Why the Proper Use of Personal Protective Equipment (PPE) Matters

The proper use of personal protective equipment is the fundamental line of defense in infection control, designed to break the chain of transmission for pathogens like bacteria and viruses. It is not merely a compliance requirement; it is a critical safety protocol that protects healthcare workers from exposure to infectious agents and prevents cross-contamination between patients.

When we talk about PPE, we are discussing a system. If one part of that system fails due to improper application or removal, the entire safety net collapses. Mastering these protocols is essential for every medical professional, from the nursing student to the veteran surgeon.

The Standard Order for Putting on PPE (Donning Sequence)

According to CDC guidelines, the standard order for putting on PPE is:

1. Gown

2. Mask or Respirator

3. Goggles or Face Shield

4. Gloves.

Following this specific sequence is scientifically designed to ensure that your most vulnerable areas (respiratory system and mucous membranes) are protected before you seal the barrier with gloves.

Memory Aid for Donning: Think “Bottom Up”. You start with the body (Gown), move up to the face (Mask/Goggles), and finish with the hands (Gloves) raised.

Step 1: Hand Hygiene and Gown Preparation

Before touching any equipment, thorough hand hygiene is non-negotiable. Use an alcohol-based hand sanitizer or wash with soap and water for at least 20 seconds. Once your hands are clean, select the appropriate size isolation gown. A gown that is too small leaves skin exposed; one that is too large can become a tripping hazard or snag on equipment.

Step 2: Gowning PPE – Securing the Torso and Arms

Gowning PPE correctly requires full coverage.

1. Put on the gown with the opening in the back.
2. Ensure the material fully covers your torso from neck to knees and your arms to the end of your wrists.
3. Critical Detail: Fasten the ties at the back of the neck and the waist. Do not leave the waist tie loose, as a billowing gown increases the risk of snagging and contamination.
4. If the gown is too small to wrap around your back fully, use two gowns (the first worn with the opening in the front, the second over it with the opening in the back).
5. Hygiene Check: Ensure you do not touch the floor or other surfaces while securing the gown ties. If you do, perform hand hygiene again.

Step 3: Placing the Mask or Respirator

1. Secure the ties or elastic bands at the middle of your head and neck.
2. Fit the flexible band to the bridge of your nose.
3. Fit the mask snugly to your face and below your chin.
4. Fit Check: If wearing an N95 respirator, you must perform a user seal check every time you put it on to ensure no air leaks around the edges.
5. Hygiene Check: Once the mask is fitted, do not touch it again. If you need to readjust, sanitize your hands first.

Step 4: Eye Protection (Goggles or Face Shields)

1. Place goggles or face shield over your face and eyes and adjust to fit.
2. Personal prescription glasses are not considered adequate eye protection. The goggles or shield must sit securely over the mask, ensuring no gaps where splashes could enter.
3. Hygiene Check: Avoid touching the front of the mask while placing the goggles.

Step 5: Gloving – Covering the Cuffs

The final and perhaps most critical step in the order for putting on PPE is gloving.

1. Extend your hands into the gloves.
2. Crucial Safety Detail: Pull the cuffs of the gloves over the cuffs of the gown.
3. There should be no exposed skin between the glove and the gown sleeve. This “shingling” effect ensures that fluids roll off the gown and onto the glove, rather than seeping onto your wrist.
4. Hygiene Check: You are now fully protected. Do not touch your face or personal items (like phones) once gloves are on.

When selecting gloves for high-risk doffing scenarios, look for:

• Extended Cuff Gloves: These are longer than standard exam gloves (approx. 12 inches), making it easier to cover the gown sleeve and prevent exposure.
• Nitrile Material: Preferred over latex for higher chemical resistance and durability, reducing the risk of tears during the doffing process.
• Visual Contrast: Some facilities use a darker colored glove under a lighter one (Double Gloving) to easily spot tears.

The Safe Procedure for Doffing PPE (Removal Sequence)

Doffing PPE—the process of removing protective gear—poses a higher risk for self-contamination than putting it on because the equipment is now considered “dirty.” The golden rule of doffing is to proceed with the mindset that the outside of all PPE is contaminated and must not touch your skin or clothing.

Memory Aid for Doffing: Think “Alphabetical Order”. Remove in this sequence: Gloves, Goggles, Gown, Mask. (Note: Some protocols combine gloves and gown removal, but the principle remains: protect the face until the end).

Critical Doffing Checkpoints (Don’t Do This):

• ❌ Never remove the mask before the gloves (this exposes your face to dirty hands).
• ❌ Never touch the front of the gown with bare hands.
• ❌ Never reuse disposable PPE once removed.

Step 1: Removing Gloves and Gown (The Highest Risk Area)

Since the front of the gown and sleeves are contaminated, they are removed in one continuous step with the gloves.

1. Gloves: Grasp the outside of one glove at the wrist. Peel it away from your body, turning it inside out. Hold the removed glove in your gloved hand. Slide a bare finger under the remaining glove at the wrist and peel it off over the first glove. Discard.
2. Gown: Unfasten the gown ties (neck and waist), taking care that sleeves don’t contact your body when reaching for ties. Pull the gown away from your neck and shoulders, touching only the inside of the gown. Turn the gown inside out as you remove it. Fold or roll it into a bundle and discard.
3. Hygiene Check: This is the moment of highest contamination risk. Assume your hands have microscopic contamination after this step.

Step 2: Hand Hygiene (First Round)

Perform hand hygiene immediately after removing gloves and gown. This is a critical checkpoint. If your hands were contaminated during the removal of the dirty gloves/gown, you do not want to touch your face to remove your mask. Do not skip this step.

Step 3: Removing Eye Protection and Mask

1. Eye Protection: Remove goggles or face shield from the back by lifting head band or ear pieces. The front of the face shield is contaminated—do not touch it.
2. Mask/Respirator: Grasp the bottom ties or elastics first, then the top ones. Remove without touching the front of the mask. Discard.
3. Hygiene Check: With clean hands, remove these items carefully. If you accidentally touch the front of the shield or mask, stop and sanitize your hands immediately.
   

   Feature	Surgical Mask	N95 Respirator
   Fit	Loose-fitting	Tight-fitting (Requires Fit Test)
   Filtration	Blocks large droplets/splashes	Filters 95% of airborne particles
   Usage Scenario	Routine exams, droplet precautions	Aerosol-generating procedures, airborne precautions (e.g., TB, COVID-19)
   Purchasing Tip	Look for ASTM F2100 standards	Look for NIOSH approval

Step 4: Final Hand Hygiene

Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer immediately after removing all PPE. This ensures no residual pathogens remain before you leave the procedure area.

Common Mistakes in Gowning and Doffing PPE

Frequent errors include failing to pull gloves over gown cuffs during gowning PPE, touching the front of the mask during doffing PPE, or rushing the removal process. These lapses break the sterile field and significantly increase the infection risk for the healthcare worker.

• The “Wrist Gap”: Failing to pull gloves over the gown cuffs leaves wrists exposed to fluids and pathogens.
• Touching the “Dirty” Zone: Adjusting the front of the mask or goggles while in a patient room contaminates the hands.
• Improper Doffing Order: Removing the mask before the gloves puts your face at immediate risk of contact with contaminated hands.
• Re-wearing Single-Use Items: Disposable gowns and gloves are designed for one-time use; material degradation compromises safety if reused.

Frequently Asked Questions About PPE Protocols

Q: Is the order for putting on PPE different for sterile procedures?

A: Yes. While the standard order for putting on PPE applies to general isolation precautions, sterile surgical procedures require a different technique (often “assisted gloving/gowning”) to maintain a sterile field. In surgery, the mask and hair covering are donned before the surgical scrub, followed by the sterile gown and gloves inside the operating theatre.

Q: What is the most critical step in doffing PPE?

A: The most critical aspect of doffing PPE is Hand Hygiene. It must be performed immediately after removing gloves (the most contaminated item) and again after removing the mask. If at any point during the removal process you suspect your hands have touched a contaminated surface, you must stop and sanitize your hands before proceeding to the next piece of equipment.

Q: Where should PPE be removed (Doffed)?

A: Generally, PPE should be removed at the doorway of the patient’s room or in an anteroom. However, the respirator (N95) should strictly be removed after leaving the patient’s room and closing the door to prevent inhaling airborne pathogens.

Q: What should I do if my PPE tears or gets heavily soiled during a procedure?

A: If a glove tears or a gown becomes heavily soiled/compromised, you must stop working immediately. Withdraw from the sterile field or patient area, perform the doffing procedure safely, perform hand hygiene, and don new PPE before resuming care.

Conclusion: Safety is a Sequence, Not Just a Product

Protecting healthcare workers goes beyond simply purchasing the right medical gowns or nitrile gloves. It requires a disciplined commitment to the correct order for putting on PPE and, even more critically, the safe procedure for removing it.

Whether you are managing a hospital’s PPE order or are a student learning gowning PPE for the first time, remember this: Contamination happens in the margins. It happens when a wrist is exposed, when a mask is touched, or when steps are rushed.

By following this step-by-step guide and adhering to strict hand hygiene protocols, you ensure that the barrier remains unbroken—protecting not just yourself, but every patient under your care.

References & Further Reading

1. Centers for Disease Control and Prevention (CDC). Sequence for Personal Protective Equipment (PPE) Donning and Doffing. https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
2. U.S. Food and Drug Administration (FDA). Medical Gowns and Protective Apparel Regulation. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/medical-gowns
3. Occupational Safety and Health Administration (OSHA). Personal Protective Equipment Standards for Healthcare. https://www.osha.gov/personal-protective-equipment
4. National Institute for Occupational Safety and Health (NIOSH). Understanding the Difference: Surgical Masks vs. N95 Respirators. https://www.cdc.gov/niosh/npptl/pdfs/understanddifferenceinfographic-508.pdf
5. ASTM International. ASTM F2100 – Standard Specification for Performance of Materials Used in Medical Face Masks. https://www.astm.org/f2100-23.html

Disclaimer: This guide is based on CDC and OSHA standards as of 2026. Protocols may vary by facility and specific infectious disease risks. Always consult your facility’s Infection Control Department for local guidelines.