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

National Intelligence Reports (NIRs) provide new insight into current patient safety risks identified by HSIB. They include analysis and key information for consideration by relevant stakeholders to facilitate a response. When appropriate NIRs will include safety observations and safety actions, they will not include safety recommendations.

This national intelligence report provides insight into a current safety risk that the Healthcare Safety Investigation Branch (HSIB) has identified.

Background:

A safety risk was identified based on a referral to HSIB in April 2020 by a member of the public. The referral highlighted confusion around personal protective equipment (PPE) use requirements when visiting a patient at home who was in the ‘clinically extremely vulnerable’ category. The referral stated that some care workers did not use PPE when visiting their home during the Covid-19 response.

Purpose:

This report documents how concerns raised by HSIB were responded to by Public Health England, the body responsible for the development of guidelines for the appropriate use of PPE.

Outcome:

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 may be missed.

HSIB notes the following action:

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.

Flodgren, G., Hall, A. M., Goulding, L., Eccles, M. P., Grimshaw, J. M., Leng, G. C., Shepperd, S. (2016) Tools developed and disseminated by guideline producers to promote the uptake of their guidelines, Cochrane Database of Systematic Reviews, issue 8, article no. CD010669.

Public Health England. (2020a) Covid-19: guidance on home care provision [Online]. Available at: https://www.gov.uk/government/publications/covid-19-residential-care-supported-living-and-home-care-guidance/covid-19-guidance-on-home-care-provision

Public Health England, et al. (2020b) Recommended PPE for primary, outpatient, community and social care by setting, NHS and independent sector [Online]. Available at: https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=103511 (This guidance was issued jointly by the Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland, Public Health England, NHS England and NHS Improvement as official guidance).

Public Health England. (2020c) Covid-19: how to work safely in domiciliary care in England [Online]. Available at: https://www.gov.uk/government/publications/COVID-19-how-to-work-safely-in-domiciliary-care