Eastern Health



Attachment 3 in CPG 244 and Attachment 8 in 454:

Use of Personal Protective Equipment in the Ambulatory Setting during COVID-19 pandemic including in response to known or suspected outbreaks in residential care facilities including safety observer role (spotter)

Aim:

To provide a safe work place for ambulatory care staff to use PPE in the ambulatory setting during a pandemic including when required to attend an outbreak at a residential care facility.

To ensure adequate training for donning and doffing PPE for ambulatory care staff.

To ensure understanding of workflows in maintaining staff safety when in a non-Eastern Health COVID or SCOVID environment

To describe the role of the safety observer (spotter) in a covid-19 environment

Background:

The appropriate use of personal protective equipment is an essential component of staff safety that has traditionally been limited to use in controlled inpatient settings. During a pandemic, the requirement for all staff to be proficient in the use of PPE has extended to the ambulatory setting whereby unique challenges exist in the uncontrolled home environment and the relative inexperience of staff members in utilising PPE.

As of 22 July 2020, ambulatory care was reclassified as a ‘higher risk’ setting and a revision of the PPE minimal standard as described in Table 1.

Clinicians should be aware that the criteria for suspected COVID-19 includes any unwell patients and a low threshold for conversion to full PPE as per Table 1.

Consistent with Emergency Management directions from the Victorian Government, surgical masks must be worn when in public. From an ambulatory perspective this includes patients/families wearing a mask when staff are providing home visits .

The requirement for PPE has been extended to staff entering any residential aged care facilities regardless of outbreak status

In response to outbreaks within residential care facilities, Eastern Health staff may be required to attend a facility where a controlled or uncontrolled covid-19 outbreak may be occurring. This described the additional steps and processes to ensure adequate infection prevention and control is in place to protect staff safety and minimize transmission within the facility and to utilize a patient safety observer (spotter) when entering any outbreak facility.

Processes:

Preparatory learning:

All ambulatory clinicians must have completed the i-Learn training packages on hand hygiene, N-95 mask fitting, donning and doffing PPE including the video here.

All ambulatory clinicians should be familiar with CPG 454 Home community visit staff safety guideline (Section 4.8 amended for COVID-19 pandemic)

All ambulatory staff must also view the educational video demonstrating the use of PPE on the home visit available here

A range of additional resources regarding PPE, swabbing techniques and information relating to pandemic are also available at

All ambulatory streams are expected to identify a PPE ‘champion’ or ‘champions’ to act as a local resource and support for staff in learning the correct use of PPE in conjunction with their Learning and Teaching representative.

Simulated and supervised training:

All ambulatory clinicians will be offered a face to face simulated training session in donning and doffing with their stream champion.

All ambulatory clinicians will be offered a rotation through the BHH COVID-19 screening clinic to develop competency in the collection of pharynx & deep nasal swabs and in donning and doffing PPE in a controlled environment.

All ambulatory clinical streams must collate a list of staff members who are considered competent and confident in the use of PPE in the ambulatory setting and in obtaining pharynx & deep nasal swabs.

A competency package is under further development in conjunction with Learning and Teaching. Including the role of the ‘observer’ or ‘spotter’.

Outbreak training for entering residential care facility with a known or suspected outbreak of covid-19:

Staff are required to have a proficient understanding of ‘clean and dirty ‘ workflows in a Hospital COVID Ward, familiarization as to how this is operationalized in the hospital environment, and how this is operationalised within a residential care facility.

A training and competency package is under development with Learning and Teaching and IPAC.

Development of PPE packs:

Each stream to ensure adequate supply of staff use PPE packs which will include a disposal system suitable for use at the home. In addition to the standard infection control equipment routinely carried in home visit kits, specific PPE packs contain the following equipment for staff use:

• Blue gown,

• Plastic apron

• N-95 mask

• Disposable gloves

• Goggles

• Face shield (with a paper label of your name and designation)

• 2 clinical waste bags (yellow and labelled infectious waste)

• Sealed bin (see example below),

• Alcohol based hand rub/ hand sanitizer

• Tuffie wipes (full)

• Optional hair cover

• Separate plastic containers or bags for items that will be used and then removed from covid area (eg I-pad or phone)

• Spare plastic sleeves and bags.

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Patient Home (non-residential care facility) visiting process with suspected or confirmed COVID-19 patients:

Staff should be familiar with CPG 244 COVID-19 SARS CoV Management of known or suspected cases guideline.

The requirement for undertaking a home visit during the COVID-19 pandemic must be determined necessary in accordance with guidance documents developed for this purpose and attached to CPG 454 Home community visit staff safety guideline.

Only an approved and competent staff member who has undergone the training above will be assigned to cases that are considered suspected or positive COVID-19 patients are to conduct a home visit or respond to an outbreak in a residential care facility.

Staff who are responding to an outbreak in a residential care facility will be required additional training in outbreak management.

All visits conducted to a suspected or confirmed COVID-19 case will require two clinicians with one to assist as a ‘spotter’ or a ‘scout’ to provide local assistance to the staff member who will be providing the care whilst wearing the PPE. See below re the role and responsibility of the staff safety observer.

If a breach in PPE occurs, staff are advised to report this immediately to their manager and to IPAC.

Residential Aged Care Outbreak with suspected or confirmed COVID-19

Before the Visit

It is essential that any staff member proposing to visit a residential care facility with a suspected or known outbreak carefully considers whether an on-site visit is required and has considered use of telehealth or videoconferencing or other communication mechanism prior to visiting.

It is essential that the EH worker gains consent from their manager prior to conducting a visit to residential care facility with a suspected or known outbreak and that the manager is satisfied that the EH worker has the appropriate skills and training to work in a potentially uncontrolled environment.

It is essential that the EH worker has approval and consent from the facility manager prior to attending for the onsite visit.

It is essential that a second EH worker attends who can act as an observer (spotter) or support person in maintaining staff safety and protecting from PPE breach. See below regarding use of ‘safety observer’.

It is essential that one member of the team has experience in working in a COVID environment (ward or ambulatory).

Proceeding with Visit

Processes for visit to residential care facility with a suspected or known outbreak

1. Review of the pre-visit risk assessment conducted by the outbreak management team

2. Ensure PPE pack is complete within EH vehicle and any equipment required for clinical assessment or care in plastic sleeves

3. If the travel time to the facility is > 15 minutes, staff are required to travel in separate cars

4. At arrival outside the facility, staff member must notify facility of your presence and confirm from the pre-visit checklist as to where the ‘clean’ zone has been set up and how to access this and confirm planned imminent entry.

5. Don full PPE and setup up a ‘clean’ station within the car boot or near facility entrance to include lined bin with 2 plastic bags, plastic box, hand sanitizer station. Any personal items should be minimized and use a label on the face shield with your name and designation

6. Enter facility and move directly into the clean zone and plan workflow and assessments required. Designate one worker as a clinician and the second clinician as a safety observer.

7. After entering ‘dirty zone’ change gloves between each client close contact (SCOVID or COVID) using the facility doffing station. Perform hand hygiene during each glove change.

8. Any equipment must be considered dirty if it has been carried with you into the dirty zone (unless within the pocket of your personal clothing)

9. After completion of clinical work, wipe down any equipment or tools that are being taken out of the facility as best as able using a clinell or tuffie wipe. Change gloves and perform hand hygiene prior to doffing station outside the facility.

10. Doff outside the facility using your EH bucket, drop your equipment within a container (or clean clinical or infectious waste bag provided by your spotter), hand hygiene. Using a no-touch technique ensure your waste is within the second bag and tied up and disposed of on your return in Infectious waste

11. Return to EH and tuffie wipe areas within the car (as per usual process) open plastic box, further tuffie wipe contents and inside of plastic box, hot wash plastic box.

12. After your shift, immediately remove your clothes and wash in the hottest wash available.

Role of Safety Observer (Donning and Doffing) aka spotter

Whilst correct use of PPE protects staff, breaches are most likely to occur during donning and doffing. When working in a outbreak, it is required to have a trained donning and doffing safety observer (spotter)

The purpose of the PPE spotter is to ensure the safety and wellbeing of the clinician providing direct care to the patient. The spotter is a guide and protector.

This role involves:

• Vigilance i.e. constantly watching the clinician and the environment for possible contamination (what is touched, hand-to-face, torn or soiling of PPE)

• Proactivity in identifying the risks

• Verbal instructions for PPE donning and doffing which is slow, steady and at a deliberate pace

• May include scribing outside the patient’s room or outside the ‘dirty’ zone

|Before entering the |Clinician to remove all jewellery, watches, mobile phones |

|outbreak environment: |Spotter and clinician to wear a full set of PPE |

| |Determine correct size of gloves/gown/masks |

| |Practice donning-doffing PPE especially N95 mask (different approaches for duckbill vs moulded) and competence |

| |with fit check of mask |

| |Ensure clinician and spotter are both well-hydrated and have had a toilet visit |

|When outside the |Spotter Check that the clean store of PPE set-up is conveniently located, right size, free of any tears |

|covid/dirty zone |During donning – |

| |GUIDE – give step-wise instructions and check that it is verbally confirmed. |

| |ASSIST if needed, but minimise the amount of direct contact. If providing assistance, always disinfect your glove |

| |SCAN continually for possible contamination risk of the clinician and environment, check for torn or soiled PPE |

|Before the clinician |spotter checks that the clinician has all the equipment they need to take into the room for the consultation e.g. |

|enters the patient’s |vital obs equipment |

|room: |ensure that an appropriately maintained and not over-filled medical infectious waste container is available |

| |The spotter does not enter the patient’s room/dirty zone if they are able to observe the clinician from the |

| |doorway |

|When the clinician has|Spotter hands tuffywipes bucket to clinician to pull off the wipes and clean all equipment |

|finished the |Clinician then passing the wiped items to the Spotter and places in a clean bag or container |

|consultation with |Spotter puts these clean items into a receptable for use for the next patient (unless there are dedicated |

|patient and is still |equipment per patient) |

|standing inside the |Clinician verbally indicates they are ready to start doffing process |

|room: |During doffing – |

| |REMIND clinician to not touch their face or any other exposed body parts during the process |

| |GUIDE – give step-wise instructions and check that it is verbally confirmed. |

| |SCAN continually for possible contamination risk of the clinician and environment, check for torn or soiled PPE |

| |Direct the clinician to dispose of PPE items in appropriate waste receptacle |

| |ensure that an appropriately maintained and not over-filled medical infectious waste container is available |

| |ensure that the clinician simply drops waste into bin to minimize aerosol generation |

| |The Spotter does NOT assist the clinician with removing PPE, instead gives verbal instructions and request the |

| |instructions are verbalised back for confirmation as they are being actioned |

|(= Minimum Mandatory |Positive Patient regardless of where |Suspected- Swab required or |Non Suspected |Residential Care |Patients PPE requirement |

|Requirement |the patient is located |patient | |& SRS Facilities | |

| | |in quarantine | |(no outbreak) | |

|Surgical Mask | | |( |( |( If the patient is unable to tolerate a |

| | | | | |mask provide a face shield |

|Gown ** |( |( |Clinicians Discretion |( | |

|Gloves |( |( |( |( | |

|Face Shield |( |( |( |( | |

|Hair Cover |Clinicians Discretion |Clinicians Discretion |Clinicians Discretion |Clinicians Discretion | |

|Overshoes |Clinician Discretion |Clinicians Discretion |Not required |Clinicians Discretion | |

Due to the changing nature of COVID-19 PPE recommendations please note that the above information will be updated regularly

Face shields can be used instead of masks when patients have hearing deficits or require facial cues to assist with communication

Prescription glasses instead of goggles can be worn under face shields

**Use second gown to cover back if spotter deems insufficient coverage of clinician’s posterior underclothes

**When completing multiple patient care on s/COVID patients, use third gown positioned as usual and remove this gown to protect under gowns between patients .

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