SWL Clinical Cell Update – PPE, Staff Testing & SWL Ethics Committee

Second edition 26 March 2020
Update from Dr Andrew Murray

Chair of the South West London Clinical Cell

Message from your clinical leaders in South West London

Our Clinical Cell of senior clinical leaders continues to support the COVID-19 response across South West London.

We hear the words of Dr Daniele Macchine, from Bergamo, in Italy on 9 March 2020 as a call to action:

“…and there are no more surgeons, urologists, orthopaedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us…”

We do not under-estimate the challenges in the coming weeks. We need to be one team in South West London and meet this together. We are all under incredible pressure and this may increase, so we need to ensure that we put resources where they are most needed in our system and protect all our staff both physically and psychologically.

We hear from staff in our organisations that the two biggest concerns you have are around Personal Protective Equipment (PPE) and staff testing. We address these in this bulletin. In addition we want to support our clinicians as they have to make difficult decisions about patient care and thresholds for care both in our hospitals and communities. This is why we are setting up an Ethics Committee for South West London.

#PPE">PPE
Staff testing
Ethics committee for SW London

SW London Position Statement on PPE

The Clinical Cell wanted to write to reassure staff about the guidance for Personal Protective Equipment (PPE).  We know there have been staff and media concerns about the recent change in recommendations for protective wear for staff treating COVID-19 patients.  We have looked closely at the issue in the hope that we can bring some system-wide clarity on the guidance we are all following across our organisations and teams.

Public Health England and WHO guidance on PPE

As you will be aware, earlier this month Public Health England updated its COVID-19 guidance, restating what Personal Protective Equipment (PPE) should be worn by staff when caring for patients.  The key difference in this new guidance is that staff are no longer required to wear FFP3 masks or gowns for COVID-19 positive patients unless undertaking aerosol-generating procedures (AGPs) in ward areas.  Subsequently, the World Health Organisation has also updated their guidance on face masks. WHO and PHE continually update their guidance on various strategies, and in this case updated their guidance for PPE for COVID-19 as more data became available about the disease and its treatment.

Advice on PPE in different settings

We are confident that the PHE guidance for PPE is based on the latest evidence and so is what we should be following in the context of the challenges we currently face. The guidance indicates that these are safe and appropriate precautions that front line medical and ancillary staff should all be taking. It’s what we are using ourselves and in all our respective organisations.

This link below, came out recently from Dr Nikki Kanani, National Director of Primary Care, and was in the national Primary Care Bulletin:

What is the efficacy of standard face masks compared to respirator masks in preventing COVID-type respiratory illnesses in primary care staff?

This systematic review gives cautious support for the use of standard surgical masks rather than FFP respirators in non aerosol-generating procedures.

National advice is that staff working in GP practices, GP respiratory hubs, mental health inpatient facilities, any community settings and areas of the hospital where there are no AGPs, can be adequately protected by surgical face masks as well as gloves and an apron. See diagram below. We believe that this is sensible advice and all organisations in South West London will be following this national guidance.

The table below from Public Health England helps explain clearly what PPE is appropriate for different situations – and the full guidance can be found here: #PPE">https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control#PPE.

It should be noted that the use of disposable eye protection is recommended where there is a risk of contamination to the eyes from splashing of secretions (including respiratory secretions), blood, body fluids or excretions. If there is a risk of contamination to the eyes and eye protection is not available then we expect clinicians to avoid close patient contact for the purposes of assessment.

In addition it is important to state that all staff should be working remotely and conducting remote assessment of patients, whenever this is possible and appropriate.

Guidance for GPs from their professional body is also here:

https://www.rcgp.org.uk/about-us/rcgp-blog/covid-19-gp-guide-personal-protective-equipment.aspx

Action to improve the supply of PPE

We also recognise there have been significant, logistical issues in ensuring all sites and staff have the supplies they need.  We believe many of these issues have now been resolved although a number are still outstanding, with more stock on the way.  We are grateful for the exceptional way hospitals and teams have shared stock between themselves in response to the most pressing need over the last few weeks and days.

South West London now have set-up a Supply Cell to help tackle some of the issues and challenges we are all facing with equipment, including PPE, to make sure we all have the equipment we need to do our jobs. This newly formed cell is also testing the resilience of the supply process in all care settings including care homes, hospices and to Local Authorities.

This guidance relates to PPE which is needed when coming into contact with known or suspected COVID-19 but not for all patients. If we use fluid resistant masks for all patients, we could create shortages and we need to be able to meet current demand and for our stock to last the whole pandemic.

Staff Testing

We would like to be able to test all our staff across our health and care system including hospitals, mental health, primary care, community services and social care. At the moment testing capacity is limited, owing to the supply of reagent, and we will ramp up testing as soon as we are able but for now we need to focus testing on where it is needed most. This needs to be fair and based on the most pressing needs of our whole system, prioritising saving lives.

Therefore, the clinical cell has agreed a staff testing policy for every health and care organisation in South West London. The policy is attached to this email and we expect everyone to abide by this.

We hope to have antibody testing available soon, nationally it was announced 3.5 million antibody tests have been secured, which will allow staff to see whether they have had the virus and are immune to it and then could get back to work. A national new testing facility in Milton Keynes has just opened to dramatically increase testing numbers.

The policy we have attached looks at:

– testing staff who have symptoms
– testing staff who may not have symptoms
– how we might use antibody tests
– piloting testing NHS staff family members to help us get more people back into to work from self-isolation

The policy also sets out prioritisation of staff groups for all health organisations in South West London

High impact criteriaMedium impact criteria
Priority 1Priority 2*Priority 3Priority 4
Critical clinical or enabling function in high pressure areafor patient care with inability to perform duties remotely (COVID positive and negative) e.g. ITU, anaesthetics, ED [face to face category 3 contact]Critical clinical or enabling function in providing patient care with inability to perform duties remotely (COVID positive and negative) e.g. Acute on-call physical or mental health rotas; ward cover, staff visiting hot sites or face to face category 2 patients (e.g. primary care respiratory hubs).Level of specialism (not interchangeable with other members of staff)Testing result will change treatment or return to work options for staff member e.g. allow return to work sooner than recommended isolation period or inform risk for staff who are immunocompromised.

*It is likely that as we migrate into priority 2 testing, there will need to for further stratification of staff for testing to avoid exceeding testing capacity. Allocation for testing by provider type, specialism or staff group would not be able to comprehensively distinguish priorities. Staff will therefore be further stratified on the basis of two key principles:

– Fragility of rota for provision of critical clinical service e.g. Junior doctor rotas in mental health
– Face to face contact duration/intensity

We currently only have capacity to test staff in priority group 1. At present we believe that community and primary care staff fall into priority group 2 and we will issue further guidance as soon as we are able to extend testing to this category. We would welcome feedback through your local channels and we will continuously review this policy, the priority groups and will expand testing through the groups as soon as we are able.

We recognise that this might require some organisations to roll back from wider staff testing but it is important that we all work fairly together across our system based on the greatest need and all our acute hospitals have agreed to adopt this policy.

Ethics Committee for South West London NHS

It is really important that we support all our staff in making the right decisions about their patients during this difficult time.

Building on the Croydon Ethics Committee established by Dr Nnenna Osuji, Medical Director at Croydon Healthcare Services, the Clinical Cell has agreed to set up an Ethics Committee for South West London. ​The committee will help with clinical and ethical decision-making processes during the COVID-19 pandemic (and likely beyond), and will provide support across acute, community and primary care.

The committee will build on national NHS ethical guidance to develop ethical principles that will help support front-line clinicians in their day to day decision making, and to establish a consistent approach across South West London.  The new committee will not replace existing ethics committees of other NHS organisations, but will instead focus on pathways and thresholds for decision making.  There is also the potential to escalate difficult cases to the panel if they are not time critical, as this panel will meet twice a week in the first instance.

We recognise how difficult these times are for all our staff and, as your senior clinical leaders, we will continue to do everything we can to support you to continue delivering the best care possible to our patients in South West London.

Best wishes,
Dr Andrew Murray
GP Chair NHS South West London Clinical Commissioning Group
On behalf of the South West London Clinical Leadership Cell

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