Considerations for acute personal protective equipment (PPE) shortages
1. Update 3 May 2020
- HSE has examined the use of FFP2 respirators as an alternative to Type IIR surgical face masks in non-surgical settings
- if risk assessment identifies a need for FFP2 respirators the user must be face fit tested to ensure they are providing the intended level of protection
- in circumstances where a lower level of user protection is required, such as that provided by a surgical mask, an FFP2 worn without a face fit test will offer protection similar to the levels from a surgical face mask
- this is a pragmatic approach for times of severe shortage of respiratory protective equipment (RPE), FFP2 respirators being used in this way will not be carrying out the function they were designed to perform
- all healthcare settings are reminded that where their risk assessment has identified the requirement for a tight-fitting respirator users must pass a face fit test for that respirator model before it can be used
- employers and users of respirators need to be assured protective equipment is protecting the wearer
Note: Surgical masks may sometimes be used for source control, if feasible and if the mask can be tolerated by the individual; for example, a surgical mask worn by a patient with COVID-19 during transfer within a hospital. When an FFP2 respirator needs to be used in place of a surgical mask for this specific purpose, it should an unvalved FFP2 respirator (that is, no exhale valve).
2. Background to 17 April 2020 advice
This document aligns with current evidence and Centers for Disease Control (CDC) 1 and World Health Organization (WHO) 2 guidance on optimising the supply of personal protective equipment (PPE) and the use of PPE when in short supply.
The Health and Safety Executive (HSE) has reviewed the options outlined in this document. Where there are acute shortages of PPE, and where it is safe to do so, it approves the sessional and reuse of PPE.
Some of the PPE in the NHS COVID-19 Ensemble is designated by the manufacturers as being single use. However, the HSE recognises that some compromise is needed to optimise the supply of PPE in times of extreme shortages. It has agreed that the use as outlined in this document is appropriate within health and safety legislation and provides appropriate protection for health and care workers.
These are exceptional circumstances and do not reflect HSE’s standard approach. HSE expects Trusts to have an agreed action plan to support implementation which includes a consideration of all measures to manage usage effectively.
In addition, documentation of how any re-use will be managed (recognising that some PPE is personal, for example FFP3/FFP2 respirators) and should include a record of systems of work to manage how integrity checks and decontamination processes are being carried out. It should also recognise that certain equipment (for example gloves and aprons) cannot be reused.
Organisations should ensure healthcare workers are appropriately hydrated during prolonged use and trained to recognise dehydration, fatigue and exhaustion while wearing PPE.
Further work on validating methods to safely reprocess masks and fluid repellent gowns is under way and future updates will be circulated when available.
3. Purpose and scope of this document
This document aims to highlight the sessional use and reuse of PPE when there are severe shortages of supply.
The considerations are to ensure that health and care workers are appropriately protected from COVID-19, where items of PPE are unavailable, and should be considered as temporary measures until the global supply chain is adequate to meet the UK’s needs.
The reuse of PPE should be implemented until confirmation of adequate re-supply is in place.
These take into account the following important principles that should already be in place for all health and care delivery:
- Only urgent or emergency face-to-face contacts in the health and social care setting.
- Where an individual has a multi-drug resistant or other key pathogen, transmission-based infection prevention control precautions should apply to prevent cross transmission to other individuals.
Sessional use: by one health or care worker during one shift while working. Clinical areas should include all ward areas. In hospitals, leaving a ward area to continue to care or transfer a patient, the same PPE can be worn. Face masks/respirators, gowns/ coveralls and eye protection should only be changed when taking a break or when visibly contaminated or damaged.
Reuse: using the same item again, with appropriate precautions, by the same healthcare worker.
Alternatives to standard PPE: recommended where there is a crisis or short supply.
4. Medical masks
4.1 Fluid repellent surgical face masks (FRSM) and disposable respirators (FFP3/ FFP2/ N95)
This excludes re-usable respirators, that can be re-used according to manufacturer’s instructions.
FFP3/FFP2/N95 respirators have a large capacity for the filtration and retention of airborne contaminants. Sessional use or re-use over the course of a day in health or social care, would not approach anywhere near that capacity.
The use of masks for one HCW to use in one work area. This is currently recommended in the UK Infection Prevention and Control guidance.
- it should be disposed of if it becomes moist, damaged, visibly soiled
- the duration (number of hours) of sessional use is dependent on local (for example, heat, activity length, shift-length) and individual factors. In practice, this may vary from 2 to 6 hours
- if masks are touched or adjusted, hand hygiene should be performed immediately
- if the mask is removed for any reason (for example, upon exiting the ward area, taking a break or completing a shift), they are disposed of as clinical waste, unless they can be safely reused as outlined below
Important requirements are as follows:
- the mask should be removed and discarded if soiled, damaged, or hard to breathe through
- masks with elastic ear hooks should be re-used (tie-on face masks are less suitable because they are more difficult to remove)
- hand hygiene should be performed before removing the face mask
- face masks should be carefully folded so the outer surface is held inward and against itself to reduce likely contact with the outer surface during storage
- the folded mask should be stored between uses in a clean sealable bag/ box which is marked with the person’s name and is then properly stored in a well-defined place
- hand hygiene should be performed after removing the face mask
- some models of PPE cannot be physically reused as they deform once being donned and do not go back to original condition (meaning it would be difficult to re-don and achieve a fit check). Fit checks should be performed each time a respirator is donned if it is reused
Alternatives to standard PPE
There is insufficient evidence to consider homemade masks or cloth masks in health and care settings.
5. Gowns and coveralls
Fluid repellent hospital gowns or coveralls are indicated for use for the care of patients in high risk areas, where aerosol generating procedures (AGPs) are being performed.
There are 3 main options that can be considered as alternatives if gowns are not available:
- Reserve disposable, fluid repellent gown or coveralls for AGPs and surgical procedures.
- Disposable, non-fluid repellent gowns or coveralls with a disposable plastic apron for high-risk settings and AGPs with forearm washing once gown or coverall is removed.
- Reusable (washable) surgical gowns or coveralls or similar suitable clothing (for example, long-sleeved laboratory coat, long-sleeved patient gown or industrial coverall) with a disposable plastic apron for AGPs and high-risk settings with forearm washing once gown or coverall is removed. These would need to be washed in a hospital laundry and capacity for hospital laundries may need to be increased.
5.1 Sessional use
This is the use of gowns or coveralls for healthcare workers (HCWs) to use for higher risk clinical areas. This is currently recommended in the UK Infection Prevention and Control guidance.
If the gown or coverall becomes visibly soiled, it must be disposed as infectious waste (followed by hand hygiene, donning of a new gown, and appropriate donning of new gloves).
The following important factors would safely reduce gown usage over a session but organisations should develop an implementation and action plan suitable to their organisation:
- Label all higher risk area bays, single rooms, corridors, treatment rooms and nurses’ stations as ‘clinical’ areas within a specific hospital area. Limit ‘non-clinical’ areas to staff kitchen/rest areas and changing room.
- Once gown or coverall is donned, the gown/coverall should remain on the staff member until their next break. Plastic aprons and gloves should be changed between patients (with the notes from aprons highlighted below).
- Staff should doff the gown or coverall only when going from the clinical to non-clinical area of the ward, or if they are leaving the ward for a break.
- If leaving a higher risk area/theatre ward with a patient to transfer them to another area staff should retain their gown or coverall and other PPE.
- Teams that assist with turning and moving patients (“proning teams”), allied health professionals and other teams should retain gowns or coveralls on sessional basis, changing gloves/aprons between patients/residents and performing hand hygiene.
Consider shifting disposable gowns or coveralls to reusable options, retaining disposable gowns only for high risk AGPs.
If there are no available disposable gowns or coveralls, consider the use of gown alternatives including:
- reusable gowns
- reusable (washable) laboratory coats
- reusable (washable) long sleeved patient gowns
- reusable coveralls
Capacity for hospital laundering service should be considered if using these items.
6. Eye Protection
Goggles provide barrier protection for the eyes. They should fit snuggly over and around the eyes or personal prescription lenses, be indirectly-vented (to prevent penetration of splashes or sprays) and have an anti-fog coating to help maintain clarity of vision. The lens is made of plastic, commonly polycarbonate and there is an adjustable elastic strap to allow snug fit around the eyes. Goggles used for healthcare applications are typically reusable.
Visors provide barrier protection to the facial area and related mucous membranes (eyes, nose, lips) and are considered an alternative to goggles. Visors should be used if AGP aerosol-generating procedure is performed. They should cover the forehead, extend below the chin, and wrap around the side of the face. Visors are available in both disposable and reusable options.
This is currently recommended in the UK Infection Prevention and Control guidance.
The goggles or face shield should be removed upon exiting the ward area per standard practice.
This is currently recommended in the UK Infection Prevention and Control guidance, where the eye protection is not relabelled as single use only.
If in extremely short supply, single use only items could be re-used in a similar way as re-usable items.
The standard method of cleaning is to use a detergent product either combined/ sequentially with a decontamination product as agreed by the local infection prevention and control (IPC) specialists.
They should be rinsed thoroughly to remove any residual detergent or cleaning product and left to dry.
Products will degrade over time with repeated cleaning, particular the anti-fog component and will need to be resupplied regularly.
This guidance relates to examination gloves used for clinical care of COVID-19 patients. These gloves are available in a variety of materials, are single use and must be disposed of after each use. Non-powdered, nitrile gloves are the most commonly recommended for healthcare.
7.1 Additional considerations
Do not use double gloves for care of suspected or confirmed COVID-19 patients.
Sessional use or of reuse examination gloves for clinical care should be avoided.
These are indicated for use when there is risk of splashes or sprays to protect clothes, where gowns are used on a sessional basis or where the gowns are not fluid resistant.
Re-use of aprons is not recommended.
9. Associated legislation
Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.
10. Consensus statement
It is the consensus view of Health Protection Scotland, Public Health Wales, and Public Health Agency Northern Ireland that current advice remains extant; that is, single use PPE should not be reused/reprocessed and that reusable PPE should be reprocessed in accordance with the manufacturer’s instructions.
- CDC strategies for US-healthcare settings on COVID-19: Strategies for Optimizing the Supply of PPE
- WHO’s guidance on the Rational use of personal protective equipment for coronavirus disease 2019↩
Source: Public Health England, Considerations for acute personal protective equipment (PPE) shortages [updated 3 May]