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Easing of lockdown has changed what we all can do. Changes in our behaviours will follow and so, inevitably, will the way in which we all use PPE (personal protective equipment).
Many of us will have found the prolonged periods of wearing PPE to be uncomfortable and tiring; some might be tempted to relax their use of PPE and return to something that more closely resembles ‘normal’ working practice. But is now the time to lower the level of PPE protection? I don’t think so.
PHE (Public Health England) has not changed its guidance on the use of PPE, for the virus continues to spread. New elective pathways have now been introduced to reduce the likelihood of patient infection at the time of admission and therefore the risk of patients passing the virus between each other and also to staff. Such patients and their family groups must now self-isolate for 14 days before PCR testing and admission.
In reality, however, this lower risk infection pathway is all that can be achieved at present.
As there are still many new cases each day, it’s simply not yet possible to have pathways with no risk at all. Given that the consequences of infection vary greatly between individuals, it’s likely that staff at higher risk of serious consequences will not be reassured if PPE standards were changed, even when the risk of infection is reduced. For them, the personal impact of infection stays high.
In addition, fear of infection is a very significant issue, people are still very afraid. Understandable anxiety must be kept in mind when doctors consider supporting any change to guidance. Moreover, confidence in the PPE supply has been and remains very fragile. Confidence, so fragile, is easily undermined.
Changing the recommendations for the use of PPE may also be seen as a response to on-going supply difficulties.
There’s some comfort in having a clearer position on testing; our understanding of the dynamics of an outbreak is also improving. Case ascertainment methods, however, remain too crude to see increases in transmissions in real-time. Hospital admission numbers are too late in the trajectory of local increases; the outbreak at Weston General Hospital, Somerset, illustrates the difficulties in identifying upturns in cases. These and further rises in cases locally will obviously increase the potential for renewed exposure of staff to COVID-19, and possibly before such outbreaks are recognised.
As yet we have no indication, one way or another, about subsequent waves of infection and their timescales. High rates of community infection will increase risk around patient pathways and undermine confidence in their safety.
Continuing with existing PPE standards will help protect staff against such exposures.
Doctors are often team leaders and may set the tone for clinical practice in their teams. As doctors and leaders we know that, while the consequences of contracting COVID-19 varies greatly between individuals, some groups are more susceptible to serious complications and death.
We must acknowledge that strong personalities in our teams, including medical staff, can impress their views about acceptable PPE and practices. Such strong personalities may influence the protection used by other members of their teams, including those from other clinical disciplines, and so potentially expose their team members to greater individual risk.
It has been suggested that ‘enhanced PPE’ would offer sufficient protection for those at increased individual risk. Risk reduction strategies do not, however, usually suggest the use of higher level PPE as a response. All other measures should be employed first. This usually involves removing staff members from exposure to that risk.
It is also important to recognise that for healthcare staff some, possibly most, COVID-19 transmission within hospitals is understood to occur between healthcare workers - often from staff members who have no symptoms of the infection. To reduce transmission within hospitals there is a requirement for protective measures at all times within the hospital estate.
In most circumstances, outside of hospital, that means social distancing measures and these should be followed where possible. Trusts could assist with these measures with ‘workplace risk assessments’. These evaluate how each part of a hospital’s estate is used; they assess whether social distancing, outside of healthcare interactions where PPE would be worn, is possible with the usual staff complement and working practices. Such measures are particularly important in areas where staff take their breaks.
Working practices must be adapted where social distancing is found not to be possible without change. It may also be that sessional wearing of facemasks by hospital staff has a place in the reduction of COVID-19 transmission. There is some, albeit weak, evidence that wearing facemask in public may prevent transmission and even a modest protective effect could save lives.
Decision making around the use of PPE should not be devolved to the level of organisations. Clear guidance across systems is helpful and allows staff to have a measure of confidence that they are treated consistently.
Many of the issues outlined above will be ameliorated by time. In the short term, it’s important that the new clinical pathways have time to bed in. In the longer term, any change to PPE guidance will only likely follow an end to the sustained transmission of COVID-19 we currently see. In time, staff will feel greater confidence that changes to PPE use are safe for them. At some point, a change in the guidance on PPE use may be possible. But that point has not yet been reached.