Clinical SOP • Infection Prevention
Personal Protective Equipment
Select, wear, remove, and dispose of personal protective equipment correctly to reduce exposure to blood, body fluids, respiratory secretions, contaminated materials, and other workplace hazards.
Purpose
Personal protective equipment creates a barrier between employees and infectious or hazardous material. PPE must be selected based on the task, anticipated exposure, and required precautions.
Employees must assess the risk before beginning a task and wear the appropriate combination of gloves, gowns, masks, respirators, eye protection, or face shields. PPE does not replace hand hygiene, safe work practices, environmental cleaning, or sharps safety.
Select PPE Based on Anticipated Exposure
Hands
Wear gloves when contact with blood, body fluids, mucous membranes, non-intact skin, contaminated equipment, or infectious material is reasonably anticipated.
Clothing and Skin
Wear a gown or protective garment when the task may expose clothing or skin to splashes, sprays, drainage, secretions, or contaminated material.
Eyes
Wear goggles or a face shield when splashes, sprays, droplets, or debris could contact the eyes.
Nose and Mouth
Wear an appropriate mask when exposure to respiratory droplets, splashes, sprays, or infectious material is anticipated.
Respiratory Protection
Use a required respirator only when trained, medically cleared, fit-tested, and directed by clinic precautions or the exposure plan.
Multiple Exposure Routes
Wear a combination of PPE when a task could expose the hands, eyes, face, respiratory tract, skin, or clothing at the same time.
Types of PPE
Gloves
Protect hands during anticipated contact with blood, body fluids, mucous membranes, non-intact skin, contaminated items, chemicals, or infectious material.
Protective Gowns
Protect clothing and exposed skin during tasks that may involve splashing, spraying, drainage, secretions, or extensive contact with contaminated surfaces.
Medical or Procedure Masks
Protect the nose and mouth from anticipated droplets or splashes and may support source control when required.
Eye Protection
Goggles should fit securely and protect the eyes from the front and sides. Regular eyeglasses are not considered adequate eye protection.
Face Shields
Protect the eyes and face from splashes or sprays. A face shield does not replace a mask or respirator when respiratory protection is required.
Respirators
Provide respiratory protection when required for specific airborne hazards. Respirators must be used according to the clinic’s respiratory protection program.
Before Putting on PPE
Assess the Task
Identify the expected contact, procedure, patient symptoms, isolation precautions, and possible exposure to blood, body fluids, respiratory secretions, chemicals, or contaminated surfaces.
Select the Required PPE
Choose PPE that provides appropriate coverage, fits correctly, and is suitable for the expected exposure.
Inspect the PPE
Confirm the PPE is clean, intact, unexpired when applicable, and free from holes, tears, moisture, damage, or visible contamination.
Remove Interfering Items
Secure hair and remove or adjust jewelry, identification badges, or personal items that may interfere with PPE placement or removal.
Perform Hand Hygiene
Clean hands before putting on PPE, especially before gloves or a clean or aseptic task.
Standard PPE Donning Sequence
Follow posted precautions and task-specific instructions. When a full combination is required, use the following general sequence.
Perform Hand Hygiene
Clean and fully dry hands before touching clean PPE.
Put on the Gown
Cover the torso from the neck to the knees when possible, fully cover the arms, wrap the gown around the back, and secure it.
Put on the Mask or Respirator
Secure it over the nose and mouth. Adjust for a comfortable fit and follow seal-check requirements when using a respirator.
Put on Eye Protection
Position goggles or the face shield securely so the eyes and relevant portions of the face are protected.
Put on Gloves
Select the correct size and extend the gloves over the gown cuffs when a gown is worn.
Confirm Coverage and Mobility
Confirm PPE remains secure, allows safe movement, and does not expose areas expected to contact infectious material.
Safe PPE Use During Patient Care
Limit Surface Contact
Avoid touching phones, keyboards, pens, door handles, clean supply cabinets, or personal items with contaminated gloves.
Replace Damaged PPE
Stop safely and replace PPE that becomes torn, punctured, saturated, displaced, contaminated beyond its intended use, or otherwise ineffective.
Change Gloves Between Tasks
Change gloves when moving from a contaminated task or body site to a clean task or body site on the same patient.
Protect Clean Supplies
Remove contaminated gloves and perform hand hygiene before accessing medication, procedure supplies, drawers, or clean storage areas.
Do Not Adjust PPE Unnecessarily
Avoid touching the front of masks, respirators, goggles, face shields, or gowns during care.
Remain Within the Intended Area
Do not wear contaminated PPE into offices, break rooms, hallways, or other clean areas unless required by a specific precaution workflow.
Standard PPE Removal Sequence
Remove PPE carefully to avoid contaminating the hands, face, clothing, or surrounding environment.
Remove Gloves
Avoid touching bare skin. Peel the first glove away, hold it in the gloved hand, slide bare fingers under the remaining glove, and peel it off over the first glove.
Remove the Gown
Release the fasteners, pull the gown away from the neck and shoulders while touching the inside surface, turn it inward, and roll or fold it into a bundle.
Perform Hand Hygiene When Needed
Clean hands immediately if contamination is suspected and between removal steps when required by the applicable protocol.
Remove Eye Protection
Handle goggles or the face shield only by the headband, ear pieces, or clean rear portion. Do not touch the contaminated front surface.
Remove the Mask or Respirator
Handle only the ties, ear loops, or straps. Do not touch the front. Remove the lower fastener first when applicable, followed by the upper fastener.
Dispose of or Store Correctly
Place disposable PPE in the appropriate waste container. Place approved reusable equipment in the designated container or cleaning area without contaminating clean surfaces.
Perform Hand Hygiene
Clean hands immediately after all PPE has been removed.
Glove Standards
Wear gloves when hand contact with blood, body fluids, mucous membranes, non-intact skin, contaminated equipment, specimens, chemicals, or infectious material is anticipated.
Masks, Eye Protection, and Respirators
Splash or Spray Risk
Protect the eyes, nose, and mouth during procedures likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Respiratory Symptoms
Follow current clinic respiratory-hygiene, source-control, and transmission-based precaution instructions.
Mask Fit
Masks must cover the nose and mouth and remain secure during use. Replace masks that become wet, damaged, visibly soiled, or difficult to breathe through.
Eye Protection Fit
Eye protection should fit securely and provide appropriate front and side coverage for the expected exposure.
Respirator Requirements
Employees must not use a required respirator unless they have completed the organization’s required medical evaluation, training, and fit testing.
Face Shields
Face shields protect the face from splash or spray exposure but do not replace required masks or respirators.
Reusable PPE
Reusable PPE must be placed in the designated area after use and cleaned and disinfected according to manufacturer instructions and clinic infection-prevention procedures before reuse.
Exposure or PPE Failure
Torn or Punctured Glove
Stop safely, remove the damaged glove, perform hand hygiene, and replace it before continuing when appropriate.
Splash to Eyes, Nose, or Mouth
Immediately flush the affected area and report the exposure according to the clinic’s exposure-control process.
Needlestick or Sharps Injury
Stop the task, perform immediate first aid, and report the incident without delay.
Contaminated Clothing or Skin
Remove contaminated clothing when safe, wash the affected skin, and follow the exposure-reporting process.
PPE Supply Shortage
Notify leadership before beginning a task that cannot be performed safely with the available PPE.
Incorrect PPE Used
Stop safely, remove PPE correctly, perform hand hygiene, and obtain the appropriate equipment before continuing.
Do and Do Not
Always Do
- Assess the expected exposure before beginning.
- Select PPE that fits and provides adequate coverage.
- Inspect PPE before use.
- Perform hand hygiene before and after PPE use.
- Change gloves between patients and tasks.
- Remove PPE without touching contaminated surfaces.
- Clean reusable PPE before another use.
- Report exposure incidents immediately.
Never Do
- Begin a hazardous task without required PPE.
- Reuse disposable gloves or gowns.
- Wear contaminated gloves outside the task area.
- Touch clean supplies with contaminated gloves.
- Touch the front of used masks or eye protection.
- Use damaged or visibly contaminated PPE.
- Use a respirator without required clearance and fit testing.
- Delay reporting an occupational exposure.
Clinic Responsibilities
The clinic will provide appropriate PPE for assigned duties, maintain necessary supplies, train affected employees, and establish procedures for exposure reporting, cleaning reusable equipment, and managing transmission-based precautions.
Employee Competency
The employee should demonstrate each skill during onboarding or competency validation.