Mosby’s Skill Checklist: Updated 10/29/14

Caregiver
Observer
Date

S= satisfactory U=unsatisfactory NA=not applicable

Isolation Precaution: Ebola
Doffing PPE: N95Respirator / S / U / NP
1. / Inspected PPE to assess for visible contamination, cuts, or tears before starting the doffing process.
  1. If any PPE is potentially contaminated, then disinfected the PPE using an EPA-registered disinfectant wipe and allowed to dry.
  2. If the facility conditions permit and appropriate regulations are followed, an EPA-registered disinfectant spray was used, particularly on contaminated areas. Allowed to dry

2. / Entered the designated PPE removal area. Placed all PPE waste in a leak-proof infectious waste container.
3. / Disinfected outer-gloved hands with either an EPA-registered disinfectant wipe or alcohol-based hand rub (ABHR), and allowed to dry.
4. / Removed apron (if used). Removed and discarded apron by rolling it inside out and touching only the insideto avoid contaminated gloves.
5. / Inspected removed apron to assess for visible contamination or cuts or tears. If visibly contaminated, disinfected using an EPA-registered disinfectant wipe.
6. / Disinfected outer-gloved hands with either an EPA-registered disinfectant wipe or ABHR.
7. / Removedboot covers. While sitting down, removed and discarded bootorshoe covers.
8. / Disinfected and removedouter gloves.
  1. Disinfected outer-gloved hands with either an EPA-registered disinfectant wipe or ABHR.
  2. Removed and discarded outer gloves, taking care not to contaminate inner gloves during removal process.

9. / Inspected, disinfected, and removedinner gloves.
  1. Inspected the inner gloves’ outer surfaces for visible contamination, cuts, or tears.
  2. If an inner glove was visibly soiled, cut, or torn, disinfected the glove with either an EPA-registered disinfectant wipe or ABHR. Then removed the inner gloves, performed hand hygiene with ABHR on bare hands, and donned clean gloves.
  3. If no visible contamination, cuts, or tears were identified on the inner gloves, disinfected the inner-gloved hands with either an EPA-registered disinfectant wipe or ABHR.

10. / Removedand discarded face shield.
  1. Removed the full face shield by tilting the head slightly forward, grabbing the rear strap, and pulling it over the head gently so the face shield fellforward.
  2. Discarded face shield. Avoided touching the front surface of the face shield.

12. / Disinfectedinner gloveswith either an EPA-registered disinfectant wipe or ABHR.
13. / Removedsurgical hood.
  1. Unfastened (if applicable), gently removed, and discarded surgical hood.
  2. The trained observer may have assisted with unfastening hood.

14. / Disinfectedinner gloves with either an EPA-registered disinfectant wipe or ABHR.
15. / Removedand discarded gownorcoverall.
Gown Removal
  1. Depending on gown design and location of fasteners, untied fasteners, received assistance by the trained observer to unfasten to gown, or gently broke fasteners.
  2. Avoided contact of scrubs or disposable garments with outer surface of gown during removal.
  3. Pulled gown away from body, rolling inside out and touching only the inside of the gown.
Coverall Removal
  1. To remove coverall, tilted head back to reach zipper or fasteners.
  2. Unziped or unfastened coverall completely before rolling down and turning inside out.
  3. Used a mirror to help avoid touching the skin.
  4. Avoided contact of scrubs with outer surface of coverall during removal, touching only the inside of the coverall.

16. / Disinfected and changedinner gloves.
  1. Disinfected inner gloves with either an EPA-registered disinfectant wipe or ABHR.
  2. Removed and discarded gloves taking care not to contaminate bare hands during removal process.
  3. Performed hand hygiene with ABHR.
  4. Donned a new pair of inner gloves.

17. / Removed N95 respirator.
  1. Tilted the head slightly forward.
  2. Grasped first the bottom tie or elastic strap, then the top tie or elastic strap.
  3. Removed without touching the front of the N95 respirator.
  4. Discarded N95 respirator.

18. / Disinfectedinner gloves with either an EPA-registered disinfectant wipe or ABHR.
19. / Disinfectedwashable shoes. Sitting on a new clean surface (e.g., second clean chair, clean side of a bench), used an EPA-registered disinfectant wipe to wipe down every external surface of the washable shoes.
20. / Disinfect and remove inner gloves.
  1. Disinfected inner-gloved hands with either an EPA-registered disinfectant wipe or ABHR.
  2. Removed and discarded gloves taking care not to contaminate bare hands during removal process.

21. / Performed hand hygiene with ABHR.
22. / Performed a final inspection of health care personnel for any indication of contamination of the surgical scrubs or disposable garments. If contamination wasidentified, immediately informed infection preventionist or occupational safety and health coordinator (or designee) before exiting PPE removal area.
23. / Left PPE area with appropriate attire, wearing hospital scrubs or disposable garments.
24. / Showered.
  1. Showers are recommended at each shift’s end for health care personnel performing high-risk patient care (e.g., exposed to large quantities of blood, body fluids, or excreta).
  2. Showers are also suggested for health care personnel spending extended periods of time in the Ebola patient room.

25. / Performed protocol evaluation and medical assessments. Either the infection preventionist or occupational safety and health coordinator (or designee) on the unit at the time met with the health care personnel to review the patient care activities performed to identify any concerns about care protocols and to record health care personnel’s level of fatigue.
Trained Observer
1. / Was available in the PPE removal area before entering and beginning the PPE removal process.
2. / Donned appropriate PPE: gown, double gloves, face shield, and shoe covers.
3. / Supervisedthe doffing process.
4. / Read aloud each step of the procedure.
5. / Visually confirmed that the PPE was removed properly.
6. / Before doffing PPE, reminded the healthcare personnel to avoid reflexive actions that may put him or herat risk, such as touching his or herface. Posted this instruction and repeated it verbally during doffing.
7. / Minimize touching the healthcare personnelor the healthcare personnel’s PPE during the doffing process.
8. / Assisted with removal of specific components of PPE. Unfastening hood may have required assistance.
9. / Disinfected outer-gloved hands immediately after handling any healthcare personnel’sPPE.

This checklist was adapted from the Centers for Disease Control and Prevention. (2014). Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Retrieved October 22, 2014 from

Developed by: Mary Ann Liddy, RNC-OB, RNC-MN, MSN/Ed on October 27, 2014