Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response

On 13 May 2020, Public Health England withdrew the primary guidance for Covid-19 homecare provision and instead provided a link to the newer guidance on how to work safely in domiciliary care in England. This newer guidance included the personal protective equipment provisions needed when visiting people in the ‘clinically extremely vulnerable’ group, which were previously absent in the primary guidance for Covid-19 homecare provision. Healthcare system goal Reducing the risk of Covid-19 transmission when care workers deliver care in people’s homes (known as homecare or domiciliary care). Safety risk Each care sector requires specific PPE guidelines due to the wide range of scenarios in which PPE is used. As evidence emerges, it is important that any new considerations are incorporated into guidance that has already been issued. There is a risk that service providers will operate on the basis of older guidelines and might be unaware of newer considerations. Details of referral HSIB received a referral from a member of the public. The referral highlighted concerns about the use of PPE by care workers when visiting a patient at home who was in the ‘clinically extremely vulnerable’ category. In the reported case, district nurses used PPE when delivering homecare. However, other care workers did not use PPE and had been told this was not necessary. The patient later died, and their death was confirmed as being Covid-19 related. The care visits occurred when the patient and other household member were not showing any Covid-19 symptoms. Criteria evaluation All safety risks that HSIB considers for investigation are evaluated against our national investigation criteria. The need for a rapid safety action was identified. Systemic risk – How widespread and how common is the safety issue across the healthcare system? There are multiple Covid-19 guidelines for different care sectors. PPE guidelines should be used in conjunction with other guidelines, such as infection control guidelines, so that care providers can develop protocols for care delivery. This is challenging when guidelines are updated, or new guidelines are issued. There is a risk that guidance on patient safety issues may be missed. Barriers to implementing national guidelines have been reported in academic literature, and tools have been developed to facilitate implementation efforts (Flodgren et al., 2016). However, when responding to a crisis scenario where the evidence base is being rapidly developed, there is a more fundamental challenge of ensuring that guidance is kept updated and easily accessible. While it is desirable to have a central repository, for example the gov.uk website, problems can still occur. This is an emerging safety risk. Outcome impact – What impact does the safety issue have on people and services across the healthcare system? Having easy access to clear, current guidance on PPE in a pandemic will increase the likelihood of staff making correct decisions regarding infection control and therefore potentially reduce the likelihood of transmission of infection between health/social care staff and patients. Learning potential – What is the potential to drive positive change and improve patient safety? There is an opportunity to introduce a document management system for guidelines to ensure that the latest information is available. This would involve the design of a usable navigation system so that all related guidelines relevant to a particular care sector are visible and can be checked for completeness. Public Health England’s Covid-19 PPE guidance for care workers delivering homecare The primary Covid-19 guidance for homecare provision was issued on 6 April 2020 by Public Health England via the gov.uk website (Public Health England, 2020a). This guide was aimed at local authorities, clinical commissioning groups and registered providers, who support and deliver care to people in their own homes, including community health services. This guideline included the following ‘what to do if…’ scenarios: if the care worker is concerned they have Covid-19 • if the individual being cared for has symptoms of Covid-19 if the individual being cared for does not have symptoms but is part of an isolating household if neither the individual nor the care worker have symptoms of Covid-19 Within the 6 April 2020 guidance, there was no consideration of the PPE needed when caring for individuals within the ‘clinically extremely vulnerable’ group. The joint official guidance issued on 2 April 2020 by Public Health England, Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland, and NHS England and NHS Improvement (2020b), relating to PPE requirements for homecare, included the provisions needed for people in the ‘clinically extremely vulnerable’ group. The primary guidance for Covid-19 homecare provision did not include this information. There was no straightforward way of navigating the gov.uk website. The guidance was not visible. On 27 April 2020 Public Health England issued guidance on how to work safely in domiciliary care in England (Public Health England, 2020c). This guidance included the PPE provisions needed for people in the ‘clinically extremely vulnerable’ group. Again, the older primary guidance for Covid-19 homecare provision was not updated with this information and was still live on the gov.uk website Response to HSIB’s concerns On 28 April 2020 HSIB brought the referral and associated safety risk to the attention of Public Health England.