Providing a Safe Working Environment – Personal Protection Equipment (PPE)

We recommend that all intensive care personnel (medical, nursing, allied health, support service staff) receive training in infection control and personal protection equipment. In order for an N95 mask to offer the desired protection, it is important that there is a correct facial fit. The two distinct procedures used to achieve this are referred to as the ‘fit test’ and the ‘fit check’.

We recommend that fit checking for an appropriate mask seal be performed every time a HCW applies a new N95 mask. The manufacturer’s instructions for fit checking of individual brands and types of N95 respirator should be referred to at all times. N95 masks should not require excessive manipulation to achieve a seal.

We recommend the use of interdisciplinary small group simulation to practice and improve COVID-19 clinical processes and staff training in PPE.

We recommend that when a unit is caring for a confirmed or suspected COVID-19 patient that all donning and doffing is supervised by a dedicated PPE spotter to decrease staff COVID-19 infection and furloughing. The dedicated PPE spotter is a specifically trained staff member (not necessarily an intensive care staff member) whose role is to supervise donning and doffing and monitor for any breaches in PPE safety and provide education and feedback to improve performance. Where a PPE spotter is unavailable, supervision of PPE application and removal should still occur but may have to be done using a “buddy” system.

Specific recommendations for airborne precautions should follow jurisdictional infection control guidelines including fit checked N95 mask, face shield, impervious gown and gloves. In addition, the following can be considered:

• Hair cover for AGP
• Shoes that are impermeable to liquids.
• Recurrent use of shoe covers is not recommended as repeated removal is likely to increase the risk of staff contamination.

Any strategy to successfully maintain the supply of PPE during the COVID-19 pandemic needs an understanding of current PPE inventory, current and future supply, with rational and appropriate use.

Current PPE Inventory

Uncertainty in PPE inventory and supply causes anxiety in the frontline workforce. We recommend a national and jurisdictional approach which is transparent. We recommend the establishment of a clear PPE governance structure to include transparency on current inventory and supply, an escalation process in the case of critical PPE shortages and decision-making pathways which are responsive to local demand with communication to and from frontline staff.

Coordinate PPE Supply Chain Management Mechanisms

Due to increasing international demand, sourcing a reliable supply requires the current strategies of re-establishing previous supply chains, developing new supply chains and increasing local production.

Rational and Appropriate Use of PPE

The same measures to minimise overall staff exposure to COVID-19 also reduce PPE demand. We recommend that all facilities implement the previously mentioned measures to minimise overall staff exposure which also reduce PPE demand including:

• Excluding HCW not essential for patient care from entering their care area
• Reducing face-to-face HCW encounters with patients
• Cohorting patients
• Maximizing the use of telemedicine
• Reducing the number of patients going to the hospital (e.g. for outpatient appointments)

We recommend prioritisation and rapid testing of intensive care patients with suspected COVID-19 to minimise the use of unnecessary PPE.

We do not recommend any local facility policies to pre-emptively preserve PPE that reduce the occupational health and safety of health care workers.

We do not recommend:

• Using face mask PPE that has expired beyond its shelf-life.
• Continuous use in consecutive patients of N95 masks with storage in a ‘Ziplock’ bag for next use.
• Use of repurposed equipment such as sewn fabric masks and gowns.

Gowns, gloves and disposable N95 masks are designed for single use. There is significant global interest in strategies to reuse N95 masks after sterilisation. Currently, due to a lack of evidence, these strategies are not recommended.

PPE Metrics are part of clear communication directly from the hospital, the intensive care and the frontline staff.

In order to calculate intensive care PPE burn rate, we recommend that ICUs document and report their daily usage of:

• N95/P2 face masks
• Surgical face masks
• Long sleeve impermeable gowns
• Face shield/goggles.

We recommend that hospitals should, on a daily basis, estimate the number of days of PPE supply that is available for current patient load, aiming to maintain a supply to last for more than 7 days. We recommend that if a hospital has a critically low PPE supply anticipated to last less than 3 days, that a jurisdictionally defined alert state be activated, including immediate escalation to the hospital Chief Executive Officer and the relevant State Coordination body. Remote, rural and regional centres will need to factor in extra days for a resupply, as compared to a metropolitan centre.