Personal Protective Equipment (PPE)

Evidence suggests that SARS-CoV-2 RNA can be detected in people 1-3 days before symptom onset, with the highest viral loads around the day of symptom onset, followed by a gradual decline over time. Detection of viral RNA does not necessarily mean that a person is infectious to others. In studies using culture of patient samples, viable virus has been isolated from an asymptomatic case, those with mild to moderate disease up to 9 days after symptom onset, and for longer from severely ill patients.
 
Community prevalence of COVID-19 and its influence on the possibility of health care worker (HCW) infection within EDs is related to a number of factors. These include the rate at which infections actually occur in the community (infectivity), the rate of removal of infection from the population by either recovery or death, and an individual’s susceptibility to the infection.
 
Where community transmission rates are high, it is more likely that HCW will be at risk of transmission from asymptomatic or minimally symptomatic individuals, both patients and co-workers, or themselves transmit infections acquired within the community to patients and co-workers. The impact of HCW infections goes beyond the potentially devastating consequence to an individual, to workforce depletion caused by quarantine and isolation of symptomatic health-care workers, and potential spread to patients.
 
With ongoing suppression of virus transmission and eventual success in sustained absence (the timeframe being unclear at this time) of new cases in a community, the risk of a HCW encountering a patient who is infected and has the potential for COVID-19 transmission to others, is thought to be low.
 
Guidance for PPE use will thus depend on the local context in terms of community prevalence and transmission, and other measures in place to contain transmission. These factors should be reviewed by EDs, infectious disease and infection control and prevention experts with jurisdictional guidance, to determine recommendations for PPE.
 
The objective of any review of PPE guidance will always be to maintain the safety of HCW within their workplace using the precautionary principle, and then to ensure the rational use of PPE. As understanding of COVID-19 transmission evolves, PPE guidance should be regularly reviewed, with a strategy to implement the most protective regime of PPE for HCW with step down only when there is clear evidence of safety. Extended use strategies should be used where PPE supply concerns exist, and supply concerns alone are not a trigger for downgrading PPE guidance. EDs routinely encounter new and unknown patients where it is not possible to fully ascertain infection risk, therefore decisions to downgrade PPE use should be approached in a cautious manner.

There is limited evidence on face masks in community settings. Some studies have suggested that wearing masks on public transport and in workplaces where social distancing is less feasible may be useful at reducing transmission. International experience has demonstrated that universal masking coupled with other measures and high adherence can limit or mitigate large scale community outbreaks. The World Health Organization has updated its guidance to advise that to prevent COVID-19 transmission effectively in areas of community transmission, governments should encourage the general public to wear masks in specific situations and settings as part of a comprehensive approach to suppress SARS-CoV-2 transmission. Fabric masks, if made and worn properly, can serve as a barrier to droplets expelled from the wearer into the air and environment. However, masks must be used as part of a comprehensive package of preventive measures, which includes frequent hand hygiene, physical distancing when possible, respiratory etiquette, environmental cleaning and disinfection.
 
In areas with any COVID-19 community transmission, HCW in clinical areas should wear a surgical mask throughout their entire shift. In settings where aerosol-generating procedures are performed, they should wear an N95 or equivalent respirator. In regions with high community transmission, European authorities and the Centres for Disease Control and Prevention USA recommend airborne precautions for any clinical situation involving the care of possible, suspected or confirmed COVID-19 patients, and adopting a precautionary approach along similar lines has been advised in regions of higher transmission in Australia. 
 
N95 or equivalent respirators may only provide airborne protection if they properly fit to the individual's face preventing unfiltered air to be drawn inside the mask. Fit testing is performed to determine whether a specific type, model and size of respirator is a suitable fit for an individual and that it is worn correctly to achieve a facial seal. Fit-testing is best performed by personnel trained in occupational health and safety. HCW’s performing AGPs should be identified and fit-tested.
 
Fit checking describes the process that HCWs perform each time a respirator is donned to check that a good facial seal is achieved i.e. the respirator is sealed over the bridge of the nose and mouth and that there are no gaps between the respirator and face.
 
Fit-testing and fit-checking are part of a hospital’s respiratory protection program.

All staff working in health facilities (including staff with no patient contact) should adhere to simple measures that will limit COVID-19 transmission. These include avoiding touching their face or shaking hands with others, practicing respiratory hygiene and cough etiquette, meticulous hand hygiene including before and after touching objects or files that may have been in a clinical area, social distancing > 1.5m where possible, and not coming to work if they have symptoms of an acute respiratory infection.

Recommended precautions also include avoiding indoor crowded gatherings as much as possible, in particular when physical distancing is not feasible, and ensuring good environmental ventilation in any closed setting.
 
Workforce reconfigurations of split teams, or creating smaller ‘sub teams’ and establishing social distancing protocols within teams, have been described; a strategy with two medical teams working on alternate seven day periods was associated with reduced infection rates among the healthcare workforce.
 
Strategies for redeploying HCWs identified as higher risk away from frontline roles should be implemented.
 
Hospitals should have a plan for the very few healthcare workers who do not pass a fit-test. Respirators including PAPR may be an option. If a HCW fails fit-testing for all available respirators, they should be deployed away from areas with COVID-19 patients or where AGPs are performed.

PPE is one part of a package of measures to prevent transmission of COVID-19. Other controls, the implementation of which will vary according to the level local community transmission, include:

• Use telehealth where appropriate to provide care to reduce the need for patients to attend health facilities.
• Screening at entry to health facilities; limit and monitor points of entry; limit visitor numbers.
• Administrative controls such as policies, appropriate infrastructure, triage and placement of patients, physical distancing guidance, staff to patient ratios and staff training.
• Environmental and engineering controls aimed at reducing the spread of pathogens and the contamination of surfaces and inanimate objects such as adequate spacing between staff and patients, patients and patients; correct cleaning and disinfection procedures; well ventilated isolation rooms.
• Standard precautions, including hand hygiene (5 Moments) for all patients.
• Patients and health workers should observe respiratory hygiene and cough etiquette.
• Universal source control measures including:
  • The use of surgical masks by health facility staff to reduce transmission of infection between staff, as well as from patients or visitors to staff.
  • Patients and visitors wear facemasks when entering or moving around health facilities.
• In addition to using standard precautions, individuals including family members and visitors should use contact and droplet precautions before entering the room of suspected or confirmed COVID-19 patients.
• Equipment should be either single-use and disposable, or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient.
• Keyboards, phones, pagers and other mobile devices should be protected from contamination and cleaned regularly.

 
*Consider mask use to reduce possibility of infection between staff and / or site visitors, particularly as COVID-19 becomes more widespread in the community. In regions with high community transmission, face masks should be used by all health facility employees in clinical and non-clinical areas, and by all patients and visitors to the health facility in accordance with local guidance.

^Risk assessment - undertake risk assessment according to levels of community transmission, in conjunction with jurisdictional guidance, to determine need for airborne PPE; optimise environmental and administrative controls, minimise exposure of higher risk staff and duration of exposure of all staff to higher risk environment.

We recommend that all relevant staff are provided:

1. Adequate and ongoing training in PPE use, and broader infection prevention and control procedures. 
2. Opportunities to be fit tested for N95 masks.
3. Clearly demarcated donning and doffing areas before entering a room, high-risk zone or cohorted area.
4. Clear pathways for notification and management of breaches in PPE.
4. A trained PPE observer or buddy to check correct technique.

We recommend that staff working in high-risk zones or with cohorted patients with probable or definite COVID-19 practice robust but rational use of PPE. Although PPE should ideally be exchanged between each patient encounter, this may not be feasible in the context of limited resources and overwhelming demands for care.

After performing an AGP or otherwise being exposed to body fluids or contamination, all PPE should be doffed and discarded.

“Extended use” is generally accepted as up to 4 hours continuous use.

We recommend  that clinicians observe the following principles in relation to the extended use of face masks:

• Practice ‘extended use’ rather than ‘reuse’ of  surgical and N95 masks wherever possible.
• Discard N95 masks following use during aerosol generating procedures (see Table 1 in Section 3).
• Discard masks contaminated with blood, respiratory secretions or other bodily fluids.
• Discard masks following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.
• Consider use of a cleanable face shield over an N95 mask and/or other steps (e.g., masking patients, use of engineering controls) to reduce surface contamination.
• Perform hand hygiene with soap and water or an alcohol-based hand sanitiser before and after touching or adjusting the mask (if necessary for comfort or to maintain fit).
• Discard any mask that is obviously damaged or damp, or becomes hard to breathe through.
• Observe strict adherence to hand hygiene practices, and proper PPE donning and doffing technique.

We recommend that clinicians observe the following principles in relation to the rational use of gowns:

• Gown use should be prioritised for performing aerosol-generating procedures associated with definite risk of pathogen transmission and for activities that involve holding the patient close (e.g. in paediatric settings), or when other extensive direct patient contact is anticipated.
• Gowns may also be worn during the care of more than one patient in a single cohort area only, provided that the gown does not come into direct contact with any patient.

We recommend that EDs align their internal PPE procedures with guidance from the relevant government authorities for the following:

1. Patient PPE.
2. Staff clothing and personal items.
3. PPE for aerosol generating procedures.
4. PPE for clinical encounters.
5. Cleaning of rooms.
6. Cleaning and reuse of disposable equipment.
7. PPE following patient death.
8. Infection prevention and control (IPC) in non-clinical areas such as lunchrooms.

We align our recommendations with: 

1. Selection, use and maintenance of respiratory protective equipment standard AS/NZS 1715: 2009.
2. The NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare, 2019. [Link]
3. The World Health Organisation IPC [Link] and PPE [Link] recommendations. 

Exemplar documents:

1. Coronavirus disease 2019 (COVID-19) – A guide to the conventional use of PPE. Victoria State Government Health and Human Services (6 August 2020). [Link]

The following resources were used in the preparation of this section:

•  World Health Organization (WHO). Infection prevention and control during health care when COVID-19 is suspected: interim guidance. 19 March 2020. [Link]
• World Health Organisation (WHO). Transmission of SARS-CoV-2: implications for infection prevention precautions – scientific brief. 9 July 2020. [Link]
• World Health Organization (WHO)‎. Rational use of personal protective equipment for coronavirus disease (‎‎‎COVID-19)‎‎‎: interim guidance. 27 February 2020. [Link]
• World Health Organization (WHO)‎ Guidelines. Infection prevention and control of epidemic and pandemic-prone acute respiratory infections in health care. 2014. [Link]
• Department of Health, Australian Government. Coronavirus (COVID-19) advice for the health and aged care sector. [Link]
• Department of Health, Australian Government. Guidance on use of personal protective equipment (PPE) in noninpatient healthcare settings, during the COVID-19 outbreak. 11 May 2020. [Link]
• Department of Health, Australian Government. Guidance on the use of personal protective equipment (PPE) in hospitals during the COVID-19 outbreak. Modified 19 June 2020. [Link]
• Department of Health, Australian Government. Environmental cleaning and disinfecting principles for health and residential care facilities – Version 2 (26 March 2020) Coronavirus disease (COVID-19). [Link]
• New Zealand Ministry of Health. Personal Protective Equipment Use in Healthcare. [Link]
• NSW Health, COVID-19 (Coronavirus) testing advice. [Link]
• NSW Health Clinical Excellence Commission. COVID-19 Infection Prevention and Control: Amber Alert – Moderate Transmission Version 1.0. July 2020. [Link]
• NSW Health Clinical Excellence Commission. Infection Prevention and Control Application of PPE during COVID-19. Version 2.3. August 2020. [Link]
• NSW Health COVID-19 Critical Intelligence Unit. Evidence Check: Face masks and COVID-19 transmission in the community. 20 July 2020. [Link]
• NSW Health COVID-19 Critical Intelligence Unit. Evidence Check: Extended use or reuse of personal protective equipment. 6 August 2020. [Link]
• NSW Health COVID-19 Critical Intelligence Unit. Evidence Check: Workforce reconfiguration. 4 June 2020. [Link]
• Victoria State Government Department of Health and Human Services. Coronavirus disease 2019 (COVID-19) – Infection prevention and control guideline. Version 3. 8 August 2020. [Link]
• Victoria State Government Department of Health and Human Services. Coronavirus disease 2019 (COVID-19) – A guide to the conventional use of PPE. 6 August 2020. [Link]
• Victoria State Government Department of Health and Human Services. Coronavirus 2019 (COVID-19) - PPE and levels of protection. July 2020. [Link]
• The NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare, 2019. [Link]
• Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database of Systematic Reviews 2020. [Link]
• International Liaison Committee on Resuscitation (ILCOR). Consensus on Science with Treatment Recommendations (CoSTR): COVID-19 infection risk to rescuers from patients in cardiac arrest [Draft for public comment]. Online resource. [Link]
• Australian Society of Anaesthetists. N95 vs PAPR for AGPs. 27 March 2020. [Link]
• US Department of Health and Human Services. Centres for Disease Control and Prevention. Optimizing Supply of PPE and Other Equipment during Shortages. Updated 16 July 2020. [Link]
• US Department of Health and Human Services. Centres for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Updated 15 July 2020. [Link]
• Klompas M, Morris CA, Sinclair J, Pearson M, Shenoy ES. Universal Masking in Hospitals in the Covid-19 Era. NEJM. 2020;382:e63. [Link]
• Greenhalgh T, Schmid MB, Czypionka T, Bassler D, Gruer DB. Face masks for the public during the covid-19 crisis. BMJ. 2020;369:m1435. [Link]
• Regli A, von Ungern-Sternberg BS. Fit-testing of N95/P2-masks to protect health care workers. Med J Aust. 2020 [Preprint, 12 August]. [Link]
• Greenhalgh T, Howard J. Masks for all? The science says yes. fast.ai. 13 Apr 2020. [Link]
• MacIntyre CR, Ananda-Rajah M, Nicholls M, Quigley AL. Current guidelines for respiratory protection of Australian health care workers against COVID-19 are not adequate and national reporting of health worker infections is required. Med J Aust. 2020 [Preprint, 14 July]. [Link]
• Greenberg, N. Mental health of health-care workers in the COVID-19 era. Nat Rev Nephrol. 2020. 16:425–26. [Link]
• Bielicki JA, Duval X, Gobat N, Goossens H, Koopmans M, Tacconelli E et al. Monitoring approaches for health-care workers during the COVID-19 pandemic. Lancet Infect Dis. 2020 [Published Online July 23]. [Link]

Personal Protective Equipment Guidance

PPE Staff Briefing - Covid19 Together

The inclusion of links to external websites and supporting resources, and the provision of additional files, resources and materials from third parties does not constitute an endorsement of those websites, files, resources or materials, nor the information or services offered.

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources.
The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

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