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 critical to prevent self-contamination?

The correct sequence (gloves first, then gown, eye protection, respirator mask) follows CDC guidelines to remove most contaminated items first, minimizing self-contamination risk. Other options increase exposure by removing less contaminated items earlier.

Correct Sequence for Doffing PPE in High-Risk Isolation

The correct answer is to remove gloves first, then gown, followed by eye protection, and finally the respirator mask. This sequence is the most critical because it minimizes the risk of transferring highly infectious pathogens, such as the Ebola virus, from contaminated surfaces to the mucous membranes or respiratory tract during the removal process.

Rationale and Clinical Application

The process of removing personal protective equipment, known as doffing, is a high-risk moment for self-contamination among healthcare workers ^[2]. The sequence is designed based on the principle that the most contaminated items are removed first, while the equipment protecting the most vulnerable entry points for pathogens is removed last.

The correct order follows a specific clinical logic:
1. Gloves are removed first because they are considered the most heavily contaminated piece of PPE after direct patient care. Removing them initially prevents contamination of other equipment, such as the gown or eye protection, during the subsequent steps.
2. Gown is removed next. The outer surface of the gown is contaminated. By removing gloves first, you avoid touching the gown's exterior with contaminated gloves. The gown is removed by rolling it inward, containing the contamination.
3. Eye protection (goggles or face shield) is removed after the gown. At this point, your hands are clean, but the outside of the eye protection is contaminated. It is handled only by the earpieces or headband.
4. Respirator mask (such as an N95) is removed last, and only after exiting the patient's room. The respirator protects your respiratory tract, a primary portal of entry for airborne and droplet-transmissible pathogens. Delaying its removal ensures this critical barrier remains in place until the very end, after all other contaminated items have been discarded . Errors in this sequence are a significant contributor to occupational exposure ^[1].

The other options present sequences that increase the risk of self-contamination. Removing the mask or eye protection early (Options 2 and 4) exposes the facial mucous membranes while the healthcare worker's hands and clothing may still be contaminated. Removing the gown before the gloves (Option 3) forces the worker to touch the contaminated gown exterior with gloved hands, which can then transfer pathogens to the skin or clothing during the subsequent removal of the mask and eye protection. Simulation-based training programs consistently emphasize this exact doffing sequence to build proficiency and reduce errors in high-consequence infectious disease scenarios .