WHO – Hand Hygiene Technique

Hand-washing Steps Using the WHO Technique - YouTube

Proper hand hygiene is the most important thing you can do to prevent the spread of germs and to protect yourself and others from illnesses. When not done carefully, germs on the fingertips, palms and thumbs, and between fingers, are often missed. This video demonstrates the World Health Organization (WHO) technique for hand-washing. Watch the video to be sure you are washing your hands thoroughly.

Science Matters: Let’s Talk About COVID-19 – Free Course

The outbreak of the novel Coronavirus Disease (COVID-19) is the most significant public health emergency of the 21st century so far. As the epidemic spreads, people around the world want to understand the science behind the most pressing questions: how many people have been infected? How dangerous is the virus? When will a vaccine be available? How can the epidemic be contained, and the damages mitigated? What is the economic impact? What’s the role of social media and local communities in the epidemic response?

On this course, you will hear directly from our world class experts about the theory behind the analyses of COVID-19 and its spread, while learning how to interpret new information using core principles of public health, epidemiology, medicine, health economics, and social science. You will be able to watch regular situation reports about the state of the epidemic, provided by the researchers of J-IDEA and its director Professor Neil Ferguson. If you want to learn even more about these topics, a number of free MOOCs are available from Imperial College London. We also offer a fully online Global Master of Public Health for those of you who want to delve even deeper and join our professional community. Please note that we are creating all the content in real time as new information breaks, and that new material will be uploaded as it becomes available. The contents of the course are available free of charge.


  • To be aware of the scale of the emerging outbreak and know how to track trends using reliable sources of information

  • To recognise the key scientific underpinnings of evidence-based outbreak control methods

  • To recognise the importance of community involvement, multidisciplinary working and global cooperation in outbreak response

  • About how infectious disease modelling informs strategic and operational response at the local, national, and international level.


Environmental decontamination 1: what is it and why is it important?

Corona virus


Environmental decontamination 1: what is it and why is it important?


Ensuring that surfaces are clean and adequately disinfected is vital for patient safety and is a legal requirement. This article is accompanied by a self-assessment so you can test your knowledge after reading it


Contamination of the environment plays a key role in the transmission of some pathogens that cause healthcare-associated infection. This article is the first in a three-part series looking at cleaning and disinfection in healthcare settings. It describes the process of environmental decontamination, which includes cleaning and disinfection and focuses on the nurse’s role in ensuring the environment is safe for patients.

Citation: Otter J, Galletly T (2018) Environmental decontamination 1: what is it and why is it important? Nursing Times [online]; 114: 7, 32-34.

Authors: Jonathan Otter is epidemiologist (infection prevention and control), Imperial College Healthcare Trust, and honorary senior lecturer, National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London; Tracey Galletly is the lead nurse for infection prevention and control at Imperial College Healthcare NHS Trust.

  • This article has been double-blind peer reviewed
  • This article is open access and can be freely distributed
  • Scroll down to read the article or download a print-friendly PDF here
  • Assess your knowledge and gain CPD evidence by taking the NT Self-assessment test
  • This article has been supported by an educational grant from GAMA Healthcare, manufacturer of Clinell products


Environmental decontamination refers to the process by which environmental contamination is reduced to a level that is not harmful to health. Decontamination of the environment can be achieved through:

  • Cleaning;
  • Disinfection;
  • A combination of the two.

Box 1 defines these terms, as well as others that are relevant.

Box 1. Glossary of terms

  • Healthcare-associated infection (HCAI) – infection that occurs as a result of contact with the healthcare system
  • Environmental decontamination – process by which the healthcare environment is made free from a harmful level of contamination that may result in the transfer of pathogens that can cause HCAIs
  • Cleaning – removal of ‘dirt’ from surfaces, which may include microbial (for example, bacteria) and non-microbial (for example, body fluids) contamination
  • Disinfection – killing of microbes on surfaces, via chemicals, heat, or another process
  • Non-critical surfaces – surfaces that only come into contact with intact skin, such as bedrails and floors
  • Semi-critical surfaces – surfaces that come into contact with mucous membranes or non-intact skin (for example, endoscopes)
  • Critical surfaces – surfaces that enter usually sterile parts of the body (for example, scalpels)
  • Terminal decontamination – decontamination performed at the time of discharge

Cleaning and disinfection

For many years, the healthcare environment was not thought to contribute significantly to the transmission of microbes (including bacteria, fungi and viruses) that cause healthcare-associated infections (HCAIs) (Otter et al, 2011). However, recent evidence has prompted a re-evaluation of this, and it is generally accepted that the contaminated environment plays a key role in the transmission of some pathogens that cause HCAIs in hospitals, care homes and in the community.

Perhaps the most powerful evidence of the role of the contaminated environment is the finding that admission to a hospital room previously occupied by a patient with a pathogen – for example Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) or Acinetobacter baumannii – increases the risk of acquisition for the incoming occupant (Mitchell et al, 2015). This implies that we are not effectively decontaminating the environment, especially at patient discharge. Other studies show that improving the quality of cleaning and disinfection reduces the risk of infection linked to previous occupants of a room (Anderson et al, 2017; Passaretti et al, 2013).

The spread of pathogens

A range of pathogens are shed into the environment and can cause widespread contamination. For example, a study performed almost 15 years ago in London found high levels of contamination: more than three-quarters of the sites in rooms occupied by patients known to be infected or colonised with MRSA were contaminated with it (French et al, 2004). These pathogens can survive for long periods on dry surfaces (Table 1); VRE has remarkable survival properties, remaining alive on a dry laboratory surface for in excess of four years in one study (Wagenvoort et al, 2011).

table 1 pathogen survival times on dry surfaces

Cleaning and disinfection rarely eliminates pathogens from the hospital environment – typically, only about half of pathogens are removed when terminal decontamination is performed (Otter et al, 2011). This could be at least in part because not all surfaces in a room are actually cleaned or disinfected by manual processes: a well-known US study found that only half of the surfaces in patient rooms were cleaned or disinfected at patient discharge (Carling et al, 2008).

There is frequent transfer of contamination present on dry surfaces to the hands of healthcare workers, which can then colonise the patient’s skin and other body sites (Fig 1). This was demonstrated by a study undertaken almost 20 years ago, in which a telephone in one pod of a neonatal intensive care unit was seeded with marker DNA. Within hours the DNA marker had spread to healthcare worker hands and environmental surfaces around the unit (Oelberg et al, 2000).

fig 1 contamination transfer

Environmental decontamination

The Health and Social Care Act (Department of Health, 2008) requires that healthcare facilities maintain a clean, appropriate environment that facilitates the prevention and control of infection. Effective environmental decontamination is an essential part of meeting this requirement. Cleaning and disinfection in the NHS is performed to meet standards outlined in the Healthcare Cleaning Manual – this is currently being revised by NHS Improvement.

The structures around the provision of environmental decontamination services vary from hospital to hospital, but cleaning and disinfection in the clinical environment is always multiprofessional. Specifically trained non-clinical staff (cleaners or ‘domestics’) typically provide daily and terminal cleaning and disinfection of non-critical surfaces. Semi-critical surfaces are typically disinfected by nursing staff at the point of care or sent for decontamination in a reprocessing unit. Critical surfaces are usually single-patient use or sent for decontamination in a reprocessing unit using validated processes.

A particular challenge is mobile equipment (for example, blood-pressure cuffs and stethoscopes) that move from patient to patient. While the availability of disinfectant wipes at the point of care provides a good way of disinfecting these items, it is not always clear who is responsible for doing so.

The decontamination strategy will be influenced by the microbiological scenario. For example, Clostridium difficile spores are resistant to many disinfectants, so a sporicidal disinfectant (such as a chlorine-releasing disinfectant, hydrogen peroxide, or peracetic acid) must be used. Enhanced decontamination using a disinfectant is usually performed for environmental decontamination where contamination with key antibiotic-resistant bacteria is likely – for example, carbapenemase-producing Enterobacteriaceae, MRSA and VRE (Otter et al, 2011).

Nurses play a key role in environmental decontamination. As well as bearing direct responsibility for decontaminating some items, they collaborate with environmental decontamination services to develop policies and training schedules, deliver training and education, audit the cleaning process, inform purchasing decisions and escalate cleaning issues day-to-day (Bellemy et al, 2012). This will be covered in more detail in Part 2 of this series.

A range of materials and tools are required for effective decontamination of the environment. Typically in the NHS, detergent is used for cleaning most non-critical surfaces. However, detergent cleaning:

  • Does not eliminate microbial contamination;
  • May spread contamination from surface to surface;
  • Requires a drying step to avoid leaving a surface wet and prone to biofilm development.

Biofilms are communities of microbes encased in proteins that are difficult to remove through cleaning and resist disinfection. As a result, these surfaces are increasingly cleaned using disinfectant wipes. Approaches for the decontamination of semi-critical and critical devices will be covered in Part 2.

The approach to disinfection of a patient environment known to be infected or colonised with a pathogen associated with HCAI varies, but often includes the use of a disinfectant (commonly chlorine-containing agents and quaternary ammonium compound formulations, and increasingly the peroxygens such as peracetic acid and hydrogen peroxide).


Micro-organisms vary in their level of susceptibility to disinfectants, so agents must be chosen carefully for their effectiveness, particularly for C. difficile spores and norovirus (Otter et al, 2011).

Furthermore, the healthcare environment is complex and often difficult to clean, and the use of a cleaning agent that is not effective against the target organism can spread pathogens to other surfaces. Selection of disinfectants should always be based on efficacy data from independent, accredited laboratories.

Some liquid disinfectants may damage equipment, and chlorine-containing materials may corrode metals (Otter et al, 2011). Certain disinfectants can potentially harm users and the discharge of waste biocides into the environment may encourage the development of both biocide and antibiotic resistance, as well as having more general environmentally damaging effects. However, disinfectants with improved safety and efficacy profiles are being developed.

Cleaning and disinfection does not always eradicate pathogens from surfaces. The frequent finding of contamination in empty rooms and rooms occupied by patients unaffected by pathogens suggests residual contamination from previous occupants (Otter et al, 2011). There are several drivers of failures of environmental decontamination, including:

  • Disinfectant efficacy and related issues;
  • Healthcare environments being intricate and challenging;
  • Biofilms on surfaces increasing bacterial resistance to decontamination.

However, the main reason for failures in environmental decontamination relate to the procedure rather than the product: an effective manual decontamination process relies on a human being for the correct formulation, distribution and contact time of a cleaning or disinfecting agent.

Innovation and new technology

Innovation and new technology can help to improve the effectiveness of cleaning and disinfection. For example, the Design Bugs Out initiative aims to design hospital furniture and equipment that is easier and quicker to clean. In addition, new and advanced formulations of liquid disinfectants boast improved efficacy and practicability, reducing the risk of human error during use.

The emergence of wipes impregnated with disinfectants – such as quaternary ammonium compounds, hydrogen peroxide, chlorine and others – are also promising developments. These wipes are:

  • Better tolerated by nurses and cleaners;
  • Effective for surface disinfection;
  • Manufactured to provide optimal disinfectant concentration;
  • Available at the point of care.

Also, they do not require reconstitution and whereas detergent wipes require a drying step, this is not necessary with disinfectant wipes, whose efficacy depends on achieving an appropriate contact time.

Emerging new disinfectants, which can be applied as a liquid or via a wipe, include reformulated hydrogen peroxide solutions (sometimes called ‘activated’ or ‘improved’ hydrogen peroxide) and electrolysed water.

There has also been development in automated room decontamination (ARD) systems, which remove or reduce reliance on the operator to ensure distribution, contact time and process repeatability (Otter et al, 2013). Both hydrogen peroxide-based systems and ultraviolet systems have been shown to reduce the transmission of pathogens associated with HCAI (Anderson et al, 2017; Passaretti et al, 2013). The choice of ARD system should be influenced by the intended application, the evidence base for effectiveness, practicalities of implementation and cost constraints.


Published evidence now demonstrates the key role of environmental contamination in healthcare settings in relation to the transmission of pathogens associated with HCAIs. Ensuring that surfaces are clean and adequately disinfected is a vital part of patient safety – and a legal requirement. Processes for maintaining a clean, safe environment vary from setting to setting but are always multiprofessional and nurses always have a crucial role.

Key points

  • Cleaning and disinfection in the clinical environment is a multiprofessional responsibility
  • Contaminated environment plays a key role in the transmission of some pathogens
  • Patients may acquire healthcare-associated infection from being in a room previously occupied by a patient with a pathogen
  • Cleaning and disinfection does not always eradicate pathogens from surfaces and failure is usually related to the procedure used
  • Ensuring that surfaces are clean and adequately disinfected is a legal requirement

Source: https://bit.ly/2Usr90V

Infection control 2: hand hygiene using alcohol-based hand rub


Infection control


Good hand hygiene is crucial to help prevent healthcare-associated infections. This article, the second in a six-part series, discusses the principles of hand hygiene and the procedure for cleaning the hands with an alcohol-based hand rub


Hand hygiene is one of the most effective methods of preventing healthcare-associated infections. However, prevention depends on hand hygiene being performed when necessary, and the appropriate cleansing agent and technique being used. This article, part 2 in a six-part series, explains the importance of hand hygiene, when it should be performed and which cleansing agent to use. It also outlines the procedure for decontaminating the hands using alcohol-based hand rub.

Citation: Wigglesworth N (2019) Infection control 2: hand hygiene using alcohol-based hand rub. Nursing Times [online]; 115, 5: 24-26.

Author: Neil Wigglesworth is director, infection prevention and control, Guy’s and St Thomas’ Foundation Trust, London and immediate past president, Infection Prevention Society.

  • This article has been double-blind peer reviewed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
  • Click here to see other articles in this series
  • This article is open access and can be freely distributed
  • This article is funded by an unrestricted educational grant from Medipal


Healthcare-associated infections (HCAIs) are a serious risk to patients, staff and visitors and are estimated to cost the NHS £1bn a year. National surveys have identified the prevalence of HCAIs in hospital patients of 6.4% in England in 2011 (Health Protection Agency, 2012), 4.6% in Scotland in 2016 (NHS Scotland, 2017), 4.0% in Wales in 2011 (Public Health Wales, 2012), and 4.2% in Northern Ireland in 2011/12 (Public Health Agency, 2012).

Both resident and transient bacteria will be present on hands; if transferred from the hands of a health professional to susceptible sites such as wounds or invasive devices they can cause life-threatening infections, while transfer to non-vulnerable sites can leave patients colonised with bacteria that could cause a future infection in the patient or expose staff and visitors to the risk of infection (Loveday et al, 2014).

Why is hand hygiene important?

The most common mode of transmission of pathogens associated with HCAIs in care settings is via the contaminated hands of health professionals (World Health Organization, 2009). Transmission from a health professional’s hands to a patient takes place in sequential steps:

  • Organisms are transferred to the health professional’s hands from a patient or the environment;
  • The health professional fails to perform effective hand hygiene;
  • The health professional’s hands come into contact with a patient, or a vulnerable site such as the entry point for an invasive device.

Hand hygiene is the primary measure proven to be effective in preventing HCAIs and is the cornerstone of good infection prevention and control (IPC) practice (WHO, 2009). Current national and international guidance has consistently identified that effective hand decontamination results in significant reductions in potential pathogens on the hands. Loveday et al (2014) say it is therefore logical that effective decontamination decreases the incidence of preventable HCAIs, leading to a reduction in patient morbidity and mortality.

Hand decontamination can be achieved using alcohol-based hand rub (ABHR) or liquid soap and water. Staff should receive regular training on how to undertake the correct hand hygiene technique.

This article, the second in a six-part series on infection prevention and control, discusses when hand hygiene should be performed, which hand hygiene procedure to use in different situations, and the procedure for cleansing the hands with ABHR.

Part 6 in this series will discuss how to clean the hands using soap and water, and how to protect skin integrity.

When to perform hand hygiene

The WHO (2009) advises that health professionals’ hands should be decontaminated at five critical points before, during and after patient care activity; these are known as My Five Moments for Hand Hygiene:

  • Before touching a patient;
  • Before clean/aseptic procedure;
  • After body fluid exposure/risk;
  • After touching a patient;
  • After touching patient surroundings.

Hand hygiene resources and health professionals’ compliance with hand hygiene guidelines should be audited at regular intervals and the results should be fed back to health professionals to improve and sustain levels of compliance (Loveday et al, 2014).

Which cleansing agent to use

Choosing the appropriate method of hand decontamination depends on assessing a number of factors:

  • The nature of the care intervention being provided;
  • The availability of resources at or near the point of care;
  • What is practically possible;
  • The acceptability of preparations or materials in terms of ease of use, time and access, as well as dermatological effects (Loveday et al, 2014).

While either effective handwashing or effective use of ABHR will remove transient microorganisms to make the hands socially clean, ABHR will also substantially reduce resident microorganisms. It is, therefore, recommended for routine use due to its increased efficacy, easy availability at the point of care and general acceptability to health professionals (Loveday et al, 2014).

However, while ABHR reduces some resident microorganisms, it is not effective against all species (for example some viruses including norovirus and spore-forming microorganisms such as Clostridium difficile). In addition, it will not remove dirt and organic material and may not be effective in some outbreak situations; in such situations handwashing with soap and water is required.

Loveday et al (2014) recommend that ABHR is used to decontaminate hands before and after direct patient contact and clinical care except in the following situations, when soap and water must be used:

  • When hands are visibly soiled or potentially contaminated with body fluids;
  • When caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.

The procedure

Hand rub should be available at the point of care in healthcare. With regards to staff working in community settings, they should carry their own ABHR to ensure that they have some available when they visit patients’ homes or other non-healthcare facilities.

Before performing hand hygiene, you should:

  • Expose your forearms (bare below the elbows);
  • Ensure all hand/wrist jewellery is removed (staff members should be bare below the elbows at all times when working so should not be wearing any jewellery other than a single, plain metal ring, which should be removed or moved up the finger to wash underneath it, then moved back during hand hygiene if required by local policy);
  • Ensure fingernails are clean and short, and artificial nails or nail products are not worn;
  • Cover any cuts or abrasions with a waterproof dressing.

To decontaminate hands using ABHR:

  1. Ensure the hands are free of dirt and organic material.
  2. Apply a palmful of hand rub in a cupped hand and cover all surfaces (Fig 1).
  3. Rub hands palm to palm (Fig 2).
  4. Rub back of each hand with palm of other hand with fingers interlaced (Fig 3).
  5. Rub hands with fingers interlaced (Fig 4).
  6. Rub with back of fingers to opposing palms with fingers interlocked (Fig 5).
  7. Rub each thumb clasped in opposite hand using a rotational movement (Fig 6).
  8. Rub tips of fingers in opposite palm in a circular motion (Fig 7).
  9. Rub each wrist with opposite hand (Fig 8).
  10. Once dry, your hands are safe (20-30 seconds).

fig 1 apply handrub

Source: Peter Lamb

fig 2 rub palm to palm

Source: Peter Lamb

fig 3 rub back of hand with palm

Source: Peter Lamb

fig 4 rub with fingers interlaced

Source: Peter Lamb

fig 5 rub back of fingers to opposing palm

Source: Peter Lamb

fig 6 rub each thumb

Source: Peter Lamb

fig 7 rub tips of fingers

Source: Peter Lamb

fig 8 rub each wrist

Source: Peter Lamb


Health Protection Agency (2012) English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use 2011.

Loveday HP et al (2014) epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS Hospitals in England. Journal of Hospital Infection; 86, S1, 1-70.

NHS Scotland (2017) National Point Prevalence Survey of Healthcare Associated Infection and Antimicrobial Prescribing 2016.

Public Health Agency (2012) Northern Ireland Point Prevalence Survey of Hospital Acquired Infections and Antimicrobial Use, 2012.

Public Health Wales (2012) Point Prevalence Survey of Healthcare-associated Infections, Medical Device Usage and Antimicrobial Usage 2011.

World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care: A Summary.

Infection control 5: equipment for facial and respiratory protection


Infection control 5: equipment for facial and respiratory protection


Respiratory and facial protection are used to protect health professionals from the risks of blood or body fluids splashing into the face and eyes, from exposure of infectious large droplets, or of inhaling infectious aerosolised droplet nuclei. This article, part 5 in a six-part series, discusses their use.


Respiratory and facial protection are used by health professionals when there is a risk of blood or body fluids splashing into the face and eyes, of exposure to infectious large droplets or of inhaling infectious aerosolised droplet nuclei. However, it is important to use equipment appropriately to maintain adequate protection. This article – part 5 in a six-part series – discusses when and how to use protective equipment.

Citation: Wigglesworth N (2019) Infection control 5: equipment for facial and respiratory protection. Nursing Times; 10: 30-32.

Author: Neil Wigglesworth is director, infection prevention and control, Guy’s and St Thomas’ Foundation Trust, London, and immediate past president, Infection Prevention Society.

  • This article has been double-blind peer reviewed
  • This article is open access and can be freely distributed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
  • Click here to see other articles in this series
  • This article is funded by an unrestricted educational grant from Medipal


Fluid-resistant surgical face masks, eye protection and respiratory protective equipment (RPE) are important items of personal protective equipment (PPE). They are used to protect the mucous membranes of the wearer from exposure to blood and/or body fluids when splashing may occur, as well as from exposure to infectious large droplets and droplet nuclei. Surgical face masks are also used to prevent respiratory droplets from the health professional’s mouth and nose being expelled into the environment (Loveday et al, 2014). This article focuses on selecting these products for use as PPE, and explains the procedures for applying and removing them.

When to use facial and respiratory protection

The decision to use or wear PPE should be based on the results of an assessment of the level of risk associated with a specific activity, and should take account of:

  • The task being undertaken;
  • The characteristics of the biological agent to which there is a risk of exposure;
  • The duration of the task;
  • The local environment;
  • Current health and safety legislation.

Users should be trained in how to select the most-appropriate items, as well as how to apply, adjust, remove and dispose of them. There is evidence that both a lack of knowledge of guidelines and non-adherence to recommendations are common; regular in-service education and training is therefore required (Loveday et al, 2014). All PPE should be:

  • Located close to the point of use;
  • Stored in a clean/dry area until required for use (expiry dates must be adhered to) to prevent contamination;
  • Single-use only items unless specified by the manufacturer;
  • Disposed of after use into the correct waste stream: healthcare (including clinical) waste or domestic waste (Health Protection Scotland, 2015).

Facial protection, including fluid-repellent surgical face masks, is not commonly worn when caring for patients with cold or flu-like illnesses, but should be considered when:

  • Caring for those with undiagnosed respiratory illness for whom coughing and sneezing are significant features;
  • There is known widespread respiratory virus activity in the community;
  • There is a suspected or confirmed outbreak of a respiratory illness in a closed or semi-closed setting.

Respiratory protection, for example an FFP3 filtering facepiece respirator, as well as eye protection, must be worn when performing aerosol-generating procedures (AGPs) on patients with known or suspected influenza and some other respiratory viral illnesses. AGPs include positive-pressure ventilation, endotracheal intubation, airway suction, high-frequency oscillatory ventilation, tracheostomy, nebuliser treatment, sputum induction and bronchoscopy (Khai et al, 2012). The user should, however, follow local policy for a full list of AGPs in their area of work.

Facial and eye protection (including visors) should not be impeded by accessories such as false eyelashes and should not be touched when worn.

Facial protection: face masks and eye protection

Standard, single-use, fluid-resistant type IIR surgical facemasks that fully cover the nose and mouth (Fig 1) can be used:

  • To prevent respiratory droplets from being expelled into the environment;
  • In conjunction with eye protection, to protect the wearer’s mucous membranes from exposure to blood and/or body fluids in situations where splashing may occur;
  • To protect the wearer’s mucous membranes from infectious large droplets, such as those generated by
    a patient with seasonal influenza.


Source: Peter Lamb

Protective eyewear (visors or goggles) can protect health professionals against potential splashing into the eyes of blood or body fluids that may be infectious. If such an occurence is likely, these should be worn as part of appropriate facial protection. Regular spectacles are not classed as PPE and are not an appropriate alternative.

The choice of visors or goggles will depend on:

  • The procedure that is to be undertaken;
  • A risk assessment of likely exposure;
  • Local policy;
  • Availability.

A face shield that fully covers the front and sides of the face or goggles (in addition to a respirator) may be worn during AGPs on patients who are suspected of being infected with a respiratory pathogen.

Respiratory protection

RPE is used to protect the wearer from inhaling aerosolised droplet nuclei expelled from the respiratory tract. As surgical face masks are not effective at filtering out such particles, respirators are required:

  • When caring for patients with certain respiratory diseases, such as active pulmonary tuberculosis;
  • As part of a PPE ensemble for suspected high-consequence infectious diseases spread by the airborne route, such as avian influenza or Middle East respiratory syndrome coronavirus (MERS Co-V).

Patients in whom diagnoses of these diseases have been confirmed will be transferred to a specialist centre for ongoing management.

Respirators will protect the wearer from inhaling small respiratory particles but they must fit closely to the face to minimise leakage around the mask. Wearers must be ‘fit tested’ by trained personnel to the specific respirator they are using and must ‘fit check’ it every time it is donned (Coia et al, 2013). It is good practice to conduct fit tests annually unless the person has dramatic changes to the face as a result of, for example:

  • Weight gain/loss;
  • Substantial dental work;
  • Facial changes (such as scars, moles and effects of ageing) around the face seal area (Health and Safety Executive, 2019).

Respirators, also known as filtering face pieces (FFPs) are classified into three categories in Europe: FFP1, FFP2 and FFP3. FFP3 (Fig 2) provides the highest level of protection and is the only one approved for use in UK healthcare settings. Other parts of the world, for example the US, use N95, which is equivalent to FFP2.


Source: Peter Lamb

Putting on facial PPE

Hand hygiene must be performed before putting on any PPE. The items worn should be put on in the following order:

  1. Apron/gown;
  2. Face protection/respirator if worn;
  3. Eye protection;
  4. Gloves.

Face protection

When putting on a surgical face mask, secure the ties at the middle of the head and neck according to the manufacturer’s instructions (Fig 3a), then fit the flexible band to your nose ridge by pressing gently (Fig 3b).


Source: Peter Lamb

Put on and fit FFP3 respirators following the steps in Fig 4; perform a fit-check as you will have been trained to do. It may be helpful to look in the mirror when applying the FFP3 respirator.


Source: Peter Lamb

Masks and most FFP3 respirators are single-use only, they should not be worn around the neck or put to one side for later use. Reusable FFP3 respirators are available as an option for staff who cannot be successfully fit tested on single-use types.

Eye protection: goggles or visors

  • Place over the eyes (googles) or face (visor) (Fig 5).
  • Adjust to fit.


Source: Peter Lamb

Removing PPE

PPE should be removed in the following order:

  1. Gloves;
  2. Apron/gown;
  3. Eye protection;
  4. Surgical face mask or FFP3 if worn.

Eye and face protection must be removed or changed in accordance with manufacturers’ instructions at the following times, or in the following circumstances:

  • If contaminated with blood or body fluids;
  • If their integrity is compromised, for example by moisture build-up in masks;
  • At the end of the procedure;
  • Before leaving the dedicated clinical area – or, in the case of airborne infection, just outside in a designated doffing area for respirators.

Hand hygiene must be performed immediately after removing all items of PPE.

Eye protection

Avoid touching the outside surface of the goggles or visor as it is contaminated – handle only by the headband or earpieces. Discard into a lined waste bin for disposal as healthcare (including clinical) waste or, if a reusable piece of equipment – for example, reusable goggles – a receptacle for reprocessing or decontamination.

Face protection

Avoid touching the front of the mask or respirator. If wearing a facemask, unfasten the bottom ties, then those at the top. Pull the mask or respirator away from the face without touching the front. Discard into a lined waste bin for disposal as healthcare (including clinical) waste or, if suitable for a reusable piece of equipment – for example, reusable respirator – a receptacle for reprocessing or decontamination.


Respiratory and facial protective equipment is designed to protect both patients and health professionals from infection. To maximise their effectiveness, they should be selected and used after an assessment of the risks associated with a planned procedure, and used as described in this article in accordance with local policy.

Coia JE et al (2013) Guidance on the use of respiratory and facial protection equipment. Journal of Hospital Infection; 85: 3, 170-182.

Health and Safety Executive (2019) Guidance on Respiratory Protective Equipment (RPE) Fit Testing.

Health Protection Scotland (2015) National Infection Prevention and Control Manual.

Khai T et al (2012) Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One; 7: 4, e35797.

Loveday HP et al (2014) epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: Suppl 1, Sl-S70.

Sepsis Six Saves Lives

A short video highlighting the importance of early recognition and effective communication. This supports reliable delivery of the Sepsis Six within the first hour for patients who trigger the Early Warning Score.