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We are aware of concerns that chest compressions as part of CPR is not classified as an AGP (aerosol generating procedure) in Public Health England guidance.
Members of the BMA remain concerned that they are being asked to resuscitate patients without adequate protection due to a lack of national consensus on this issue.
The guidance from Resuscitation Council UK provides a clear process for both protecting patients and healthcare workers – treating chest compressions as a procedure requiring full PPE.
This involves one staff member shocking the patient up to three times with a defibrillator, whilst wearing fluid resistant surgical mask, disposable apron, disposable gloves and disposable eye protection, giving others – if they are not already wearing it – time to put on full protective PPE; namely FFP3 respirator, disposable gown, disposable gloves and disposable eye protection.
Our position is that chest compressions as part of CPR should be reinstated to the list of aerosol generating procedures by PHE.
We need to stand together for doctors and the NHS, and we can only do that with you.
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Official guidance on PPE
UK-wide guidance on PPE was reissued and updated on 2 April 2020.
Guidance about acute PPE shortages was published on 17 April 2020 and updated again on 3 May to advise on FFP2 respirators in cases of severe shortages.
The BMA has raised serious concerns regarding the 17 April amendment.
Public Health England has produced guidance on putting on and taking off PPE, including videos on how to follow best practice. This includes putting on and taking off coveralls.
What PPE should I expect to have for different clinical settings?
In all settings, when in close patient contact where you determine that there is a risk of being exposed to COVID-19, you should expect to have access to:
- surgical face mask
- disposable apron
- disposable gloves
- eye protection (if risk of contamination of eyes by splashes or droplets).
When working in higher-risk acute areas, including when carrying out aerosol generating procedures, or in areas where AGPs are being conducted you should expect to have:
- FFP3 respirator
- long sleeved disposable gown or disposable coveralls (see more information below about alternatives where there are shortages of gowns or coveralls)
- disposable gloves
- disposable eye protection.
The guidance emphasises that “where staff consider there is a risk to themselves or the individuals they are caring for they should wear a fluid repellent surgical mask with or without eye protection, as determined by the individual staff member for the episode of care or single session.”
The guidance outlines the PPE recommendations for all healthcare contexts and provides summary tables for the following settings:
- NHS and independent sectors in secondary care inpatient clinical settings
- primary, outpatient and community care settings
- ambulance, paramedics, first responders and pharmacists.
Alternatives to gowns/coveralls (set out in Government guidance)
These are listed as:
- disposable, non-fluid repellent gowns or coveralls with a disposable plastic apron for high-risk settings and AGPs with forearm washing once gown or coverall is removed
- reusable (washable) surgical gowns or coveralls or similar suitable clothing (for example, long-sleeved laboratory coat, long-sleeved patient gown or industrial coverall) with a disposable plastic apron for AGPs and high-risk settings with forearm washing once gown or coverall is removed.
Using your own PPE
Your employer must provide you with a safe working environment and with appropriate PPE for the area in which you are working.
For the level of PPE you need in different clinical settings, please see the response above.
You should not have to purchase your own PPE. However, if there is no alternative, you may decide to buy and wear the correct level of PPE for the area you are working in. You should not face criticism or more serious action if you do this.
The BMA is continuing to press the government to ensure that you can work safely and can protect yourself, your colleagues, your patients and your family.
Please contact us on [email protected] for further clarification and support. You may also find it helpful to contact our wellbeing support services on 0330 123 1245 which are open 24 hours a day, 7 days a week.
Note: If you are a doctor in a supervisory or managerial role you may be in breach of GMC guidance if you take steps to prevent or discourage the use of appropriate and necessary PPE. Employers and/or individual employees may also be in breach of health and safety legislation if such steps are taken.
Using respiratory protective equipment including face masks
The Health and Safety Executive has produced guidance outlining the correct use of respiratory masks, including fit-testing:
"Tight-fitting respirators (such as disposable FFP3 masks and reusable half masks) rely on having a good seal with the wearer’s face. A face fit test should be carried out to ensure the respiratory protective equipment (RPE) can protect the wearer.
To ensure you put on tight-fitting RPE correctly, use a mirror or ask a colleague. Fit-testers should follow government advice on social distancing, as they can make observations from this distance and deliver any instructions verbally.
The user should then carry out a pre-use seal check or fit check."
Steps for maintaining good hand hygiene
The WHO advises healthcare workers to perform hand hygiene at five key moments.
This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings.
This approach recommends health-care workers to clean their hands:
- before touching a patient
- before clean/aseptic procedures
- after body fluid exposure/risk
- after touching a patient
- after touching patient surroundings.
What is being done nationally to ensure stocks of PPE are replenished?
It is vital for both staff and the patients they care for that they are provided with adequate protection from infection. Employers and commissioners have both a legal and ethical responsibility to protect their staff. They must ensure that adequate protective equipment is available and that staff are trained in its use.
The Government says that services across the NHS are urgently being sent stocks of PPE to help them manage cases and potential cases of COVID-19 and keep staff safe. Deliveries may be provided outside or normal working hours to ensure stocks are replenished.
The BMA continues to raise concerns about PPE supplies and to support individual members where they do not have the right PPE for the setting in which they’re working.
I wear a beard for religious reasons - am I required to remove it?
FFP3 masks are recommended to protect staff who may be exposed to COVID-19 from aerosolised pathogens. These require the removal of beards to fit effectively.
A policy requiring beard removal will have more of an impact on doctors who have a religious obligation to wear a beard. Under the Equality Act 2010, a policy that may have a negative impact on a certain group is justifiable if it is a proportionate way of meeting a legitimate organisational need (eg health and safety).
In deciding if a requirement to shave is proportionate, your employer must consider the impact shaving would have upon you (eg the psychological impact of abandoning a religious practice) and balance this against the needs to protect the health and safety of others. In our view any requirement to remove a beard is likely to be highly exceptional. If there is an alternative way to meet those needs then it is unlikely to be proportionate.
You should ask if alternative PPE can be made available for you, such as a PAPR (powered air purifying respirator) hood that provides the same protection as FFP3. Be aware it may difficult for your employer to access them at this time. You will also need to be trained on how to use, clean and re-use it effectively.
Or, you could also ask whether, because of your religious obligations, you can be exempted from tasks that require the highest level PPE.
If you need employment advice on your particular circumstances contact the BMA.
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