DONNING &

DOFFING
DR. SIA


1 of 6 CCCA | INSIGNIS
LEARNING OBJECTIVES - Aerosol generating procedures (AGP)

- To know the specific areas and the recommended • Any medical and patient care procedure that results
level of PPE
in the production of airborne particles (aerosols)

- To know the materials needed (PPE)

- To know the steps of doing the DONNING and LIST OF AEROSOL GENERATING PROCEDURES
DOFFING
- Intubation, extubation and related procedures (manual
ventilation, open suctioning)

HISTORY OF COVID-19 - Tracheostomy

- The coronavirus disease 19 (COVID-19) is a highly - CPR

transmittable and pathogenic viral infection

- Bronchoscopy

- Caused by severe acute respiratory syndrome - Dental procedures

coronavirus 2 (SARS-CoV-2)
- Surgical procedures in which high speed devices are
- Wuhan, China —> spread around the world
used (energy devices)

• December 2019
- NIV (non-invasive ventilation)

• In Wuhan China (an emerging business hub in - High frequency oscillation ventilation

China)
- High flow nasal ventilation

- Outbreak of novel coronavirus was noted

- EGD

- Within the first 15 days of the pandemic, 70000 - Laparoscopic procedures (evacuation of
individuals were infected and >1800 people were pneumoperitoneum)

killed

- Genomic analysis revealed that SARS-CoV-2 is

phylogenetically related to severe acute respiratory TYPES OF MASKS
syndrome-like (SARS-like) bat viruses, therefore bats
could be the possible primary reservoir

- The intermediate source of origin and transfer to

humans is not known, however, the rapid human to
human transfer has been confirmed widely

- There is no clinically approved anti-viral drug or

vaccine available to be used against COVID-19

A. Powered Air Purifying Respirator

• Protects the user by filtering out contaminants in

the air and uses a battery operated blower to
provide the user with clean air through a tight-
fitting respirator and a loose-fitting hood

B. Full Face Respirator

C. Half Face Respirator

D. N95 Mask

- The COVID19 pandemic is exerting tremendous

pressure on all healthcare systems worldwide

- Strategies must be employed to care for our px the LEVELS OF PROTECTION

best that we can while protecting our HCW from - Most institutions are adapting levels of protection worn
contracting the disease.
by HCWs to the risk of contracting the disease based
- Ensuring the availability and appropriate use of PPE is on the ff:

necessary for the safety of HCW.

• Px COVID 19 status

- The mandate to protect the HCW from COVID 19 has • Level of interaction

resulted in an alarming increase in demand for PPE - Procedure

worldwide, leading to shortage in some areas.

- Time of contact

- Distance

DEFINITION OF TERMS • Transmission dynamics of the virus (droplet or

- COVID area
aerosol)

• A space or place in the hospital (e.g. private room or - This will avoid the unnecessary over-consumption of
ER) where a probable or confirmed COVID 19 px PPEs on relatively low risk patient encounters and
stay for significant periods of time (>6 hours) or conserving them for the high risk patients

where potentially AGP procedures are performed

2 of 6 CCCA | INSIGNIS
 •Level 1 PPE — surgical mask, alcohol hand wash/ spray

•Level 2 PPE — surgical mask, goggles or face shield

•Level 3 PPE — N95 mask, goggles or face shield,

gloves, surgical cap, scrub suits, gowns (or coveralls),
shoe covers

•Level 4 PPE — N95 mask (or PAPR), goggles or face

shield, double gloves, surgical cap, scrub suits, coveralls,
dedicated shoes, shoe covers

PERSONAL PROTECTIVE EQUIPMENT

-Includes any gear to protect against infection i.e. gloves,
face mask, N95 mask/ respirators, goggles, face shields,
gowns, scrub suits, coveralls, shoes, booties/ shoe
covers

APPROPRIATE USE OF PPE

- Reduce need for PPE to save supply

• Limit access to COVID19 px and essential healthcare personnel

• Combine activities to reduce entry into px area (i.e. obtain vital signs at the same time as delivering food)

- Use technology for evaluation of possible cases for testing and/or clinical evaluation

- Use physical barriers to reduce exposure to COVID19 (glass/ plastic windows)

SPECIFIC AREAS AND RECOMMENDED USE OF PPE

Settings in HC Activity Risk Type of PPE

Facility Level

ER COMPLEX

Triage area Preliminary screening for Low Maintain physical distance of at least 1 meter

prioritization of care according to • Ideally, build glass/ plastic screens to

severity create a barrier between HCW and px

• Level 1 PPE
• Perform hand hygiene

When physical distance is not feasible and yet

no px contact

• Level 2 PPE
• Perform hand hygiene
ER setting Providing direct care to COVID19 px, Moderate • Level 3 PPE
Px room/ ward in the absence of AGP • Perform hand hygiene
ER setting Providing direct care to COVID19 px High • Level 4 PPE
Px room/ ward in settings where AGP are frequently • Perform hand hygiene
in place

PRIVATE ROOMS

Private room Px without symptoms suggestion of Low to • PPE according to standard precautions and
COVID19 Moderate risk assessment

• Level 2 PPE
• Perform hand hygiene
Private room Px is probable or confirmed High • Level 3 PPE
COVID19 • Perform hand hygiene

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 Settings in HC Activity Risk Type of PPE
Facility Level

OPD

Triage area Preliminary screening not involving Low Maintain physical distance of at least 1 meter

direct contact • Ideally, build glass/ plastic screens to

create a barrier between HCW and px

• Level 1 PPE
• Perform hand hygiene

When physical distance is not feasible and yet

no px contact

• Level 2 PPE
• Perform hand hygiene
Consultation PE of px without symptoms Low to • PPE according to standard precautions and
room suggestive of COVID 19 Moderate risk assessment

• Level 2 PPE
• Perform hand hygiene
Consultation PE of px with symptoms suggestive Moderate • Level 3 PPE
room of COVID 19 • Perform hand hygiene
OPERATING RM

Operating Room Surgery on COVID19 positive or High • Level 3 PPE

procedures probable px • Sterile gown and gloves over PPE

• Perform hand hygiene

Local/ Regional
anesthesia (No
AGP)

Operating Room Surgery on COVID19 positive, High • Level 4 PPE

procedures probable or suspect patients • Sterile gown and sterile gloves over
coveralls, use of PAPR if available

- With AGP
• Perform hand hygiene
- Px under
general
anesthesia

DONNING AND DOFFING OF PERSONAL PROTECTIVE EQUIPMENT

(UP PHILIPPINE GENERAL HOSPITAL)
- Before donning, make sure you have eaten a proper meal, had adequate hydration, used the restroom and attended to
personal needs. Change into clean surgical scrubs and closed waterproof shoes. Remove all personal items (jewellery
watch, cellphone, pens)

- Visually inspect the complete and intact PPE which should include:

• Alcohol-based disinfectant

• Protective coverall/ suit

• Shoe cover

• N95 mask

• Face shield

• Goggles

• Surgical hood/ cap

• 2 pairs of gloves

4 of 6 CCCA | INSIGNIS
DONNING
- Reminder: The inner, non-sterile layer should be donned in the donning area.

- Reminder: The outer, sterile layer should be donned in the OR suite/ patient’s area.

STEP 1 Perform hand hygiene using an OH-based sanitizer. If a sink is available, perform your surgical scrub.

STEP 2 Wear shoe covers. Using the clean chair in the Donning Area, you may sit down for support and apply for shoe covers
one at a time.

STEP 3 Perform hand hygiene again with an OH-based sanitizer.

STEP 4 Wear inner, non-sterile gloves preferably with nitrile material.

STEP 5 Wear protective suit or coverall, with arm cuffs over the gloves.

STEP 6 Properly fit N95 mask in a tight seal and check for leaks. Mold the metal part of the mask over the nose bridge, no
gaps between the cheeks. If you have not been fit tested by your institution, you may perform a leak test. If a mask-
type air purifying respirator is available, you may wear it in place of the N95 mask.

STEP 7 Wear goggles/ eyeglasses. Put your eyeglasses on first before your goggles.

STEP 8 Wear surgical cap and coverall hood. Hair should not be exposed. For women with long hair, the hair must be placed in
a bun or ponytail.

STEP 9 Wear face shield. Put it over your goggles or mask.

STEP 10 Wear another pair of outer, non-sterile gloves.

STEP 11 Ensure that no skin or hair is exposed

STEP 12 Proceed to the surgical scrub area

STEP 13 Perform surgical scrub with an OH-based sanitizer.

STEP 14 Proceed to the OR Suite

STEP 15 Wear sterile OR gown. Make sure that the inside tie is not knotted.

STEP 16 Wear sterile outer gloves

STEP 17 Make sure gear is well-fitted, complete and intact

DOFFING
- Reminder: The outer, soiled layer should be doffed in the OR suite.

- Reminder: The inner layer should be doffed in the doffing area.

STEP 1 Check shoe covers for gross contamination. If there is gross contamination, dispose of shoe covers

STEP 2 Properly remove outer gown. Untie the gown and pull down at the waist away from the body. Once the gown is off the
shoulders, pull the gown one arm at a time from the sleeves.

STEP 3 Properly remove outer gloves while removing gown. Bunch up gown and gloves in a tight ball and dispose.

STEP 4 If you removed your shoe covers earlier, put on a new pair of shoe covers.

STEP 5 Disinfect hand with an OH-based disinfectant.

STEP 6 Exit the OR area.

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 STEP 7 Enter the doffing area.

STEP 8 Check for signs of gross contamination of PPE. Use a disinfectant wipe to remove any gross contamination before
doffing.

STEP 9 Disinfect with an OH-based hand rub.

STEP 10 Sit down on the dirty chair and remove shoe covers and dispose them.

STEP 11 Disinfect with an OH-based disinfectant.

STEP 12 Remove and dispose the outer gloves. Grab the cuff of one glove from the wrist and gently remove. Hook the inner
aspect of the other glove and gently pull away. Dispose the gloves immediately.

STEP 13 Check inner gloves for tears. If there are tears, remove the gloves, do hand hygiene, put on a new pair of gloves, and
do hand hygiene again.

STEP 14 Remove face shield. Tilt your head forward and grasp the garter from the back of your head and dispose of the face
shield directly to the disposal.

STEP 15 Disinfect with an OH-based disinfectant.

STEP 16 Properly remove the protective coverall suit. Remove the hood, unzip the suit and remove the sleeves by pulling them
from the outside of the suit. Remove the pant legs one at a time. You may sit on the clean chair while removing the
protected suit, keeping your legs apart. Roll the suit inside out to form a ball. Immediately dispose the protective suit
in the disposal area.

STEP 17 Disinfect with an OH-based disinfectant.

STEP 18 Remove inner gloves. Grab the cuff of one glove from the wrist and gently remove. Hook the inner aspect of the other
glove and gently pull away. Dispose the gloves immediately.

STEP 19 Disinfect with an OH-based disinfectant.

STEP 20 Wear a new pair of gloves.

STEP 21 Leave the doffing area and proceed to the decontamination area.

STEP 22 Remove goggles and personal eyewear. Decontaminate your personal eyewear with disinfectant wipes.

STEP 23 Disinfect hand with OH-based disinfectant.

STEP 24 Remove N95 mask. Make sure not to touch the outer part of the mask. Remove the garter one at a time from the back
of the head. Shoot it directly in the waste disposal.

STEP 25 Disinfect hand with OH-based disinfectant.

STEP 26 Decontaminate your shoes with disinfectant wipes, or step on the decontaminating mat.

STEP 27 Disinfect hand with OH-based disinfectant.

STEP 28 Remove inner gloves. Grab the cuff of one glove from the wrist and gently remove. Hook the inner aspect of the other
glove and gently pull away. Dispose the gloves immediately.

STEP 29 Disinfect hand with OH-based disinfectant.

STEP 30 Inspect for rips, tears or gross contamination on clothing. Immediately report this to the trained observer.

STEP 31 Proceed to the shower room to shower and change into clean clothes or scrub suit.

Reminder: If proceeding to a Level 2 Zone, wear a new pair of goggles and a surgical mask.

6 of 6 CCCA | INSIGNIS
 Matias H. Aznar Memorial College of Medicine
Simulation Center for Integrated Teaching and Training Innovations
(SimCITTI)

Donning and Doffing MODULE

Objectives of this module

1. To be able to prepare yourself prior to donning and doffing.

2. To be able to understand the importance of doing proper donning and doffing.
3. To be able to know the materials needed
a. Alcohol based disinfectant
b. Protective coverall/suit
c. Shoe cover
d. N95 mask
e. Face shield
f. Goggles
g. Surgical hood/cap
h. 2 pairs of gloves
4. To be able to know the the different levels of personal protective equipments
for health care workers
a. Level 1 PPE
b. Level 2 PPE
c. Level 3 PPE
d. Level 4 PPE
5. To be able to perform the correct sequence of donning and doffing without
compromising sterility and safety.
6. To be able to apply the procedure in an actual scenario either in the ward or in
the operating room.
 Matias H. Aznar Memorial College of Medicine
Simulation Center for Integrated Teaching and Training Innovations
(SimCITTI)

PERFORMANCE RATING SCALE

DONNING AND DOFFING EXAMINATION
(SIMULATED OR ACTUAL PATIENT)

Name of Student: Medical School Year: Name of Rater:

3rd
Date: Start Time: Total Time
Stop Time:

Technique; Errors; Product

Procedural Steps for DONNING
Characteristics
Check each box if the steps was done Check the box only if the error occurred.
correctly and in an appropriate Leave the box blank if the error did not
sequence. Leave the box blank if the occur. Errors are subtracted from
step was done incorrectly, out of steps.
sequence, or was omitted
Perform hand hygiene Failure to do hand hygiene
Wear shoe cover Failure to wear non- sterile
Perform hand hygiene gloves
Wear inner, non-sterile gloves Failure to fit N95 or respirator
Wear protective suit or coverall Failure to scrub
Properly fit N95 mask and check
for leaks
Wear goggles/eyeglasses
Wear surgical cap and coverall
hood
Wear face shield
Wear another pair of non sterile
gloves
Ensure that no skin or hair is
exposed
Proceed to the surgical scrub
area
Perform surgical scrub
Proceed to the OR suite
Wear sterile OR gown
Wear sterile outer gloves
Make sure gear is well-fitted,
complete and intact.

(17 points)

Procedural Steps for DOFFING Technique; Errors; Product

 Characteristics
Check each box if the steps was done Check the box only if the error occurred.
correctly and in an appropriate Leave the box blank if the error did not
sequence. Leave the box blank if the occur. Errors are subtracted from
step was done incorrectly, out of steps.
sequence, or was omitted
Remove sterile gown and sterile Failure to remove the sterile
gloves at the OR suite gown and sterile gloves at the
Proceed to the doffing area then OR suite
disinfect your outer gloves Failure to proceed at the doffing
Remove shoe cover area
Disinfect outer gloves Failure to disinfect the gloves in
Remove outer gloves between procedure.
Disinfect inner gloves Failure to wear a new set of
Remove the face shield gloves
Disinfect inner gloves Failure to do handwashing,
Remove the protective coverall decontamination or take a bath.
suit
Disinfect inner gloves
Remove inner gloves
Disinfect hands
Wear a new set of gloves
Remove the goggles
Disinfect the gloves
Remove the N95
mask/respirators
Disinfect the gloves
Remove gloves
Do handwashing and proceed to
decontamination area or take a
bath.
(19 points)

Total Score: _____________ (possible

36 points)

Global Rating Scale: Professionalism and Communication Skill (circle one number)
1 2 3 4 5
Rude and/or abrupt, no Appropriate introduction, Appropriate introduction,
eye contact throughout minimal conversation & converses and explains
explanation, occasional examination, and frequent
eye contact eye contact

Global Rating Scale: Examination Completeness (circle one number)

 1 2 3 4 5
Misses large portion of Misses small portion of Performs thorough
the examination, is rough the examination, performs examination, uses
& causes pain complete exam but appropriate pressure and
causes unnecessary pain causes no unnecessary
pain

Final Grade
Comments
(Check one)
Strengths
Need further review or
instruction

What to improve
Proficient in simulated
setting with assistance

How to improve
Proficient in simulated
setting without assistance

Proficient in clinical setting

(actual patient) under
direct supervision

TOTAL SCORE: Procedural Skills _______ + Global Rating Scale ______ =

Total possible score is 36+10= 46.