Personal Protective Equipment – rationale and recommendations for a pragmatic approach

Guidance is available from many sources, some of this is conflicting and inconsistent. Having studied guidance from the World Health Organisation (WHO)[i], UK Government[ii], Public Health England (PHE)[iii] The International Pharmaceutical Federation (FIP)[iv]  and spoken with colleagues in Europe, the resulting PDA synopsis provides a pragmatic approach to the use of PPE and other measures aimed at optimizing safety for patients, customers and staff.

Thu 16th April 2020 The PDA

Public control measures in community pharmacy

Ensure all members of the public and staff adhere to the 2m social distancing guidance wherever possible:

  • Display posters advising members of the public that they should not be entering community pharmacies if they have any COVID-19 symptoms.
  • Individuals should maintain 2m distance when queuing
  • Pharmacies should restrict the number of customers and patients allowed into the pharmacy to support social distancing. Members of the public may need to queue outside to allow this.
  • Once a maximum number of patients and customers has been reached, operate a one-in-one-out process
  • Floor markings at 2m intervals inside the store and in the queuing area outside can be of benefit.

Physical Barriers

  • Retractable tape barriers or other measures can be used inside the pharmacy to direct queues appropriately and help enforce social distancing.
  • Clear Perspex or glass screens provide a physical barrier at the counter to reduce exposure to the virus and are recommended by the WHO. https://apps.who.int/iris/handle/10665/331498
  • Consultation rooms should be taken out of service during the COVID-19 crisis since social distancing is not possible in such confined spaces.

Fluid-resistant surgical masks (FRSMs)

PHE guidance published on 2nd April 2020 stated that staff working in pharmacies where adequate social distancing is not possible should wear fluid-resistant surgical masks (FRSMs)[v]. The PDA understood this guidance to cover the whole of the pharmacy including dispensary areas since widespread dissemination of the virus now means that anyone could be a possible carrier. Whilst this interpretation of the PHE guidance seems rational and fairly widespread[vi][vii][viii], at a Webinar on 8th April, Dr Susan Hopkins, Public Health England’s National Incident Director for COVID 19 stated that the masks were only for use on the shop floor and counter when dealing with members of the public and not for providing protection between colleagues in the dispensary or back office.  This view was reiterated in an NHS England Primary Care COVID bulletin of 9th April which contained the following:

Updated guidance on Personal Protective Equipment (PPE) was published by Public Health England (PHE) on 2 April 2020. If social distancing of 2 metres from patients attending the pharmacy can be maintained there is no indication for PPE in a pharmacy setting. If this distance cannot be maintained, use of fluid-resistant surgical masks (FRSM) is recommended.

…………….. We recognise that some pharmacy staff cannot stay more than 2 metres away from symptomatic people and will need masks. Pharmacy staff working in dispensaries but unable to maintain 2 metres from their work colleagues do not necessarily need to wear masks. It would be extremely helpful, both to protecting longer term supplies to pharmacies and to keeping supplies going to other health professionals, if pharmacies limit the number of staff that have to be within 2 metres of the public to help manage the use of masks and maintain availability.

The PDA position

The wearing of face masks can have a dual-purpose. Face masks are good at capturing droplets – they can therefore provide some protection when dealing at close quarters with an infected person[ix]. They also prevent infected droplets being transmitted when an infected wearer speaks, coughs or sneezes[x].

Given the evidence that individuals can be pre-symptomatic and still spread coronavirus[xi], a fact recognized by the UK government[xii], the PDA has concerns about the way in which this advice is being provided. It is apparent that there are significant shortages of PPE in several sectors leaving front line workers without PPE. One NHS Trust Hospital (Wolverhampton) has even appealed to their local community to donate PPE to assist with their critical shortage. It is understandable that the NHS would seek to ensure that the stocks it has are distributed to those workers in the most hazardous settings as a priority. The government must redouble its efforts to secure more supplies of PPE so as to protect all staff providing front line services to patients. However, this situation does not remove the current increased risk to individuals working within a pharmacy with regular exposure to possible asymptomatic carriers of coronavirus and the inability to socially distance themselves. The PDA believes that PHE should provide the facts based on the science , clearly communicate the risks involved and then allow pharmacists and their teams to decide how best to manage those risks.

The International Pharmaceutical Federation (FIP) COVID-19: Guidelines for pharmacists and the pharmacy workforce[xiii]  encapsulates the PDA view succinctly:

Considering that transmission has occurred from asymptomatic and/or pre-symptomatic individuals (Ruiyun Li, 2020) and the frequent contact that pharmacists and the pharmacy workforce have with the public (including infected individuals), it is reasonable to recommend that pharmacy staff wear a face mask to protect themselves from infection, and to avoid further dissemination in case the pharmacy personnel becomes infected themselves.

The Employers responsibility in law

This is an area where healthcare guidance is not the only governing factor – employers have a regulatory duty under the Health & Safety at Work Act to ensure that their workers can do their job safely and that appropriate PPE is provided. Should an employee come to harm as a result of working unprotected, their employer would have a legal obligation to report this under RIDDOR regulations[xiv] and we urge all pharmacist employees to bring such cases to their employers notice as and when this occurs.

The PDA advice

In light of the above, the PDA believes that there is a pragmatic approach which seeks to protect pharmacy workers and their families whilst recognizing that there are significant shortages of some PPE and that those healthcare workers in the highest risk areas (such as in Intensive Care Units) need to be protected as a priority.

We believe that members and the teams that they work in close proximity with will have a choice of four alternatives when working in dispensaries where 2m social distancing is not possible and NHS supplies of face masks are not available:

  • To request that their employer fulfils their H&SW obligations by providing suitable face masks.
  • To provide their own face masks and seek recompense from their employer.
  • Ask to be moved to a less hazardous work area where protection measures may be in place or where 2m distancing is possible, or ask to be furloughed (if they are high-risk individuals or share their home with high-risk or vulnerable individuals).
  • Work without a mask (if they feel their risk is relatively low and they do not have at-risk individuals at home).

As key members of the teams keeping the last remaining walk-in access to frontline NHS services running, community pharmacy staff need to be adequately protected. A multiple pharmacy chain recently noted that one in five of their pharmacy staff was currently self-isolating[xv]. Despite this, reports from PDA members indicate that some employers are still prohibiting the use of PPE in their pharmacies as they claim that it is counter to advice from the Public Health England. It is important that measures are taken to ensure that risks to this crucial sector of the workforce are mitigated as far as possible, be that by the NHS or pharmacy employers. The NHS needs to improve its efforts to source and then distribute PPE generally. However, the primary responsibility for the protection of employee’s in the workplace lies with the employers and those employers who do not take their responsibilities under Health and Safety Legislation seriously during the crisis, run the risk of action being taken against them under the H&SW legislation once the crisis is over.

Risk managing your safety

Over and above the use of Perspex screens and the wearing of face masks, the PDA shares advice on Covid-19 infection mitigation, much of this advice is based on successful initiatives used in pharmacies in other countries.

Disposable gloves

Whilst PHE does not feel that any further PPE is required in community pharmacy, the PDA view is that the risk of transmission of virus fragments via surfaces including seating, counters, bank card machines, money and pens provided for signing prescriptions as well as the stock that is handed over by a member of the public during a transaction makes the wearing of disposable gloves prudent. Regular handwashing is important for public protection but expecting staff to go and wash their hands after each potentially risky contact is impractical.

Clothes worn in the pharmacy

Clothes worn during the working day in a pharmacy could very easily attract and retain virus particles. Thought should be given to wearing a set of clothes in the workplace, which is then immediately removed and laundered once returning home. Different attire should then be worn at home, so as to protect other members of the family where appropriate.

Staffing; longer hours and introduction of shift patterns

In some European countries, the closure of general practice to routine face to face consultations and resultant increase in attendance at community pharmacies has resulted in additional government support to allow pharmacies to remain open for extended hours. Funding has facilitated longer hours of opening and increases in the numbers of pharmacy team members. Business continuity and resilience has been enhanced by the pharmacy workforce splitting into two teams working early or late shift, with no crossover. This has reduced the risk of coronavirus infection spreading throughout the entire workforce in a particular pharmacy.

Cleaning regimes

Routine cleaning of high-risk areas such as door handles, counters, pens, shopping baskets all counters as well as communal staff areas should be adopted. Many retail outlets are enabling members of the public to wipe down and clean their own shopping basket handles.

Handling of used PPE

All types of PPE must be donned and removed taking care not to introduce contamination in the process. In particular, when removing masks or gloves care should be taken so as not to touch the outside surface which may carry virus particles and ensure items are disposed of safely.

Infection control damaged by employer practices

The PDA has been made aware of many examples of poor employer behaviour related to the wearing of PPE by pharmacy staff, including locums being informed that they would no longer be booked because they chose to provide their own face mask and wear it at work. One of the worst examples was an email to staff at a chain of pharmacies which banned the wearing of PPE by any staff in any pharmacy. The PDA is always keen to receive information about unacceptable employer practices and will raise issues with regulatory and other bodies as appropriate.

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