerable
risk of self-contamination due to lack of patients from
skill and confusion in the correct removal acquiring infections
method. PPE should not be used, nor tasks from staff
undertaken that require its use, until staff
are confident and competent in doing so. 4 PPE must be
assessed for
each procedure
When should PPE be used?
Gloves
Gloves are single-use items and should be
5 Change PPE
whenever it is
heavily splashed
used for invasive procedures including and between
contact with sterile sites, non-intact skin procedures with
or mucous membranes, and for all activi- different patients
ties that have been assessed as carrying a
risk of exposure to blood, body fluid or Box 1. hand hygiene
infectious respired aerosols or droplets.
They must be put on immediately before Hands must be decontaminated in line
an episode of patient contact or treatment; with the World Health Organization’s
they must not be used to open doors and (2009) five moments:
collect equipment before patient contact. ● Immediately before each episode of
Gloves should be: direct patient contact or care
» Used when handling sharps or con- ● Before clean/aseptic procedures,
taminated devices (Loveday et al, 2014) whether or not personal protective
– micro-organisms can survive on equipment has been worn
objects, or “fomites”, and become a risk ● After risk of body fluid exposure
for transmission of infection; ● After touching a patient
» Removed as soon as the episode of care ● After touching a patient’s
is completed – hands must be decon- surroundings
taminated immediately after glove Hands should also be decontaminated
removal; immediately after gloves have been
» Changed when soiled – they must not removed.
be washed or decontaminated with
 When When caring
caring for patients
for patients with with suspected
suspected or confirmed
or confirmed infectious
infectious respiratory
respiratory virus,
virus,
all healthcare
all healthcare workers
workers needneed to – prior
to – prior to patient
to any any patient interaction
interaction – assess
– assess the infectious
the infectious
The authors of this article
risk posed
risk posed to themselves
to themselves and and
wearwear the appropriate
the appropriate personal
personal protective
protective
won the Infection
equipment
equipment
Prevention
(PPE)(PPE) to minimise
to minimise that risk.
that risk. and Control category of the
2014 Nursing Times Awards
When
When to use
to use a surgical
a surgical faceface
maskmask When
When to use
to use an FFP3
an FFP3 respirator
respirator
fig 1. WHEN fig 2. WHEN TO
TO USE A USE AN FFP3
SURGICAL RESPIRATOR
FACE MASK

IN PATIENTS WITH RESPIRATORY INFECTIONS ● Carrying out potentially infectious aerosol-generating

CarryingCarrying out potentially
out potentially infectious
infectious aerosol aerosol generating
generating
procedures procedures
procedures
In cohorted area (but no Close patient contact ● Where a patient is known/suspected to have an infection
In cohorted
In cohorted area area Close patient
Close patient contact contact WhereWhere a patient
a patient is known/suspected
is known/suspected to havetoan
have an
patient contact)
(but no(but no patient
patient
(within
contact)
1m)
contact) (within(within one metre)
one metre)
spread via the aerosolvia
infection
infection
route
spreadspread thevia the aerosol
aerosol route route
● When caring for patients
When caring
known/suspected
for patients known/suspected
to be infected
When caring for patients known/suspected to be to be
For example For example with ainfected
newlyinfected
identified
with a with
respiratory
newlya newly virus
identified
identified respiratory
respiratory virus virus
● Room cleaning ● Providing patient care
● EquipmentFor For example: ● DirectFor
cleaning
example: home For example:
care
example: visit For example For example:
For example:
Cleaning theequipment
room, equipment Providing
patient patient care, direct bronchoscopy,
bronchoscopy, endotracheal intubation, tracheostomy
● Cleaning aCleaning the room,
discharged Providing
● Diagnostic imaging care, direct Bronchoscopy, endotracheal
endrotracheal intubation,
intubation, tracheostomy
tracheostomy
cleaning,
cleaning, discharge
discharge patient patienthome care
home care
visit, visit, diagnostic
diagnostic procedures,
procedures, cardiopulmonary
cardiopulmonary resuscitation,
resuscitation, diagnostic
diagnostic sputumsputum
patient’s room room cleaning,
room cleaning, etc
●
etc Phlebotomy services
imaging,
imaging, phlebotomy
phlebotomy
procedures, cardiopulmonary
services, induction:
services, induction: resuscitation, diagnostic
● Physiotherapy physiotherapy,
physiotherapy, etc etc sputum induction
Source: NHS England, Public Health England (2013b) Source: NHS England, Public Health England (2013b)
PPE toPPE to be worn
be worn PPE toPPE to be worn
be worn PPE toPPE to be worn
be worn
alcohol products between
• Surgical
• Surgical procedures
face maskface(along
mask (along • in how to use
• Surgical
Surgical face andmask
face
mask adjust it in accordance
• FFP3•respirator contact and loose hair falling forward. All
FFP3 respirator
and should bewith
changed between
withdesignated
other caring
other designated
PPE PPE • with
Apron• Health
Apron and Safety Executive • Gown (2012)
• Gown strings from masks and visors should be
for cleaning) • Gloves
for cleaning)
for different patients. • regulations.
Gloves Staff should
• Eye protection (if risk of
not use FFP3•• res-
• Gloves Gloves
placed over hair protection – this allows
Eye protection
• Eye protection (if risk of • Eye protection
Since the effect of alcohol hand gels on pirators unless
contamination fit
contamination of eyes by
tested
of eyes as
by safe. Figs 1 and them to be removed after a procedure
glove material has not been tested, the 2splashes outline orfactors
splashes influencing the choice
or droplets)
droplets) oftesting
without contaminating the hair. trained
• Fit testing should should
• Fit be carried
be carried out by aout by a properly
properly trained
integrity of gloves decontaminated in this single-use masks for use whencompetent treating
competent fit tester.
fit tester.
way cannot be guaranteed. patients who have respiratory infections. Putting on PPE
These images
These images are for illustrative
are for illustrative purposespurposes only. Always
only. Always follow thefollow the manufacturer’s
manufacturer’s instructions.
instructions.When putting on PPE, the following
Aprons and gowns Footwear sequence should be followed:
Remember
Remember
Aprons are single-use items and must be Wellington boots or water-repellent boots » Decontaminate hands before putting on
worn when in close contact with patients, should be worn when there is a risk of PPE – gloves provide an ideal, warm,
materials or equipment
• PPE • should
PPE should
that pose bea risk
put beof
onput on removed
and removed
blood/body
and an in an•leaks
fluidinsplashes, Hand•or Hand
large
hygiene hygiene
moist must
mustenvironment
always always
bewhere bebacteria
performed
performed
contamination with order order
bloodthat that minimises
or minimises
body fluids the the potential
spillages,
potentialsuchfor for cross‑
as oesophageal
cross‑ bleeds following
and
following in removal removal
thrive. ofHand
PPE.ofdecontamination
PPE. will
(Loveday et al, 2014). Fluid-repellent
contamination. gowns the operating theatre. If protective footwear • Healthcare remove any transient
workers who have bacteriahad from a
influenza
contamination. • Healthcare workers who have had influenza
must be worn when•there is an
The order extensive
for removal is required,
PPE removal consider
is gloves, the following: previous patient or the environment
• The order for PPE is gloves,
risk of the splashing of blood or body fluid » Hands become contaminated from
apronapron vaccination, vaccination, or(Box or confirmed
confirmed
1).
influenza
influenza
or gown,
onto the skin or clothing
or gown, eye
eye workers.
of health
protection,
protection, surgical surgical
touching and face face mask
maskon footwear
pulling
infection,
infection,
from are
are
» still
Put on
still
advised advised to useabove
to useUsually
plastic apron. the the above
aprons are
or FFP3
Staff should ensure or FFP3
aprons/gowns respirator.
respirator. are: whatever has splashed onto its infectioninfection
surface control control precautions.
precautions.
supplied on a roll and are folded. Open
» Changed when visibly soiled – although or been picked up on the sole during a the apron outwards towards the patient
it takes some time for fluid to seep patient care episode; so any environmental contamination
through fluid-repellent gowns (strike » If you remove footwear and stand in the on the outer surface does not come into
through), they are not waterproof; same space, your feet will be contami- contact with the patient.
» Worn for one procedure or episode of nated. Have a “dirty” area for footwear » Put on gloves. Remember, touching
patient care only. removal and a “clean” one where nobody door handles or equipment after
Non-disposable PPE should be sent for walks in contaminated footwear; putting on gloves may contaminate
appropriate decontamination (Loveday et » There is little evidence of gross them before you reach the patient.
al, 2014). infection transmission from the floor
surface unless there are large spillages Removing PPE
Masks of infected material so protective PPE must be removed in the following
Fluid-repellent masks and eye protection footwear is not usually required; sequence to minimise the risk of cross/
should be worn: » Where possible, protective footwear self-contamination:
» When there is a risk of blood or body should be single use. If re-used, follow » Gloves;
fluid splashing onto the eyes and face of the manufacturers’ instructions to » Apron/gown;
the health worker; decontaminate. Dependent on the » Mask/respirator, when worn;
» To protect against respired infectious contamination 10,000ppm chlorine » Hands must be decontaminated after
aerosols/droplets (Loveday et al, 2014). agent should be used. the removal of PPE (Loveday et al, 2014).
Appropriate respiratory PPE should be Aprons and gowns should be removed
chosen according to a risk assessment that Head protection by pulling them away from the face/shoul-
takes account of the infective micro- Hair nets and caps are single-use items and ders and rolling them downwards so the
organism, anticipated activity and dura- prevent shedding from the wearer’s hair contaminated outer surface is folded
tion of exposure. Respiratory PPE must fit onto the patient, as well as acting as a bar- inwards; in this way, only the clean, inner
the user correctly and staff must be trained rier protecting hair from inadvertent hand surface is exposed. This reduces contami-

www.nursingtimes.net / Vol 110 No 51 / Nursing Times 17.12.14 15

 Nursing Practice
Practice educator
fig 3. glove removal
Glove 1
Pinch away from the Pull cuff outwards
right wrist over right hand
fingers
Source: World Health Organization (2009)
nated surface contact with user’s skin,
clothing and the environment in which
PPE is being removed. Fig 3 outlines the
procedure for removing gloves.
Masks and visors should be removed by
pulling strings (or other securing devices)
away from the side of the face. If a surgical
cap is used, the strings can be removed
from the back of the head. Remember:
» If the health professional is not wearing
a cap, fumbling for strings will contam-
inate the hair;
» Pulling masks off from the front
surface means the hands grasp the
most contaminated surface of the
mask, thereby increasing the risk of
self-contamination.
Disposal of PPE
It is vital that PPE is disposed of correctly:
» PPE from non-infectious patients can be
disposed of in “offensive” waste (yellow
and black striped bags) or clinical or
infectious waste (orange bags) streams.
» PPE from patients who are infectious
must go into clinical infectious waste
streams (orange bags), usually for
incineration. This waste may be
autoclaved and sent for alternative
treatment like shredding and landfill.
Yellow waste bags may also be used.
» PPE from cytotoxic management must
go into the cytotoxic waste stream
(purple and yellow striped bags).
Enhanced PPE
Enhanced PPE must be used with high-risk
patients including those with ebola virus
disease (EVD). Expert guidance on ebola is
continually being updated as lessons are
learnt from workers on the front line. The
most up-to-date version of guidance from
the Department of Health (2014) provides
information on what PPE should be con-
sidered for use in caring for patients with
suspected or confirmed ebola infection.
Nurses should consult local policies and
procedures in their own organisations for
further information.
16 Nursing Times 17.12.14/ Vol 110 No 51 / www.nursingtimes.net
Glove 2
Pull glove off inside
out
PPE choice, training and support
There are often no set rules for PPE choice
and practice in patient care so a risk assess-
ment based on patient history, presenting
care needs and experience of the user must
guide PPE use. The steps detailed above pro-
vide a guide for users, but additional advice
should always be sought from local infec-
tion prevention and control specialists.
All staff should be trained in using the
PPE they need in their normal working
duties. Those who have not had appro-
priate training or lack confidence in using
PPE should not be expected to undertake
these procedures. All staff using PPE
should be competence assessed as safe to
do so and understand the underpinning
evidence to support their practice.
A “buddy” is always helpful in ensuring
the safe use and removal of PPE. This is
another trained person who:
» Checks that items fit correctly;
» Prevents inadvertent breach of PPE;
» Assists in the removal of PPE to reduce
the risk of self-contamination by the
wearer.
A buddy is essential in high-risk care
situations such as EVD.
Staff should be actively encouraged to
challenge potential breaches in PPE use
and removal, regardless of the seniority of
the wearer. A culture promoting courteous
acceptance of a challenge should be
adopted to ensure staff safety in high-risk
situations. Junior staff and learners watch
senior, experienced staff and learn from
their practices so keeping very strict obser-
vance of protocol in PPE use and removal
fosters a safe environment for all staff.
Patient wellbeing in isolation
Patients with an infection or suspected
infection may be kept in isolation. There
are many studies of the impact of such iso-
lation on patients (Abad et al, 2010; Madeo,
2003) and, while they may initially feel
alone and abandoned, these feelings can
give way to an appreciation of a quiet, pri-
vate space. Everyone reacts differently in
Slide right hand Turn cuff outwards
fingers under left and pull glove off
hand glove cuff inside out
stressful surroundings and care should be
individualised.
When dealing with infections such as
ebola, strict isolation is vital for contain-
ment and must be the prime consideration.
All efforts must be made to make patients
in these circumstances feel as informed,
comfortable and anxiety free as possible.
Conclusion
PPE is part of everyday healthcare and it is
vital that nurses and other health profes-
sionals have appropriate training to mini-
mise the risks of cross-contamination
between patients and between patients and
staff. Staff should feel able to challenge
practice and have access to training that is
based on the best available evidence. Hand
hygiene remains the cornerstone of infec-
tion prevention and all health workers must
be aware that wearing PPE does not replace
the need to carry out safe, hand-hygiene
practices and hand decontamination. NT
References
Abad C et al (2010) Adverse effects of isolation in
hospitalised patients: a systematic review. Journal
of Hospital Infection; 76: 2, 97-102.
Department of Health (2014) Management of
Hazard Group 4 Viral Haemorrhagic Fevers and
Similar Human Infectious Diseases of High
Consequence. tinyurl.com/DHHazardGroup4
Health and Safety Executive (2012) Fit Testing of
Respiratory Protective Equipment Facepieces.
tinyurl.com/FaceFitTest
Loveday H et al (2014) epic3: National evidence-
based guidelines for preventing healthcare-
associated infections in NHS hospitals in England.
Journal of Hospital Infection; 86S1: S1-S70.
Madeo M (2003) The psychological impact of
isolation. Nursing Times; 99: 7, 54-55.
NHS England and Public Health England (2013a)
How to Put On and Fit Check an FFP3 Respirator.
tinyurl.com/NHSEFFP3respirator
NHS England and Public Health England (2013b)
When to Use a Surgical Face Mask or FFP3
Respirator. tinyurl.com/NHSEFFP3respirator
World Health Organization (2009) WHO
Guidelines for Hand Hygiene in Health Care: A
Summary. tinyurl.com/WHO-HH-2009
For more on this topic go online...
Does glove use increase the risk
of infection?
B
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