donning and doffing by Grainne Flannelly

AT A GLANCE

Use of personal protective equipment during the COVID-19 pandemic Charlotte Gordon, Senior Lecturer, Adult Nursing (charlotte.a.gordon@northumbria.ac.uk), Northumbria University, and Abigail Thompson, Infection and Prevention Control Nurse, NHS County Durham and Darlington Clinical Commissioning Groups

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an overall reduction in disease spread (Gov. uk, 2020a). The overall number of deaths involving COVID-19 at the time of writing is currently at its lowest level in the past 12 weeks (Office for National Statistics, 2020). The risk of severe disease in the UK is currently considered low to moderate for the general population, but moderate to very high for populations with risk factors (aged more than 65 years of age and/or those with underlying health conditions. This is about 31% of the population of European heritage, depending on the effectiveness of physical distancing and the current level of community transmission (European Centre for Disease Prevention and Control, 2020). Daily situation reports from the WHO, while showing decreasing cases since the peak of the pandemic, continue to demonstrate that the UK has the highest number of deaths to date in Europe, with 43 550 as of 29 June, exceeded only by the USA and Brazil globally (WHO, 2020b). The ability to limit the transmission of COVID-19, the disease caused by the novel coronavirus, in the healthcare setting requires infection prevention and control measures, of which PPE is a fundamental element (PHE, 2020b). This is essential to limit the acquisition and transmission of the virus to protect both health professionals, the patients they care for and the wider community. Protecting health professionals not only limits disease spread, but also ensures that there are adequate numbers of staff to cope with inevitable increasing demands for healthcare services in the coming weeks and months ahead. When used correctly, PPE such as gloves, aprons, eye protection, masks and gowns function as a physical barrier to the transmission of infectious particles present in bodily fluids. It also protects patients from transmission via the contaminated hands or clothing of healthcare staff (Brown et al, 2019).

PPE supplies Sufficient supply of PPE is essential to meet increased demand during the COVID-19 pandemic. The Government has sought to put measures in place to improve supply chains and provisions of PPE by, for example: ■ Enabling the Health and Safety Executive (HSE) and local authorities to fast track product safety assessment processes and prioritise this activity ■ Allowing PPE lacking a European CE safety mark on to the market, provided that it meets essential safety requirements (Gov.uk, 2020b) ■ Making a public callout for organisations that can manufacture and supply testing consumables, equipment and laboratory PPE (Department of Health and Social Care (DHSC), 2020).

Mitigating risk UK-wide guidance on PPE for the care of patients with suspected or confirmed COVID-19 was updated on 18 June, issued jointly by PHE, NHS England and other key stakeholders across the devolved nations (PHE, 2020c). There are risks to both staff and patients with respect to inappropriate use of PPE, namely cross-contamination and the spread of infection. Bovin (2015) highlighted the reasons that can lead to inappropriate use, which include: ■ Lack of awareness about the importance of PPE ■ Time constraints for donning/doffing the equipment ■ Lack of realisation about the importance of the technique for proper safe removal. All of the above ultimately relies on staff being properly educated on the use of PPE. Concerns regarding the sufficient supply of PPE and the evolving nature of the current pandemic, with many staff working in

his article provides an introduction to personal protective equipment (PPE) and looks at the latest guidelines in the context of nursing patients with COVID-19 in the UK. The current situation is such that the reader should continue to refer to contemporary guidelines because they are frequently updated as the situation evolves. COVID-19 is an infectious respiratory disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Public Health England (PHE), 2020a). The SARS-CoV-2 virus replicates efficiently in the upper respiratory tract and appears to cause less abrupt onset of symptoms than the common cold, which means that infected individuals carry on usual activities for longer, increasing asymptomatic transmission of infection (Heymann and Shindo, 2020). The virus is primarily transmitted between people through respiratory droplets and contaminated objects; airborne transmission may be possible in specific circumstances where aerosol-generating procedures (AGP), such as suctioning, are performed (World Health Organization (WHO), 2020a). The UK has seen widespread transmission of the virus with outbreaks in long-term care homes associated with high mortality, highlighting the extreme vulnerability of the elderly in this setting. The introduction of physical distancing measures, such as the cancellations of large gatherings and the closure of educational and public spaces, alongside ‘stay at home’ policies has collectively helped reduce transmission and the 14-day incidence by 18% since 8 April 2020. The reduction in lockdown measures and relaxation of physical distancing, implemented since 23 June reflects a further reduction in incidence rate within England. Data from Gov.uk as of 30 June indicate a growth rate of -4% to -2% in the UK, demonstrating

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Guide to donning and doffing standard Personal Protective Equipment (PPE) for health and social care settings

AT A GLANCE

Before putting on the PPE, perform hand hygiene. Use alcohol handrub or gel or soap and water. Make sure you are hydrated and are not wearing any jewellery, bracelets, watches or stoned rings.

Box 1. COVID-19 guidance on donning and doffing standard and aerosolgenerating PPE, and which equipment to use in which settings,

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Donning or putting on PPE Put on your plastic apron, making sure it is tied securely at the back.

Put on your surgical face mask, if tied, make sure securely tied at crown and nape of neck. Once it covers the nose, make sure it is extended to cover your mouth and chin.

Put on your eye protection if there is a risk of splashing.

Put on non-sterile nitrile gloves.

You are now ready to enter the patient area.

Doffing or taking off PPE

Surgical masks are single session use, gloves and apron should be changed between patients. 1

Remove gloves, grasp the outside of the cuff of the glove and peel off, holding the glove in the gloved hand, insert the finger underneath and peel off second glove.

Perform hand hygiene using alcohol hand gel or rub, or soap and water.

Snap or unfasten apron ties the neck and allow to fall forward.

Snap waste ties and fold apron in on itself, not handling the outside as it is contaminated, and put into clinical waste.

Once outside the patient room. Remove eye protection.

Perform hand hygiene using alcohol hand gel or rub, or soap and water.

Remove surgical mask.

Now wash your hands with soap and water.

Best Practice: how to hand wash step by step image* https://tinyurl.com/phe-handwashing ■ COVID-19: personal protective equipment use for non-aerosol generating procedures (quick and extended guides)* https://tinyurl.com/PPE-standard ■ COVID-19: personal protective equipment use for aerosol generating procedures (quick and extended guides)* https://tinyurl.com/ppe-aerosol ■ PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector* https://tinyurl.com/PPE-inpatients ■ PPE for primary, outpatient, community and social care by setting, NHS and independent sector* https://tinyurl.com/PPE-primary-social-other ■ Additional considerations, in addition to standard infection prevention and control precautions, where there is sustained transmission of COVID-1* https://tinyurl.com/add-info ■ COVID-19: infection prevention and control (IPC) guidance https://tinyurl.com/IPC-guidance * Available as posters from Public Health England

Figure 1. Quick guide to the correct sequence for donning and doffing standard PPE in health Please the PHE standard PPE video in the COVID-19 guidance and socialrefer caretosettings, https://tinyurl.com/standard-dondoff (PHE, 2020d)collection: www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-non-aerosol-generating-procedures

If you require the PPE for aerosol generating procedures (AGPs) please visit:

www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures unfamiliar areas with unfamiliar equipment, list of PHE guidance on the recommended may serve to further compound issues in PPE for different settings, with web links to relation to inappropriate use of PPE and the the information. risks this presents. Updated guidance from PHE has sought It is important to give due consideration to provide clarity regarding the use of the to several issues in order to mitigate risk: the right COVID-19 PPE and is, in some part, a associated risk with incorrect use of PPE response to the concerns of healthcare unions highlights the importance of carrying out and national media coverage regarding the donning and doffing in the correct sequence. risks associated with an insufficient supply of PHE (2020c) cites the importance of safe PPE. The updated guidance ensures that PPE ways for working for health and care workers, is used appropriately in order to ensure stock which includes ensuring that staff are trained control, and maintain the safety of nursing on correct donning and doffing of PPE and staff, key personnel and patients. The guidance staff knowing which PPE they should wear in relates solely to considerations for PPE and each setting and context. represents one element of infection prevention Although there is a recognised standardised control guidance for dealing with COVID-19 order of donning PPE, the most critical and it should therefore be used alongside local is the exact sequence for doffing it. Figure policies (PHE, 2020c). 1 provides a step-by-step quick guide to donning and doffing standard PPE for health PHE guidance on COVID-19 PPE and social care settings (PHE, 2020d)). For Recommendations for practice: a summary donning and doffing AGP PPE, see Figure 2 of the main changes to the previous guidance and Figure 3 (PHE, 2020e). Box 1 provides a are presented in Box 2; the guidance was

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Box 2. Summary of main changes to previous guidance Enhanced 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 for single sessional (extended) use of SOME PPE items ■ Re-usable PPE can be used with reference to manufacturers, supplier and local infection control guidance on decontamination ■ Guidance for when case status is unknown in areas of high-level incidence ■ Recommendation of patient use of face masks ■ Emphasising staff are able to risk assess if there is a risk to themselves or the individuals in their PPE decision making on wearing a mask ■ Recommendation on the use of disposable fluid-repellent coveralls as an alternative to long-sleeved fluid-repellent gowns for aerosolgenerating procedures or when working in higher risk acute areas. Staff need to be trained in the safe removal of coveralls ■

Source: Public Health England, 2020c

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Quick guide – gown version

Putting on (donning) personal protective equipment (PPE) for aerosol generating procedures (AGPs)

Removal of (doffing) personal protective equipment (PPE) for aerosol generating procedures (AGPs)

This is undertaken outside the patient’s room. Pre-donning instructions • ensure healthcare worker hydrated • tie hair back • remove jewellery • check PPE in the correct size is available

COVID-19

Quick guide – gown version

Put on the long-sleeved fluid repellent disposable gown

Perform hand hygiene before putting on PPE

PPE should be removed in an order that minimises the potential for cross contamination.

Eye protection

Gloves

Figure 2. PHE quick guide to donning personal protective equipment for aerosolgenerating procedures, https://tinyurl.com/qk-donning-agp-ppe (PHE, 2000e)

updated to reflect the evolving situation and the changing level of risk of healthcare exposure to COVID-19. Certain areas of practice may pose a higher risk of transmission (Box 3), with AGPs presenting an increased risk of transmission. The updated guidance also highlights the need for enhanced protection of patients in vulnerable groups, undergoing social shielding. NHS National Medical Director Stephen Powis, Chief Medical Officer for England Chris Whitty and PHE National Incident Director for COVID-19 Susan Hopkins (Powis et al, 2020) summarised the initial guidance in relation to COVID-19 and PPE, which were consistent with WHO recommendations, in settings with the highest risk of transmission, as follows: ■ In some circumstances PPE, particularly masks and eye protection that are there to protect health and care workers, can be worn for an entire session and do not need to be changed between patients, as long as it is safe to do so ■ When carrying out AGPs clinicians should wear a higher level of protective equipment 750

Gloves – the outsides of the gloves are contaminated

Respirator Perform a fit check.

Clean hands with alcohol gel

The order of removal of PPE is as follows:

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Gown – the front of the gown and sleeves will be contaminated

Eye protection the outside will be contaminated

Respirator

Clean hands with alcohol hand rub. Do not touch the front of the respirator as it will be contaminated

Wash hands with soap and water

Figure 3. PHE quick guide to doffing personal protective equipment for aerosolgenerating procedures, https://tinyurl.com/qk-doffing-agp (PHE, 2000e)

Use of aprons rather than gowns for nonAGPs, including guidance to thoroughly wash forearms if there is a risk of exposure to droplets, consistent with the UK policy of bare below the elbows and evidence reviews on the risks of healthcareacquired infections WHO (2020c) recommends the use of FFP2 face masks, but the UK has gone further in recommending the use of FFP3 face masks. However, FFP2 masks have been approved by the WHO and can be used safely, if needed. There is good stock of FFP3 face masks in the UK.

Respirators and face masks The HSE (2020a) has stated that FFP2 and N95 respirators (filtering at least 94% and 95% of airborne particles respectively) offer protection against COVID-19 and may be used if FFP3 respirators are not available (DHSC, 2020). FFP3 respirators filter at least 99% of airborne particles and it could therefore be argued are more effective protection against COVID-19. It should be noted that the cost of FFP3 face masks is higher than that of FFP2

masks; the stock price of a single FFP mask varies, with one source retailing FFP2 for £15 and FFP3 for £30 (UKMeds, 2020). Despite assurances from government during this pandemic of the sufficient supply of PPE, healthcare unions and frontline staff continue to raise concerns regarding the provision of appropriate PPE (Kinnair, 2020). Some clarity should also be given to the recommendation regarding the use of surgical face masks: these protect against infectious agents transmitted by droplets, such as saliva or secretions exhaled from the upper respiratory tract. If worn by the caregiver, the mask protects the patient and the environment, and protects the wearer from splashes of biological fluids. If worn by an infected patient, it prevents contamination to the surrounding environment. Surgical masks may also be equipped with a visor for eye protection. In contrast to FFP3 masks, they do not offer protection against airborne transmission (Sampol, 2020). Feng et al (2020) have highlighted the argument that surgical face masks provide no effective protection against COVID-19

AT A GLANCE

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AT A GLANCE

infection; however, the authors also note that guidance within the UK indicates that, although there is little evidence of widespread benefit for members of the public, they do play an important role in hospitals. PHE and other healthcare agencies (PHE, 2020f) have provided guidance on PPE recommended for health staff working across a range of settings. See Box 1 for details.

PPE during cardiopulmonary resuscitation The Resuscitation Council (UK) (RCUK) has indicated that it was not involved in the initial preparation of PHE guidance on the use of PPE. It published an updated statement on PHE PPE guidance on 28 April 2020 (https://tinyurl.com/y8e3jcua) (RCUK, 2020a). It has provided several resources for healthcare settings, including a statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings, which includes a flowchart (https://tinyurl.com/ COVID-RCUK) (RCUK, 2020b).

FFP3: fit testing Fit testing is a method of checking that a specific model and size of a tight-fitting face piece matches the wearer’s facial features and seals adequately to the person’s face (HSE, 2019). HSE has provided guidance on the use of disposable respirators (HSE,2020b) (Figure 4). The HSE (2019) states that all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers’ guidance). This must be repeated for each different mask manufacturer and has led to staff being required to be fit tested each time a particular face mask went out of stock and was replaced by a different make of FFP3. In some instances where staff fail a fit test on one type of mask, they may pass on a mask from another manufacturer, therefore, clinical areas are required to keep a stock of various FFP3 face masks for different staff for this reason (PHE, 2020c). Compliance with HSE guidance regarding fit-testing requirements presents practical difficulties during a pandemic, where hundreds of staff require appropriate provision of this equipment.

PHE summary The updated guidelines provide an extensive summary of care contexts, sessional use and British Journal of Nursing, 2020, Vol 29, No 13

Using disposable respirators

risk assessment in relation to PPE. Healthcare Box 3. Areas of higher risk of trusts and all nurses should ensure that they are transmission familiar with the recommendations for PPE in Pre-use checks A higher risk acute inpatient care area is their particular area of practice alongside local defined as a clinical environment whererespirators. AGPs n You should be clean-shaven around the face seal to achieve an effective fit when using disposable infection prevention and control policies. aretoregularly Beards and stubble will stop the disposable respirator sealing your faceperformed. and protecting you properly PHE (2020c) summarises safe ways of Higher risk acute care areas include: n Make sure it is the right disposable respirator for your work and for you - have you passed a face fit test in this working for all healthcare workers including: ■ Intensive care and high dependency care disposable respirator? units (ICU or HDU) ■ Staff should be trained on donning and n Make sure the disposable respirator is clean and undamaged before you use it ■ Emergency department resuscitation areas doffing PPE and videos should be available n Follow the manufacturer’s instructions for checking the disposable respirator and putting it on ■ Wards or clinical areas where AGPs are for training n Check the fit every time you put on the disposable respirator to ensure there are no leaks regularly performed (such as wards with NIV ■ Staff should know what PPE they should or CPAP) wear for each setting and context ■ Operating theatres, where AGPs are ■ Staff should have access to the PPE that performed protects them for the appropriate setting ■ Endoscopy units, where bronchoscopy, and context upper gastrointestinal or nasoendoscopy are ■ Gloves and aprons are subject to single use, performed with disposal after each patient or resident Source: Public Health England, 2020c contact ■ Fluid-repellent surgical mask and eye protection can be used for a session of work, rather than a single patient or resident contact Clean ■ Gowns or coveralls can be worn for a shaven? session of work in higher risk areas Cup the disposable respirator ■ 1All staff should adhere to social distancing Edges Nose clip in one hand, with the straps 2 Hold the disposable respirator tight? shaped? (2 metres) possible, if hanging out of the wherever way. in place particularly on your face. not wearing PPE and in non-clinical areas, for example during work breaks and when in communal areas Chin Straps snug? in place? ■ Hand hygiene should be practised and extended to exposed forearms, after removing any element of PPE ■ Staff should take regular breaks and rest consider staggering staff breaks to 3periods; Pull the bottom strap over your 4 Pull the top strap over your head, to the back of your neck. head to sit above your ears. limit the density of healthcare workers in specific areas. 7 Before entering the workplace, a user seal check should be carried

Putting the disposable respirator on and checking it fits

Sessional use

Figure 4. isChecking theyour fithands of aover disposable respirator. out. This done by placing the filter material and Fullbreathing guidance using disposable respirator at in. Theon mask shouldasuck down onto your face when you breathe in sharply. You should hold your breath for ten seconds and the https://tinyurl.com/hse-disposable-resp (HSE, 2020b)

disposable respirator should not loosen. If it does, you should readjust It is important to note that there remains and repeat. a lack of clarity regarding ‘sessional’ versus single versus sessional use, dependent on the Checkofyour before put it on. ‘single’ use. Once stock issues in relation to nature thedisposable activity.respirator A session endsyouwhen 5 Check the straps are not Then do a pre-use seal check or fit check - for a thetwisted. amount of toPPE the healthcare worker leaves the care setting/ If you need tightenavailable for staff were proper seal each time: Clean shaven? Edges tight? the straps, pull both ends at the 6 If there is a nose clip, press this identified, together with a need to potentially exposure environment. Sessional should Chin snug? Nose clip shaped? Straps inuse place? same time, bottom first, then top. firmly to the shape of your nose. cohort patients in a specific area, guidance always be risk assessed and considered where This poster illustrates a typical disposable respirator, there are many other types available. Follow the manufacturer’s instructions on putting your type of disposable respirator on and checking it fits. switched from single-use PPE to some there are high rates of hospital cases. PPE equipment being used on a ‘sessional’ basis. should be disposed of after each session or Visit hse.gov.uk/respiratory-protective-equipment for more information PHE (2020c) does not specifically define earlier, if damaged, soiled or uncomfortable. ©Crown copyright 2020 Published by the Health and Safety Executive C100 03/2020 the duration of a ‘session’, making reference to a single session as a period of time where a Skin integrity health and social care worker is undertaking The increasing use of FFP3 respirators duties in a specific clinical care setting or has presented an additional risk for some exposure environment, for example during healthcare workers. As Payne (2020) highlights, a ward round or when providing ongoing the prolonged wearing of tight-fitting FFP3 care for inpatients PHE (2020f). PHE masks has caused some healthcare workers (2020c) further advocates the need to follow to suffer skin damage, frequently around manufacturing instructions and local risk the bridge of the nose, from the constant assessment regarding the appropriateness of pressure applied to the skin by the face mask.

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AT A GLANCE

Hand hygiene As previously discussed, there is a hierarchy of infection control measures, of which PPE is one aspect. Standard of infection control precautions (SICPs) remain paramount. This includes single use of gloves and aprons (and their appropriate disposal), with hand hygiene after each patient contact (PHE, 2020c). PHE (2020f) details the best practice handwashing technique (see Box 1 and https://tinyurl.com/phe-handwashing). In addition, PHE (2020g), in issuing new guidance to NHS teams, highlights the need to wash not only the hands, but also thoroughly washing the forearms, if there is a risk of exposure to droplets if an apron has been worn.

Conclusion Staff working without appropriate PPE, or using PPE inappropriately, are at significant risk of infection, potentially increasing transmission, and leading to reduced workforce capacity and potentially higher mortality. Updated guidance seeks to inform nurses of the right PPE to use, depending on their care setting and the procedures undertaken. PHE guidance provides extensive instruction on the use of PPE for standard care or when carrying out an AGP, or working in an area of high risk, during the COVID-19 pandemic. However, updated guidelines in relation to cardiopulmonary resuscitation are required in the context of the updated PHE recommendations. Appropriate and timely provision of effective PPE, alongside strict hand hygiene, will contribute to reducing the impact of COVID-19 in both human and economic terms. BJN

LEARNING OUTCOMES ■

There are concerns about the provision of appropriate personal protective equipment (PPE) for healthcare workers

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PPE guidance in relation to COVID-19 has been updated in order to ensure healthcare professionals use PPE effectively to ensure their own and patient safety, to maximise efficient use of PPE resource

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Nurses should ensure they are familiar with the updated PPE guidelines, relevant to their area of practice, alongside local policy to ensure the appropriate use of PPE and to limit risk of COVID-19 transmission

Bovin J. PPE used incorrectly half the time. Health Leaders. 2015. https://www.healthleadersmedia.com/strategy/ ppe-used-incorrectly-half-time (accessed 29 June 2020) Brown L, Munro J, Rogers S. Use of personal protective equipment in nursing practice. Nurs Stand. 2019;34(5):59–66. https://doi.org/10.7748/ns.2019. e11260 Department of Health and Social Security. Guidance. Help the government increase coronavirus (COVID-19) testing capacity. 4 June 2020. 2020c. https://tinyurl. com/qk4uvlq (accessed 29 June 2020) European Centre for Disease Prevention and Control. Rapid risk assessment. Coronavirus disease 2019 (COVID-19) in the U/EEA and the UK—ninth update. 23 April 2020. https://tinyurl.com/y8n6an7g (accessed 29 June 2020) Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID19 pandemic. Lancet Respir Med. 2020;S22132600(20)30134-X. https://doi.org/10.1016/S22132600(20)30134-X Gov.uk. The R number and growth rate in the UK. The latest reproduction number (R) and growth rate of coronavirus (COVID-19) in the UK. 25 June 2020. https://tinyurl.com/y9z3p9o8 (accessed 1 July 2020) Gov.uk. Regulations temporarily suspended to fast-track supplies of PPE to NHS staff and protect companies hit by COVID-19 (press release). 2020b. https://tinyurl. com/sb3s7hw (accessed 29 June 2020) Health and Safety Executive. Guidance on respiratory protective equipment (RPE) fit testing. 2019. https:// tinyurl.com/yaq6efl4 (accessed 29 June 2020) Health and Safety Executive. Research: review of personal protective equipment provided in health care settings to manage risk during the coronavirus outbreak (COVID19). 2020a. https://tinyurl.com/y8klq5wg (accessed 29 June 2020) Health and Safety Executive. 2020b. Using disposable respirators. https://tinyurl.com/hse-disposable-resp (accessed 29 June 2020) Heymann DL, Shindo N; WHO Scientific and Technical Advisory Group for Infectious Hazards. COVID-19: what is next for public health? Lancet. 2020;395(10224):542–545. https://doi.org/10.1016/ S0140-6736(20)30374-3 Kinnair D. Royal College of Nursing. Open letter to The Rt Hon Boris Johnson MP regarding lack of PPE and COVID-19 testing for staff. 23 March 2020. https:// tinyurl.com/y8d2xh7h (accessed 29 June 2020) NHS England. Helping prevent facial skin damage beneath personal protective equipment. 9 April. 2020. https:// tinyurl.com/y954gbpq (accessed 29 June 2020) Office for National Statistics. Deaths registered weekly in England and Wales, provisional: week ending 19 June 2020. https://tinyurl.com/y9vzbkep (accessed 1 July 2020)

Payne A. Rapid response. Re: Are UK doctors getting sufficient protective equipment against COVID19. BMJ 2020; 369:m1297. https://www.bmj.com/ content/369/bmj.m1297/rr-3 Powis S, Whitty C, Hopkins S. COVID-19: PPE guidance update. 2 April 2020. https://tinyurl.com/y8gvmaub (accessed 1 July 2020) Public Health England. COVID-19: epidemiology, virology and clinical features. Updated 29 June. 2020a. https:// tinyurl.com/w922exj (accessed 29 June 2020) Public Health England. Guidance. Introduction and organisational preparedness. Updated 18 June 2020. 2020b. https://tinyurl.com/ydc9nslm (accessed 29 June 2020) Public Health England. COVID-19 personal protective equipment (PPE). Updated 18 June 2020. 2020c. https://tinyurl.com/to3l2ey (accessed 29 June 2020) Public Health England. Guide to donning and doffing standard personal protective equipment. 2020d. https:// tinyurl.com/standard-dondoff (accessed 29 June 2020) Public Health England. COVID-19: Personal Protective Equipment use for aerosol generating procedures. 2020e. https://tinyurl.com/ppe-aerosol (accessed 29 June 2020) Public Health England. Guidance. COVID-19: infection prevention and control (IPC). 2020f. https://tinyurl. com/rdp4ab4 (accessed 29 June 2020) Public Health England. New personal protective equipment (PPE) guidance for NHS teams (press release). 2020g. https://tinyurl.com/yx79q8jo (accessed 29 June 2020) Resuscitation Council (UK). Updated RCUK statement on PHE PPE guidance. 28 April 2020a. https://tinyurl. com/y8e3jcua (accessed 29 June 2020) Resuscitation Council (UK). RCUK statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings. Updated 6 April 2020b. https:// tinyurl.com/COVID-RCUK (accessed 29 June 2020) Sampol C. Surgical masks, respirators, barrier masks: which masks actually protect against coronavirus? Medical Expo e-mag. 28 February 2020. https://tinyurl.com/ y6utcnvt/ (accessed 29 June 2020) UKMeds.co.uk. Face masks. 2020. https://tinyurl.com/ ybkgvk6l (accessed 29 June 2020) World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. 2020a. https://tinyurl.com/sxhgcxl (accessed 29 June 2020) World Health Organization. Coronavirus disease (COVID19). Situation report—161. 29 June 2020. 2020b. https://tinyurl.com/y84yxj4s (accessed 1 July 2020) World Health Organization. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19). Interim guidance. 19 March 2020. 2020c. https://tinyurl.com/qvofaf5 (accessed 29 June 2020)

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Continuous use of surgical masks also can cause soreness on the skin from the straps of the mask resting on the upper ears.This has led to NHS England (2020) issuing an alert detailing how to prevent facial skin damage beneath PPE. Although advocating the prevention of skin damage, it recognises that skin breaks may occur and provides advice regarding how to manage pressure-damaged skin.

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