RCUK Statement on PHE PPE Guidance

Updated RCUK Statement on PHE PPE Guidance:
28 April 2020

RCUK recognises the statements made by Public Health England on 24 and 27 April on the issue of NERVTAG’s consideration of chest compressions as potential AGPs and the associated guidance to NHS Trusts. 

NERVTAG’s appraisal focuses purely on the theoretical science of AGPs, without appropriate consideration of the clinical realities of conducting repeated chest compressions as part of a resuscitation attempt. 

RCUK’s principal focus throughout the COVID-19 pandemic has been to balance the potential for positive outcomes for patients with safety for Health Care Professionals (HCPs). RCUK guidance is in accordance with international best practice issued by organisations such as WHO, ILCOR, European CDC and ERC.

In the absence of high-quality evidence to state that anything less than AGP PPE is sufficient for healthcare professional safety, Resuscitation Council UK maintains its belief that AGP PPE provides the safest level of protection when administering chest compressions, CPR, and advanced airway procedures in known or suspected COVID-19 patients. For this reason, we welcome the fact that PHE’s guidance of 24 April now aligns with that of RCUK, inasmuch as it allows Trusts to opt for AGP levels of PPE if they consider this appropriate to best ensure HCP safety. 

We recommend that Trusts adopt this approach, thereby seeking to ensure appropriate protection for their staff. We would also urge HCPs engaged in resuscitation in COVID-19 circumstances to highlight this aspect of the amended PHE guidance to their Trusts, to best ensure their safety and that of their colleagues and families.

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Previous statements: 

Updated 20 April 2020:

“We are deeply concerned by Public Health England (PHE)’s continued insistence on designating chest compressions as non Aerosol Generating Procedures (AGPs). The absence of high-quality evidence for this should not be interpreted as the absence of risk. The clinical reality is that chest compressions produce excretions from a patient’s nose and mouth. As such, irrespective of whether this is via aerosol or droplet or both, this poses a demonstrable risk to Health Care Professionals (HCPs). Resuscitation Council UK (RCUK) COVID-19 guidance recognises this risk and designates that Level 3 PPE should be donned before chest compressions are undertaken by HCPs. We also advise that a defibrillator be employed at the earliest opportunity. This buys crucial time for patients and HCPs alike and provides the most appropriate balance of HCP safety and care for patients. 

RCUK guidance is based upon WHO and International Liaison Committee on Resuscitation (ILCOR) guidance and the emerging evidence available to us through the world experts in resuscitation who make up our membership. Our guidance is also being used by clinicians around the world.  
We have sought to engage with PHE on the scientific complexities and clinical realities of this issue over the last few weeks. We have also shared with them the latest evidence which serves to reinforce the need to provide Level 3 PPE to HCPs in this situation. It is regrettable that this has not persuaded them to alter their policy on this issue. 
In the meantime, significant confusion exists across the NHS, with many Trusts and HCPs choosing to follow RCUK Guidance, in opposition to that of PHE. RCUK’s position has been clear and consistent throughout this crisis. Our guidance is based on scientific evidence and a wealth of clinical experience across the resuscitation world. Our concern remains that not providing Level 3 PPE to HCPs performing chest compressions is a clear risk to their safety. In a pandemic where HCPs are tragically dying, we challenge the rationale for advocating a lesser form of PPE where expert consensus states that such a risk to safety exists. Irrespective of their stance on the AGP issue, we ask PHE to recommend Level 3 PPE for chest compressions to ensure safety for the healthcare workforce.”

- Professor Jonathan Wyllie, RCUK President

Notes to editors:

1.All RCUK guidance for COVID-19 can be found here.

2. Supporting Evidence: 

a.International Liaison Committee on Resuscitation (ILCOR): https://www.ilcor.org/covid-19

b.World Health Organisation (WHO): https://apps.who.int/iris/bitstream/handle/10665/331695/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf

c.Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html

d.Australian and New Zealand Intensive Care Society (ANZICS): https://www.anzics.com.au/wp-content/uploads/2020/04/ANZI_3367_Guidelines_V2.pdf

e.DoD COVID-19 Practice Management Guide - Health.milhealth.mil › Reference-Center › Technical-Documents › 2020/03/24 2 

f. Resuscitation Journal: https://doi.org/10.1016/j.resuscitation.2020.04.022 (Added 22.04.20)

3.CPR advice for a home setting: https://youtu.be/f4ZI1PAsmks

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Updated as of 15 April 2020:

During the course of the last week, Resuscitation Council UK (RCUK) has been in close discussion with colleagues at Public Health England (PHE) and many subject matter experts on the question of appropriate levels of Personal Protective Equipment (PPE) for Health Care Professionals (HCPs) performing chest compressions and CPR.  

Following these discussions, and having reviewed the latest evidence from around the world, RCUK’s position on the need for Level 3 PPE to ensure healthcare professionals’ safety remains unchanged and consistent with our original COVID-19 Guidance published on 4 March 2020. 

Indeed, the discussions between PHE and our resuscitation experts strengthen our belief that such protection is necessary, given the aerosol and droplets excretion that typically results from chest compressions.  

This Guidance should apply in both acute and non-acute hospital settings, as the risk to healthcare professionals is equivalent in both settings.

Early application of a defibrillator, while other healthcare professional colleagues don Level 3 PPE, maximises healthcare professional safety, while also providing the patient the best chance of effective resuscitation. 

RCUK remains committed to working with PHE and their counterparts in the devolved nations to ensure that resuscitation treatment delivered throughout the COVID-19 crisis is based on healthcare professional safety and patient efficacy.

Originally Published 28 March 2020:

Resuscitation Council UK [RCUK] has been made aware of the revised PPE guidance published by PHE on Friday 27 March 2020. 

RCUK is committed to the safety of both healthcare staff and patients during a cardiac arrest resuscitation attempt and we also understand the concerns raised about the adequate supply of PPE to clinical areas. 

RCUK was not involved in the preparation of the PHE guidance. We are currently awaiting the results of an international evidence review process, and this is expected very soon. We remain committed to working with PHE and NHSE to enable the delivery of safe, high quality care during these exceptional times, and will share the results of this review with them when available. 

In the interim, however, our current guidance (dated 27 March 2020) remains unchanged.