A nurse is caring for a patient with suspected Ebola virus disease in the isolation unit. Which sequence of personal protective equipment (PPE) removal is most appropriate to prevent contamination?

The correct sequence involves multiple hand hygiene steps between PPE removal to minimize contamination risk, starting with gloves and ending with the respirator.

Correct Answer and Rationale

The most appropriate sequence for removing personal protective equipment (PPE) after caring for a patient with suspected Ebola virus disease is Option 4. This procedure involves removing gloves first, performing hand hygiene, removing the gown, performing hand hygiene again, removing eye protection, performing hand hygiene, and finally removing the respirator. This method integrates hand hygiene between each step, which is critical for breaking the chain of contamination.

Why This Sequence is Correct

The fundamental principle of safe PPE doffing is that the outside of all equipment is considered contaminated. The goal is to remove items in an order that minimizes the risk of transferring pathogens from the contaminated exterior of the PPE to the healthcare worker's skin, clothing, or mucous membranes. The sequence in Option 4 is correct because it systematically removes the most heavily contaminated items first while incorporating a crucial step: hand hygiene after each removal. This is not merely a ritual; it is a scientifically grounded practice to decontaminate the hands after they have touched a soiled surface, preventing the transfer of infectious particles to the next, cleaner area or piece of equipment ^[1].

Research on PPE doffing procedures highlights that contamination frequently occurs when complex, multi-step processes are not strictly followed. A study using lipid nanoparticles as viral surrogates demonstrated that even with structured doffing protocols, potential "blind spots" for contamination exist, and the inclusion of disinfection steps, like hand hygiene, is what protects the healthcare worker if a contamination event occurs during removal ^[1]. By performing hand hygiene after removing the gloves and again after the gown, you are actively eliminating any viral particles that may have been transferred to your hands before you touch the relatively cleaner surfaces of the eye protection and respirator straps.

Analysis of Incorrect Options

- Option 1 (Gloves, gown, eye protection, respirator with hand hygiene after each step): While this sequence incorporates hand hygiene, the order of removal is flawed. After the gown is removed, the hands may be contaminated. Touching the eye protection next is risky because the mucous membranes of the eyes are a portal of entry for viruses like Ebola. The eye protection should be removed before the gown or with a hand hygiene step immediately before, but the risk is higher if the hands are not thoroughly decontaminated after handling the heavily soiled gown.
- Option 2 (Gown and gloves together, then eye protection, hand hygiene, then respirator): This method is dangerous. Removing the gown and gloves as a single unit is a complex maneuver that often leads to the outer surface of the gown contacting the skin of the wrists or hands as the gloves invert. More critically, it delays the first instance of hand hygiene until after the eye protection is removed. This means the hands, which are likely contaminated from the gown/glove removal, are brought directly to the face to handle the eye protection, creating a direct route for self-contamination.
- Option 3 (Respirator first, then eye protection, gown, gloves): This sequence is incorrect and highly hazardous. The gloves and gown are the most contaminated pieces of PPE. Removing the respirator first forces the healthcare worker to bring their heavily contaminated gloved hands near their face and airway, which is the primary route of infection for respiratory viruses and a significant risk for contact-transmissible diseases like Ebola if splashes are present. The most contaminated items must always be removed first to reduce the bioburden before addressing the head and neck area .

Clinical and Pathophysiological Link

Ebola virus disease is a severe, often fatal illness with a high viral load in blood and body fluids. Transmission occurs through direct contact with infected fluids via broken skin or mucous membranes. The doffing procedure is the highest-risk moment for healthcare worker infection because the outside of the PPE is assumed to be heavily contaminated . A real-world study analyzing PPE doffing in a large COVID-19 facility found that interception problems, such as touching the inner surface of PPE or performing steps out of sequence, were common and directly led to self-contamination events . The stepwise approach with integrated hand hygiene in Option 4 directly addresses this by creating a safety net: if a breach in technique occurs and hands become contaminated during the removal of one item, the immediate hand hygiene step decontaminates them before the next item is touched, thereby preventing the cascade of contamination to the healthcare worker's body or clothing ^[1].