Table 3.

Principles of personal protective equipment (PPE)

PRINCIPLE	PRACTICE
Protect healthcare providers through appropriate PPE	Appropriate PPE depends on exposure risk, separated into three types: (1) Contact and droplet precautions (2) Airborne, droplet and contact precautions (3) Precautions for high-risk aerosol-generating medical procedures (AGMPs).
There is no one “ideal” PPE	Supplies of specific PPE equipment may become depleted and other equipment substituted. Front-line and IPAC (infection prevention and control) healthcare professionals must work together locally to co-ordinate and train healthcare professionals on PPE equipment and donning and doffing procedures during these changes.
Do not “MacGyver”17 homemade combinations of PPE without IPAC approval	Creation of “homemade” or “MacGyvered” PPE without IPAC knowledge and approval potentially places healthcare professionals at risk, and undermines the public healthcare principles of consistent, predictable evidence-based prevention of disease spread during an infectious outbreak.
During high-risk AGMPs, decrease exposure of healthcare providers by limiting those present to essential providers only	Only those required to perform the procedure should be in the room during an AGMP. A dedicated “runner” donned in airborne, droplet and contact precautions outside the room for additional equipment is recommended. We recommend airway managers have the assistance they would normally require for that particular AGMP in the room with them, donned in PPE for high-risk AGMP.
Donning (putting on) PPE should be in accordance with institutional guidelines	A checklist is essential. Donning should be performed with a spotter who can observe and correct inadequacies (e.g., tuck head covering into goggles to cover forehead) during the process. Appropriate donning of a fit-tested N95 respirator is critical.
Pay attention to how you don to augment your ease of doffing	For AGMPs, your N95 respirator goes on first so it can come off last. Tie a bow rather than a knot on the front of your surgical gown; loop rather than tying anything at the back of your surgical gown to aid easy removal and avoid tearing the gown.
Contamination of a healthcare provider can occur either in the patient’s room or during the doffing process	Contamination in the patient’s room should trigger immediate careful doffing when it is safe to do so. Re-donning of PPE should occur outside the patient’s room should returning to the patient’s room be required. There are currently no specific measures recommended should self-contamination during the doffing process occur. We recommend consulting the institutional IPAC team as outlined below.
Doffing (PPE removal) is a high-risk procedure because of risk of self-contamination that is not necessarily detected by the doffing healthcare professional	Interruptions, distractions, and tangents during the doffing protocol are hazardous to all healthcare providers involved. Doffing should be considered a “sterile cockpit” situation. The most effective strategy to prevent self-contamination during doffing is the presence of a spotter, reading the doffing checklist step-by-step, and/or usage of clear signage describing the steps.
The surgical mask or N95 respirator should be the last item removed	Removal should be done very last, and in the anteroom, or outside the patient’s room when there is no anteroom available. Avoid touching the front of the surgical mask or N95 respirator during doffing.
PPE donning and doffing requires education and practice prior to their use during patient care	Practicing PPE donning and doffing enhances patient safety by improving speed and efficiency. It also reduces PPE wastage by preventing the need to don and doff repeatedly due to self-contamination or breaching of PPE.
Hand hygiene performed throughout the donning and doffing processes should be done according to your institution’s IPAC guidelines	Many PPE guidelines recommend hand hygiene be applied to gloves prior to the doffing process to decrease possibility of self-contamination by the healthcare provider’s hands should a doffing breech occur.40
There are currently no specific measures recommended should self-contamination during the doffing process occur. Liaise with your IPAC to classify contamination as high, moderate, or low risk. A course of action can be determined based on risk of exposure.	Alcohol sanitizer to the area of contamination for > 20 sec is reasonable. More recommendations may be produced as more is known. Some centres are recommending healthcare professionals take a shower with soap post-AGMP, whether self-contamination occurs or not. This seems reasonable at present until more guidance is known.
Track and protect PPE supply	Educate staff around appropriate PPE use determined by level of care required (droplet/contact vs AGMP, infrequently airborne).
Promote scalable, generalizable innovations in accordance with institutional IPAC	Get involved in innovative projects (e.g., 3D-printing, design, advertising for N95 masks from the community or companies etc.)