The use and supply of personal protective equipment

First published: 07/04/2020 Last updated: 07/05/2020

Introduction

There have been strong concerns among our members and the wider health sector that appropriate personal protective equipment (PPE) is not reaching teams in the quantity needed and in a timely fashion, leaving many staff feeling unable to safely provide care for patients. This briefing summarises the current guidance on PPE and the arrangements for its distribution.

Updated guidance (10 April 2020) from the Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland, Public Health England and NHS England and NHS Improvement clarifies the type of PPE required for different circumstances. Guidance on PPE will be kept under review.

The key changes to PPE guidance are:

• enhanced PPE 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 of single sessional (extended) use of some PPE items
• updated guidance on 10 April includes 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.

NEW: Public Health England has released new guidance for times of acute PPE shortages. It includes recommendations on reusing medical masks and options that can be considered as alternatives if gowns are not available.

The following sections provide a summary of the recommendations relevant to different areas of care.

Secondary care

Aerosol generating procedures and higher risk areas

• A long-sleeved disposable fluid repellent gown (covering the arms and body) or disposable fluid repellent coverall, a filtering face piece class 3 (FFP3) respirator, a full-face shield or visor and gloves are recommended during aerosol generating procedures (AGPs) involving possible and confirmed COVID-19 cases.
• For those working in higher risk acute inpatient care areas, where AGPs are regularly performed and there are confirmed cases, long-sleeved disposable fluid repellent gowns (or disposable fluid repellent coveralls), FFP3 respirators, eye protection, and gloves must be worn. If non-fluid-resistant gowns are used, a disposable plastic apron should be worn underneath.
• Updated guidance on 10 April states that disposable fluid repellent coveralls can be used as an alternative to long-sleeved fluid repellent gowns for aerosol generating procedures or when working in higher risk acute areas.

Other areas

• For health and social care workers entering or present in any other inpatient area (for example, wards) containing possible or confirmed COVID-19 cases, a fluid resistant (Type IIR) surgical face mask (FRSM) should be worn, whether or not they are involved in direct patient care. When undertaking any direct patient care in these areas, disposable gloves, aprons and eye protection should be worn.
• For health and social care workers working in inpatient areas with no identified possible or confirmed cases, use of PPE should be risk assessed. Aprons, gloves and FRSMs may be indicated in certain inpatient areas dependent on intensity of COVID-19 transmission in the local context and the nature of clinical care undertaken.
• For operations without AGPs, standard infection prevention and control practice should be adopted as normal for the procedure with additional use of FRSM and eye protection for any possible or confirmed cases. Use of long-sleeved disposable fluid repellent gowns is indicated for possible and confirmed cases when there is perceived risk of exposure to bodily fluids.
• For care of possible or confirmed cases during the second and third stage of labour (vaginal delivery) long-sleeved disposable fluid repellent gowns, plastic aprons, FRSMs, eye protection and gloves should be used.

View the visual explainer of PPE recommendations for health and social care workers in secondary care inpatient clinical settings.

Primary care

• Plastic aprons, fluid-resistant surgical masks (FRSMs), eye protection and gloves should be used for any direct care of possible and confirmed cases. Such PPE may be indicated for work in such settings regardless of case status, subject to local risk assessment.
• For health and social care workers working in reception and communal areas but not involved in direct patient care, every effort should be made to maintain social distancing of two metres. Where this is not practical, use of FRSM is recommended.
• For provision of direct care to any member of a household where one or more is a possible or confirmed case, plastic aprons, FRSMs, eye protection and gloves are recommended.
• For delivery of care to any individual meeting criteria for shielding (vulnerable groups) or where anyone in the household meets criteria for shielding, as a minimum, single use disposable plastic aprons, surgical mask and gloves must be worn for the protection of the patient. If the individual is encountered in any context described, or if they meet the case definition, then additional PPE should be applied as above.
• The principles described in this guidance apply to all health and social care settings.
• Evidence from the Centre of Evidence-Based Medicine on PPE in primary care (30 March) suggests that, for non-AGP, there is no evidence that respirator masks add value over standard masks when both are used wiht recommended wider PPE measures.

Mental health and community care

• For direct care of possible or confirmed cases in facilities such as community care homes, mental health inpatient units, learning disability residential units, hospices, prisons and other overnight care units, plastic aprons, FRSMs and gloves should be used. The need for eye protection is subject to risk assessment, depending on whether the nature of care and whether the individual symptoms present risk of droplet transmission.
• For provision of direct care in a patient household where one or more member is a possible or confirmed case, plastic aprons, FRSMs, eye protection and gloves are recommended.
• For delivery of care to any individual meeting criteria for shielding (vulnerable groups) or where anyone in the household meets criteria for shielding, as a minimum, single use disposable plastic aprons, surgical mask and gloves must be worn for the protection of the patient.

View the visual explainer of recommended PPE for primary, outpatient and community care settings.

Ambulance staff

• Where AGPs such as intubation are performed, PPE guidance set out for AGPs (see above) should be followed (disposable fluid repellent coveralls may be used in place of long-sleeved disposable gowns)
• For any direct care of a patient known to meet the case definition for a possible case, plastic apron, FRSMs, eye protection and gloves should be used.
• Where it is impractical to ascertain case status of individual patients prior to care, use of PPE including aprons, gloves, FRSM and eye protection should be subject to risk assessment according to local context.
• PPE is not required for ambulance drivers of a vehicle with a bulkhead and those otherwise able to maintain social distancing of two metres. If the vehicle does not have a bulkhead then use of a FRSM is indicated for the driver.
• Updated guidance on 10 April states that ambulance staff conveying a patient into a high-risk area are not required to change or upgrade their PPE for the purposes of patient handover.

Take a look at the visual explainer of recommended PPE for ambulance, paramedics, first responders and pharmacists.

PPE shortages

We are conscious that supply, particularly for gowns, has become a serious concern for members. We are doing all that we can to ensure the government is pursuing all possible avenues to resolving this situation and will keep you updated on any new developments.

We are also aware that some trusts have taken steps to reuse some equipment when there are shortages. PHE has released guidance on what procedures to follow when this is the case. This is summarised below.

Fluid repellent surgical face masks (FRSM) and disposable respirators (FFP3/FFP2/N95)

FFP3/FFP2/N95 respirators have a large capacity for the filtration and retention of airborne contaminants. Sessional use or re-use over the course of a day in health or social care, would not approach anywhere near that capacity.

Important requirements are as follows:

• the mask should be removed and discarded if soiled, damaged, or hard to breath through
• masks with elastic ear hooks should be reused (tie on face masks are less suitable because they are more difficult to remove)
• hand hygiene should be preformed before removing the face mask
• face masks should be carefully folded so the outer surface is held inward and against itself to reduce likely contact with the outer surface during storage
• the folded face mask should be stored between uses in a clean sealable bag/box which is marked with the user's name and is then properly stored in a well-defined place
• hand hygiene should be performed after removing the face mask
• some models of PPE cannot be physically reused as they deform once being donned and do not go back to original condition (meaning it would be difficult to re-don and achieve a fit check). Fit checks should be performed each time a respirator is donned if it is reused.

UPDATED guidance (3 May) states that HSE has examined the use of FFP2 respirators as an alternative to Type IIR surgical face masks in non-surgical settings, finding that:

• in circumstances where a lower level of user protection is required, such as that provided by a surgical mask, an FFP2 worn without a face-fit test will offer protection similar to the levels from a surgical face mask
• if risk assessment identifies a need for FFP2 respirators, such as for AGPs or higher risk acute areas, the user must be face fit tested to ensure they are providing the right level of protection
• surgical masks may sometimes be used for source control, if feasible and if the mask can be tolerated by the individual, for example, a surgical mask worn by a patient with COVID-19 during transfer within a hospital. When an FFP2 respirator needs to be used in place of a surgical mask for this specific purpose, it should be an unvalved FFP2 respirator (that is, no exhale valve).

There is insufficient evidence to consider homemade masks or cloth masks in health and care settings.

Gowns and coveralls

Fluid repellent hospital gowns or coveralls are indicated for use for the care of patients in high-risk areas, where aerosol generating procedures (AGPs) are being performed.

There are three main options that can be considered as alternatives if gowns are not available.

• Reserve disposable, fluid repellent gowns or coveralls for AGPs and surgical procedures.
• Disposable, non-fluid repellent gowns or coveralls with a disposable plastic apron for high-risk settings and AGPs with forearm washing once gown or coverall is removed.
• Reusable (washable) surgical gowns or coveralls or similar suitable clothing (for example, long-sleeved laboratory coat, long-sleeved patient gown or industrial coverall) with a disposable plastic apron for AGPs and high-risk settings with forearm washing once gown or coverall is removed. These would need to be washed in a hospital laundry and capacity for hospital laundries may need to be increased.

PHE guidance currently does not recommend reusing disposable gowns.

Further work on validating methods to safely reprocess masks and fluid repellent gowns is under way. We will update members when this is available.

Eye protection

• Goggles used for healthcare applications are typically reusable.
• If in extremely short supply, single use only visors could be reused in a similar way as reusable items. The standard method of cleaning is to use a detergent product either combined/sequentially with a decontamination product as agreed by the local infection prevention and control (IPC) specialist.

Gloves and aprons

• Do not use double gloves for care of suspected or confirmed COVID-19 patients.
• Sessional use or of reuse examination gloves for clinical care should be avoided.
• Reuse of aprons is not recommended.

This guidance is of a general nature and that an employer should consider the specific conditions of each individual workplace and comply with all applicable legislation.

Supply chain

The demand for PPE is now tens of thousands of times higher than usual and this is impacting the supply chain. NHS England and NHS Improvement is working hard to respond to demand and is confident there is sufficient supply to support this new guidance.

A new parallel supply chain for PPE has been developed set up by NHS Supply Chain, the Ministry of Defence, Unipart Logistics and supported by Clipper Logistics, which will be delivering the service in England and Wales. Access to this supply chain depends on the type of organisation in need, summarised below:

Acute, community, mental health and ambulance trusts

Acute, community, mental health and ambulance trusts receive the daily ‘push’ deliveries from the dedicated PPE channel. Members from these providers who are in emergency need can escalate according to the following steps:

1. Contact your NHS Supply Chain account manager with your stock request. Your account manager will look for both regular national supply and local solutions.
2. If your account manager is unable to source stock, you will be advised to contact the National Supply Disruption Response (NSDR)  helpline 8am-6pm Monday to Friday on 0800 915 9964 (UK) or 0191 383 6543 (overseas). The NSDR will support with fulfilment if possible and escalate if not.

Not all trusts will receive deliveries every day; this is the case only for acute and ambulance trusts. For updates on the content of the deliveries and days of delivery, see the dedicated PPE channel website.

Primary care, adult social care, dentists, pharmacies and third sector

We know that general practice, social care providers and others who do not normally use the NHS supply chain have experienced difficulties. NHS Supply Chain is developing a new e-commerce platform to improve access, which will be rolled out over the next two weeks.

Orders on this new platform will be managed in line with the published guidance from Public Health England, integrated with NHS Supply Chain's central PPE logistic operations and shipped directly via Royal Mail.

The NHS Confederation is continuing to monitor the development of this platform and will update as soon as possible on how it will support members. In the meantime, NHS Supply Chain has advised primary, adult social care, dentists, pharmacies and third sector providers in need of PPE stock to take the following steps:

1. First, try your ‘business as usual’ wholesalers. NHS Supply Chain has shipped PPE to wholesalers in order to increase supply. View the list of wholesalers for GPs and social care providers who have received stock.
2. If wholesaler supply is insufficient, contact your local resilience forum (LRF). NHS Supply Chain has distributed stock to LRFs, who can support GPs and social care providers according to local need.
3. If the LRF is unable to help, contact National Supply Disruption Response (NSDR) helpline 8am-6pm Monday to Friday on 0800 915 9964 (UK) or 0191 383 6543 (overseas). The NSDR will support with fulfilment if possible and escalate if not.

Donations and loans of equipment

Many of our members receive offers of equipment directly from sources such as individuals, companies and charities in their local or regional area. NHS England and NHS Improvement has released (7 April) guidance for hospitals on handling donations and loans of medical equipment to hospitals in response to the COVID-19 pandemic, which includes PPE.

This guidance is summarised below.

When hospitals receive an offer of medical equipment from elsewhere in the NHS, or from companies, charities or the public, they need consult with their clinical engineering service before accepting the equipment. This applies whether that offer is a donation or a loan.

Before accepting a donated or loaned item, hospital clinical engineers should:

• consult with clinicians who will be involved in using the equipment to decide whether it can be put to practical use, that trained staff will be available to use it, and to check that any auxiliary equipment/consumables necessary for its intended function are included in the donation or can be obtained
• check that equipment offered for donation or loan that was already in use before the COVID-19 outbreak has been constructed to relevant medical device standards and has a valid Electrical Certification (EC) Declaration of Conformity (CE mark). However, newly developed COVID-19 related PPE has been granted exemption from the medical device regulations by the MHRA. Manufactures still need to apply to the MHRA for this exemption.
• ensure equipment offered for donation or loan is complete and in a satisfactory condition for clinical use. This will include looking at up-to-date service records and may include physical inspection and basic testing.
• plan how to fully and adequately decontaminate and refurbish the equipment, and ensure the continued availability of associated spares and consumables.

Hospital management should:

• assign the inspection and refurbishment of donated and loaned equipment a suitable priority alongside other exceptional demands being made on clinical engineering resources during the COVID-19 pandemic
• consider the alternative of diverting donated or loaned equipment to an organisation that is able to make use of them during the pandemic.

Contact us

We know the use and supply of PPE are key concerns for our members and we will continue to monitor and report on developments. If you have experienced PPE supply or related issues, or have questions or concerns about the updated guidance, we would like to hear from you. Please do contact us at externalaffairs@nhsconfed.org