Personal protective equipment (PPE) – guidance, resources and FAQs

Find out what you need to do to remain safe while treating patients with Covid-19, and your rights and responsibilities.

National infection prevention and control (IPC) guidance

Update

The IPC has just published new infection prevention and control (IPC) guidance for seasonal infections in healthcare settings for winter. The focus of this new guidance is predominantly NHS acute settings and covers all respiratory viruses including Covid-19. However it does cover all healthcare settings, although it is more difficult to apply to those working in their own physiotherapy practice or in leisure settings.

What are the key changes?

The key changes in this new guidance are as follows:

  • The removal of the three distinct Covid-19 care pathways (high, medium and low) to one respiratory pathway applying transmission-based precautions.
  • Use of gloves and disposable aprons can now be risk assessed.

What does this mean for my physiotherapy practice/service?

  • Triaging and testing will continue over the winter period.
  • Physical distancing should be at least 1m in clinical areas, increasing whenever feasible to 2m for the respiratory pathways and admission units.

Standard Infection Control Measures for PPE for those not considered to be have a respiratory infection are:

  • Universal use of masks to remain as an IPC measure within healthcare clinical settings across the winter period.
  • Gloves: risk assess. Single use when risk for exposure to blood or body fluid (BBF), non-intact skin (NIS) or mucous membrane (MM), please note: excludes sweat.
  • Disposable aprons/gowns: risk assess. Used where exposure to BBF, NIS, MM is anticipated/likely.
  • Fluid-resistant gowns during aerosol generating procedures (AGPs): single use and changed immediately post treatment.
  • Eye protection during AGPs and/or likely splash exposure by BBF.
  • Where tolerated patients should wear a mask.

This means that all four home countries are now following the same guidance.

(Last reviewed: 23 November 2021)

Resources to support your PPE decision-making

  1.  CSP guidance on aerosol generating procedures (AGPs)

  2. Government guidance on aerosol generating procedures (AGPs) 

  3. Face masks and coverings for NHS hospital trusts and private hospital providers

Frequently asked questions

What do I do if my organisation refuses to provide me with appropriate PPE?

  • Raise this with your line manager, head of department and/or infection control department highlighting the CSP guidance and position statement.
  • Contact your local CSP representative for support and intervention.
  • Your local rep can seek further advice and support from a CSP senior negotiating officer if it is required.
  • If you do not have a local rep, contact the CSP to gain advice from the senior negotiating officer for your region.

If physiotherapy staff still cannot obtain the correct PPE for the service they provide, then they can decline to offer this service until their employer provides the appropriate equipment.


Should I be fit tested for a mask before treating Covid-19 patients?

Yes. You should be fit tested for an FFP3 mask before seeing high-risk patients.

Once you have been fit tested, then you should carry out a fit check every time you use a mask. Should the model of FFP3 mask you are using change, then a new fit test will be required.

If you were fit tested within the past two years, this will count as having been fit tested unless the shape of your face has changed over this time, in which case you should request to be fit tested again.

We advise that if your employer fails to fit test you as set out in the criteria listed above, you should record this on their incident reporting system – for example, Datix. 

Always ensure best practice with hand hygiene before and after patient contact, and also before entering and exiting any clinical area.


What should I do if I cannot get a good fit with an FFP3 face mask and I am due to be on call?

The NHS Staff Council statement suggests that systems should be in place to manage staff who cannot get a good fit with an FFP3 face mask. This may include the use of other equipment such as protective hoods. However, these are very costly and it is unlikely they will be readily available for all staff. In these circumstances, discussions will need to be held locally and, on rare occasions, it may be that a particular member of staff is unable to carry out on-call duties.

If the FFP3 face mask does not fit due to the member of staff having a beard, it is likely that it would be deemed a reasonable management request to shave in order to wear the protective mask unless the beard was necessary, such as for religious reasons.

Following the updated infection and prevention control guidelines released on 21 August 2020, you may be able to undertake some on call when patients are classified as low risk.

Guidelines for patient risk categories


Can I record on Datix that my trust failed to give me the PPE I should have received under the government’s guidance?

Yes, we encourage all members to make a notification on their employer’s incident reporting systems every time they are placed in an unsafe situation where they or others may or have been harmed at work. Examples of incidents that should be reported include staff ill-health directly related to their work, violence, and aggression.

The Health and Safety Executive (HSE) recently issued guidance on when Covid-19-related incidences must be reported by employers under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). Reporting now should happen when:

See examples of the above, provided by the HSE.


What should I do if I experience skin issues from wearing PPE?

The CSP is aware of NHS staff incurring skin abrasions, bruising and pressure sores on the face through wearing their PPE for extended periods.

The key issue with wearing PPE is that your skin can become hot and sweaty when the equipment is worn for too long. Apart from this making the mask uncomfortable, there is a potential risk that its effectiveness may be compromised if it loosens or detaches while you are working. Regular breaks from wearing PPE are therefore essential throughout your shift.

The advice of the Health and Safety Executive (HSE) on disposable FFP3 masks is that they should be worn for less than an hour at any one time. The estimated total time of use should last no more than a work shift of 8 hours.

If you are experiencing skin abrasion or pressure sores on the face as a result of your PPE do:

  • Notify your manager and infection control lead as soon as possible.
  • Follow your trust’s reporting processes for this injury incurred at work.
  • Make and keep a copy of your report.
  • Contact your CSP safety rep (if you have one). They have rights under legislation to investigate and request remedial action.

Dermatitis

Check the skin of your hands regularly, particularly if you are experiencing any itching or pain. The signs you need to be wary of are redness, scaling, flaking, blistering, weeping, cracking of the skin, and any swelling.

How can I prevent developing dermatitis when handwashing?

  • Thoroughly rinse off residual soap/hand cleanser.
  • Ensure your hands are completely dry before you put on your gloves.
  • Use emollient creams regularly, especially after you finish work. Check that all parts of your hands are covered.
  • Report concerns to your infection control lead and line manager. Early detection can help to prevent the development of more serious dermatitis.
  • Ask for hand hygiene products that are effective but gentle on your skin.
  • Your employer should provide good hand-drying facilities such as good-quality paper towels, and emollients in suitable dispensers to prevent cross-contamination.

Your employer’s health and safety responsibility

They have a duty of care to you under the Health and Safety at Work Act 1974. They should take prompt action when made aware of problems arising. If you find that your issues are not adequately resolved, then do contact your CSP safety rep or steward for support. If there is no CSP representative at your Trust, please call the CSP enquiries unit on 020 7306 6666 – they will refer you to the senior negotiating officer for your region.


Why does the CSP suggest different PPE requirements for rehabilitation and chest physiotherapy interventions?

The World Health Organisation is clear that coughing and sneezing produce respiratory droplets. Therefore, when providing rehabilitation to patients who are coughing, you should be using droplet precautions as a minimum. 

Certain chest physiotherapy techniques are intended to increase the strength and effectiveness of someone’s cough as part of an airway clearance regime. This may include manual techniques such as an assisted cough, expiratory thoracic compressions or mechanical devices. 

The World Health Organisation, therefore, suggests that ‘chest physiotherapy’ may be an AGP and it would be prudent to use airborne precautions (Infection control guidance, October 2019). 

Because of this, the CSP advises droplet precautions for mobility or rehabilitation where patients may cough or sneeze, and airborne precautions for chest physiotherapy treatments.

It is important to note that there may be individual clinical situations in which you feel that a higher level of PPE is required. In these circumstances, you should carry out and document a risk assessment and, if needed, this should be discussed with your line manager or infection control department. 


What is the current AGP guidance for clinicians working in education, childcare and children’s social care settings in England?

The CSP is aware of updated guidance for staff working in these settings issued by the Department of Education on 20 June, which explicitly excludes chest physiotherapy as an aerosol generating procedure (AGP), with reference to the Public Health England (PHE) PPE guidance. 

The CSP does not agree with this viewpoint and has lobbied PHE to change its position for some time (see other FAQs in this section).  We continue to advise all members, working in all contexts, to take aerosol precautions when performing chest physiotherapy with patients on the medium- or high-risk pathways.  Members should work with their local infection, prevention and control teams, NHS, education and public health teams to determine and agree local pathways. Risk assessment, in conjunction with national, professional and local guidance, remains key in order to determine the level of PPE required. 


What has the CSP done to address members' concerns about AGPs (aerosol generating procedures)?

In response to members' concerns and emerging evidence, the CSP has actively pursued clarification on the level of PPE that is appropriate to use with the coughing patient. We have also repeatedly requested transparency in the evidence used to define the list of AGPs (aerosol generating procedures). A summary of evidence justifying the selection of AGPs was published on 12 May 2020.

The CSP has joined with other professional bodies and trade unions to form part of the AGP Alliance who wrote to prime minister Boris Johnson in late September 2020, highlighting concern over the current list of AGP’s and seeking they include a number of physiotherapy interventions.

In January 2021, the AGP Alliance wrote to Health Secretary Matt Hancock directly on the findings of the High Risk AGP Panel and the need for more urgent action on PPE. The AGP Alliance issued a statement about the letter.

In mid-October 2020, Ema Swingwood, Chair of ACPRC was invited to provide her expertise to the AGP panel which is reviewing the evidence regarding AGPs. Following this, in June 2021, the AGP Alliance submitted further evidence to the Public Accounts Committee as they undertook the next stage of their review into the government’s response to the Covid-19 pandemic.

In June 2021, the AGP Alliance delivered a presentation to the Department of Health and Social Care, the Infection Prevention and Control Cell and Public Health England. This was specifically to press the government to change its UK Infection Prevention Control Guidance to reflect short and long-range airborne transmission of Covid-19 and to recognise the need to provide frontline healthcare workers with enhanced PPE. This was in light of the new urgency created by the Delta variant.

Despite our constant lobbying, additional physiotherapy procedures have not yet been added to the list of AGPs. While this is disappointing, we encourage CSP members to continue to liaise with managers, infection control and CSP representatives should they have any concerns about individual risk in the workplace, while the CSP continues to lobby at a national level.

The CSP continue to be in regular contact with the public health bodies throughout the UK to ensure that our members have the most up to date guidance on PPE.


What should I do if my employer is providing FFP2 masks, when the task I am doing requires FFP3 masks?

You should raise this with your manager in the first instance and challenge the level of PPE being provided to you through the use of a risk assessment.

If this does not resolve the issue, contact your CSP health and safety rep or steward as well as the infection control manager for your employer.

If this does not resolve the issue, your health and safety rep or steward will contact the CSP for support from a senior negotiating officer.

For more information, see the CSP workplace and employment FAQs.


Are there any other considerations with regards to uniform, additional PPE and disposal, and using my own car if I work in the community?

Regarding uniforms, ensure the correct level of PPE is worn for each patient contact, and disposed of in line with your local infection control policies and the guidance above. This, along with good hand hygiene, should reduce contamination of uniforms or cars.

For more advice, please refer to GOV.UK website document: Coronavirus (Covid-19): Disposing of waste when treating patients with Covid-19.

You must also follow the current Public Health England (PHE) household guidance for advice on households with possible or confirmed infection.


Where does the CSP stand on the continued use of face coverings?

From a public health perspective, the CSP believes and would encourage the ongoing use of face coverings and/or face masks in all indoor spaces, as well as spaces that may be classed as outside but have poor or little ventilation – for example, a lean-to or enclosed gazebo.

Evidence supports a reduction in Covid-19 infection where a face covering is used. This protection is increased by the use of face masks as opposed to face coverings, and also by the number of individuals that use a face covering or mask in an indoor setting.

Please do note face coverings continue to be mandated in Scotland.


What should I do about PPE requirements for my students at university?

Staff and students at higher education institutions (HEIs) need to follow their institution's PPE guidelines/policy.


What are my obligations around patients who are exempt from wearing a face mask?

Last reviewed: 21 October 2021


Do I need to see evidence that a patient is exempt from wearing and/or refuses to wear a face mask?

No. Patients are under no obligation to explain why they are exempt from wearing a face covering. This approach applies both to the relevant coronavirus rules and restrictions related to face coverings as well as a duty on providers of goods and services to make reasonable adjustments under the Equality Act 2010. (Please note the Equality Act 2010 applies to England, Scotland and Wales; other jurisdictions may have similar provisions, and are outside the scope of this document).

The duty to make reasonable adjustments relates to patients that may be covered under the Equality Act 2010. These are individuals with a protected characteristic.

Further information on protected characteristics


Can I refuse to see a patient because they are exempt from wearing a face mask?

No. However, you may determine that the patient’s needs are best met by a virtual consultation rather than a direct face-to-face appointment.  

Providing you are wearing the required level of PPE for your setting, there is no requirement to insist any patient wears a face mask as well, although many patients may voluntarily choose to wear one, or agree your request.

If you plan to see a patient who will not wear a mask, then you should undertake a risk assessment in order to minimise the risk to them, yourself and anyone else within the practise.

You may be able to ventilate the consultation area more than normal, or upgrade the level of PPE your or others are using.

Read HSE advice on ventilation.

Remember that protected characteristics are not always visible, a patient is under no obligation to share this information with you, and that discrimination does not need to have been intentional to be unlawful.

If a patient refuses to wear a face mask, and they confirm to you that they have no underlying medical reason or a protected characteristic that prevents them from doing so, then you may decide to decline to treat them in person on that basis.

Ideally, you would have a policy in place that supports this action.

You may also refuse to treat a patient for other reasons, such as competency to treat a certain condition or an inability for the patient to access the service while needing a hands on treatment, but if you believe the patient has ongoing health needs that you cannot meet, you should advise the patient where they can access services

Remember that you are responsible for the decision to treat or not, therefore keep records that justify your position.


What can I do to minimise the risk of discrimination?

Screening and risk assessment is key for all patients prior to deciding whether to treat them remotely or face-to-face.

Asking in a neutral manner whether a patient is exempt from wearing a face covering early should assist in this process i.e. a yes/no response without asking why.

Triage your patients’ needs to decide whether you can offer a remote treatment, or if they require an in-person appointment.

A flat refusal to treat based on a patient stating they are exempt from wearing a face covering runs the risk of being potential discrimination should a patient have a protected characteristic.

You should keep clearly documented notes of any decision you make, along with your clinical reasoning and any recommendations made to the patient.

The potential exemption of mask wearing may form part of the overall reason not to treat. However, it must not be the reason you decide not to treat.


Can I treat everybody the same and say 'no mask, no treatment'?

No. For any patient that holds a protected characteristic and is exempt from wearing a face covering, this could potentially be discriminatory and leaves you open to a potential legal challenge.


I have received a letter claiming discrimination – what should I do?

If you are employed, raise this with your employer immediately. Your employer may decide to seek an independent legal opinion prior to responding to any communication.

It is worth noting that an employer may be held responsible for any discrimination an employee commits. This is known as 'vicarious liability'.

If you are self-employed, and/or are a limited company or partnership  covered by the terms and conditions of the CSP PLI scheme, you must make a PLI notification immediately. If your PLI cover is with another insurer you should contact them for advice.

You may also wish to seek an independent legal opinion prior to responding to any communication.

A template letter has been made freely available by Disability Rights UK for patients that feel they have been discriminated against, and it is this template that we are seeing used to communicate with members. 


Where do my obligations to maintain HCPC standards fit in?

Ethical framework, standard 6 – Identify and manage risk

  • 6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
  • 6.2 You must not do anything or allow someone else to do anything that could put the health or safety of a service user, carer or colleague at unacceptable risk.

Proficiency for physiotherapists, standard 15 – Understand the need to establish and maintain a safe environment.

  • 15.1 Understand the need to maintain the safety of both service users and those involved in their care.
  • 15.3 Be aware of applicable health and safety legislation, and any relevant safety policies and procedures in force at the workplace, such as incident reporting and be able to act in accordance with these.
  • 15.4 Be able to work safely including being able to select appropriate hazard control and risk management, reduction or elimination techniques in a safe manner and in accordance with health and safety legislation.
  • 15.6 Be able to establish safe environments for practice that minimise risk to service users, those treating them, and others, including the use of hazard control and particularly infection control.

The HCPC standards mentioned above should inform your reasoning when taken in conjunction with your screening and risk assessment, prior to deciding how best to offer treatment based on your patient’s clinical need.


Last reviewed: