Personal Protective Equipment (PPE)

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.

PPE is one part of a package of measures to prevent transmission of COVID-19. Other controls include:

• Administrative controls such as policies, appropriate infrastructure, triage and placement of patients, 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.
• 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 with respiratory symptoms should be provided a face mask.
• In addition to using standard precautions, individuals including family members, 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

*Note on use of coverall: There is some evidence that doffing and disposal of coveralls between patients increases the risk of contamination. The use of an apron, which can more easily be doffed, over coveralls is recommended.

^Note on powered air purifying respirators (PAPR): PAPR should only be considered where a clinician: cannot find an N95 mask that fits adequately; has facial hair that cannot be removed; is likely to be performing multiple AGPs, for example as part of the intubation team when there are multiple patients who are likely to require intubation AND a PAPR is available along with adequate training in its use.

	No PPE	Surgical MaskHand Hygiene Use gloves for patient contact	Droplet PPE Surgical mask Eye protection Gloves Gown / apron Consider hair cover	Airborne PPE N95/P2 respirator Eye protection +/- face shield Gloves Long sleeved gown +/- apron Hair cover or hood
Staff not directly in contact with patients > 1.5m distance at all times*	✔	✔ Surgical mask and gloves if entering cohorted isolation area
COVID assessment clinic			✔ (risk assessment^)	✔ (risk assessment^)
Triage			✔ (risk assessment^)
Clinical staff in direct contact with patients Assess COVID risk status and AGP likelihood		✔ Patients screened negative or minimal for COVID risk and no respiratory symptoms	✔ Fever or acute respiratory infection or, screened suspected or definite COVID, no AGPs	✔ Severe acute respiratory infection (or undifferentiated case requires AGPs + admission)
Performing Aerosol Generating Procedures				✔
Prolonged direct clinical care in higher risk patient environments			✔ Clinical ED areas with cohorted fever or acute respiratory infection or, screened suspected or definite COVID no AGPs  (risk assessment^)	✔ Clinical ED areas with cohorted severe acute respiratory infection (or undifferentiated case requires AGPs + admission)  (risk assessment^)
Resuscitation Team			✔ No AGPs	✔ Likely AGPs
Trauma Team			✔ No AGPs	✔ Likely AGPs
Paediatric patients with AGPs				✔

 
*Consider mask use to reduce possibility of infection between staff and / or site visitors, particularly as Covid-19 becomes more widespread in the community.

^Risk assessment - undertake risk assessment in conjunction with facility infection control and prevention and infectious disease advice 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.

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.

Experience from countries ahead in their pandemic phase of our region is that, in addition to meticulous hand hygiene, social distancing in clinics, and cohorting higher and lower risk patient groups, the use of basic PPE for every patient interaction is practiced.
This includes:

1. All staff at healthcare facilities wear surgical masks.
2. In Hong Kong, all patients in healthcare facilities inpatient areas and attending outpatient clinics are provided surgical masks for daily use.
3. In China, all staff working in the emergency department, outpatient departments of infectious diseases, respiratory care, endoscopic proceduralists must upgrade their surgical masks to medical protective masks (N95).
4. Staff must wear a protective face screen while collecting respiratory specimens from suspected / confirmed patients.

For further information see:

• Hong Kong Hospital Authority Communication Kit - 27 February 2020, via IFEM website [Link]
• Ministry of Health, Singapore, The National Infection Prevention and Control Guidelines for Acute Healthcare Facilities 2017 [Link]
• Handbook of COVID-19 Prevention and Treatment. The First Affiliated Hospital, Zhejiang University School of Medicine. March 2020, via IFEM website [Link]

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. COVID-19 assessment and streaming matrix. Victoria State Government Health and Human Services. [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 Organization (WHO). Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Scientific brief. 29 March 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. 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]
• The NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare, 2019. [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. Strategies to Optimize the Supply of PPE and Equipment. [Link]
• Klompas M, Morris CA, et al. Universal Masking in Hospitals in the Covid-19 Era. NEJM. Published online: 1 April 2020. [Link]
• Greenhalgh T, Schmid MB et al. Face masks for the public during the covid-19 crisis. BMJ. 2020:369, m1435. [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.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.