News

Australia’s most stringent PPE recommendations just got stronger


Matt Woodley


22/10/2020 4:20:02 PM

The break from national guidelines means all Victorian healthcare workers must use full airborne protection with probable or confirmed COVID cases.

Close up shot of an N95 respirator
Airborne protection also recommended when conducting aerosol generating procedures on suspected COVID cases.

The upgraded advice, issued on 21 October, also expands scenarios in which Tier 2 droplet and contact precautions should be used to include caring for suspected cases, who exhibit symptoms that could be consistent with coronavirus but have no epidemiological risk factors.
 
Airborne protection, including a P2/N95 mask and disposable gown, is now also recommended when conducting aerosol generating procedures (AGPs) on this patient cohort.
 
The new recommendations follow a spate of healthcare worker infections in Victoria, and are now far stronger than national guidelines set by the Infection Control Expert Group (ICEG), which only require the use of airborne protection in very specific settings.
 
The ICEG has so far pushed back against the ‘clinical significance’ of airborne transmission and stated there are more important protections than respirators, despite other health bodies such as the US Centers for Disease Control and Prevention (CDC) gradually accepting its role in spreading coronavirus.
 
Dr Kat Mclean, who works at a GP respiratory clinic on the Gold Coast specifically set up to test for COVID, told newsGP the rest of Australia should ‘absolutely’ learn from Victoria’s experience and upgrade infection control advice to better protect healthcare workers.
 
‘It’s a change that’s long overdue and hopefully the catalyst to increase recommendations elsewhere,’ she said.
 
‘In my respiratory clinic role I hear regularly from healthcare workers who continue to feel unsafe in their workplaces. Many report feeling dismissed and bullied if they question current guidelines.’
 
Dr Mclean said GPs are ‘incredibly fortunate’ to have the ability to apply their own infection control procedures based on individual contexts, but warned this flexibility – derived from practices being mostly required to purchase their own personal protective equipment (PPE) – comes with drawbacks.
 
‘Many of us have taken a more precautionary approach and it’s reassuring to finally see movement on the official recommendations occurring,’ she said.
 
‘However, significant support is required for all GP clinics as the cost of PPE and logistics remain significant challenges.’
 
Likewise, RACGP Victoria council member Dr Bernard Shiu said local GPs still need more support to practice safely, despite the upgraded advice.
 
‘I understand the divide between state and Commonwealth jurisdiction regarding the resources and allocation of funding – but the virus does not,’ he told newsGP.
 
‘It is unfair for us to have to source our own PPE.
 
‘We are all in this together and will be affected the same. We urge the State Government to re-visit this issue again and start to protect us.
 
‘The GPs working in the community are at the frontline and are often the first to come across this infection.
 
‘Alternatively, the Commonwealth Government should match the state guidelines for GPs and provide adequate and appropriate PPE to GPs accordingly via the PHNs [Primary Health Networks].’
 
However, even if national guidelines are made equivalent to Victoria’s, such an approach would require a change in policy from the Federal Government, which currently encourages clinics to source their own PPE and only rely on PHNs to cover shortfalls.

Kat-McLean-article.jpg
Dr Kat Mclean says she regularly speaks to healthcare workers who continue to feel unsafe in their workplaces. 

ICEG Chair Professor Lyn Gilbert told newsGP the group has ‘no problem’ with the Victorian Department of Health and Human Services (DHHS) applying its own enhanced recommendations and that all infection control guidelines are subject to ‘appropriate, context-specific modification’.
 
‘Our advice has always been what the evidence suggests is the minimum safe requirement,’ she said. ‘There is nothing to stop individual states and territories from providing different advice in addition, if required by local circumstances.
 
‘At present, most of them fully support and follow ICEG guidance and even Victoria indicate that they support it, but have gone further based on the “precautionary principle”.
 
‘However, it is also ICEG’s role and duty to point out that there are disadvantages and potential dangers in the use of additional PPE in excess of the minimum – including the use of particular filter respirators [PFRs] such as N95 masks – unless appropriate training and precautions are implemented.’
 
Professor Gilbert also said ICEG’s specific advice related to mask use is ‘almost identical’ to guidelines recently adopted by the CDC.
 
But, while ICEG only says healthcare workers ‘may consider’ using a PFR instead of a surgical mask in specified settings, these are limited to emergency departments, residential care facilities, COVID-19 wards, and other hospital in-patient settings, in areas with significant community transmission, where one or both of the following apply: 

  • For the clinical care of patients/residents with suspected, probable or confirmed COVID-19, who have cognitive impairment, are unable to cooperate, or exhibit challenging behaviours (ie dementia patients who shout or wander)
  • Where there are high numbers of suspected, probable or confirmed COVID-19 patients/residents AND a risk of challenging behaviours and/or unplanned aerosol-generating procedures (including intermittent use of high flow oxygen)
Conversely, the CDC simply states healthcare workers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should ‘adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator’ if available.
 
Regardless, South Australian GP Dr Alvin Chua told newsGP that while the new recommendations may be appropriate for areas with high community transmission, such as Melbourne, it is not necessary for other parts of Australia.
 
‘In SA we have been extremely blessed. Whilst the rate of cases in the community are almost zilch –as of yesterday we had eight active cases, all from returned overseas travellers who are currently in medi-hotels in isolation – I don’t believe we necessarily have to adopt N95/P2 masks in our clinics,’ he said.
 
‘As for interstate, if working in an area where there have been known COVID cases in the community, I’d still say a surgical mask first and foremost. And if taking nasal swabs which can generate aerosols, then a P2/N95 should be used.’
 
However, even this approach would be considered above and beyond current national guidelines, which do not consider the collection of nasal and nasopharyngeal specimens as AGPs.
 
Dr Chua also qualified his remarks by warning of the ramifications of coronavirus transmission within a general practice.
 
‘As evidenced by the NSW cluster where two staff at a practice were linked to an outbreak, from an infectious disease outbreak perspective and also from a PR perspective, it would be a disaster to hear of someone getting infected by their GP or a general practice staff member,’ he said.
 
‘While we are not superhuman nor immune to COVID, as per the Dr Higgins and [former Victorian Health Minister Jenny] Mikakos being “#flabbergasted” saga, it’s certainly not great to be named in the press and to have all the trolls and keyboard warriors putting their two cents in, let alone the likes of Pete Evans having more ammunition to gaslight.’
 
According to Professor Gilbert, the new partnership between ICEG and the National COVID-19 Evidence Taskforce has recently revised a paper detailing the evidence on which infection control guidance is based, and will likely be published in coming days following approval from the Australian Health Protection Principal Committee.
 
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