5.15 - Personal Protective Equipment (PPE)

5.15.1 Extended use of face masks for staff, visitors and outpatients

5.15.2 Sessional use of FRSMs, FFP3 respirators and/or eye/face protection

5.15.3 Filter Face Piece 3 (FFP3) Respirators

5.15.4 PPE worn when caring for service users on the respiratory pathway

5.15.5 Access to PPE

5.15.6 Aerosol Generating Procedures (AGPs)

5.15.7 Determining the IPC precautions required for AGPs

5.15.8 PPE for AGPs

5.15.9 Post AGP Fallow Times

 

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken.  As part of SICPs, all staff undertaking in procedure, should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken. More information on PPE including donnng and doffing resources can be found in the NIPCM.

Care home settings

Staff within Care Homes can find more general information on PPE in the CHIPCM for Older People and Adult Care Homes.  Staff in care homes must follow the PPE guidance below.

When caring for a service user who has respiratory symptoms PPE should be selected to protect against droplet or in some circumstances, airborne spread.

PPE must not be used inappropriately.  It is of paramount importance that PPE is worn at the appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

PPE is the least effective control measure within the hierarchy of controls and other mitigation measures must be implemented and adhered to wherever possible. 

 

5.15.1 Extended use of face masks for staff, visitors and outpatients

The extended use of facemasks by health and care workers and the wearing of face coverings by visitors and outpatients (unless exempt) is designed to protect staff and service users as part of the COVID-19 pandemic.  This is because COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or pre-symptomatic). 

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

Primary Care and Community Health and Social Care settings - Face coverings for individuals and service users

Any service users attending a health and care facility should be encouraged to wear a face covering in line with Scottish Government guidance unless exempt.  Type II FRSM should be available should an individual or service user attend without a face covering.

 

Dental  settings

Any patient attending a health care facility should be encouraged to wear a face covering in line with Scottish Government guidance unless exempt.  Type II FRSM should be available should a patient  attend without a face covering.

 

Secondary care settings - Face masks for inpatients

A facemask should be worn by all inpatients across all inpatient areas regardless of respiratory symptoms unless exempt and where it can be tolerated and does not compromise their clinical care for example when receiving oxygen therapy. All patients should be encouraged to adhere to this which is part of COVID-19 pandemic control measures. The purpose of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination.  This should be actively promoted throughout the healthcare setting.It is recognised that it will be impractical for inpatients to wear facemasks at all times and these will have to be removed for reasons such as eating and drinking or showering. There is no need for inpatients to wear a facemask when sleeping provided bed spacing requirements in line with current guidance are met.A facemask should be worn by all inpatients across all pathways during transfer between departments within the hospital unless exempt. Where an inpatient is isolated in a single room, they do not need to wear a facemask. However, the inpatient must be asked to don their mask when any staff or visitors enter the room unless exempt.

 

Care home settings- Face masks for residents

Residents on the respiratory pathway should be encouraged to wear a facemask, if these can be tolerated and do not compromise care, when moving around the care home and when care staff, other residents or visitors enter their individual room.

 

5.15.2  Sessional use of FRSMs, FFP3 respirators and/or eye/face protection

FRSMs and eye/face protection (goggles/visors) may be used sessionally.  This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to respiratory pathogens.  A session ends when the healthcare worker leaves the clinical setting or exposure environment. 

Typically, sessional use of any PPE is not permitted within health and care settings at any time as it is associated with transmission of infection between service users within health and care settings.

Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks policy, sessional use of FRSMs and eye/face protection is permitted at this time. 

However, in using FRSMs/eye and face protection/RPE sessionally, it is important to note the following;

The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.

No other PPE is permitted to be worn sessionally moving between service users or care tasks.  This includes gloves, aprons and gowns.

Dental settings - sessional use of FRSMs, FFP3 respirators and/or eye/face protection

Within dental settings, HCWs may wear FRSMs sessionally to account for the extended use of facemask policy outside of direct patient care delivery and provided they are changed at the points listed above.  It should be noted that due to the procedures being undertaken in dentistry and the splash/spray generated during those procedures, that FRSMs should be changed between patients in line with standard practices.  FFP3 respirators should not be worn sessionally at any time.

Secondary care settings - sessional use of FFP3 respirators

Sessional use of FFP3 respirators is also permitted only where unit wide airborne precautions are applied throughout a unit/care area however all other AGP PPE should be removed when no longer within 2 metres of a patient or, if still within 2 metres of the patient, then after the AGP is complete and fallow time has elapsed. It is not necessary to wear sessional gowns moving around a unit or department.  Gowns protect against excessive splash and spray which is associated with AGPs and other direct patient care procedures.

 

5.15.3  Filter Face Piece 3 (FFP3) Respirators

FFP3 respirators must only be worn by staff who have undergone and passed a fit test.  FFP3 respirators must be worn by HCWs in the following scenarios;

More information can be found on RPE within chapter 2 of the NIPCM.

 

5.15.4 PPE worn when caring for service users on the respiratory pathway

Table 7 details the PPE which should be worn when providing direct care for service users on the respiratory pathway.

Type IIR FRSM should be worn for all direct care delivery regardless of whether the service user is on the respiratory pathway or not.  This measure has been implemented alongside physical distancing specifically for the COVID-19 pandemic.

Type IIR FRSMs can be worn sessionally when going between service users on the respiratory pathway. Type IIR FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a service user isolated with any other suspected or known infectious pathogens and when leaving respiratory pathway areas. 

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

Health and care staff moving between different settings, wards and departments to provide care/consultations or undertake service user transfers (e.g. portering and theatre staff) throughout the course of their working day must ensure they first clarify with the person in charge or named health and care worker what pathway the service user they are attending to is on and what PPE is required.

Table 7 PPE worn for SICPs and TBPs (see table 8 for AGP PPE)

PPE item

Non Respiratory pathway (SICPs)*

Respiratory pathway (TBPs)

Gloves

Risk assessment - wear if contact with blood and body fluid (BBF) is anticipated.

Single-use

Worn for all direct care delivery.

Single use.

Apron or gown

Risk assessment - wear apron if direct contact with service user, their environment or BBF is anticipated. (Gown if extensive splashing anticipated)

Single use

Apron to be worn for all direct care delivery (Gown if extensive splashing anticipated)

Single-use

Face mask (FRSM)/FFP3 respirator

Always within 2 metres of a service user- Type IIR FRSM

(Wearing a Type IIR FRSM as part of SICPs would normally only be worn when splash/spray is anticipated. Use of FRSM for all service user direct care and exists as an ongoing COVID-19 pandemic measure)

Single use or Sessional use

Always within 2 metres of a service user - Type IIR FRSM

FFP3 respirator required when caring for service user with a known or suspected pathogen transmitted by the airborne route e.g. pulmonary TB

Single use or Sessional use

Eye & face protection

Risk assessment - wear if splashing or spraying with BBF including coughing/sneezing anticipated.

Single-use or reusable following decontamination.

Worn for all direct care delivery provided to service users with respiratory symptoms

Single-use, sessional or reusable following decontamination.

*Ensure that PPE is worn appropriately for TBPs as per NIPCM on the non-respiratory pathway if caring for service users with any other known or suspected infectious pathogen requiring TBPs.

5.15.5 Access to PPE

NHS staff should continue to obtain PPE through their health board procurement contacts, who will raise their needs via an automated procurement portal to NHS National Services Scotland (NHS NSS). This automated internal procurement system has been specifically developed to deal with increased demand, give real time visibility to Health Boards for ordered stock, as well as enabling quick turnaround for delivery.

Those providing services within social care settings (including personal assistants and unpaid carers) who have an urgent need to access PPE, can contact the PPE support centre on 0300 303 3020 or their local HSCP PPE hub.

 Please note that hubs are to be used only in cases where there is an urgent supply shortage after “business as usual” routes have been exhausted.

The contact details below will direct social care providers to the NHS National Services Scotland Social Care PPE Support Centre, and the team there will point you towards your local Hub.

Email: support@socialcare-nhs.info

Phone: 0300 303 3020.

The helpline is open (8am - 8pm) 7 days a week.

Further information can be found at: Coronavirus (COVID-19): PPE access for social care providers and unpaid carers.

 

5.15.6 Aerosol Generating Procedures (AGPs)

An 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. It is also possible for asymptomatic and pre-symptomatic carriers of COVID-19 to transmit COVID-19 during AGPs.

A full list of AGPs can be found in Appendix 17 of the NIPCM.

 

5.15.7 Determining the IPC precautions required for AGPs.

Airborne precautions and subsequent post AGP fallow times are required for all patients undergoing an AGP on the respiratory pathway. 

A risk assessment should be undertaken prior to performing an AGP on patients on the non-respiratory pathway and take account of any presenting respiratory symptoms.  Optionally a laboratory based PCR test, COVID-19 Rapid Diagnostic Test (including POCT) or LFD test may also be used to support the risk assessment. Where there is no evidence of a respiratory virus, the AGP may be performed using standard infection control precautions and also negating the need for post AGP fallow times.

NB: where SICPs are applied for an AGP, HCWs are still required to wear an FRSM and eye/face protection to protect against splash/spray generated by the AGP.

 

Dental Settings - Determining IPC precautions required for AGPs

Airborne precautions and post AGP fallow times must be applied for any patients requiring treatment on the respiratory pathway as outline in the respiratory screening questions.  Dental teams must continue to ask patients the respiratory screening questions prior to attendance for appointments to determine the IPC precautions required prior to undertaking AGPs.

 

5.15.8 PPE for AGPs

The required PPE when undertaking AGPs is listed in table 8.

 **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 8: PPE for AGPs

PPE Item

Non Respiratory pathway where there is no evidence of a respiratory virus

Respiratory pathway (TBPs) 

Gloves

Single-use

Single use

Apron or gown

Single-use

Risk assess – use fluid resistant gown if excessive splashing/spraying anticipated otherwise apron is sufficient

Single-use fluid resistant gown

Face mask (FRSM) or Respirator

Type IIR FRSM*

Single or Sessional use

FFP3 mask or powered respirator hood  

Single or Sessional use

Eye & face protection

Single use or reusable following decontamination

Single-use, sessional or reusable following decontamination

*Where staff have concerns about potential COVID-19 exposure to themselves during this ongoing COVID-19 pandemic, they may choose to wear an FFP3 respirator rather than an FRSM when performing an AGP on any patient provided they are fit tested. This is a personal PPE risk assessment.

5.15.9 Post AGP Fallow Times

Time is required after AGPs undertaken with airborne precautions are performed to allow the actual/potential infectious 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 PAGPFTs can be found in appendix 17 of the NICPM.

Dental settings - AGPs

Staff within dental settings should refer to the ‘Mitigation of AGPs in dentistry; A Rapid Review which details fallow times specific to this setting and the mitigations used.  The methodology work was undertaken by SDCEP and Cochrane oral Health. Post AGP down time (fallow time) is not considered necessary for successive appointments between members of the same household within dental settings; to minimise aerosol spread dentists should use mitigating measures such as high volume suction/rubber dam.  It is essential that staff change their PPE and adhere to SICPs between family members.Treatment rooms in dental practices should be aiming for a minimum of 10ACH.