The medical PPE shortage has been one of the prevailing issues of the Covid-19 epidemic in the UK. With inadequate supply levels inevitably threatening the protection of UK healthcare staff, Public Health England (PHE) have controversially approved the reuse of PPE equipment to optimise supplies during acute shortages. This came after at least 60 NHS trusts warned of near-exhausted PPE supplies. Reuse is defined in two ways at differing levels of risk, which should be considered accordingly:
- Reuse refers to the same item being used again by the same healthcare worker.
- Sessional reuse is where one health or care worker wears the same PPE throughout their shift, while treating different patients.
Various medical experts have spoken of their concerns over the new guidance, which condones the reuse of masks, gowns, coveralls and eye protection. So, given that it contravenes previous WHO and PHE guidelines around safe use, what grounds is this updated advice based on?
The official published document, Considerations for Acute PPE Shortages, has been reviewed by the Health and Safety Executive (HSE), and states that the revised directive is in line with ‘current evidence’. It also asserts that the guidance is in line with that of the Centers for Disease Control (CDC) and World Health Organization (WHO). It claims that their recommendations for reuse are within health and safety regulations, providing “appropriate protection for health and care workers”.
The publication acknowledges that while some of the NHS COVID-19 Ensemble is single-use PPE only, compromise is necessary to optimise supplies. However, attention is drawn to the fact that these are exceptional circumstances which do not reflect HSE’s standard approach. It was reported mere days prior to this new amendment that the reuse of supplies was a ‘last-resort’ plan. There are exceptions to this guidance, though – the reuse of some equipment, such as aprons and gloves, is still prohibited. The new advice also states that in the absence of full-length gowns, aprons can be worn instead – a practice which would have been deemed unacceptable just weeks ago.
So what are the principles of wearing medical PPE, and can the reuse of PPE realistically be safely implemented during Covid-19?
The Importance of Wearing PPE
The PPE at Work Regulations were created under the Health and Safety at Work etc. Act 1974, to place a duty of care on employers to protect their workers. It stated that employees must be provided with PPE where their health or safety may be at risk from their work.
HSE advises that in order to make the workplace safe, it is necessary to wear PPE. In health and social care settings, PPE protective clothing is designed to safeguard workers against biological hazards, such as exposure to coronavirus. Injuries to the lungs are a key risk which PPE serves to mitigate, so as Covid-19 is a respiratory illness, it is crucial that healthcare workers make proper use of equipment which offers this kind of protection.
The hazard of not wearing PPE for those exposed to Covid-19 can be deadly, so the shortage of stock is a dire situation which authorities have been fighting against the clock to come up with solutions for. However, the reuse of PPE as a means to cope with depleted supplies is seen by many as the worst possible answer. Michael Griffin, president of the Royal College of Surgeons of Edinburgh, stated that the reuse, or even absence of equipment by frontline staff is a severe risk to both clinicians and patients, especially in surgical settings.
When to Use PPE in Healthcare
HSE advises that before using PPE, consideration must be given to who is exposed, what they are exposed to, the length of time exposure occurs for, and the amount of exposure. They state that adherence is still necessary even if workers are exposed to risk for a minimal amount of time. Those most at risk of Covid-19 transmission are professionals working within health and social care settings, so their level of protection should not be compromised.
Respiratory protective equipment (RPE), should be worn by those who may breathe in contaminated air. RPE includes respirators, which filter out harmful substances from the air; and breathing apparatus, which provide clean air for breathing. PPE should also be worn by domestic / cleaning staff undertaking environmental decontamination in Covid-19 treatment or risk areas, after proper training in its use.
The standard PPE kit in the UK should include a surgical gown, surgical gloves, visor, goggles, alcohol hand rub, and an FF3 respirator. PHE guidance states that where a higher level of risk is found to be present, additional PPE should be worn. Clinicians in hospitals, primary care or community care settings, who will be within two metres of suspected / confirmed Covid-19 patients, should take extra protective measures designed for airborne infections, by wearing additional items including a mask or face shield, head cover and rubber boots.
WHO recommend the use of FFP2 masks, but PHE took further steps in recommending FFP3 masks, while maintaining that either can be safely used. One of the most critical issues with the guidance for reusing PPE is that the risk of contamination is increased exponentially in high-exposure settings such as the operating theatre.
How to Use PPE Properly
PPE requirements state that employees should be trained in how to use equipment before use. The PPE wearing sequence is designed to give proper steps to donning (putting on) and doffing (taking off) protective wear. Respirators must fit properly, with a fit test advised prior to use, and provide adequately-controlled inhalation exposure.
PPE waste should be treated as clinical waste, according to PHE guidelines. While medical uniforms will be protected by PPE “in most circumstances”, they should be laundered by healthcare laundry services where available; otherwise transported home in a disposable plastic bag. These stringent procedures for cleaning the uniforms worn underneath PPE gives an indication of the risks involved with reusing the PPE itself. With disposable PPE, there is no effective method of disinfection, so in ideal circumstances, reuse would be completely avoided.
The current guidelines for reuse have been refuted by various medical bodies. Rob Harwood, Consultants Committee chairman at the British Medical Association, stated that such advice must be “demonstrably driven by science”, but there is currently no evidence of such corroboration. The Royal College of Nursing states that if your employer asks you to reuse PPE, you should raise several questions in writing. These include querying the additional risks to you and your colleagues, which control measures have been considered, the agreed action plan for the shortage, and the length of time expected for reusing equipment.
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