October 3, 2024

ppe shortage

“Gowns out of garbage bags”: study highlights lack of PPE for primary health

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An Australian study has found “insufficient personal protective equipment (PPE)” was being made available in primary health care settings, putting nurses at incredible risk through COVID-19. 

The study of 637 primary health nurses from across the country indicated a severe shortage of PPE in many primary health workplaces, with only 26% of respondents indicating they had sufficient access to gown and 23% indicating they had access to P2/N95 masks at all time. 

Worryingly, less than half (47%) of respondents said that their workplaces had COVID-19-specific PPE guidelines at their facilities. 

Survey respondents revealed that they were forced to resort to shockingly inadequate PPE measures, including purchasing stock privately or making gowns out of garbage bags. 

“We couldn’t source long sleeved gowns when COVID hit so had some home‐made”, one respondent said. 

The lack of PPE was resulting in primary health nurses considering resignation, with 52% of those who were considering leaving the profession blaming “personal safety” as their reason. 

The authors noted that “more needs to be done to ensure sufficient stockpiles [of PPE] are maintained”. 

“The shortage of PPE during the COVID‐19 pandemic has been extensively reported”, the study stated. 

The NSW Nurses and Midwives’ Association is continuing its advocacy to ensure all nurses and midwives have access to adequate personal protective equipment. Members can report unsafe PPE practices here. If you’re not yet a member, you can join today. 

COVID-19 demands higher standards of protection

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Fit testing is seen as the gold standard in PPE, but in the face of the coronavirus’s virulence it is the defence that nurses require.

On 6 May, the International Council of Nurses (ICN) estimated that the novel coronavirus pandemic had infected at least 90,000 healthcare workers and killed more than 260 nurses worldwide.

The ICN said official statistics undoubtedly underestimated the true nature of the problem.

“The lack of official data on infections and deaths among nurses and other healthcare workers is scandalous,” said ICN chief executive officer Howard Catton.

“Nurses and healthcare workers have been put at greater risk because of the lack of personal protective equipment (PPE) and poor preparedness for this pandemic.”

Australia has faced its own challenges with supply and preparedness.

Prior to the COVID-19 outbreak the vast majority of our PPE was manufactured overseas and fit testing – a stringent standard for the use of P2/N95 respirators – had been applied in a very limited way.

NSW Health commits to fit testing

In the early days of the pandemic NSW Health was reluctant to embrace fit testing.

But following pressure from the NSWNMA and our branches and other health unions, NSW Health now says the evidence around fit testing “remains equivocal” but “in the interests of staff welfare we are supportive of the implementation of fit testing until there is more unequivocal evidence available”.

NSW Health has flagged difficulties with the immediate statewide implementation of fit testing “due to limited supplies and range of types/sizes available”.

It has committed to implementing fit testing across NSW as a “rolling program” learning from the Sydney LHD and Hunter New England LHD, which have focused on limited fit testing with high risk staff in high risk areas, caring for high risk patients.

Sydney LHD was an early adopter of all COVID-19 planning and protection. Early in the outbreak they limited the size of meetings and used Zoom for communication.

Where fit testing has been implemented the feedback from nurses has been positive.

Katina Skylas, NSWNMA Branch President at Concord Hospital, who works in the intensive care unit, says fit testing gives nurses some peace of mind.

“Knowing when you walk into that room that you are safe relieves an immense amount of pressure,” she said.

“We are all going home to families and elderly parents and people who are sick at home; we need to know we are safe for them.

“Fit testing is part of Australian Standards, but a new concept to most workplaces; everyone knows fit checking, but fit testing is a new practice. We are fortunate in the Sydney LHD to have the support of district executive: they have purchased testing devices.”

NSWNMA Secretary Brett Holmes says COVID-19 has highlighted in stark terms the need to protect frontline nurses in the midst of a highly virulent pandemic.

“Everything has to be done to minimise the risk to nurses,” he said.

“The nature of their jobs makes social distancing impossible. It is essential we have the highest standards of PPE to protect them.

“That means broadening what our traditional concept of best practice in PPE is.

“It also means improving local manufacture of equipment so we are not relying on overseas suppliers to meet healthcare supply chain needs.”

“Fit testing is extremely important”

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Katina Skylas, NSWNMA Branch President  at Concord Hospital, tells The Lamp how fit testing works.

“We put a mask on our face that is connected to software that measures particulate level inside the mask to assess effective mask seal.

“As part of the test we do a range of activities, such as bending up and down, turning your head left and right and saying a phrase that has a mix of all the possible consonant combinations to emulate every shape our face would move in when we are talking.

“There is a threshold number it has to reach for it to be a good fit.

“We need to reduce the risk of potential exposure to any pathogens, so fit testing is extremely important. I need to know that a particular mask fits me, and every time I put that mask on, I need to know it works properly.

“At Concord we had a stock of masks that everyone thought were superior, but on testing they actually failed the fit test for a number of people: it wasn’t the best mask for them, but it did fit others.

“Conversely, there were a lot of P2 masks that we thought were ineffectual: we didn’t think they provided a good seal, but in testing it was actually a very good mask for many staff.

“Staff try a range of masks that are available, and if they don’t fit it is deemed not safe for them to walk into the infectious room, and they aren’t allocated to those patients.

“About nine per cent of tested staff have failed the fit test, which highlights the need to find other solutions.

“We’ve been able to get access to other masks, including reusable battery-powered face masks. They are expensive but important to maintain workplace safety.”

“Best practice is that fit testing should take place to protect health care workers”

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Local campaigns by numerous NSWNMA branches have led to a larger uptake of fit testing. The Lamp talked to Shoalhaven Hospital branch secretary Michael Clarke about the experiences of his branch.

As a health worker do you feel you’ve been sufficiently prepared and protected to work effectively?

I don’t think the health system had really prepared for a pandemic; there’s been issues with PPE and PPE supply. We are getting enough through, but all our members are aware that there is a scarcity of appropriate PPE, and that provides some concern.

What was your branch’s position on fit testing?

We’re guided by what the Association is telling us locally. A lot of our members hadn’t heard of fit testing before; they had heard of fit checking, which is something you can do … as a ward-based solution, but if the best practice is that fit testing should take place to protect health care workers, then we believe as a branch that should happen.

Our organiser has been quite active in making sure we have the appropriate PPE at our hospital, and where it has become evident that we’re short, the branch, our organiser and the Association have been quite active in working out what is going on.

Our organiser also made us aware of the importance of fit testing. We had an issue with fit testing of P2 and N95 masks and our branch passed a resolution…to ensure fit testing was made available to members.

Why is it critical that the masks fit properly?

We are using a number of P2 and N95 masks that are made quite differently, and obviously we are working with all sorts of people…so the branch feels it’s essential that the masks are fit tested to protect members from cross-contamination from airborne droplets when dealing with potential COVID-19 patients.

Is it just ICUs or are other wards vulnerable too?

There are a number of hospital areas where our members are wearing P2 and N95 masks … it’s ED, and we also have a medical ward that is dealing with suspected and confirmed COVID-19 patients and a walk-in testing clinic.

What was happening when the masks didn’t fit?

I’m aware of there being a limited supply of P2 and N95 that can fit all face types, so where that has been a problem we’ve encouraged staff to not go ahead and wear the wrong mask and we’ve asked management to make sure that the right mask is made available.

It has been a bit of a learning curve for management as well, so now they know we have a large number of people that need to be tested.

Comparing Australian PPE guidelines with the NHS

The emergence of COVID-19 has led to a rethink on PPE internationally. In Britain the NHS has revised its guidelines on PPE as of April 2020.

The main changes are:

  • enhanced PPE recommendations for a wide range of health and social care contexts
  • inclusion of individual and organisational risk assessment at local level to inform PPE use
  • recommendation of single- sessional use of some PPE items
  • reusable PPE can be used. Advice on suitable decontamination arrangements should be obtained from the manufacturer, supplier or local infection control
  • guidance for when case status is unknown and SARS-CoV-2 is circulating at high levels
  • a recommendation on patient use of face masks.

Key differences between the new UK advice and current Australian advice include:

  • The UK has a much wider definition as to who should be considered a potential case
  • The masks recommended in the UK for airborne risk are FFP3s; these filter 99 per cent compared to the P2/N95, which filter 94 per cent and 95 per cent respectively
  • Surgical masks in the UK are divided into two types – surgical masks, and fluid resistant (Type IIR) surgical masks. There are very few situations where the use of surgical masks is being recommended in the UK, whereas these are the masks being recommended in NSW hospitals for all routine care of COVID-19 patients.

NSWNMA COVID-19 resources available online

All nurses and midwives in NSW have a right to stay safe and be protected at work. The NSWNMA has produced numerous online resources for members seeking information regarding COVID-19:

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