There’s a huge amount of academic and pragmatic discussion and debate about the appropriate levels of PPE to wear in various healthcare settings to reduce the risk of spreading COVID-19 to yourself and others in healthcare settings. And more recently, when to wear face coverings / masks / shields in public areas of hospitals, on public transport, and in shops. However, there is much, much less discussion about the importance of careful doffing (removal) of PPE and face coverings etc in order to ensure the safe and effective use of PPE. This helpful Cochrane Review, updated for the COVID-19 era, covers a lot of ground and one key conclusion is that doffing is key: if it is done carefully, the risk of self-contamination is lower.

When we wear PPE in healthcare settings or a mask/face covering outside of healthcare settings, there certainly a feeling of self-protection. This is a good thing – and the PPE etc does offer you personal protection! However, the removal of the PPE is probably the most risky part of the task that you have performed and yet practice around the doffing of PPE can be poor – to say the least.

I think these three steps, in line with the key findings of the Cochrane Review, are key to keep in mind when managing PPE (especially when doffing) in a healthcare setting or a face mask / covering / shield outside of a clinical area or in public:

1. Have a plan. There’s clear guidance for PPE donning and doffing in healthcare and non-healthcare This includes using the correct waste-steam for disposable PPE and having a plan for what to do with a face covering (i.e. a clean box and not a pocket!). Here’s my personal plan for managing a face covering on public transport:

My personal protocol for #facecovering use on trains:
1. Pre-hydrate.
2. Gel.
3. Apply #facecovering & adjust to fit.
4. Resist urge to fiddle with it.
5. [At destination station]. Gel.
6. Carefully remove.
7. Place in plastic box.
8. Gel.

Everybody’s doing this, right?

— Jon Otter (@jonotter) June 16, 2020

2. Please please please avoid the all-too-common pitfalls of incorrect PPE use, especially masks. Masks worn on chins and foreheads don’t provide respiratory protection and risk spreading SARS-CoV-2 to your face for subsequent self-inoculation. The image below is from a studyusing UV fluorescence as a training tool to illustrate the risks associated with PPE doffing:

3. Hand hygiene is key – and should be done before putting on PPE and before and after touching each item of PPE during doffing. This seems a bit much at first glance. Why bother doing hand hygiene before touching contaminated PPE? Because you also touch your skin / clothing and don’t want to leave SARS-CoV-2 behind!

So, please take care when wearing PPE or a face covering / mask / shield. If done right, it will protect you and your patients, but if done badly, it will increase the risk than it is designed to reduce!