Use of personal protective equipment during the COVID-19 pandemic

This article provides an introduction to personal protective equipment (PPE) and looks at the latest guidelines in the context of nursing patients with COVID-19 in the UK. The current situation is such that the reader should continue to refer to contemporary guidelines because they are frequently updated as the situation evolves.

COVID-19 is an infectious respiratory disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Public Health England (PHE), 2020a). The SARS-CoV-2 virus replicates efficiently in the upper respiratory tract and appears to cause less abrupt onset of symptoms than the common cold, which means that infected individuals carry on usual activities for longer, increasing asymptomatic transmission of infection (Heymann and Shindo, 2020). The virus is primarily transmitted between people through respiratory droplets and contaminated objects; airborne transmission may be possible in specific circumstances where aerosol-generating procedures (AGP), such as suctioning, are performed (World Health Organization (WHO), 2020a).

The UK has seen widespread transmission of the virus with outbreaks in long-term care homes associated with high mortality, highlighting the extreme vulnerability of the elderly in this setting. The introduction of physical distancing measures, such as the cancellations of large gatherings and the closure of educational and public spaces, alongside ‚Äėstay at home‚Äô policies has collectively helped reduce transmission and the 14-day incidence by 18% since 8 April 2020. The reduction in lockdown measures and relaxation of physical distancing, implemented since 23 June reflects a further reduction in incidence rate within England. Data from¬†Gov.uk¬†as of 30 June indicate a growth rate of -4% to -2% in the UK, demonstrating an overall reduction in disease spread (Gov.uk, 2020a). The overall number of deaths involving COVID-19 at the time of writing is currently at its lowest level in the past 12 weeks (Office for National Statistics, 2020).

The risk of severe disease in the UK is currently considered low to moderate for the general population, but moderate to very high for populations with risk factors (aged more than 65 years of age and/or those with underlying health conditions. This is about 31% of the population of European heritage, depending on the effectiveness of physical distancing and the current level of community transmission (European Centre for Disease Prevention and Control, 2020). Daily situation reports from the WHO, while showing decreasing cases since the peak of the pandemic, continue to demonstrate that the UK has the highest number of deaths to date in Europe, with 43 550 as of 29 June, exceeded only by the USA and Brazil globally (WHO, 2020b).

The ability to limit the transmission of COVID-19, the disease caused by the novel coronavirus, in the healthcare setting requires infection prevention and control measures, of which PPE is a fundamental element (PHE, 2020b). This is essential to limit the acquisition and transmission of the virus to protect both health professionals, the patients they care for and the wider community. Protecting health professionals not only limits disease spread, but also ensures that there are adequate numbers of staff to cope with inevitable increasing demands for healthcare services in the coming weeks and months ahead.

When used correctly, PPE such as gloves, aprons, eye protection, masks and gowns function as a physical barrier to the transmission of infectious particles present in bodily fluids. It also protects patients from transmission via the contaminated hands or clothing of healthcare staff (Brown et al, 2019).

PPE supplies

Sufficient supply of PPE is essential to meet increased demand during the COVID-19 pandemic. The Government has sought to put measures in place to improve supply chains and provisions of PPE by, for example:

  • Enabling the Health and Safety Executive (HSE) and local authorities to fast track product safety assessment processes and prioritise this activity

  • Allowing PPE lacking a European CE safety mark on to the market, provided that it meets essential safety requirements (Gov.uk, 2020b)

  • Making a public callout for organisations that can manufacture and supply testing consumables, equipment and laboratory PPE (Department of Health and Social Care (DHSC), 2020).

Mitigating risk

UK-wide guidance on PPE for the care of patients with suspected or confirmed COVID-19 was updated on 18 June, issued jointly by PHE, NHS England and other key stakeholders across the devolved nations (PHE, 2020c).

There are risks to both staff and patients with respect to inappropriate use of PPE, namely cross-contamination and the spread of infection. Bovin (2015) highlighted the reasons that can lead to inappropriate use, which include:

  • Lack of awareness about the importance of PPE

  • Time constraints for donning/doffing the equipment

  • Lack of realisation about the importance of the technique for proper safe removal.

All of the above ultimately relies on staff being properly educated on the use of PPE.

Concerns regarding the sufficient supply of PPE and the evolving nature of the current pandemic, with many staff working in unfamiliar areas with unfamiliar equipment, may serve to further compound issues in relation to inappropriate use of PPE and the risks this presents.

It is important to give due consideration to several issues in order to mitigate risk: the associated risk with incorrect use of PPE highlights the importance of carrying out donning and doffing in the correct sequence. PHE (2020c) cites the importance of safe ways for working for health and care workers, which includes ensuring that staff are trained on correct donning and doffing of PPE and staff knowing which PPE they should wear in each setting and context.

Although there is a recognised standardised order of donning PPE, the most critical is the exact sequence for doffing it. Figure 1 provides a step-by-step quick guide to donning and doffing standard PPE for health and social care settings (PHE, 2020d)). For donning and doffing AGP PPE, see Figure 2 and Figure 3 (PHE, 2020e). Box 1 provides a list of PHE guidance on the recommended PPE for different settings, with web links to the information.

Figure 1.

Figure 1. Quick guide to the correct sequence for donning and doffing standard PPE in health and social care settings, https://tinyurl.com/standard-dondoff

Figure 2.

Figure 2. PHE quick guide to donning personal protective equipment for aerosol-generating procedures, https://tinyurl.com/qk-donning-agp-ppe

Figure 3.

Figure 3. PHE quick guide to doffing personal protective equipment for aerosol-generating procedures, https://tinyurl.com/qk-doffing-agp

Box 1. COVID-19 guidance on donning and doffing standard and aerosol-generating PPE, and which equipment to use in which settings,

* Available as posters from Public Health England

Updated guidance from PHE has sought to provide clarity regarding the use of the right COVID-19 PPE and is, in some part, a response to the concerns of healthcare unions and national media coverage regarding the risks associated with an insufficient supply of PPE. The updated guidance ensures that PPE is used appropriately in order to ensure stock control, and maintain the safety of nursing staff, key personnel and patients. The guidance relates solely to considerations for PPE and represents one element of infection prevention control guidance for dealing with COVID-19 and it should therefore be used alongside local policies (PHE, 2020c).

PHE guidance on COVID-19 PPE

Recommendations for practice: a summary of the main changes to the previous guidance are presented in Box 2; the guidance was updated to reflect the evolving situation and the changing level of risk of healthcare exposure to COVID-19. Certain areas of practice may pose a higher risk of transmission (Box 3), with AGPs presenting an increased risk of transmission. The updated guidance also highlights the need for enhanced protection of patients in vulnerable groups, undergoing social shielding.

Box 2. Summary of main changes to previous guidance
  • Enhanced recommendations for a wide range of health and social care contexts

  • Inclusion of individual and organisational risk assessment at local level to inform PPE use

  • Recommendation for single sessional (extended) use of SOME PPE items

  • Re-usable PPE can be used with reference to manufacturers, supplier and local infection control guidance on decontamination

  • Guidance for when case status is unknown in areas of high-level incidence

  • Recommendation of patient use of face masks

  • Emphasising staff are able to risk assess if there is a risk to themselves or the individuals in their PPE decision making on wearing a mask

  • Recommendation on the use of disposable fluid-repellent coveralls as an alternative to long-sleeved fluid-repellent gowns for aerosol-generating procedures or when working in higher risk acute areas. Staff need to be trained in the safe removal of coveralls

Source: Public Health England, 2020c
Box 3. Areas of higher risk of transmission

A higher risk acute inpatient care area is defined as a clinical environment where AGPs are regularly performed. Higher risk acute care areas include:

  • Intensive care and high dependency care units (ICU or HDU)

  • Emergency department resuscitation areas

  • Wards or clinical areas where AGPs are regularly performed (such as wards with NIV or CPAP)

  • Operating theatres, where AGPs are performed

  • Endoscopy units, where bronchoscopy, upper gastrointestinal or nasoendoscopy are performed

Source: Public Health England, 2020c

NHS National Medical Director Stephen Powis, Chief Medical Officer for England Chris Whitty and PHE National Incident Director for COVID-19 Susan Hopkins (Powis et al, 2020) summarised the initial guidance in relation to COVID-19 and PPE, which were consistent with WHO recommendations, in settings with the highest risk of transmission, as follows:

  • In some circumstances PPE, particularly masks and eye protection that are there to protect health and care workers, can be worn for an entire session and do not need to be changed between patients, as long as it is safe to do so

  • When carrying out AGPs clinicians should wear a higher level of protective equipment

  • Use of aprons rather than gowns for non-AGPs, including guidance to thoroughly wash forearms if there is a risk of exposure to droplets, consistent with the UK policy of bare below the elbows and evidence reviews on the risks of healthcare-acquired infections

  • WHO (2020c)¬†recommends the use of FFP2 face masks, but the UK has gone further in recommending the use of FFP3 face masks. However, FFP2 masks have been approved by the WHO and can be used safely, if needed. There is good stock of FFP3 face masks in the UK.

Respirators and face masks

The HSE (2020a) has stated that FFP2 and N95 respirators (filtering at least 94% and 95% of airborne particles respectively) offer protection against COVID-19 and may be used if FFP3 respirators are not available (DHSC, 2020). FFP3 respirators filter at least 99% of airborne particles and it could therefore be argued are more effective protection against COVID-19. It should be noted that the cost of FFP3 face masks is higher than that of FFP2 masks; the stock price of a single FFP mask varies, with one source retailing FFP2 for £15 and FFP3 for £30 (UKMeds, 2020).

Despite assurances from government during this pandemic of the sufficient supply of PPE, healthcare unions and frontline staff continue to raise concerns regarding the provision of appropriate PPE (Kinnair, 2020).

Some clarity should also be given to the recommendation regarding the use of surgical face masks: these protect against infectious agents transmitted by droplets, such as saliva or secretions exhaled from the upper respiratory tract. If worn by the caregiver, the mask protects the patient and the environment, and protects the wearer from splashes of biological fluids. If worn by an infected patient, it prevents contamination to the surrounding environment. Surgical masks may also be equipped with a visor for eye protection. In contrast to FFP3 masks, they do not offer protection against airborne transmission (Sampol, 2020).

Feng et al (2020) have highlighted the argument that surgical face masks provide no effective protection against COVID-19 infection; however, the authors also note that guidance within the UK indicates that, although there is little evidence of widespread benefit for members of the public, they do play an important role in hospitals.

PHE and other healthcare agencies (PHE, 2020f) have provided guidance on PPE recommended for health staff working across a range of settings. SeeBox 1 for details.

PPE during cardiopulmonary resuscitation

The Resuscitation Council (UK) (RCUK) has indicated that it was not involved in the initial preparation of PHE guidance on the use of PPE. It published an updated statement on PHE PPE guidance on 28 April 2020 (https://tinyurl.com/y8e3jcua) (RCUK, 2020a). It has provided several resources for healthcare settings, including a statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings, which includes a flowchart (https://tinyurl.com/COVID-RCUK) (RCUK, 2020b).

FFP3: fit testing

Fit testing is a method of checking that a specific model and size of a tight-fitting face piece matches the wearer's facial features and seals adequately to the person's face (HSE, 2019). HSE has provided guidance on the use of disposable respirators (HSE, 2020b) (Figure 4).

Figure 4.

Figure 4. Checking the fit of a disposable respirator. Full guidance on using a disposable respirator at https://tinyurl.com/hse-disposable-resp

The HSE (2019) states that all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers' guidance). This must be repeated for each different mask manufacturer and has led to staff being required to be fit tested each time a particular face mask went out of stock and was replaced by a different make of FFP3.

In some instances where staff fail a fit test on one type of mask, they may pass on a mask from another manufacturer, therefore, clinical areas are required to keep a stock of various FFP3 face masks for different staff for this reason (PHE, 2020c). Compliance with HSE guidance regarding fit-testing requirements presents practical difficulties during a pandemic, where hundreds of staff require appropriate provision of this equipment.

PHE summary

The updated guidelines provide an extensive summary of care contexts, sessional use and risk assessment in relation to PPE. Healthcare trusts and all nurses should ensure that they are familiar with the recommendations for PPE in their particular area of practice alongside local infection prevention and control policies.

PHE (2020c) summarises safe ways of working for all healthcare workers including:

  • Staff should be trained on donning and doffing PPE and videos should be available for training

  • Staff should know what PPE they should wear for each setting and context

  • Staff should have access to the PPE that protects them for the appropriate setting and context

  • Gloves and aprons are subject to single use, with disposal after each patient or resident contact

  • Fluid-repellent surgical mask and eye protection can be used for a session of work, rather than a single patient or resident contact

  • Gowns or coveralls can be worn for a session of work in higher risk areas

  • All staff should adhere to social distancing (2 metres) wherever possible, particularly if not wearing PPE and in non-clinical areas, for example during work breaks and when in communal areas

  • Hand hygiene should be practised and extended to exposed forearms, after removing any element of PPE

  • Staff should take regular breaks and rest periods; consider staggering staff breaks to limit the density of healthcare workers in specific areas.

Sessional use

It is important to note that there remains a lack of clarity regarding ‚Äėsessional‚Äô versus ‚Äėsingle‚Äô use. Once stock issues in relation to the amount of PPE available for staff were identified, together with a need to potentially cohort patients in a specific area, guidance switched from single-use PPE to some equipment being used on a ‚Äėsessional‚Äô basis.

PHE (2020c)¬†does not specifically define the duration of a ‚Äėsession‚Äô, making reference to a single session as a period of time where a health and social care worker is undertaking duties in a specific clinical care setting or exposure environment, for example during a ward round or when providing ongoing care for inpatients¬†PHE (2020f).¬†PHE (2020c)¬†further advocates the need to follow manufacturing instructions and local risk assessment regarding the appropriateness of single versus sessional use, dependent on the nature of the activity. A session ends when the healthcare worker leaves the care setting/exposure environment. Sessional use should always be risk assessed and considered where there are high rates of hospital cases. PPE should be disposed of after each session or earlier, if damaged, soiled or uncomfortable.

Skin integrity

The increasing use of FFP3 respirators has presented an additional risk for some healthcare workers. As Payne (2020) highlights, the prolonged wearing of tight-fitting FFP3 masks has caused some healthcare workers to suffer skin damage, frequently around the bridge of the nose, from the constant pressure applied to the skin by the face mask.

Continuous use of surgical masks also can cause soreness on the skin from the straps of the mask resting on the upper ears. This has led to NHS England (2020) issuing an alert detailing how to prevent facial skin damage beneath PPE. Although advocating the prevention of skin damage, it recognises that skin breaks may occur and provides advice regarding how to manage pressure-damaged skin.

Hand hygiene

As previously discussed, there is a hierarchy of infection control measures, of which PPE is one aspect. Standard of infection control precautions (SICPs) remain paramount. This includes single use of gloves and aprons (and their appropriate disposal), with hand hygiene after each patient contact (PHE, 2020c).

PHE (2020f) details the best practice handwashing technique (see Box 1 and https://tinyurl.com/phe-handwashing).

In addition, PHE (2020g), in issuing new guidance to NHS teams, highlights the need to wash not only the hands, but also thoroughly washing the forearms, if there is a risk of exposure to droplets if an apron has been worn.

Conclusion

Staff working without appropriate PPE, or using PPE inappropriately, are at significant risk of infection, potentially increasing transmission, and leading to reduced workforce capacity and potentially higher mortality.

Updated guidance seeks to inform nurses of the right PPE to use, depending on their care setting and the procedures undertaken. PHE guidance provides extensive instruction on the use of PPE for standard care or when carrying out an AGP, or working in an area of high risk, during the COVID-19 pandemic. However, updated guidelines in relation to cardiopulmonary resuscitation are required in the context of the updated PHE recommendations.

Appropriate and timely provision of effective PPE, alongside strict hand hygiene, will contribute to reducing the impact of COVID-19 in both human and economic terms.

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