CanadiEM Frontline Primer

CanadiEM Frontline Primer – ED Skills – Handling PPE

In Medical Concepts by Patrick BoreskieLeave a Comment

Points to focus upon

  • Provider safety while caring for patients throughout the pandemic starts with donning appropriate personal protective equipment (PPE). There will be institutional variation with regards to available or required PPE, but the following section will help you with general principles and precautions, including when to use what PPE, and how to properly don and doff.
  • Similar to other respiratory viruses, SARS-CoV-2 is thought to be transmitted via droplet/contact routes, both directly from coughing, sneezing, talking “moistly”, or performing aerosol-generating medical procedures(AGMPs) or indirectly through fomites and subsequent contact with mucus membranes​1,2​. Recent studies also indicate that asymptomatic carriers likely contribute to the spread of COVID-19​3​. The CDC, WHO and Public Health Agency of Canada therefore emphasize the importance of hand hygiene, proper screening procedures including triage barriers to limit patient contact, cohorting suspected or confirmed COVID-19 patients into “hot zones” within the waiting room, emergency department, and hospital, limiting numbers of staff involved in individual patient care, and of course optimizing PPE strategies for both safety and conservation of supplies​4–7​.

List of Aerosol Generating Medical Procedures (i.e. instances during which an N95 is recommended)​8,9​

  • CPR
  • Intubation
  • Manual ventilation before intubation
  • Tracheostomy / Cricothyroidotomy
  • Nebulized therapy
  • Sputum Induction
  • Non-invasive ventilation
  • Bronchoscopy

Points to Focus upon

  • At minimum, enhanced droplet/contact PPE for care of COVID-19 patients without an active AGMP should include a gown, gloves (standard gloves are fine), a surgical/procedural mask, and eye protection (goggles or face shield). Considering social distancing is not feasible in a healthcare setting, most public health agencies and hospitals are recommending that medical personnel wear a surgical mask and eye protection throughout the duration of their clinical shift.
  • To the detriment of patients and physicians worldwide, there is also a ubiquitous assumption that transmission can also occur via smaller airborne particles that can hang around in the air for several hours​10​. These particles are thought to be fairly negligible in the average stable patient, but there are critical-to-know scenarios when aerosolization is more likely. These are also scenarios when the patient should ideally be moved to a negative-pressure or HEPA-filtered space.
  • It’s important to liaise with your local infection prevention and control teams, including provincial Infection Prevention And Control (IPAC), to determine the most appropriate course of action for PPE use.

General Tips for Success

1. Declutter
  • Remove all ID badges, lanyards, jewellery, watches, stethoscopes and unnecessary accessories prior to donning PPE.
2. Buddy up
  • Don and doff with a buddy. Watch each other to ensure no steps were missed, technique is safe and possible contamination is noted right away!
3. Police the process
  • Anecdotally, many COVID-19 resuscitation teams have a designated PPE monitor to police the process and manage contaminated workers should the need arise. Have a “Dofficer” standing by to watch.
4. Practice makes perfect
  • Just like any other skill, we have to practice to become proficient. Mistakes are made when we’re anxious, rushed or have knowledge gaps. This can be circumvented by practicing!
5. Be flexible
  • As new evidence becomes available, supply chains change or your local COVID-19 cases increase, your PPE process may also change. Mentally prepare for this. Stay informed, keep up to date with national and local guidelines and be aware of your local contingency plans. If you don’t have one, start working on it!

Recommended reading, videos, and podcasts

The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.

This post was copyedited and uploaded by Johnny Huang.


  1. 1.
    Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. March 2020. doi:10.1002/jmv.25748
  2. 2.
    World Health Organization (WHO). Coronavirus disease (COVID-19) Situation dashboard. . Coronavirus disease (COVID-19) Situation dashboard. . Accessed April 10, 2020.
  3. 3.
    Lai C, Liu Y, Wang C, et al. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. March 2020. doi:10.1016/j.jmii.2020.02.012
  4. 4.
    World Health Organization (WHO). Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19). World Health Organization. March 2020:1-7.
  5. 5.
    Centres for Disease Control and Prevention . Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Centres for Disease Control and Prevention. April 2020.
  6. 6.
    Centers for Disease Control and Prevention . Using Personal Protective Equipment (PPE). Centers for Disease Control and Prevention. April 2020.
  7. 7.
    Adams J, Walls R. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA. March 2020. doi:10.1001/jama.2020.3972
  8. 8.
    World Health Organization (WHO). Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. World Health Organization. June 2007:1-93.
  9. 9.
    Public Health Agency of Canada . Interim Guidance: Infection Prevention and Control Measures for Prehospital Care. Public Health Agency of Canada. July 2009:1-7.
  10. 10.
    van D, Bushmaker T, Morris D, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973

Patrick Boreskie

Dr. Patrick Boreskie is a chief Emergency Medicine resident at the University of Manitoba in Winnipeg. He is a CanadiEM Digital Scholars Fellow and International Conference on Residency Education Chief Resident. He has a particular interest in knowledge translation, gerontology, and ultrasound.

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Tamara McColl

Dr. McColl is an Assistant Professor and Director of Education Scholarship and Faculty Development with the Department of Emergency Medicine at the University of Manitoba. She is also the CAEP21 Scientific Chair.

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