Covid-19 personal protective equipment (‘PPE’)

Published 26 May 2020

Overview of Guidance

Guidance has been issued jointly by the Department of Health and Social Care (‘DHSC’), Public Health Wales (‘PHW’), Public Health Agency (‘PHA’) Northern Ireland, Health Protection Scotland (‘HPS’), Public Health England (‘PHE’) and NHS England (‘NHSE’) in relation to the use of PPE by health and social care workers in the context of Covid-19 (the ‘Guidance’).

The Guidance sets out the specific PPE that should be worn by health and social care workers operating in specific environments and performing particular tasks. We have not reproduced the detail of the Guidance in this note but the most recent Guidance, updated on 3 May 2020, can be found here.

The levels of PPE required for staff in a social care context can be found in Tables ‘2’ and ‘4’ of the Guidance.

• Table 2 of the Guidance summarises the level of PPE recommended for staff in a social care setting (no matter what the setting may be i.e. care home or a patient’s own home) in certain circumstances when performing particular tasks.
• Table 4 of the Guidance summarises ‘additional considerations’ in relation to the level of PPE recommended where there is sustained transmission of Covid-19 in any setting (and it is noted that at the time of drafting this article, the UK remains in a nationwide period of sustained transmission, meaning that Table 4 should be considered in all settings).

The Guidance has been prepared to apply across a wide variety of health and social care settings and by its nature, it cannot provide specific instruction to apply to every possible scenario that providers are facing. Providers will therefore need to consider this issue in more detail and in light of their own particular circumstances, following a risk based approach to allow them to balance, what can be competing risks relating to the protection of workers and maintaining safe and effective care for service users. In conducting risk assessments relating to PPE, usual considerations include:

• Does the Provider have adequate levels of PPE to enable staff to comply with Table 4, and if so, for how long?
• Can the Provider undertake sessional use/re-use of PPE where appropriate to do so?
• Has adequate training been provided to staff in relation to use, storage and disposal of PPE?
• Is there a plan in place for procurement of PPE? If so, how does the Provider intend to satisfy itself that the PPE meets the required minimum technical specification (as required by DHSC) and the relevant infection control guidelines, particularly if new or alternative suppliers are being used?
• Is there a plan in place for circumstances in which the Provider runs out of PPE and how would a “worst case scenario” be managed?
• Is there a mechanism for responding to specific concerns or questions raised by staff, service users and others?
• Is there sufficient documentary evidence of all actions and decisions, and the supporting reasons, in the event that questions or claims are raised at a later date?

PPE and Resuscitation Activity

Provider’s should ensure staff are aware of the PPE requirements when service user’s require resuscitation.

The most recent Guidance notes that the highest risk of transmission of respiratory viruses is during Aerosol Generating Procedures (‘AGPs’) of the respiratory tract and use of enhanced respiratory protective equipment is indicated for health care professionals performing or assisting with such procedures. In such circumstances, a long sleeved-disposable fluid repellent gown/disposable fluid repellent coveralls, a filtering face piece class 3 (‘FFP3’) respirators, a full face shield/visor and gloves are recommended (‘Enhanced PPE’) during AGPs regardless of the clinical setting and irrespective of care status in contexts of sustained Covid-19 transmission (i.e. whether or not there are possible or confirmed cases of Covid-19 at a service).

PHE guidance goes on to note that chest compressions and defibrillation (as part of resuscitation) are not considered AGPs and first responders (in any setting) can commence chest compressions and defibrillation without the need for Enhanced PPE while awaiting the arrival of other clinicians to undertake airway manoeuvres.

However, ‘supplementary’ guidance issued by the Resuscitation Council UK (‘RCUK’) makes the picture less clear. The RCUK position is that where there are possible or confirmed cases of Covid-19 at a service, ‘Level 3 PPE’ should be worn by all members of the resuscitation team before entering the room and no chest compressions or airway procedures should be undertaken without Level 3 PPE. ‘Level 3 PPE’ appears to be the equivalent of the Enhanced PPE specified by PHE. RCUK guidance also states that mouth to mouth ventilation should not occur and the number of staff in the room should be restricted.

The key difference between RCUK and PHE’s guidance, as identified in RCUK’s statement dated 20 April 2020, is that RCUK consider chest compressions to be AGPs whereas PHE does not consider chest compressions to be AGPs as set out above.

The guidance documents referred to above can be found here and here. 

The Guidance has been updated recently to address this discrepancy (as acknowledged by RCUK on 28 April 2020) however, PHE have not changed their stance on whether chest compressions are considered to be AGPs and have simply stated the following:

“Based on the NERVTAG evidence review and consensus statement, chest compressions will not be added to the list of AGPs. Healthcare organisations may choose to advise their clinical staff to wear FFP3 respirators, gowns, eye protection and gloves when performing chest compressions but it is strongly advised that there is no potential delay in delivering this life saving intervention. Table 4 in the revised PPE guidance recommends clinicians wear PPE during sessions in all settings when they assume there is widespread transmission in the community.”

There is an apparent conflict between the respective guidance and it is therefore recommended that provider’s consider this issue on a pre-emptive basis and provide guidance to staff on the actions that should be taken if needed. This decision around how these risks should be balanced, and the reasons for it should then be clearly documented and communicated to members of staff.

Practical Tips for Providers

There are a number of issues for Providers to consider and monitor in relation to the use of PPE in the context of Covid-19 and these issues are likely to subsist for some time as we begin the gradual process of recovery through the pandemic. This is an issue which should be carefully managed to mitigate the risks of civil claims and regulatory scrutiny both now and in the future. We have set out below some ‘top tips’ to assist in managing this issue:

• Ensure you are up to date with and aware of all relevant guidance in relation to PPE – the guidance and associated risks are changing rapidly and it is important that practical arrangements are in place to keep pace with these changes as effectively as possible;
• Continue to discuss and risk assess PPE at a Senior Management and local level and clearly document these discussions as evidence of the attention and resource being provided to manage the associated issues;
• Monitor levels of PPE at an organisational and local level to ensure you have taken all reasonably practicable steps to ensure safe care is being provided to service users and staff are able to work in a safe environment; and
• Provide staff with clear training and guidance in relation to the use of PPE including the level of PPE required depending on the setting and context.

If you require any specific guidance and / or advice in relation to this issue, please do not hesitate to contact a member of our team.