Peer-to-peer support/Hot Topics and FAQs
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Current hot topics include:
- 1. PPE and staff protection
- 2. Use of NIV
These are both evolving topics, please keep this page under review for updates.
1. Protecting you and your staff
Cross-infection can be reliably prevented with effective correct location, effective use of PPE, and good working practices. Critical care requires specific consideration, as critical care patients undergo more frequent aerosol-generating procedures and prolonged exposure with 1:1 nursing.
Live and updated information can be found on the Public Health England's guidance: on COVID-19 infection, prevention and control.
We recognise that two models of PPE have been in use in critical care in the UK since the beginning of the outbreak.
- Public Health England recommend single-layer PPE for droplet-mediated airborne disease, including COVID-19.Many hospitals, including some HCID centres and some with substantial military/overseas expertise, have implemented and are comfortable with this.
- Other hospitals, including some HCID centres, have chosen to voluntarily employ enhanced PPE (with complete skin and hair cover) for COVID-19 patients. This is reflected in recent FICM guidance.
There was previously no specific mention of critical care in PHE guidance. Following approach by the ICM professional bodies, Public Health England have now (6 March 2020) added a critical care section [section 17] to their infection and prevention guidance , which implies that standard PPE is regarded as sufficient in an ICU setting but does not go into greater depth. Further discussion is in progress but this is likely to be around adding explanatory detail rather than a change of direction.
In the interim, our guidance is as follows:
- By local decision and at discretion, units may additionally choose to utilise enhanced PPE, in which case they should follow the available guidance for this, with particular attention once again to correct donning and doffing, in particular of headwear [https://www.ficm.ac.uk/sites/default/files/resppolicyhcidlevel3ppe_donningdoffing.pdf – credit: FICM/Sheffield].
- Strategic PPE stockpiles are based on PHE guidance. We recommend that units using enhanced PPE should plan ahead for transition and re-training in the event of stock exhaustion of enhanced items.
- In an ICU setting, checklists and buddy supervision should be used for donning and doffing until all staff are fully confident, and units should be staffed accordingly for as long as sustainable. We recognise this may evolve over time.
- Equal attention should be given to adequate daily environmental cleaning, and safe sample and waste management.
- FFP3 masks should be fit-tested according to manufacturer recommendation (note that this varies by manufacturer, and supplies are likely to change over time).
There is 2007 CDC guidance on facial hair and best mask fit. In general, shaving is recommended during this epidemic. We acknowledge that some people have cultural and religious needs, and they are recommended to seek advice from religious leaders for appropriate guidance for their own and patient safety.
Staff who do not pass fit-testing for whatever reason should be at the back of the queue for managing COVID-19 patients. Some units have procured powered air protective respirators (PAPR), but should note that HCIDs such as Royal Free have rejected these as there is no reliable way to decontaminate the external parts.
2. NIV and HFNO
The latest PHE guidance [section 5.4] recognises these as aerosol-generating procedures (AGP). Unlike other AGPs, these are continuous rather than intermittent, and may therefore pose additional risk.
In collaboration with the HCIDCs, we have previously recommended avoiding these in COVID-19 patients and moving to early intubation in deteriorating acute respiratory illness. The benefits of delay with NIV are unclear, and the risks of aerosol generation are recognised.
We are engaging with the British Thoracic Society with regard to scenarios such as pre-existing complex respiratory illness and those with treatment ceilings.
In the interim, the principles in the opening statement apply: clinicians should prioritise the best interests of the patient, and work with colleagues to provide shared and robustly documented decision-making for difficult decisions.