The term “doffing” refers to the act of safely removing personal protective equipment (PPE) after potential exposure to infectious agents or hazardous materials. This process is contrasted with “donning,” which is the act of putting the equipment on before entering a contaminated area. While donning establishes a protective barrier, proper doffing is equally important because it prevents the wearer from inadvertently contaminating themselves or the surrounding environment. Failing to follow a precise doffing procedure significantly increases the risk of transferring pathogens from the contaminated exterior of the PPE to the skin or mucous membranes.
Understanding Contamination Zones
The entire strategy for removing PPE is founded on the concept of contamination zones, which dictates the order in which items must be removed. The exterior surfaces of all PPE—including the gloves, gown, and face shield—are considered highly contaminated, having served as the primary barrier against pathogens. Conversely, the skin and the interior surfaces of the PPE are considered clean. This fundamental distinction guides the systematic sequence of removal.
The objective of doffing is to ensure that the clean surfaces of the wearer’s body, particularly the hands and face, never make contact with the contaminated exterior surfaces of the equipment. Each step in the doffing process is specifically designed to roll or peel the contaminated material inward, effectively containing the potential hazard. This process minimizes the transfer of microbes from the “hot zone” of the equipment to the wearer’s body.
Step-by-Step Removal Sequence
The standardized procedure for doffing is a strictly defined sequence designed to move from the most contaminated items to the least. Hand hygiene is performed at specific intervals. The sequence typically begins with the items most likely to harbor the highest concentration of pathogens, which are the gloves and the gown. This order is based on evidence that the hands and body are the most common sites of self-contamination if removal is performed incorrectly.
The removal process begins with the gloves, which are taken off using the “glove-in-glove” technique to avoid touching the contaminated outer surface with bare skin. This involves grasping the palm of one glove near the wrist and peeling it off completely, turning it inside out while holding it in the gloved hand. The second glove is removed by sliding two fingers of the now-bare hand under the wrist of the remaining glove, peeling it off over the first one to create a contained bundle of waste. Hand hygiene must be performed immediately after the gloves are removed.
Next, the gown is removed, using a technique that rolls the contaminated exterior surface inward and away from the body. The wearer should unfasten any ties and pull the gown away from the neck and shoulders, only touching the inside of the garment. The gown is then turned inside out as it is peeled down and away from the arms, being carefully folded or rolled into a compact bundle. This inward folding ensures that infectious particles remain trapped inside the discarded garment, which is then placed into a designated waste receptacle.
The eye protection, such as goggles or a face shield, is the next item to be removed. It must be handled only by the clean, unexposed ear pieces or head strap. The contaminated front lens is never touched during this step, and the item is then either discarded or placed in a container for reprocessing, depending on whether it is reusable. Hand hygiene is then performed again before moving on to the final piece of equipment.
The mask or respirator is removed last because it protects the mouth and nose from airborne or droplet exposure during the preceding removal steps. To remove the mask or respirator, the wearer must avoid touching the front surface, which is contaminated by respiratory droplets. Instead, the mask is removed by grasping the ties, straps, or elastic loops from behind the head or ears. Once the straps are released, the mask is pulled away from the face and discarded immediately into the waste container. For a respirator, this final step is often performed outside the patient care area, such as in an anteroom, to ensure safety before the face is fully exposed.
Final Steps and Waste Handling
After the mask is removed, the final step in the doffing procedure is thorough hand hygiene. This action is the last line of defense against any microbes that may have inadvertently come into contact with the skin during the removal process. The hands must be washed with soap and water for a minimum of 20 seconds, ensuring all surfaces, including under the fingernails, are properly scrubbed. If soap and water are not immediately available, an alcohol-based hand rub containing at least 60% alcohol should be used until the hands are dry.
All removed PPE must be disposed of correctly and promptly to prevent further environmental contamination. Used equipment is typically placed into designated waste containers, which are often color-coded or clearly marked as biohazard receptacles. This specialized waste handling ensures the materials are treated as infectious, preventing the spread of pathogens to sanitation workers or other areas of the facility. The wearer should then immediately exit the area where the doffing took place to transition fully into a clean environment.