The Science of Physical Safety
Who deserves a mask? Telescope straight to the scientific policy answer from the Australian and New Zealand College of Anaesthetists guidelines : this is the gold standard for hospital anaesthesia and a template for all others, makes complete sense, and is based on great science. Inside a shiny operating theatre with subdued beeping it fits right in. But science is about argument, and everyone is entitled, every scientist is obligated, to question the science. Especially when they might be the one to die if it is wrong – cue bias.
Scenarios Triggering Stages of PPE
|Level of PPE||Patient at Low Risk of Covid||Patient at High Risk of Covid||PPE Detail|
|Standard Precautions||Yes depending on situation||Inadequate||Hand hygiene, cough etiquette|
|Contact Precautions||Yes depending on situation||Inadequate||Add gloves, scrubs or gown|
|Droplet Precautions||Yes – must use this if “aerosol generating procedure”*||Minimum||Add surgical mask, goggles, waterproof gown with sleeves|
|Airborne Precautions||Only for high risk surgery with instruments in airway||For any aerosol generation||Replace surgical with N95/P2 respirator mask. Powered Air Protective Respirator (PAPR) in specific high risk settings.|
* You will hear a lot about aerosol generating procedures (AGPs) : there is argument at the fringes of what they include but think : unprotected violent coughing, or a procedure putting a tube down someone’s throat to assist their breathing.
The guidelines are formed by respected committees of experts including clinicians who make balancing judgements about safety and resource in good faith. They are backed by the available science, which, although new, is so far rigorous in supporting that most transmissions are by contact, with some due to close contact with aerosol generation.
Notably the guidelines do not stratify risk by individual practitioner characteristics, such as age, illness causing immune suppression, or take any account at all of mental health exposure to anxiety and work related stress and burnout. These factors are well known to limit workforce participation.
Those in favour of a more conservative approach are often specialists who work in General Practice, ED, ICU or Anaesthesia, where many would prefer a minimum of Droplet Precautions for all patient contacts.
Some even choose to use masks, gloves & goggles for situations of limited social distance such as shopping. It seems a bizarre outcome that they can use protections in the supermarket that they are not allowed to use at work in a hospital.
A significant number of them would prefer a lower threshold for moving to Airborne Precautions, such as close contact with any patient for any procedure, based on a belief that the science is too new, the consequence too great, to trust that droplet precautions alone are safe.
Their arguments include:
- COVID19 is a new disease and the “precautionary principle” should apply, ie safety first until we know more. Science that backs the view that airborne spread is minimal in the absence of generating events is authoritative, but subject to review with such a new virus.
- the exposure opportunities for healthcare workers accumulate over time in difficult environments and while the guideline may work most of the time, for an individual it needs to work all the time.
- clinical settings are widely variable and what may work in a hospital may be not be as safe in less structured settings.
- the stakes of losing healthcare workers are very high in a time of crisis and shortage, and they may have worse outcome from the disease than others due to immune modulation, so more caution is warranted.
- the high number of healthcare workers infected shows the current PPE regime is unsafe in practice. Victorian HCW have an order of magnitude higher infection rate than the public.
- unprotected exposures result in quarantining and loss of healthcare workforce, which can be devastating to service sustainability.
- this is also safer for patients in the context of an unknowingly infected contagious healthcare worker.
- recent revision of guidelines to reduce requirements in the context of resource shortage wrongly preference continuation of care provision over worker safety.
- reduced anxiety and stress, improved psychological safety when feeling more protected.
Arguments against using more PPE include
- the guidelines are based on best scientific evidence available, so it is simply not necessary.
- there are shortages of PPE and we might run out.
- we can’t give everyone just what they want or there will be chaos.
- it may create anxiety in those who see healthcare workers using it who assume there is a greater risk present than there is. The discussion about reducing anxiety is not usually accepted as a reason by the same people to increase use of PPE.
- HCW can’t use their own supply as it may be of low standard or may create jealousy or ethical imbalance with those who cannot access PPE. Better to use none, than allow BYO.
The Culture of Psychological Safety
We should examine the outcomes of guidelines in their uncomfortable real world context. It is a reasonable proposal that most healthcare systems, and organisations, have significant pathology in their culture. The ideal : a well functioning team-based organisation that values it employees, is lead by virtuous and talented figures, and delivers faithfully on its mission and vision, is aspirational. In Australian healthcare delivery it is a mirage, with some few exceptions.
Even small practices, where such things are achievable through dedication of good owners, exist within a landscape of distorted incentives, such as the Medicare Benefits Schedule and bulk billing competition.
Although we have good outcomes in Australia on many OECD metrics, this is because of organic work arounds and widespread failures in other countries, rather than by genius design and implementation. We could be doing much better. Our successes come because professionals in medicine, and other disciplines at the coal face, have successfully sponsored and nurtured islands of success despite problematic structures and behaviours.
The scientifically valid PPE guidelines do not have within their scope considerations of worker psychological safety. Or indeed any of the cultural or social workplace problems that directly affect their implementation, such as lack of trust, deception, bullying and harassment.
It is possible that healthcare workers would be much safer from the adverse effects of these well documented workplace phenomena, in the context of covid19, if the guidelines for PPE were more conservative and demand driven.
Many healthcare workers do not trust that their managers have their best interests at heart. Many of them are proven correct in relation to their career, leave entitlements, rostering, and so on. They have seen conditions and morale widely eroded over the last three decades in many places, as documented in research such as Hospital Health Checks in WA.
There is no precedent in modern times for a workplace hazard like this one.
When someone who works in an emergency department or clinic is not granted droplet precautions as a minimum because we have to conserve the masks for later, they are unhappy about it, as they feel exposed. They get coughed on, or even spat on, unpredictably at work by patients who harbour unknown diagnoses.
To then be told they are also not permitted to bring their own mask to work, which they can legally wear anywhere else, starts to seem like the institutional bullying, the cruel enforcement of rules without empathy or flexibility, that they have encountered many times before.
What if we do run out of PPE? If every last mask and gown is gone then the system has failed and we need to ration care. It is not acceptable to sacrifice healthcare workers in a futile bid to treat patients in a failing system.
One way to chart a path that makes up for some of the cultural problems, scientific uncertainty and resource shortage would be to
- permit any healthcare worker who inusingtheir professional judgement wants to use droplet precautions to do so
- if immune suppressed or special circumstances then consider and support redeployment
- preserve aerosol precautions as they are, with proper fit testing as per the standard that applied before COVID
- where the system cannot provide PPE the user should be allowed to substitute reasonable quality self sourced items
- extensive community social and travel controls should remain to keep cases very low until such time as PPE is in plentiful supply and widely available.
Trust, control, avoidance of anxiety, and maintenance of an engaged workforce through attention to welfare are all valid considerations when implementing guidelines for PPE.
Genuinely considering these important factors will inevitably push the balance in favour of more protection, driven by user demand. That demand will drop when confidence rises in the healthcare workforce that the system will protect them when the time comes.