Personal Protective Equipment (PPE) primary care briefing


 Personal Protective Equipment (PPE) in Primary Care 

  • All primary care healthcare workers (including staff working in general practice, community and social care settings and care homes) within two metres of a patient who might have, or has confirmed, COVID-19 should always wash hands prior to and after patient contact and use full PPE as outlined below (apron, gloves, fluid repellent facemask and eye protection, based on the risk).
  • For other 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 they should wear a fluid repellent facemask (FRSM).
  • Attempts should be made, where appropriate, to ascertain whether a patient or individual might have COVID-19. This is outlined in the risk assessment section below but the guidance is to use caution and wear PPE if you are unsure. Some primary care settings may consider using PPE for all patient contact.
  • Aerosol generating procedures (AGPs) such as intubation, extubation and manual ventilation require higher levels of PPE and should not be undertaken in primary care settings. PPE guidance for AGPs is here.
  • Primary care clinical staff working in Hot Hubs are also advised to also obtain scrubs or wear old clothes which are suitable for a hot wash, to remove before they leave at end of the day and put in a pillow case.  The pillowcase and contents can then be put straight into home washing machine on a hot wash.

Wash hands prior to and after patient contact as follows

  • bare to the elbows
  • removal of all hand and wrist jewellery
  • clean short fingernails and no artificial nails or nail products
  • all cuts or abrasions covered with waterproof dressings 

Use the following PPE 

  • fluid repellent (Type IIR) facemask (FRSM)
  • apron
  • gloves
  • eye protection 

This video shows how to put on and dispose of PPE and take the proper precautions in a primary care setting.

 

Risk assessment 

Attempts should be made, where appropriate, to ascertain whether a patient or individual meets the case definition for a possible or confirmed case of COVID-19 before the care episode. Refer to the current COVID-19 case definition.

Initial risk assessment where possible should take place by phone, or other remote triage, prior to entering the premises or clinical area or at 2 metres social distance on entering.

Where the health or social care worker assesses that an individual is symptomatic and meets the case definition, appropriate PPE should be put on prior to providing care.

Where the potential risk to health and social care workers cannot be established prior to face-to-face assessment or delivery of care (within 2 metres), the recommendation is for health and social care workers in any setting to have access to and, where required, wear PPE - aprons, FRSMs, eye protection and gloves.

Health and social care workers should consider need for contact and droplet precautions based on the nature of care or task being undertaken. Risk assessment on use of eye protection for example, should consider the likelihood of encountering a case(s) and the risk of droplet transmission (risk of droplet transmission to eye mucosa such as with a coughing patient) during the care episode.

Ultimately, where staff consider there is a risk to themselves or the individuals they are caring for they should wear a FRSM with or without eye protection, as determined by the individual staff member for the episode of care or single session. 

Some primary care settings may consider using PPE for all patient contact regardless of case status, subject to local risk assessment. 

Patient use of PPE

In clinical areas, communal waiting areas and during transportation, it is recommended that possible or confirmed COVID-19 cases wear a FRSM if this can be tolerated. 

A FRSM should not be worn by patients if there is potential for their clinical care to be compromised (for example, when receiving oxygen therapy via a mask). An FRSM can be worn until damp or uncomfortable. 

PPE usage and disposal guidance

Aprons and gloves are subject to single use as per Standard Infection Control Precautions (SICPs), with disposal and hand hygiene after each patient contact. 

FRSM, eye protection and long sleeved disposable fluid repellent gowns can be subject to single sessional use.

A single session refers to a period of time where a health and social care worker is undertaking duties in a specific clinical care setting or exposure environment.

A session ends when the health and social care worker leaves the clinical care setting or exposure environment. Once the PPE has been removed it should be disposed of safely. The duration of a single session will vary depending on the clinical activity being undertaken.

While generally considered good practice, there is no evidence to show that discarding facemasks or eye protection in between each patient reduces the risk of infection transmission to the health and social care worker or the patient.

Indeed, frequent handling of this equipment to discard and replace it could theoretically increase risk of exposure in high demand environments, for example by leading to increasing face touching during removal. The rationale for recommending sessional use in certain circumstances is therefore to reduce risk of inadvertent indirect transmission, as well as to facilitate delivery of efficient clinical care.

PPE should not be subject to continued use if damaged, soiled, compromised or uncomfortable and a session should be ended. While the duration of a session is not specified here, the duration of use of PPE items should not exceed manufacturer’s instructions. 

Appropriateness of single vs sessional use is dependent on the nature of the task or activity being undertaken and the local context. 

Fluid resistant surgical masks 

Fluid-resistant (Type IIR) surgical masks (FRSM) provide barrier protection against respiratory droplets reaching the mucosa of the mouth and nose.  

FRSMs are for single use or single session use and then must be discarded.

The protective effect of masks against severe acute respiratory syndrome (SARS) and other respiratory viral infections has been well established. There is no evidence that respirators add value over FRSMs for droplet protection when both are used with recommended wider PPE measures in clinical care, except in the context of AGPs.

Eye and face protection

Eye and face protection provides protection against contamination to the eyes from respiratory droplets, aerosols arising from AGPs and from splashing of secretions (including respiratory secretions), blood, body fluids or excretions.

Eye and face protection can be achieved by the use of any one of the following:

  • surgical mask with integrated visor
  • full face shield or visor
  • polycarbonate safety spectacles or equivalent

Regular corrective spectacles are not considered adequate eye protection.

The same as for respirators and FRSMs, eye protection should: be well fitted; not be allowed to dangle after or between each use; not be touched once put on; be removed outside the patient room, cohort area or 2 metres away from possible or confirmed COVID-19 cases.

Disposable, single-use, eye and face protection is recommended for single or single session use and then is to be discarded as healthcare (clinical) waste. However, re-usable eye and face protection is acceptable if decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.

It is important that the eye protection maintains its fit, function and remains tolerable for the user. Eye and face protection should be discarded and replaced and not be subject to continued use if damaged, soiled (for example, with secretions, body fluids) or uncomfortable.

Disposable aprons and gowns

Disposable plastic aprons must be worn to protect staff uniform or clothes from contamination when providing direct patient care and during environmental and equipment decontamination.

Long sleeved disposable fluid repellent gowns must be worn when a disposable plastic apron provides inadequate cover of staff uniform or clothes for the procedure or task being performed, and when there is a risk of splashing of body fluids such as during AGPs in higher risk areas or in operative procedures. If non-fluid-resistant gowns are used, a disposable plastic apron should be worn. If extensive splashing is anticipated then use of additional fluid repellent items may be appropriate.

Disposable aprons are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact as per SICPs. 

Hand hygiene should be practiced as per SICPs and extended to exposed forearms. Long sleeved disposable fluid repellent gowns are for single use or for single session use in certain circumstances but should be discarded at the end of a session or earlier if damaged or soiled. 

Disposable gloves

Disposable gloves must be worn when providing direct patient care and when exposure to blood and or other body fluids is anticipated or likely, including during equipment and environmental decontamination. Disposable gloves are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact, as per SICPs, followed by hand hygiene.

PPE delivery

Step 1 - Business as Usual

  • Please continue to order PPE equipment through your business as usual routes, your service does not need to be set up for any new supply chains.
  • When ordering PPE equipment, please only order for staff that will be working face to face with patients to ensure there is enough PPE equipment for front line staff across the system.
  • The Government, NHS Supply Chain, and the NHS are doing everything to work with industry to secure additional supplies and manufacture further PPE. There are shortages in the short term but we expect the situation to ease as stocks from overseas arrive into the UK system.

Step 2 – New Supply Chain eCommerce Platform

  • https://www.ppe-dedicated-supply-channel.co.uk/
  • The dedicated PPE supply channel for core COVID 19 core PPE products has launched. This is through a new e-commerce platform (live from the 7th April 2020).
  • Deliveries will be made through the Royal Mail.
  • Disposable Gloves will remain through your normal business as usual ordering.

Step 3 - How do I report supply disruption?

  • The National Supply Distribution Response helpline can answer PPE calls and emails 24/7 via the supply disruption helpline on 0800 915 9964 or email supplydisruptionservice@nhsbsa.nhs.uk to help with queries. Emails will be answered within one hour.
  • Trusts should raise non-PPE orders with NHS Supply Chain in the usual way.
  • The National Supply Disruption Response (NSDR) can issue ‘pre-packed kits’ with a minimum of (100 Type IIR face masks; 100 aprons and 100 pairs of gloves) within 72 hours.

Step 4 - How do I gain access to NEL escalation stock?

  • NEL have worked to develop an escalation pathway for services within the STP to utilise should you not have sufficient stock for seeing patients face to face for the next 36 hours only.
  • This service should not be used as an alternative supply chain and should only be used when your service requires stock in escalation.
  • To request NEL Escalation Stock please complete the request form contained within this link to submit you escalation request: https://www.surveymonkey.co.uk/r/NELPPECOVID-19
  • Follow all instructions on the form and complete all information requested to mitigate any delay
  • You can also contact the NEL PPE Escalation team by contacting: ppe.emergencysupplyrequests@nhs.net if you do not have sufficient stock for staff seeing patients face to face for the next 36 hours. The inbox is managed between 8am to 8pm, 7 days a week
  • Please check PHE guidance to understand the level of PPE you require and request orders on this basis.

How do I donate PPE?

Finally, anyone sourcing PPE themselves must ensure it is consistent with these national guidelines and will need to keep a record of all COVID-19 related spend.