To All Members of the East of England Ambulance Service Unison Branch,
Over recent days there has been a further update from NHS England and Public Health England to the guidance for the use of personal protective equipment (PPE) by healthcare workers dealing with suspected COVID-19 patients. The Trust continues to follow the national guidance, which is informed by the latest evidence base and a national expert group (NERVTAG). EEAST Unison Branch have listened to the concerns which have been raised by our members and have been trying to secure the best arrangement possible to protect employees and patients.
The Medical Director of the Trust and representatives of the Branch have worked together to produce this joint statement, recognising that further guidance, in addition to the Trust guidance already provided, would help further support employees and members at this challenging time.
The updated guidance supports the fact that a dynamic risk assessment must be carried out with every patient contact, as is standard IPC practice, and that the level of PPE required should be informed by this individual risk assessment. As the prevalence of COVID19 increases in the community this should be taken into consideration and Level 2 PPE (fluid-resistant surgical mask, gloves, apron, and consider if eye/face protection is required) should be used for all patient contact(within 2 metres). This applies equally to PTS and frontline crews.
As a good example of this dynamic risk assessment; clinicians are encouraged (when more than one clinician is attending) for only one clinician to initially assess the patient (within twometers) and for other clinians to stand back unless required. This will allow for the appropriate level of patient care, reduce the risk of transmission to more than one clinician and allow for a proportionate usage of PPE. This reflects the approach to any hazard i.e. to risk assess and not expose additional clinicians if not necessary.
Unison have worked with the Trust to source an alternative product to the aprons presently available. The Trust has committed to sourcing a heavier apron and these are coming through our supply chain now. Where the current aprons are in use, these can be doubled up to reduce the risk. Gowns are not routinely used within the ambulance sector and increase the risk of transmission if they are not used correctly, particularly when removing. Therefore, it is not a simple exchange as this would present a greater risk to staff. The Trust is engaged nationally with work to identify suitable alternatives. Before any new alternatives are introduced, risk assessments will be carried out to make sure they are suitable when used in the pre-hospital environments our members are used to working in.
The Trust has advised that if a member of staff feels that their uniform has been contaminated then enough time should be allowed to change uniform. This will be supported by local management teams and AOC. Staff should, where possible, carry a change of uniform with them on a shift. Where a spare uniform is not available, local management teams will facilitate this from station stocks.
There has been much discussion about Aerosol Generating Procedures (AGPs), generated by a differing opinion between some national / international bodies and NHS England / Public Health England. NHS England is advised by NERVTAG, a national expert body with access to the up to date evidence base. The NHSE/PHE definition of AGPs has not changed but NERVTAG are reviewing the evidence base again. The current guidance clearly states that intubation, extubation, suctioning and manual ventilation all constitute AGPs; it also re-states that chest compressions, defibrillationand nebulisation are not considered AGPs (noting this is chest compressions alone and not as part of advanced CPR).
In recognising the concerns of staff and Unison members, the Medical Director is working with ambulance Medical Directors nationally to provide additional guidance to clinicians on the use of nebulisation; whilst it is not considered an AGP we acknowledge the anxiety this is causing clinicians and the Trust are working at pace to provide guidance on alternative options along with Unison at a National Ambulance Level. If the perceived risk is high, or the clinician is in doubt, they should feel able to opt for a higher level of PPE when performing nebulisation.
With respect to cardiac arrest situations the current national guidance supports the following approach to cardiac arrest. The national ambulance Medical Directors are constantlyreviewing this and will continue to do so. The Trust and Branch agree that it provides the appropriate level of protection to the clinician, whilst offering the patient the optimal care in the context of COVID19:
In a cardiac arrest all available information should be used to make a dynamic risk assessment of the situation. The first clinician should approach and assess the patient in Level 2 PPE (fluid-resistant surgical mask, gloves, apron, eye/face protection), whilst other clinicians (if applicable) take time to understand the initial assessment of need of the patient and, if indicated, take time to appropriately don Level 3 PPE [gloves, fluid repellent coverall, filtering face piece respirator (FFP3 or hood)]. The first clinician, if clinically indicated, should commence chest compressions and place the defibrillator/shock if appropriate. If there is a perceived risk of infection, the first clinician on scene may choose to cover the patient’s mouth and nose with a surgical or an oxygen mask.Once another clinician has donned Level 3 PPE the first should withdraw and only return having donned Level 3 PPE.
Employees who are not yet fit tested for their FFP3 mask should speak with their local management team at the earliest opportunity to get fit tested. Staff who have not passed a fit test with their FFP3 mask and do not have access to a hood, should not be within two metres of an Aerosol Generating Procedure, and should ideally not be in the same room as the patient when an AGP is being performed. Fit testing is specific to each model of FFP3 mask and the Trust is working with partners to ensure that, where required, staff have access to the appropriate testing and masks.
The Trust and Unison Branch agree that our staff/members should not be put in position where they are attending withoutthe appropriate level of PPE. The Trust Management will not ask staff/members to attend if the appropriate level of PPE is not available to them. The Trust will continue to secure alternative options to the aprons but do not believe this changes the current risk assessment.
Concerns have been raised about the supply of PPE. This Trust has had a significant amount of PPE delivered in the last few weeks. Whilst there are concerns being raised by staff/members that stocks are not visible at stations, the Trust Management has confirmed that full stocks are available for crews, and that we are working with the NHS supply chain on a 72-hour cycle.
The Medical Director has agreed to continue to work with Unison and the clinical team to produce several action cards to support staff/members and managers in dealing with common patient scenarios. These will be distributed over the next few days.