Much has been said over the last 72 hours about why the NHS’ national supply and distribution system is running out of gowns. Little has been said, however, about what local NHS trusts are doing to address this critical problem.
For the trust leaders that NHS Providers represents, nothing could be more important than ensuring their staff have the personal protection equipment they need. For them, it is extremely worrying that staff who need long-sleeved gowns, in line with formal PPE guidance from Public Health England, cannot access them because of national supply shortages. Trust leaders have therefore been pursuing a number of different approaches to ensure their staff have the protection they need when they need it.
For the trust leaders that NHS Providers represents, nothing could be more important than ensuring their staff have the personal protection equipment they need.
Over the last ten days, national NHS leaders have been distributing gown stocks extremely carefully, allocating the last remaining deliveries to those trusts most in need. A huge amount of work involves mutual aid, with trusts and other local partners voluntarily sharing stock between themselves where possible. Trusts have been talking to local authorities and police and fire services to secure more gowns. Veterinary surgeons have proved a particularly valuable source of supply, with one trust telling us it had secured 2,000 gowns from a local veterinary supply distribution company. Meanwhile, the relentless work to secure new gowns deliveries has continued, with a particular effort to secure emergency supplies.
But some trusts have reached the point where they cannot provide gowns to all staff who need them in line with existing national guidance. This can rightly be described as “running out” of gowns. But there is a misconception that, when a trust reaches this point, it runs out of all types of gown protection and trust staff will have to revert to only using a plastic apron and a gown with no sleeves. This is not the case.
It is important to understand that there are different types of gown. The highest level of protection is a long-sleeved fully fluid repellent gown. Friday’s emergency advice, issued by Public Health England and backed by the Health and Safety Executive, in line with emergency World Health Organisation guidelines, states that in a shortage or outage of this equipment, trusts should reserve these higher grade gowns for the highest risk procedures.
That means NHS frontline staff who would usually wear the highest grade of gown may be asked to wear the “next best thing” which could be a disposable, non-fluid repellent, gown or coverall plus a disposable plastic apron. Or a reusable/washable surgical gown or coverall, long-sleeved laboratory or industry coverall plus a disposable apron.
It is important not to imply that this offers exactly the same level of protection as a fully fluid repellent gown. It does not, but if NHS staff follow a careful procedure to take the gown on and off, this can provide a similar level of protection as a fluid repellent gown. Trusts are therefore doing the following three things when they experience a shortage of fluid repellent gowns.
First, they are allocating their remaining fluid repellent gowns on the basis of clinical risk, reserving these for the areas of highest clinical risk. This includes surgery and aerosol generating procedures such as intubation — inserting a tube into a patient to enable mechanical ventilation.
Second they are investigating, at pace, whether there are safe ways of reusing what are meant to be single use fluid repellent gowns. One trust has been experimenting with washing the gowns at 60C and they have, so far, remained water repellent for three washes. The trust’s infection control team and its microbiologists are happy with the process and quality of the gown that has resulted.
Two trusts have been looking at whether gowns can be disinfected using innovative automated room disinfection technology, which relies on ultraviolet or fume disinfection. The gowns are placed in a dedicated room and sterilised using the disinfectant technology. Another trust is experimenting with a standalone disinfection pod, usually used for wheelchairs and other large bits of equipment, to disinfect used gowns. If successful, either approach will provide a means of cleaning used gowns while ensuring fluid repellence is maintained.
Third, trust leaders are sourcing as many reusable/washable gowns, coveralls, long-sleeved laboratory coats and industry coveralls as they can, from whatever source. Trusts have been purchasing these from local builders merchants and DIY stores and many have been donated. One trust, in a large university town, has secured all its spare laboratory coats. Another has secured 3,000 washable gowns from a local industry and is repurposing these for use in the NHS. Trusts have also been working with local textile manufacturers to produce long-sleeved fluid resistant gowns. Barbour, for example, is said to be aiming to supply 23,000 gowns to trusts in the north east in the next three weeks.
The UK national pandemic stock reserve had insufficient stock of gowns. There is unprecedented worldwide demand for gowns and delivery of stocks ordered from overseas weeks ago is highly erratic. Trusts are therefore in an impossible position. But given that gown shortages are a reality, trust leaders are doing everything they can to give their staff the highest degree of personal protection possible.
But given that gown shortages are a reality, trust leaders are doing everything they can to give their staff the highest degree of personal protection possible.
For those leaders, this is just the latest in a series of unprecedented problems that they have had to surmount over the last ten weeks, doing the best they can with the resources available.
They have created 33,000 beds to treat COVID-19 patients — the equivalent of 53 new district general hospitals. They have established 24/7 mental health emergency services to cover every part of the country. They have built new online community services consultation facilities from scratch to meet the needs of patients who have been quickly discharged from hospital or have to be shielded because they are in a vulnerable group.
Trust leaders have built seven new Nightingale Hospitals across the country. They have expanded oxygen supply systems overnight to meet the unprecedented oxygen demand from the thousands of extra ventilators needed to treated COVID-19 patients. They have expanded their ambulance and 111 call handling capacity. They have increased testing capacity from 1,500 tests a day to 23,000 a day.
These achievements show that trust leaders will leave no stone unturned to protect and support their staff and provide the best possible care to patients, whatever the circumstances. But, clearly, the sooner we can get to a sustainable long-term supply of gowns and move away from the current hand to mouth approach, the better.
This was first published in the Times Red Box.