COVID-19 dominated headlines in 2020 and continues to severely affect lives and livelihoods as 2021 begins. With vaccine development giving hope that an end to the crisis may be in sight, attention has turned to the long-term impacts of the pandemic and of public health responses to it: our actions and policies will always have unanticipated consequences. For IPC teams, the unforeseen consequences of adopting new policy around PPE use in the context of COVID-19 patient care are becoming more apparent. Our recent report in the Journal of Hospital Infection outlines in detail the need for more research into the impact of PPE use on patient outcomes.

New guidance and unexpected outbreaks

In April 2020, guidance was issued by Public Health England on the use of PPE in high-risk areas (such as critical care units) during the pandemic. The first guidance to be issued advised that staff working with suspected or confirmed COVID-19 cases should wear a fit-tested FFP3 respirator, a long-sleeved fluid-repellent gown (when aerosol generating procedure or contamination with other body fluids was likely), eye and face protection and disposable single-use gloves. Guidance published later the same month advised that fluid-repellent surgical gowns could be worn as sessional use within critical care units.

Following the implementation of the guidance, the IPC team at our hospital carried out observations and audits of IPC practices in a 12-bed critical care area that was used exclusively for patients with confirmed COVID-19. Our audits identified a reduction in hand hygiene compliance after the introduction of long-sleeved gowns: hand hygiene compliance among staff had been judged to be 92% in December 2019, compared with 75% in May 2020 when our study was carried out.

In addition, we noted a cluster of three central venous catheter (CVC) infections over four weeks in April and May 2020, caused by Citrobacter sp., Proteus sp. and Staphylococcus aureus. There had been no CVC infections during the preceding 12 months, and none with enteric gram negative bacteria in the preceding 10 years. In 18 patients, Klebsiella spp. was isolated from sterile sites (blood culture or bronco-alveolar fluid) in 2020, compared with four in the same period in 2019. Similar increases in other enteric Gram-negative bacteria were noted.

Regulations and responses

The Personal Protective Equipment at Work Regulations 1992, Section 4(1), Provision of Personal Protective Equipment, states that ‘Every employer shall ensure that suitable personal protective equipment is provided to his employees who may be exposed to a risk to their health or safety’. However, what constitutes ‘suitable’ PPE for a respiratory virus such as SARS-CoV-2 has not been established to date: the reasoning behind the requirement for long-sleeved gowns and other PPE such as routine use of gloves and aprons or layering of such PPE for staff caring for patients with COVID-19 is therefore unclear.

Further, the Health and Safety Executive ‘Pandemic Flu – Workplace Guidance’, while emphasizing the need for respiratory protection, states ‘Workers should adopt good working practices and not rely solely on personal protective equipment as a means of protection. They need to adopt sensible hygiene measures by washing their hands thoroughly and more frequently than normal and avoiding unnecessary hand to mouth or hand to eye contact’. It is interesting to note that the guidance adopted during the pandemic is different to that recommended in this document, although the transmission modes of influenza and coronavirus are expected to be similar.

We currently lack robust scientific evidence to suggest that PPE, other than good respiratory protection combined with general infection control measures, such as hand hygiene, adds benefit to the protection of healthcare workers. Additionally, while PPE is designed to protect healthcare workers, we also have a duty to protect patients and their environment from risks that will promote transmission of infection.

In our hospital, we used local risk assessments and a review of the above legislation and recommendations to enable the IPC team, hospital health and safety, and senior management teams to move to a policy of using short-sleeved gowns within the critical care unit to facilitate effective hand hygiene. Since doing so, hand hygiene compliance has returned to the hospital's baseline standards. For eight weeks after instituting the policy change, no further CVC infections were observed, and an immediate reduction in the environmental sites contaminated by Gram negative bacteria in the critical care unit was noted

Addressing unintended consequences: future policy change

It is now more than a year since SARS-CoV-2 was first sequenced. The focus of the global scientific community on COVID-19 research has led to the rapid availability of evidence around transmission risks with various bodily fluids, the persistence of the virus on different surfaces and understanding of mechanisms of modes of transmission. As with other coronaviruses and other respiratory viruses, it is clear that the infection is transmitted predominantly by the droplet/aerosol modes. Effective respiratory protection combined with good hand hygiene and standard infection prevention and control precautions should therefore protect healthcare workers. In an era of increasing bacterial drug resistance, the issue of what constitutes appropriate PPE for COVID-19 needs to be reassessed to protect our patients and our ecosystem.

Long-sleeved gowns were observed to be a barrier to healthcare workers cleaning their hands effectively after glove removal. The use of these gowns may therefore have contributed to wider contamination of the critical care unit with gram negative bacteria and the potential transmission of these bacteria to patients through contact with contaminated surfaces.

Our experience, reflected in the experiences of critical care units around the country, serves as a reminder of the serious impact the unintended consequences of policy change can have on patient care. While it is important to respond speedily in a crisis, as posed by a pandemic, it is vital to ensure full understanding of the scientific rationale for recommendations of PPE before recommendations are made: it is important to understand how these may contribute to the transmission of infectious agents and adapt these promptly as scientific evidence becomes available.

Given the current pandemic situation, urgent action is needed by Public Health England and the UK Government to establish these risks and review current PPE guidance.

The full JHI report is free to read and download here:

M Meda, V Gentry, P Reidy, D Garner. Unintended consequences of long-sleeved gowns in a critical care setting during the COVID-19 pandemic. Journal of Hospital 2020; 106(3)

References:

Public Health England, Recommended PPE for healthcare workers by secondary care inpatient clinical setting NHS and independent sector. PHE: London, 2020.

Public Health England, Considerations for acute personal protective equipment (PPE) shortages PHE: London, 2020.

UK Statutory Instruments The Personal Protective Equipment at Work Regulations 1992 No 2966, reg 4.

Health and Safety Executive. Pandemic flu – workplace guidance HSE: London.

Prestel C, Anderson E, Forsberg K, et al. Candida auris Outbreak in a COVID-19 Specialty Care Unit — Florida, July–August 2020 MMWR Morb Mortal Wkly Rep. 2021 Jan.

Wölfel, R., Corman, V.M., Guggemos, W. et al. Virological assessment of hospitalized patients with COVID-2019 Nature 2020; 581:465–469.

Fennelly, K.P. Particle sizes of infectious aerosols: implications for infection control Lancet Respir Med. 2020; 8(9).