Infection prevention in settings with shortages of PPE

ASHM regional task force Covid 19

Infection prevention and control in settings with shortages of PPE

Prepared by Matthew Mason, Associate Professor Catherine O’Connor, Professor Allen Cheng, Dr Nicholas Medland (RAG Chair) and members of the RAG’s Clinical Care – COVID-19, HIV, Viral Hepatitis and SRH Sub-Groups 

 

UPDATED ON: 17 June 2020

 

 

SUMMARY OF RECOMMENDATIONS FROM WHO, US CDC AND UK PHE (1-3).
Australian PPE guidelines can be found here(4).
 

Disclaimer: The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings. The recommendations are not intended to replace national guidance.   

 

 

Triage

>1.5m distancing

Separation screen

Mask and eye protection if above not possible.

Hand hygiene

 

Patients with COVID-19 symptoms

Patients without COVID-19 symptoms

 

Patient waiting area (patient)

Medical/Surgical mask if tolerated

Move immediately to isolation area

>1.5m distancing

Hand Hygiene

No PPE required

 

 

Hand Hygiene

Consultation and examination

(worker)

Medical/Surgical mask

Gown

Gloves

Eye protection (Goggles or face shield)

Hand hygiene

No PPE required

 

 

Hand hygiene

 

Carer or HCW (Entering room only)

> 1.5m distancing

Medical/Surgical mask

Hand hygiene

Carers (Providing direct care or when handling stool, urine, or waste from known/suspected COVID-19 patient being cared for at home)

Medical/Surgical mask

Apron (if risk of splash is anticipated)

Gloves

Hand hygiene

HCW (Providing direct care or assistance to a known/suspected COVID-19 patient at home)

Medical/Surgical mask (Respirator for Aerosol Generating Procedures)(5)

Gown

Gloves

Eye protection (Goggles or face shield)

 

Reducing the need for PPE though the hierarchy of controls: Elimination / Substitution / Engineering / Administrative / PPE (6)
Examples: 

  • telemedicine where possible (Substitution)
  • Stage appointments to limit crowding in outpatient areas (Administrative)
  • physical barriers in triage areas (Engineering)
  • restrict PPE to HCWs (PPE)
  • dedicated teams and staff for care to patients with COVID-19 (Administrative)
  • restrict number of individuals who are in contact with patients with known/suspected COVID-19 (Administrative)
  • limit visitors to health facilities (Administrative)
  • provide education on safe practices for visitors (Administrative)

Emergency measures for acute PPE shortages: extended use, re-use and alternatives should only be adopted only as an emergency measure (1, 5)

 

Extended/sessional use:
  • up to 2-6 hours
  • dispose if wet, soiled, or damaged
  • perform hand hygiene immediately after touching or adjusting
re-use of masks (for same worker)
  • elastic ear hooks preferred to avoid contact in removing
  • dispose if wet, soiled, damaged or hard to breathe through
  • perform hand hygiene immediately after removing, touching, handling or refitting
  • fold outer surface inward touching itself, store in sealed bag or box

Alternatives:    

  • * evidence for cloth or handmade masks for HCW use is lacking (5)
  • *the same use above should be applied including hand hygiene after removing, touching, handling or refitting (5, 7)

extended/session use
  • disposed if soiled
  • hand hygiene immediately after touching or adjusting
re-use of gowns/coveralls (for same worker)
  • consider washable patient gowns/laboratory gowns/coats/coveralls

Alternatives:

  • Nil

extended/sessional use

  • remove and dispose/clean on exiting the clinical area
  • hand hygiene immediately after touching or adjusting

re-use of eye protection (for same worker)

  • Wearing gloves, wipe inside and out using a clean cloth with a neutral detergent.
  • remove gloves 
  • perform hand hygiene
  • allow equipment to fully air dry before re-use

Alternatives:

  • Nil

extended/sessional use

  • Restrict and control glove use to recommended indications 
  • disinfection of gloved hands  
  • gloves should be visibly clean and have no visible perforations(7, 8)
  • dispose if soiled or damaged
  • maximum 4 hours

Alternatives 

  • Use bare hands with Hand Hygiene or see WHO recommendations (9)
  • soap and running water for at least 40 seconds (9)
  • alcohol based hand sanitiser: (>60% ethanol or 70% isopropyl alcohol) 

Alternatives

  • see WHO recommendations including friction and or the repurposing of water (10)

  1. World Health Organization. Rational use of personal protective equipment for coronavirus disease (‎‎ COVID-19)‎‎ and considerations during severe shortages: interim guidance, 6 April 2020: World Health Organization; 2020 [Available from: https://www.who.int/publications/i/item/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages.
  2. Centres for Disease Control and Prevention. Strategies to Optimize the Supply of PPE and Equipment 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.
  3. Public Health England. Considerations for acute personal protective equipment (PPE) shortages 2020 [Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/managing-shortages-in-personal-protective-equipment-ppe.
  4. Australian Government Department of Health. Coronavirus (COVID-19) resources for health professionals, including aged care providers, pathology providers and health care managers 2020 [Available from: https://www.health.gov.au/resources/collections/coronavirus-covid-19-resources-for-health-professionals-including-aged-care-providers-pathology-providers-and-health-care-managers.
  5. World Health Organization. Advice on the use of masks in the context of COVID-19: Interim guidance, 5 June 2020: World Health Organization; 2020 [Available from: https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak.
  6. Liberati EG, Peerally MF, Dixon-Woods M. Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare. Int J Qual Health Care. 2018;30(1):39-43.
  7. Kampf G, Scheithauer S, Lemmen S, Saliou P, Suchomel M. COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves and gowns – proposal for a risk-adapted approach to ensure patient and healthcare worker safety. Journal of Hospital Infection. 2020.
  8. Kampf G, Lemmen SJJoHI. Disinfection of gloved hands for multiple activities with indicated glove use on the same patient. 2017;97(1):3-10.
  9. World Health Organization. WHO guidelines on hand hygiene in health care: World Health Organization; 2009 [Available from: https://www.who.int/gpsc/5may/tools/9789241597906/en/.
  10. World Health Organization. Considerations for community hand hygiene practices in low- resource situations. World Health Organization, Western Pacific Regional Office; 2020 12/5/2020.