6.5 Personal Protective Equipment (PPE)

6.5.1 Extended use of face masks for staff and visitors

6.5.2 Face masks for residents

6.5.3 PPE determined by COVID-19 care pathway

Table 2: PPE for direct resident care determined by category

6.5.4 PPE - Putting on (donning) and taking off (doffing)

6.5.5 Aerosol Generating procedures (AGPs)

Table 3: PPE for AGPs determined by pathway

6.5.6 Post AGP Fallow Times (PAGPFT)

Table 4: PAGPFT calculation

6.5.7 Sessional use of PPE

6.5.8 PPE for delivery of COVID-19 Vaccinations

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. 

PPE requirements as per standard infection prevention and control are detailed in section 1.4 SICPs.   

PPE requirements during the COVID-19 pandemic are determined by the care categories and are detailed in 6.5.1.

It is of paramount importance that PPE is worn only at the recommended appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

PPE is the least effective control measure for COVID-19 and other mitigation measures as per the hierarchy of controls must be implemented and adhered to wherever possible.  More details on the hierarchy of controls can be found in section 6.12.

6.5.1 Extended use of face masks for staff and visitors

New and emerging scientific evidence suggests that COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or pre-symptomatic). 

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and residents.  The guidance and FAQs are available Scottish Government guidance and associated FAQs.

A poster detailing the ‘Dos and don’ts’ of wearing a face mask is available.

Extended use of face masks relates to the specific guidance that staff should wear Fluid Resistant (Type IIR) Surgical Mask (FRSM) at all times for the duration of their shift in the care home setting.  Face masks must be removed and replaced as necessary (observing hand hygiene before the mask is removed and before putting another mask on).

In Scotland, staff are provided with Type IIR masks for use as part of the extended wearing of facemasks.

It is recommended that FRSMs should be well fitting and fit for purpose, covering the nose and mouth in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask). A ‘How to wear facemasks’ poster suggests ways to wear facemasks to help improve fit.

6.5.2 Face masks for residents

Residents in the medium or high risk category should be encouraged to wear a FRSM, if these can be tolerated and do not compromise care, when moving around the care home and when individuals enter the room.

Appropriate physical distancing and wider IPC measures are critical, with the use of face masks being a further line of defence.

Scottish Government guidance is available on the extended use of face masks in hospitals and care homes.  

Where clinical waste disposal is not available, used face masks should be double bagged and disposed of in domestic waste.

6.5.3 PPE determined by COVID-19 care category

Table 2 details the PPE which should be worn when providing direct resident care in each of the COVID-19 care risk categories.

Type IIR facemasks should be worn for all direct care regardless of the risk category.  This is a measure which has been implemented alongside physical distancing specifically for the COVID-19 pandemic. FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a resident isolated with a suspected or known infectious pathogen and when leaving resident areas on high risk categories.

Further guidance on glove use can be found in Appendix 5

Table 2: PPE for direct resident care determined by risk category

PPE used

Medium-risk category

High-risk category

Gloves

Risk assessment - if contact with BBF is anticipated.

Single use

Worn for all direct care.

Single use.

Apron or gown

Risk assessment - if direct contact with resident, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated).

Single use.

Always within 2 metres of resident (Gown if splashing spraying anticipated).

Single-use.

Face mask

Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask

Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask

Eye and face protection

Risk assessment - if splashing or spraying with BBF anticipated.

Single-use or reusable following decontamination.

Always within 2 metres of a resident

Single-use, *sessional or reusable following decontamination.

*Sessional use see section 6.5.7  

6.5.4 PPE - putting on (donning) and taking off (doffing)

All staff must be trained in how to put on and remove PPE safely.  A short film showing the correct order for putting on and the safe order for removal of PPE is available.  The video will also describe safe disposal of PPE.  A poster describing the donning and doffing of PPE is available in the NIPCM Appendix 6 .

Putting on PPE

Before putting on PPE:

PPE should be put on before entering the room.

When wearing PPE:

Removal of PPE

PPE should be removed in an order that minimises the potential for cross-contamination.

Gloves

 Gown

Eye Protection (if worn)

Fluid Resistant Surgical facemask

To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.

Perform hand hygiene immediately after removing all PPE.

6.5.5 Aerosol Generating procedures (AGPs)

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

Below is the list of medical procedures for COVID-19 that have been reported to be aerosol-generating and are associated with an increased risk of respiratory transmission:

 

*Note : The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.    It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  This applies to upper gastro-intestinal endoscopy also and as such it has also been changed to reflect risk associated with suctioning beyond the oro-pharynx.

Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres. On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

This recommendation comes from Public Health England and the New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG).  The published evidence view and consensus opinion can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp--2

Certain other procedures/equipment may generate an aerosol from material other than an individual’s secretions but are not considered to represent a significant infection risk and do not require AGP PPE. Procedures in this category include:

Note: During nebulisation, the aerosol derives from a non-resident source (the fluid in the nebuliser chamber) and does not carry resident-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol.

Staff should use appropriate hand hygiene when helping residents to remove nebulisers and oxygen masks.

For residents with suspected/confirmed COVID-19, any of the potentially infectious AGPs listed above should only be carried out when essential. The required PPE for AGPs should be worn by those undertaking the procedure and those in the room, as detailed above. Where possible, these procedures should be carried out in a single room with the doors shut. Only those staff who are needed to undertake the procedure should be present.

It is the responsibility of care home providers to ensure that all staff have been fit tested for FFP3 respirators, when appropriate. If you do not anticipate the need for FFP3 respirators and are not caring for anyone currently receiving AGPs such as CPAP, these should not be ordered or stockpiled and any surplus stock should be returned.

A Situation, Background, Assessment and Recommendations  (SBAR ) has been produced by Health Protection Scotland (HPS)/ARHAI Scotland and agreed by New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) specific to AGPS during COVID-19.

The NERVTAG consensus view is that the HPS document accurately presents the evidence base concerning medical procedures and any associated risk of transmission of respiratory infections and whether these procedures could be considered aerosol-generating. NERVTAG supports the conclusions within the document and supports the use of the document as a useful basis for the development of UK policy or guidance related to COVID-19 and aerosol-generating procedures (AGPs).

Airborne precautions are required for the medium and high-risk categories where AGPs are undertaken and the required PPE is detailed in table 3. Ongoing requirement for airborne precautions in the medium risk pathway when a patient is undergoing an AGP recognises the potential aersolisation of COVID-19 from an asymptomatic carrier.

**Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators, including powered respirators, for decontamination. This literature review will be updated to incorporate recommendations from this group when available. In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.

Table 3: PPE for aerosol-generating procedures, determined by risk category

PPE used

Medium-risk category

High-risk category

Gloves

 Single-use.

 Single-use.

Apron or gown

Single-use gown.

Single-use gown.

Face mask or respirator**

FFP3 mask or powered respirator hood.2

FFP3 mask or powered respirator hood.

Eye and face protection

Single-use or reusable.

Single-use or reusable.

**FFP3 masks must be fluid resistant. Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated. There is a theoretical risk of exhaled breath from the wearer of a valved respirator or powered air purifying respirator (PAPR) transmitting COVID-19 where asymptomatic carriage is present however, following introduction of staff testing and uptake of vaccination, this risk is likely to be low.  Valved respirators and PAPRs should not be used when sterility directly over a surgical field/surgical site is required and instead a non-valved respirator should be worn.  

6.5.6 Post AGP Fallow Times (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted.  This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate. 

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 4. It is often difficult to calculate air changes in areas that have natural ventilation only.  All point of care areas require to be well ventilated. Natural ventilation, provides an arbitrary 1-2 air changes per hour. To increase natural ventilation in many community health and social care settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  it is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.  

During the PAGPFT staff should not enter this room without FFP3 masks.  Residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately (see table 5 and 6)

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 4). Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Table 4: Post AGP fallow time calculation
Duration of AGP (minutes) 1 AC/h 2 AC/h 4 AC/h 6 AC/h 8 AC/h 10 AC/h 12 AC/h 15 AC/h 20 AC/h 25 AC/h
3 230 114 56 37 27 22 18 14 10 8 (10)*
5 260 129 63 41 30 24 20 15 11 8 (10)*
7 279 138 67 44 32 25 20 16 11 9 (10)*
10 299 147 71 46 34 26 21 16 11 9 (10)*
15 321 157 75 48 35 27 22 16 12 9 (10)*

* Note that for duration of 25 air changes per hour the minimum fallow time (to allow for droplet settling time) is 10 minutes.

6.5.7 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between residents and for a period of time where a member of staff was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is no longer recommended other than when wearing a visor or eye protection in a communal area where the resident is on the high-risk pathway and when wearing a fluid-resistant surgical face mask (FRSM) across all pathways. Sessional use of all other PPE is associated with transmission of infection amongst residents and is considered poor practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) pathway areas.

The same principles should be observed for staff post toilet and meal breaks, when a new face mask should be put on, once removed the FRSM must never be reused.

Employers are encouraged to plan breaks in such a way that allows 2 metre physical distancing and therefore staff not having to wear a face mask, with natural ventilation where possible.

6.5.8   PPE for delivery of COVID-19 vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

The resident on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

As per SICPs;

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.