Introduction
January 20th 2020 was an auspicious day for two reasons; first, two Chinese nationals staying in York tested positive for Corona virus disease 19 (Covid-19) and second, an evacuation flight of British nationals arrived from Wuhan, and its occupants were placed into a 14-day quarantine at a specialist hospital.1
The World Health Organization consider that the virus is transmitted primarily through respiratory droplets and direct contact with infected people, and indirect contact with surfaces in the immediate environment or with objects used on the infected person.2 Accordingly, health care professionals (HCPs) need appropriate protective equipment to protect them from potential infection from an infected patient and to prevent cross-infection between patients in their care.
Which PPE?
In April 2020, Public Health England (PHE) updated its guidance on the use of PPE, including the reuse of certain pieces of equipment.3 It is not the intention of this article to consider this change either from a legal or moral view, rather to reflect the guidance as it stands at the time of writing. The PHE guidance lays out which equipment should be used by whom in which care setting and in accordance with risk-assessment. An example of the clinical areas where PPE is to be used and at what level is summarised below and in table 1.
Areas where aerosol generating procedures (AGPs) are undertaken
These include intensive care and/or high=dependency units, operating theatres, resuscitation areas of emergency departments and clinical areas where AGPs are performed, such as wards with non-invasive ventilation (NIV) or Continuous Positive Airway Pressure Ventilation (CPAP).
The AGP procedures deemed to be potentially infectious include (PHE 2020):
- intubation, extubation and related procedures such as manual ventilation and open respiratory tract suctioning (including the upper respiratory tract)
- tracheotomy or tracheostomy (insertion or open suctioning or removal)
- surgery and post-mortems involving high-speed devices
- non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
- high frequency oscillatory ventilation (HFOV), high flow nasal oxygen (HFNO)
In these areas, practitioners are required to wear a long-sleeved disposable fluid repellent gown/overall (covering the arms and body), a filtering face piece class 3 (FFP3) respirator, a full-face shield or visor and gloves for both possible and confirmed cases. Where an AGP is a single procedure, PPE is subject to single use with disposal after each patient contact or procedure as appropriate.
Inpatient areas with possible or confirmed COVID-19 cases
A fluid resistant surgical facemask (FRSM) (Type IIR) whether or not involved in direct patient care. Disposable gloves, aprons and eye protection should be worn if giving direct care. If there are no identified possible or confirmed cases, aprons, gloves and FRSMs may be indicated dependent on intensity of COVID-19 transmission in the local context and the nature of clinical care undertaken.
Operating theatres (no AGP undertaken)
Standard infection prevention control (IPC) should be adopted. Additional FRSM and eye protection is required for any possible or confirmed cases, and long-sleeved disposable fluid repellent gowns are indicated for possible and confirmed cases when there is perceived risk of exposure to bodily fluids.
Issues of PPE
According to a recent BBC report, the personal protective equipment (PPE) available to the front-line health care professionals caring for Covid-19 patients, is not particularly suitable for women, despite its ‘unisex’ design.4 In particular, for some female (and male) workers, the smallest size of gown is still too big, which compromises the effectiveness of the equipment, and gloves and goggles often are not produced in appropriate sizes. This problem of ‘female-sized’ equipment was highlighted in a 2017 Trades Union Congress report.5 Their survey found that 57% of women stated that their PPE sometimes or significantly hampered their work.5
The full-length gowns, gloves, masks and face-shields can become hot and uncomfortable to wear, particularly challenging on an eight or twelve-hour shift. In addition, the N95 mask, usually used in the United States of America, only comes in two sizes; most people’s faces don’t.
These issues arise because PPE is generally based on the sizes and characteristics of European and United States male populations, therefore most women, and some men from black and minority ethnic groups or with facial hair, will find that respiratory protective equipment, overalls, eye protectors, gloves and boots do not fit. A smaller size or scaled-down version of such equipment is not the solution; face and body characteristics need to be taken into account.
Continuing challenges relate to the well-documented difficulties on accessing personal protective equipment (PPE) in the United Kingdom.6 Acute care services were not alone in being affected; General Practitioners surgeries and other primary care settings faced problems (Box 1).
These problems are in part, due to the sheer number of pieces of equipment required. Consequently, emergency PPE may not be of the same brand usually used; for example, up to five different brands of FFP3 masks have been delivered.6 In order to meet Health and Safety Executive regulations each mask requires fit testing, which can take up to an hour each time.7
Public Health England guidance states that both FFP3 and fluid-resistant (Type IIR) surgical masks (FRSM) facial masks are for single use or single session use. This places a burden on both supply and cost.6
Well-fitted eye and face protection is required against eye from respiratory droplets, aerosols (from AGPs) and from splashing of secretions (including respiratory secretions).6
Such protection is provided by:
- a surgical mask with integrated visor
- a full face shield or visor
- polycarbonate safety spectacles or equivalent
Again, this protective equipment is for single or single session use only. However, Public Health England suggest that re-usable eye and face protection can be used if it is decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.6
The current Covid-19 pandemic has also highlighted the enormous supply and demand issues caused by the first serious global pathogenic threat in a Century. The lack of genuine preparedness not only led to serious and perhaps unnecessary risk to health amongst frontline workers in healthcare, security, transport, etc, but also commercial exploitation and potential for negative environmental impact.
Conclusion
Some of the challenges related to the acquisition and use of personal protective equipment have been raised in this article. At the time of writing, Lord Deighton has been charged with heading a task-force to lead the national effort to produce essential personal protective equipment (PPE) for frontline health and social care staff. The Government have asked industry to make essential PPE that meets our technical specifications. This has provided an opportunity for novel products to be evaluated; one such product, the Virimask eye and face protection unit, will be presented in the next article in this series.
If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.
References
- Holmes F. Covid-19 Timeline. British Foreign Policy Group. April 2020. Available at: https://bfpg.co.uk/2020/04/covid-19-timeline/
- World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. March 2010. Available at: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
- Public Health England. Guidance COVID-19 personal protective equipment (PPE). May 2020. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-4. and-control/covid-19-personal-protective-equipment-ppe
- Kleinman Z. PPE ‘designed for women’ needed on frontline. Available at: https://www.bbc.co.uk/news/health-52454741
- Trades Union Congress. Personal protective equipment and women. 2017. Available at: https://www.tuc.org.uk/sites/default/files/PPEandwomenguidance.pdf
- NHS Providers. The Supply of Personal Protective Equipment. NHSP. April 2020. Available at: https://nhsproviders.org/media/689480/nhs-providers-briefing-spotlight-onthe-supply-of-personal-protective-equipment.pdf
- Health and Safety Executive. Fit testing face masks to avoid transmission during the coronavirus outbreak. HSE. 2020. Available at: https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm
Box 1: Accessing PPE: A practitioner’s personal experience
This reflects the experience of a senior practitioner in a Clinical Commissioning Group. Given the potential issues arising from speaking truth to power, the author wishes to remain anonymous.
“We are in the 8th week of Covid 19 lock-down, yet guidance on what constitutes an appropriate PPE for general practices, the regularity of the supply chain and the escalation processes remain muddled and ineffective.
As per the national guidance, general practices are provided with surgical masks, aprons and gloves. The Government directed General practitioners (GPs) and Clinical Commissioning Groups (CCGs) to set up ‘hot zones’ and respiratory clinics to provide clinical services to patients with respiratory symptoms. However, as full-length gowns and FFP3 mask supplies have been limited to those care services performing aerosol generating procedures, the GPs refused to work in the respiratory clinics due to the transmission risk.
Clinical Commissioning Groups and GPs are expected to source their own PPF3 masks, eye protection/face visors and surgical gowns. In addition, the processes required to order PPE via the national supply chain, and the escalation route through local resilience forum (LRF) should the normal supply chain are unable to provide the PPE in time, are failing. Daily feedback from the practices indicate that clinics are being cancelled due to lack of PPE; supplies are irregular and/or not of the amount requested, out of date, or the wrong size. PPE supply problem affects GPs and other parts of the health and social care systems; the lack of PPE in community home visiting services, secondary care and care home settings has often led to disruption of services, with local organisations arranging PPE for provider services at premium prices.
Sourcing PPE has almost become a full-time job for commissioners and providers which they could have done without. As the lock-down eases and more regular patient facing services are back up and running, situation will only get worse if the PPE national response does not improve soon.”
Tables
Table 1: Summary of PPE required in Clinical Areas
| Areas where AGPs are performed | Inpatient areas with possible or confirmed COVID-19 cases | Operating theatres (no AGP undertaken) | |
|---|---|---|---|
| Long-sleeved, fluid repellent gown (cover arms and body) | At all times | Where perceived risk of exposure to bodily fluids | |
| Filtering face-piece (FFP3) respirator | At all times | ||
| Full-face shield or visor | At all times | ||
| Gloves | At all times | ||
| Fluid-resistance surgical facemask (FRSM Type IIR) | At all times | Possible and confirmed cases | |
| Disposable gloves | Giving direct care | ||
| Disposable apron | Giving direct care | ||
| Eye protection | Giving direct care | Possible and confirmed cases |
