The government have released updated guidance on infection prevention and control for COVID-19, for health and social care workers involved in receiving, assessing and caring for patients who are a possible or confirmed case of COVID-19. It is based on the best evidence available from previous pandemic and inter-pandemic periods and focuses on the infection prevention and control aspects of this disease only, recognising that a preparedness plan will consider other counter measures.
The Resuscitation Council UK has produced guidance for healthcare workers who are performing CPR in mental health, learning disability and autism inpatient settings (non-acute hospital settings), as well as healthcare workers in the community.
They state that chest compressions should be considered an aerosol generating procedure (AGP) and, in inpatient settings, level 3 PPE should be donned before commencing either chest compressions or airway manoeuvres during resuscitation. They indicate that defibrillation is not an AGP and can be performed safely without level 3 PPE. You can read their guidance in full here.
In contrast, Public Health England has produced revised guidance on PPE which included advice on CPR in healthcare settings. Based on the NERVTAG evidence review and consensus statement, PHE has stated that chest compressions and defibrillation (as part of resuscitation) will not be added to the list of aerosol generating procedures (AGPs). Therefore, their advice is that first responders (any setting) can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other clinicians to undertake airway manoeuvres.
The new PHE guidance, however, goes on to say that healthcare organisations may choose to advise their clinical staff to wear FFP3 respirators, gowns, eye protection and gloves when performing chest compressions but it is strongly advised that there is no potential delay in delivering this life saving intervention.
We support the Academy of Medical Royal Colleges' statement which identifies that the evidence itself is inconclusive but has lead two highly respected scientific groups, NERVTAG and RCUK, to draw different conclusions as to the AGP nature of chest compressions and the appropriate course of action with regard to PPE. While that is legitimate, it may create dilemmas for individual clinicians and healthcare organisations.
Along with the Academy, we believe that it is essential that health workers have appropriate protection for the circumstances in which they are working. It is important to recognise that clinical and situational circumstances vary and requirements in different settings will not be the same.
We suggest that mental health and learning disability/autism organisations and clinicians should agree, as soon as possible, on the local policy regarding availability and use of PPE in resuscitation situations in order to provide the proper protection for staff.
It is anticipated that they are guided by the consensus view of those clinicians likely to be involved in resuscitation and that local decisions are transparently agreed, understood, shared and adequately resourced. Risk assessment is the first action in resuscitation and this needs to be undertaken with staff and patient safety foremost.
The necessary equipment must be to hand so that these risks can be met or mitigated in all situations.
You can find Public Health England’s guidance for donning and doffing PPE for both non-aerosol generating procedures and aerosol generating procedures below, along with youtube videos providing guidance on donning and doffing.
In clinical areas, communal waiting areas and during transportation, it is recommended that possible or confirmed COVID-19 cases wear a surgical face mask if this can be tolerated. The aim of this is to minimise the dispersal of respiratory secretions, reduce both direct transmission risk and environmental contamination.
A face mask 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). A face mask can be worn until damp or uncomfortable.
This table summarises the revised PPE guidance for clinicians working with patients who are NOT confirmed to have the virus, in any setting, but when they assume there is widespread transmission in the community (as is currently the case).
- liaison mental health services
- all adult acute inpatient wards
- all older adult inpatient wards
- all inpatient wards for children and young people
- all inpatient facilities for those with intellectual disabilities
- specialist eating disorder units
- mother and baby units
- ECT suites
all secure inpatient wards.
For healthcare professionals working in primary, outpatient and community care, the following PPE guidelines apply. This might be relevant to those working in the following services:
- all community mental health teams, including children & young people, adults, older adults, perinatal, rehab and forensic mental health teams
- crisis resolution and home treatment teams and other similar models
- assertive outreach and other similar models
- single point of access services
- primary mental health care
- IAPT services for children, adults and older adults, and other psychological therapies
- all mental health outpatient services and specialist clinics
- prison healthcare
- residential settings, supported housing and care homes
Guidance has also now been issued on the supply and use of PPE by NHS England and NHS Improvement. Concerns about the supply of PPE can be raised 24/7 via the helpline on 0800 915 9964 or via email to email@example.com. Emails should be answered within an hour.
PHE's guidance on staff uniform states that appropriate use of PPE will protect staff uniform from contamination in most circumstances. Healthcare facilities should provide changing rooms/areas where staff can change into uniforms on arrival at work.
Organisations may consider the use of theatre scrubs for staff who do not usually wear a uniform but who are likely to come into close contact with patients (for example, medical staff and mental health nurses).
Healthcare laundry services should be used to launder staff uniforms. If there is no laundry facility available, then uniforms should be transported home in a disposable plastic bag. This bag should be disposed of into the household waste stream.
Uniforms should be laundered:
- separately from other household linen
- in a load not more than half the machine capacity
- at the maximum temperature the fabric can tolerate, then ironed or tumbled-dried
Note: It is best practice to change into and out of uniforms at work and not wear them when travelling; this is based on public perception rather than evidence of an infection risk. This does not apply to community health workers who are required to travel between patients in the same uniform.