Comment: The failure over PPE is still with us and will continue putting our lives at risk in a second wave.

We are performing unsafe work as a result of our moral code to care for patients, writes Dr Andrew Miller

28th May 2020

While Australia has thankfully been saved from the worst ravages of the virus, the alarm raised by doctors working in hospitals, GP clinics and aged care facilities about the adequacies of personal protective equipment continue unabated.

Below, Dr Andrew Miller, a Perth anaesthetist and president of AMA WA, says the debate is much more than just demands for masks — it is a symbol of the personal struggle for understanding.

Healthcare workers, including doctors, run toward COVID-19.

After all, medicine is our calling, our identity and the profession that sustains our families and builds their future.

During this time, we face an unprecedented risk of becoming a statistic, or of making our loved ones sick. 

There are more than 280 known infected healthcare workers in Australia who acquired the disease in the workplace.

And we are all familiar with reports of hundreds of healthcare worker deaths internationally, and the fact that inadequate PPE use has contributed to the tragedy.

What is the big deal?

Discussion around PPE has become emblematic of concerns of healthcare workers in relation to management response to COVID-19. In reality, PPE use is simply a lower-level front-line control, in a hierarchy of controls to manage the risk. 

The reason PPE is thrown into sharp relief is that it is visible, and is to some degree in the hands, literally, of the individual healthcare worker.

It is like the bulletproof vest as a last line of defence.

And PPE, like all personal equipment, has as large a role in providing psychological safety.

It is a tangible indication that the organisation is protecting the individual and in the context of COVID-19, protecting their family and the wider health system.

When the patient is positive and contact is unavoidable, PPE is the only control left to protect doctors and nurses from a highly infectious disease. 

Our issues with the current PPE policy stem from the guidelines themselves, the implementation and the result. 

The PPE guidelines for doctors are confusing

The Infection Control Expert Group advises the Communicable Disease Network of Australia (CDNA) and the Australian Health Protection Principal Committee on guidelines for PPE.

These authorities prefer that all other recommendations from the various colleges, associations and institutions submit to this advice.

It means front-line workers have had little to no say in the development of the guidelines, or their implementation — there has been no consultation with professional representative bodies like the AMA. 

Yet the burden of failure of the PPE is borne by the front-line worker.

There have been frequent changes to the guidelines since the onset of COVID-19.

All of the iterations have reduced the requirement for more aggressive protective measures, with the result that less resource is required.

This has led to distrust from healthcare workers, who do not see the evidence to support a shift away from aggressive protective measures as being any more convincing than it was at the outset.

Many would prefer a more precautionary approach to this new and evolving disease risk.

Examples of reduced PPE protection given in these guidelines include:

• N95 masks no longer being required for aerosol-generating procedures unless in suspected or confirmed COVID-19 positive patients. This is in the setting of no pre-procedure testing of patients.
• The removal of any requirement for fit testing of N95 masks, which is mandated in the Australian Standard but not required in the guidelines, seemingly due to the administrative and resource burden that could result.
• Insistence that droplet precaution is not required for standard consultations.

The CDNA guidelines are also based on the generally accepted view that most spread is by droplet or contact rather than by aerosol.

This is where the 1.5m recommendation originates — when someone talks, then we are far enough to not get their droplets from speech in our face.

This is an arbitrary cut-off and lacks the nuance that individual healthcare workers should be able to apply to their workplace depending on the clinical situation.

Applying the 1.5m rule in many clinical situations is unrealistic and impossible.

However, if the droplet theory is not always correct, in even a small number of cases, then PPE should be more conservative due to the catastrophic potential of the risk.

The precautionary principle would dictate higher-grade protection until more time has passed and more is certain about a new disease.

The guidelines do refer to the “supply chain” and “supply considerations” as influential in their formulation.

However, these are not areas of expertise for the authors of the guidelines.

They have to accept what they are told in relation to supply, and are not in a position to push back and say that the supply must simply be fixed or the work must not be done.

Companies outside of healthcare are not able to use the short supply of safety equipment as a reason to request their industry’s regulator amend safety guidelines.

They are required to meet the independent standard or cease operations. 

As a wealthy nation, we have the resources and the community goodwill to equip front-line workers with the world’s best PPE.

In a time of low community spread, gained through a combination of aggressive lobbying, swift political decision-making and societal compliance, WA has the enviable opportunity to use very high standard PPE along with other controls to aim for zero healthcare worker infections.

Rather than aspire to this achievable outcome, the guidelines meekly state that things will be reviewed if the supply chain shifts. 

Anecdotal statements like healthcare worker infections in the workplace in Australia have “generally occurred in situations where respiratory symptoms were present and PPE was not used” are used to bolster a lower standard than could and should be offered.

What is meant by “generally” is not detailed.

It is also true that complaints from front-line workers about lack of protection have been dismissed as “chatter” by those in senior positions, and the pre-COVID-19 cultural disconnect between workers and management in many of our health institutions has been exacerbated.

The well-documented high rates of burnout and disengagement result largely from a clash of command and control culture with the need for empathy, collaboration and communication that modern professionals rightly expect and on which patient outcomes depend.

Unfortunately there is a narrative of sacrifice in relation to healthcare, where the culture expects and relies on the workers to ‘step up’ and ‘do the right thing for the patient’ rather than complain about conditions, such as lack of access to the PPE that the healthcare worker feels or knows they need.

And we know that while governments are prone to thanking workers publicly, quick to identify with the positive brand, they fail to listen to, let alone fulfil requests for better conditions.

And we know they will attribute blame to workers when things go badly. 

Front-line doctors are stressed

Wrongful assertions about workers possibly causing their own infections through flouting restrictions are reported as having been made by those in positions of authority, including the Chief Medical Officer of Australia.

GPs in WA who did not want to see fever patients without PPE were also criticised by the WA State Health Minister who reportedly opined they were evading their moral and legal obligations.

In fact, the GPs were properly analysing the risk to their practice, staff and other patients and acting on the duty of care to invoke a high level of control.

If a health service cannot or will not provide PPE, it should either accept a reasonable substitute from the worker or provide other higher-level controls that remove the risk of COVID-19. 

The fact that healthcare worker infections have already occurred at such high rates in Australia despite low overall incidence means the hierarchy of controls has failed.

Being forced to continue in unsafe work by one’s own moral code, or peer group pressure, because of a desire to continue caring for patients despite a lack of PPE, should be prevented through proper management.

Apart from infection, the mental health risks of post-traumatic stress disorder, moral trauma and anxiety are unreasonable.

The provision of patient care should not come at the expense of healthcare workers’ physical and mental wellbeing, especially when such circumstances are entirely avoidable.

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This is an edited version of an article first published in the May 2020 edition of Medicus, the monthly magazine of the AMA (WA) originally printed in Ausdoc here.

To see Ausdoc stories mentioning Dr Andrew Miller