4. Personal protective equipment

4. Personal protective equipment

The supply, availability, and appropriate usage of PPE has emerged as a key issue nationally during the COVID-19 pandemic. It has rightly attracted significant community interest noting its importance in preventing the further spread of COVID-19 and protecting frontline workers against infection. Global supply issues relating to PPE have also been experienced in Tasmania despite efforts to support sufficient supply levels. Prior to the North West outbreak, measures were in place to monitor and report PPE stock levels (to enable any emerging shortages at state or regional levels to be addressed), and to ensure appropriate staff training regarding PPE use. These measures were expanded and further strengthened during and following the outbreak.

Further information regarding the supply of PPE during the COVID-19 pandemic and the measures put in place leading up to and during the North West outbreak is provided below.

4.1 Standard PPE supply and management arrangements

Supply of medical equipment for Tasmanian public hospitals, including PPE, has been centrally managed by the THS, both prior to, and during, the COVID-19 pandemic. In addition to public hospitals, other healthcare services in Tasmania are provided with PPE through the THS (including AT, Oral Health Services Tasmania and the Child Health and Parenting Service). The THS uses warehouses in each region to store and rotate PPE using normal stock access and management processes. The warehouse supplying PPE to the NWRH is located at the MCH, due to lack of available storage space onsite at the NWRH.

In addition to the THS managed supply, the DoH also maintained a limited strategic reserve of PPE supplemented by the Australian Government National Medical Stockpile through prepositioned PPE in Tasmania. Since the North West outbreak, further work is progressing to strengthen strategic PPE reserve capacity through the establishment of the State Medical Emergency Stockpile.

4.2 PPE supply challenges during the COVID-19 pandemic

While these existing state and national measures were in place to support a sufficient supply of PPE in response to emergencies, the DoH has experienced challenges in sourcing reliable and sustainable supplies of PPE. COVID-19 has resulted in unprecedented levels of demand globally for PPE as well as reduced capacity in existing supply chains. Existing THS PPE suppliers put the THS ‘on allocation’, meaning suppliers would only supply quantities of PPE based on historical consumption rates (which was less than the increased COVID-19 demand). While it is recognised this measure was implemented to support suppliers to manage increased demand, this contributed to PPE supply pressures in Tasmania.

As a result of existing supply contracts being unable to adapt to the change in demand, alternative products have had to be sourced to meet operational needs. The vast majority of offers for alternative products considered by the DoH were unable to provide evidence of product compliance with Australian Standards or provide assurance products were suitable for use in a medical setting. Where supplies could be demonstrated as suitable, there were challenges with their importation into Tasmania. The national response to COVID-19 meant there was a significant reduction in flights to Australia and particularly into Tasmania. Border travel restrictions also initially had an impact on shipping into Tasmania.

The management of PPE supply was further complicated by the delivery of health services across multiple care settings, with competing demands on PPE supplies across public and private hospitals, primary health, community health, public health, and private pathology settings (amongst others). Allocation of limited resources had to be prioritised based on greatest benefit to the emergency response, with restricting certain services aiding in the preservation of PPE (as noted in section 1 of this submission). In addition to the PPE requirements of public hospitals and other health services, several government agencies and non-government and private sector organisations have requested support from the DoH to supply PPE to maintain safe services during the response to COVID-19, including for example the disability sector, general practices, dental practices and correctional facilities.

Theft of critical PPE and hand sanitizer became a real issue in March 2020, forcing the locking up of key PPE supplies to protect their availability in hospitals and daily distribution of PPE rather than weekly to open cupboards. The DoH acknowledges this change may have caused the perception by some staff that PPE was not readily available. Due to global shortages, brands of PPE preferred by some clinicians also disappeared, leading to some staff concerns as to PPE levels despite alternate brands or substitute products being offered.

4.3 PPE arrangements in the lead up to the North West outbreak

In response to the significant challenges impacting on global supplies of PPE as a result of COVID 19, the DoH put in place a number of arrangements to ensure a sufficient statewide supply of recommended PPE throughout the course of the pandemic.

On 3 April 2020, a senior executive was appointed as a PPE Lead within the DoH ECC with a dedicated PPE team to manage logistics and statewide supply. This enabled the centralisation of decision making around the provision of state and Australian Government supplies. The role of the PPE team includes monitoring and reporting on the use of PPE, providing centralised procurement processes to ensure adequate supply statewide, and ensuring appropriate use of PPE in accordance with state and national guidelines.

While the establishment of the PPE team in the ECC centralised the monitoring and procurement of PPE at a statewide level, work had been occurring at the local level prior to this time. On 28 January 2020, the DoH Secretary requested the THS Executive provide information on PPE stock and general preparedness for the potential escalation of COVID-19 in each THS region. The review of PPE stock in the THS North West Supply Department found that, as of 28 January 2020, there was approximately one month’s supply of each PPE line item, with orders being processed to increase stock to three or four months’ supply (depending on the item).

Throughout February and March 2020, NWRH Infection Prevention and Control staff undertook actions to support PPE preparedness in the North West, including providing the THS North West Supply Department and the THS Response Planning Group with a list of hospital areas that should be prioritised for the provision of P2/N95 masks, and moving excess PPE stock from the inpatient hospital wards (excluding the emergency department and ICU) into secure storerooms to prevent theft, excessive overuse of supplies and ensure a steady ongoing supply when needed. Nurse Unit Managers and After-Hours Nurse Managers were advised of the reason for the removal of excess stock and the location of stored stock to ensure PPE could be accessed as needed.

Infection Prevention and Control staff also monitored the PPE stocks of different areas of the NWRH and MCH and arranged for delivery of items to those areas as required. While ongoing monitoring found supply levels in the North West were generally sufficient, there were occasional reported instances of low levels of stock on hand in the North West prior to the outbreak. Stock remained available and wasn’t exhausted, and additional supplies were positioned in the North West. Further information on the measures taken to increase PPE supply is outlined below.

4.4 North West outbreak

The DoH worked to increase PPE positioned in the North West, as outlined above in the early stages of the North West outbreak. In early April, surgical masks and P2 respirators were sourced from the National Medical Stockpile and a number of additional supply sources were investigated including international and local suppliers.

The ECC actively worked with the Department of State Growth to identify local business manufacturers that could meet hospital PPE requirements. For example, the DoH signed a contract with a supplier in early April 2020 to coordinate the production of 20 000L of pharmaceutical grade hand sanitiser utilising Tasmanian Alkaloids facilities (with a further order placed in June 2020 for additional stock).

In addition to sourcing PPE supplies, the dedicated PPE team in the ECC worked to ensure sufficient distribution of PPE across the three regions of the state. This included relocating stock from the south to the North West when necessary to ensure that sufficient volumes of PPE were available for healthcare workers to continue to provide safe care in the context of COVID-19.

While there were times that PPE stock had to be couriered between sites and regions, there were no times during the outbreak that the NWRH ran out of PPE. When the hospital closed, remaining PPE (including unopened boxes of P2/N95 respirators) were retrieved for quarantine and ongoing use following recommissioning.

Regular updates on PPE supplies have been provided by the State Health Commander to all staff during and following the North West outbreak (from mid-April 2020) including current stock numbers, assurance regarding the availability of appropriate PPE supplies to safely respond to patients’ clinical needs, and advice on issues such as indications and requirements for use of PPE during the COVID-19 response. A dedicated PPE email address (ecc.ppe@health.tas.gov.au) was also provided to staff, with a call to voice any concerns or issues regarding PPE.

4.5 PPE guidance and training provided in the North West

All THS medical, nursing and allied health professionals are required to participate in mandatory infection prevention and control training held annually, which includes PPE use. Additional guidance and training on PPE was also provided to hospital staff in the North West as part of the response to COVID 19.

Global demand for PPE increased to unprecedented levels due to increased PPE usage in response to COVID-19. Guidance and protocols for PPE use in Tasmanian public hospitals are based on current national guidance. This includes pre-existing national guidance on PPE use provided under the Australian Infection Prevention and Control Guidelines, and COVID-19 specific guidance issued by the Australian Government on the use of PPE in hospital care of people with COVID-19 (first published in  February 2020 with subsequent updates developed through the Infection Control Expert Group and endorsed by the AHPPC through-out the COVID-19 response).

Advice on usage of PPE was targeted at ensuring staff were informed how and when to use PPE in accordance with evidence-based national guidelines, as well as limiting potential overuse in order to preserve stock levels.

There was regular communication with THS managers and staff around training, resources and protocols for the management of COVID-19. These included training resources circulated to all staff from late January 2020 on the appropriate use of PPE, infection control and hand hygiene in line with the WHO and national guidelines, including demonstration videos and printable documents providing instructions with photographs.

In addition to regular circulation of updated guidance and training materials, face-to-face PPE training sessions were regularly provided at the NWRH and MCH from February through to April. Inservice PPE sessions were provided to attendants, catering, theatre, emergency department, ambulance, anaesthetic, pharmacy, speech therapy and cleaning staff, as well as P2/N95 respirator fit checks for relevant healthcare workers in line with national guidance.

A key component of the PPE training sessions was reinforcing the appropriate sequence for ‘donning and doffing’ of PPE to avoid contamination. While many of these training sessions occurred in February and March 2020 prior to the first cases of COVID-19 in the North West, the frequency of sessions increased from the date the first positive case in the North West was notified to PHS on 21 March 2020.

During the closure of the NWRH and NWPH in April, senior staff provided ongoing training and supervision to healthcare workers at the MCH, with additional staff rostered on each shift to supervise PPE usage.

As noted in section 2 of this submission, a comprehensive learning and reskilling package was developed as part of the Return to Work Program for quarantined hospital staff returning to work in April 2020, including online and face-to-face learning on PPE use and infection control. All NWRH and MCH staff (over 2 000 employees) completed the online PPE training and were required to complete face-to-face sessions prior to their first shift upon returning to the workplace. PPE coaches were also made available across the North West; working on each ward to provided face-to-face support to staff.

Prior to handing back control of the NWPH to Healthecare, the State Health Commander also required that all NWPH staff (including clinical and non-clinical staff) undertake online infection prevention and control training for COVID 19, and face-to-face training upon returning to work, to be delivered by a PPE coach.

4.6 Conclusion

While the DoH had arrangements in place for supply and management of medical equipment including PPE prior to COVID-19, the unprecedented global demand for PPE caused by the pandemic resulted in challenges for the supply of PPE in Tasmania (as it has across Australia and internationally). The DoH responded by putting in place a number of new arrangements in the lead up to, and during, the North West outbreak, including establishing centralised monitoring and procurement processes to ensure that sufficient supplies of PPE continue to be available.

Measures were also put in place to provide additional training and support to healthcare workers in the correct use of PPE, with further resources put in place in the North West to provide staff with additional training and supervision regarding PPE during and following the North West outbreak.

The DoH is committed to continuous improvement to ensure Tasmania’s health system is in the best possible position to help manage any potential future COVID-19 outbreaks. Given the highly infectious nature of COVID-19 and the importance of ensuring infection control practices remains a priority focus of response efforts, a number of measures have been put in place within the THS including: recruitment of additional dedicated infection control staff; enhanced infection control and PPE training and education; and increased monitoring of infection prevention and control practices. These measures are targeted at further strengthening protections against virus spread in the high-risk hospital environment.