Although the pandemic is primarily affecting Victoria, NSW and SE Queensland, there are messages for general practice around Australia. Since mid-July more than 2700 healthcare workers in Victoria have been infected with COVID-19 and at the time of writing, healthcare workers (in all settings, including general practice) make up 50 per cent of new cases. A high proportion (over 70 per cent) contracted the disease at work during this second wave, raising concerns about PPE – both adequacy of supply and correct use of equipment.

Compared with the general community, healthcare workers are at increased risk of contracting COVID-19, ranging from just over one times the risk for ‘other healthcare workers’ to over 9 times the risk for those working in aged care. Medical practitioners have over twice the risk of the general community. Currently, in Victoria, healthcare workers in general have over 4 times the risk of the general community of catching COVID-19.

Risk (odds ratio) of COVID infection in healthcare workers compared with general community
Practitioner type Mean Odds Ratio (OR)
Medical practitioner 2.24
Nurse 3.79
Aged care 9.49
Other healthcare worker 1.19
Source: Victorian Healthcare Worker COVID-19 Tracker. (https://twitter.com/healthcare_19). 25 August 2020.

A report of UK/US data published recently in the Lancet has shown a similar increased risk among healthcare workers, and that risk increases with reuse of PPE or inadequate PPE. Frontline healthcare workers who worked in inpatient settings and nursing homes (where inadequate PPE was most frequently reported) had the greatest risk.

What level of PPE is warranted in general practice?

Recommendations for the use of PPE vary between Federal guidelines and state and territory guidelines. They depend on levels of community transmission, infection status of the patient (known or otherwise), and the setting, e.g. aged care. Advice for using PPE is being continually reviewed and the Department of Health advises to check with your state or territory health department.

Department of Health. Personal protective equipment (PPE) for the health workforce during COVID-19.

PPE in aged care

Commonwealth Department of Health guidelines for PPE in aged care settings state that PPE should be worn whenever caring for someone with a confirmed or suspected case of COVID-19, or in quarantine, or where you will be exposed to body fluids or very contaminated surfaces. PPE includes gown, mask, protective eyewear and gloves.

Department of Health. When to use personal protective equipment in aged care. [Flowchart].

Individual states and territories have varying advice for aged care, depending on levels of community transmission.

Here’s a round-up of the state and territory recommendations

Victoria

In Victoria, guidance has been updated for all healthcare workers, due to the increased risk of transmission.

Dhss.vic.gov.au. Personal Protective Equipment (PPE) – coronavirus (COVID-19).

Victoria State Government. Health and Human Services. Coronavirus (COVID-19) – A guide to the conventional use of PPE. [Word – Download]. Updated 27 August 2020.

As of 27 August, guidelines state:

  • Eye protection is mandatory in all settings for staff directly involved in treating patients. Use a face shield where practical.
  • Surgical masks (level 1 or type 1) – not cloth masks – mandatory for all staff, including non-public facing staff.

Not suspected or not confirmed COVID-19

  • Disposable gloves – as per standard precautions
  • Level 1 gown and plastic apron – as per standard precautions
  • Disposable gown – as per standard precautions
  • Surgical mask (minimum Level 1) – required
  • Eye protection – required; face shield where practical.

Suspected or confirmed COVID-19

  • Disposable gloves – required
  • Level 1 gown and plastic apron OR Disposable gown (level 2, 3 or 4) – required
  • Surgical mask (level 2 or 3) – required
  • Eye protection – required; face shield where practical.

Suspected or confirmed COVID-19 cases, with aerosol generating procedures, cohorted settings, frequent, prolonged episodes of care, uncontrolled settings with cohorting

  • Disposable gloves – required
  • Disposable gown (level 2, 3 or 4) – required
  • P2/N95 respirator (fit-checked) – required. Respirators with exhalation valves are not recommended.
  • Eye protection – required; face shield where practical.

Residential aged care

The situation in residential aged care facilities and recommendations for PPE are changing rapidly in Victoria. The following links to the relevant documents covering PPE requirements.

Australian Government. Victoria State Government. Victorian Aged Care Response Centre. Personal Protective Equipment (PPE) FAQ. 14 August 2020.

New South Wales

NSW Health advice on PPE is based on the 2 standard tiers of precautions. There is a framework for escalation in response to the level of community transmission, including the advice on PPE.

Standard precautions – normal practice, regardless of whether an infection is suspected or confirmed. These precautions must be applied to all patients in healthcare. Clinical care of patients who are NOT suspected, probable or confirmed COVID-19.

Transmission based precautions – for patients known or suspected to be infected, and where transmission cannot completely be prevented using standard precautions alone.

The precautions for COVID-19 are:

  • Contact and droplet precautions
  • Addition of airborne precautions for respiratory AGPs
  • Hand hygiene
  • Environmental cleaning
  • Cleaning of shared patient care equipment.

NSW Health recommendations for PPE are:

Respiratory specimen collection in [ . . .] GP practices where in hospital or outpatient setting

  • Disposable gloves (single use)
  • Plastic apron (single/extended use) OR
  • Fluid resistant or isolation gown (risk assessment)
  • Surgical mask (single/extended use)
  • Eye protection (single/extended use, clean reusable between use)

Working in primary care – with suspected, probable or confirmed cases

  • Disposable gloves (single use)
  • Plastic apron (single/extended use) OR
  • Fluid resistant or isolation gown (Risk assessment)
  • Surgical mask (single/extended use)
  • Eye protection (single/extended use, clean reusable between use)

From: NSW Government. Clinical Excellence Commission. Infection Prevention and Control. Application of PPE during COVID-19. Version 2.3. August 2020. Appendix A: Recommended PPE for health workers in clinical settings.

NSW Government. Clinical Excellence Commission. Personal Protective Equipment. Last updated 27 August 2020.

NSW Health. Personal Protective Equipment. Updated 24 July 2020.

NSW Government. COVID-19 Infection Prevention and Control Response and Escalation Framework.

ACT

Advice from ACT Health is to use contact and droplet precautions during consultations with patients who have potential or confirmed COVID-19 and for collecting specimens from these patients.

Isolate and apply infection control precautions

  • Provide patients with acute respiratory symptoms a surgical mask to put on and separate them from other patients without these symptoms by at least 2 metres or direct them to a single room with the door closed.
  • Assess patients with potential COVID-19 (including patients who are in quarantine) using contact and droplet transmission precautions. This includes a surgical mask, disposable gown, gloves, and eye protection (goggles or face shield). Refer to ACT Health advice on donning and doffing PPE.
  • Wear new PPE for each patient.
  • Use contact and droplet precautions while collecting specimens from patients undergoing testing for COVID-19.
  • For further details, refer to ACT HealthSpecimen Collection guidance.
  • Following the consultation and/or specimen collection, room surfaces should be wiped clean with detergent and disinfectant by a person wearing gloves, gown and surgical mask.

ACT Government. ACT Health. Chief Health Officer alerts. Information for health professionals in the ACT.

ACT Government. ACT Health. Office of the Chief Health Officer. COVID-19: Updated information for GPs and Community Health Practitioners.

Queensland

Queensland guidelines for PPE are consistent with the Australian Government Department of Health guidelines and are based on whether or not the patient meets current case definition of suspected, probable or confirmed COVID-19, and if yes, whether there will be direct patient contact within 1.5 metres, or an aerosol generating procedure.

Queensland Health. Personal Protective Equipment (PPE).

Western Australia

PPE use is dictated by which of 3 patient scenarios is most appropriate:

  • patient who does not meet the definition of confirmed, suspected or probable COVID-19 (low or no community transmission)
  • patient who is confirmed, probable or suspected COVID-19 patient (low or no community transmission)
  • patient who is confirmed, probable or suspected COVID-19 patient (low or no community transmission), but with added criteria, e.g. undergoing aerosol-generating procedures, have severe disease, require prolonged episodes of care, exhibit challenging behaviours).

Government of Western Australia. Department of Health. Identification and use of personal protective equipment in the clinical setting during the coronavirus (COVID-19) pandemic policy. Effective 24 August 2020.

South Australia

SA Health has issued a quick reference guide to PPE for GPs taking COVID-19 specimens, with donning and doffing instructions. The guide lists eye protection (face shield or goggles), surgical mask (level 2), disposable gloves and disposable gown (long sleeve) as PPE requirements.

SA Health. COVID-19 Personal Protective Equipment (PPE) Guide. General Practitioners taking COVID-19 specimens. 25 August 2020.

Residential aged care

In relation to residential aged care facilities, from the 27 August, there is a directive for ‘appropriate PPE, in accordance with the Australian Guidelines’, for all persons providing nursing, medical or allied health or personal care services . This includes a mandatory requirement to wear a surgical mask at all times when unable to physically distance, alongside standard and transmission-based precautions.

SA Health. COVID-19. Infection Prevention and Control. Residential aged care facilities. Version 1.0. Last updated 19 August 2020.

SA Health’s main webpage regarding PPE requirements: SA Health. Infection control and personal protective equipment (PPE) advice.

Northern Territory

The Northern Territory Government refers to the Federal Department of Health guidelines for PPE in non-inpatient health care settings.
NT Health. A focus on: Coronavirus (COVID-19): Personal Protection Equipment.

Respiratory specimens should be collected in accordance with appropriate guidelines below, which includes good hand washing, surgical mask, gloves and goggles/face shield for taking a throat and deep nasal swab.

Department of Health. Coronavirus (COVID-19) guidance on use of personal protective equipment (PPE) in non-inpatient health care settings, during the COVID-19 outbreak. Last updated 31 July 2020.

RACGP COVID-19 infection-control principles

RACGP guidelines on dealing with a suspected COVID-19 case – preparing the consultation room, taking a swab, and environmental cleaning afterwards.

RACGP. 2020. COVID-19 infection-control principles.

Correct use of PPE

All states and territories have advice re correct use of PPE, including donning and doffing advice and fit-checking of masks. See below for links to individual states and territory advice.

Particulate filter respirators (PFRs), such as P2/N95 respirators, should be fit-checked with each use. Users should be trained in their correct use, including fit-checking and safe removal. Note that PFRs with valves should not be used, due to the risk of an infected wearer exhaling viral particles.

Fit-testing is individualised testing of mask fit for healthcare workers. International and Australian bodies, as well as mask manufacturers, recommend fit-testing to ensure proper fit of respirators. The Australian standard (AS/NZS 1715-2009) recommends annual fit-testing.

Four states (NSW, Queensland, South Australia and Western Australia) recommend fit-testing of healthcare workers wearing P2/N95 masks in high-risk areas.

  • In NSW, guidance has been released (August 2020) requiring respirator fit testing for healthcare workers performing respiratory AGPs (aerosol-generating procedures) on patients with COVID-19 or providing clinical services to patients under airborne precautions in high risk areas. 
  • South Australia has a state-wide fit-testing programme.
  • Queensland Health has just instigated respiratory protection programs including fit-testing of P2/N95 masks.
  • WorkSafe Victoria also recommends fit-testing of healthcare workers.

Incorrect use of P2/N95 respirators may lead to infection of healthcare workers, especially when carrying out aerosol-generating procedures.

RACGP. Full version – How to use personal protective equipment (PPE).

RACGP. Using PPE and hand sanitising. Part 3 – How to fit a P2/N95 mask.

NSW Health. Personal Protective Equipment. PPE training videos.

NSW Health. Principles of fit checking. How to don and fit check P2 and N95 masks. February 2020.

NSW Government. Clinical Excellence Commission. Respiratory Protection in Healthcare. August 2020. 

Victorian Government. How to put on (don) and take off (doff) your personal protective equipment (PPE).

Victoria State Government. How to put on and fit check a P2 respirator/mask. Advice for General Practitioners.

Queensland Government. Safe fitting and removal of personal protective equipment (PPE) for healthcare staff.

Queensland Government. P2/N95 mask fit checking.

ACT Health. Donning PPE.

SA Health. PPE Guide. General Practitioners taking COVID-19 specimens. Suggested PPE sequence.

SA Health. P2/N95 respirator (flat or cupped): Donning and fit checking.

WA Health. Appendix 1. Fit checking a P2 or N95 respirator (mask).

Last Reviewed: 01/09/2020

myDr



References

1. K Mackinnon. Data sourced from DHHS Victoria.
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3. Department of Health. Guidance on the use of personal protective equipment by health care workers in areas with significant community transmission. https://www.health.gov.au/sites/default/files/documents/2020/08/coronavirus-covid-19-guidance-on-the-use-of-personal-protective-equipment-by-health-care-workers-in-areas-with-significant-community-transmission-coronavirus-covid-19-guidance-on-the-use-of-personal-protective-equipment-by_0.pdf
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8. NSW Government. Clinical Excellence Commission. Infection Prevention and Control. Application of PPE during COVID-19. Version 2.3. August 2020. Appendix A: Recommended PPE for health workers in clinical settings. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/590307/Application-of-PPE-in-COVID-19.pdf
9. NSW Government. Clinical Excellence Commission. Personal Protective Equipment. Last updated 27 August 2020. http://cec.health.nsw.gov.au/keep-patients-safe/COVID-19/personal-protective-equipment
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11. ACT Government. ACT Health. Chief Health Officer alerts. Information for health professionals in the ACT. https://www.health.act.gov.au/health-professionals/chief-health-officer-alerts
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13. Queensland Health. Personal Protective Equipment (PPE). https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/novel-coronavirus-qld-clinicians/personal-protective-equipment-ppe
14. Government of Western Australia. Department of Health. Identification and use of personal protective equipment in the clinical setting during the coronavirus (COVID-19) pandemic policy. Effective 24 August 2020. https://ww2.health.wa.gov.au/-/media/Files/Corporate/Policy-Frameworks/Public-Health/Policy/Identification-and-Use-of-Personal-Protective-Equipment/Identification-and-Use-of-PPE-in-the-Clinical-Setting.pdf
15. SA Health. Infection control and personal protective equipment (PPE) advice. https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/infectious+disease+control/coronavirus+disease+2019+information+for+health+professionals/infection+control+and+personal+protective+equipment+%28ppe%29+advice
16. COVID-19 Personal Protective Equipment (PPE) Guide. General Practitioners taking COVID-19 specimens. 25 August 2020. https://www.sahealth.sa.gov.au/wps/wcm/connect/6260d535-a592-472f-acd2-cd23753c392b/20015.18_PPE_Workflow_Healthcare+Workers_V10.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-6260d535-a592-472f-acd2-cd23753c392b-ngF8ttM
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