This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes recommendations for physiotherapy workforce planning and preparation, a screening tool for determining requirement of physiotherapy, recommendations for the selection of physiotherapy treatments and personal protective equipment.# ACKNOWLEDGEMENTS:
This work was adapted from a guideline originally prepared by Dr Peter Thomas and endorsed by the Queensland Cardiorespiratory Physiotherapy Network (QCRPN). The QCRPN was involved in the design of the work and development of statements. Representatives included: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new coronavirus that emerged in 2019 and causes Coronavirus Disease 2019 (COVID-19) .
SARS-CoV-2 is highly contagious. It varies from other respiratory viruses in that it appears that human-to-human transmission occurs approximately 2 to 10 days prior to the individual becoming symptomatic . The virus is transmitted from person to person through respiratory secretions. Large droplets from coughing, sneezing, or a runny nose land on surfaces within two meters of the infected person. SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to eight hours on soft surfaces . The virus is transferred to another person through hand contact on a contaminated surface then touching the mouth, nose, or eyes. Aerosol airborne infected particles created during a sneeze or cough remain viable in the air for at least three hours . These airborne particles of SARS-CoV-2 can then be inhaled by another person or land on the mucosal membranes of the eyes.
Individuals with COVID-19 can present with an influenza like illness and respiratory tract infection demonstrating fever (89%), cough (68%), fatigue (38%), sputum production (34%) and/or shortness of breath (19%) . The spectrum of disease severity ranges from an asymptomatic infection, mild upper respiratory tract illness, severe viral pneumonia with respiratory failure and/or death. Current reports estimate that 80% of cases are asymptomatic or mild; 15% of cases are severe (infection requiring oxygen); and 5% are critical requiring ventilation and life support .
Preliminary reports indicate that chest radiographs may have diagnostic limitations in COVID-19 . Clinicians need to be aware of lung CT scan findings that often include multiple mottling and ground-glass opacity . Lung ultrasound is also being utilised at the bedside with findings of multi-lobar distribution of B-lines and diffuse lung consolidation  At present, the mortality rate is 3 to 5%, with new reports of up to 9%, in contrast to influenza, which is around 0.1% .The rates of admission to an intensive care unit (ICU) are approximately 5% . Half of patients admitted to hospital (42%) will require oxygen therapy . Based on emerging data, individuals at highest risk of developing severe COVID-19 disease requiring hospitalisation and/or ICU support are those who are older, male, have at least one co-existing comorbidity, higher severity of illness scores (measured via SOFA scores), elevated d-dimer levels and/or lymphocytopenia .

# PURPOSE:
This document has been prepared to provide information to physiotherapists and acute care healthcare facilities about the potential role of physiotherapy in the management of hospitaladmitted patients with confirmed and/or suspected COVID-19.
Physiotherapists who work in primary healthcare facilities are likely to have a role in the management of patients admitted to hospital with confirmed and/or suspected COVID-19.
Physiotherapy is an established profession throughout the world. In Australia and overseas, physiotherapists often work in acute hospital wards and the ICU. In particular, cardiorespiratory physiotherapy is focussed on the management of acute and chronic respiratory conditions and aims to improve physical recovery following an acute illness.
Physiotherapy may be beneficial in the respiratory treatment and physical rehabilitation of patients with COVID-19. Although a productive cough is a less common symptom (34%) , physiotherapy may be indicated if patients with COVID-19 present with copious airway secretions that they are unable to independently clear. This may be evaluated on a caseby-case basis and interventions applied based on clinical indicators. High risk patients may also benefit. For example, patients with existing comorbidities that may be associated with hypersecretion or ineffective cough (e.g. neuromuscular disease, respiratory disease, cystic fibrosis etc). Physiotherapists who practice in the ICU environment may also provide airway clearance techniques for ventilated patients who show signs of inadequate airway clearance and they can assist in positioning patients with severe respiratory failure associated with COVID-19, including the use of prone position to optimise oxygenation .
Given the intensive medical management for some COVID-19 patients including prolonged protective lung ventilation, sedation and use of neuromuscular blocking agents, patients with COVID-19 who are admitted to ICU may be at high risk of developing ICU acquired weakness (ICU-AW) . This may worsen their morbidity and mortality . It is therefore essential to anticipate early rehabilitation after the acute phase of ARDS in order to limit the severity of ICU-AW and promote rapid functional recovery. Physiotherapy will have a role in providing exercise, mobilisation and rehabilitation interventions to survivors of critical illness associated with COVID-19 in order to enable a functional return to home.

# SCOPE:
This document is focused on the adult acute hospital setting.
The recommendations for physiotherapists are outlined below and focus on the specific health questions of this guideline:
- SECTION 1: Workforce planning and preparation including screening to determine indications for physiotherapy. - SECTION 2: Delivery of physiotherapy interventions including both respiratory and mobilisation / rehabilitation as well as PPE requirements.
It is recognised that physiotherapy practices vary across the world. When utilising this guideline, the scope of practice within the local context should be considered.

# GUIDELINE METHODOLOGY AND CONSENSUS APPROACH:
A group of international experts in cardiorespiratory physiotherapy came together to rapidly prepare a clinical practice guideline for physiotherapy management of COVID-19. Our guideline group initially convened on Friday March 20, 2020 at 10:00am (Australian Eastern Standard Time) to discuss the urgent need for acute care physiotherapy guidance world-wide in relation to COVID-19. We quickly prioritised our efforts to develop specific guidance for physiotherapists in the acute care settings.
The AGREE II framework  was used to guide our development, recognising the expediency of our work required pragmatic, yet transparent reporting. We modelled our conduct after the GRADE Adolopment Process  and Evidence to Decision framework  for recommendations and decision-making. Our expertise includes ICU and acute inpatient physiotherapy (all), rehabilitation interventions in the intensive care unit (all), physiotherapy administration (PT, IB, RG, AJ, RM, ShP), systematic reviews (PT, CB, CG, RG, CH, MK, SP, ShP, LV), guideline methodology (PT, IB, RG, CH, MK, RM, ShP, LV), and epidemiology (CH, MK). We documented all conflicts of interest a priori using the World Health Organisation (WHO) form.
Through a web search and personal files, we identified recently developed guidelines for COVID-19 management of critically ill patients from international agencies (i.e. WHO), critical care professional societies or groups (e.g. Australia and New Zealand Intensive Care Society, Society of Critical Care Medicine / European Society of Intensive Care Medicine), or physiotherapist professional societies up to March 21 2020. These guidelines were used to inform the consensus guideline developed in conjunction with expert opinion of the guideline authorship group.
A priori we decided to develop a consensus guideline, given the time sensitive nature of our guidance. We agreed that we required  70% agreement for a recommendation. On Friday March 20, 2020 the lead author (PT) circulated draft recommendations to all guideline panel members. All guideline panel members returned comments to the lead author independently. The lead author (PT) collated all comments for further discussion. We discussed all guideline recommendations in a teleconference on Sunday, March 22, 2020 at 10:00am (Australian Eastern Standard Time).
14 people participated in the guideline process. We developed 66 recommendations. A consensus of >70% was achieved for all items. Further discussion was focused on greater clarity in wording and/or reduction of items where overlap occurred.
We sought endorsement for our guideline from physiotherapy societies, physiotherapy professional groups and the World Confederation for Physical Therapy. We circulated our guideline to these groups on March 23, 2020 (Australia Eastern Standard Time) requesting endorsement. Endorsements will be updated as these are confirmed.

# STRENGTHS OF THIS GUIDELINE:
Our guideline has several strengths. We respond to an urgent need for clinical guidance for acute care physiotherapists worldwide. We base our guidance on the most recent, relevant COVID-19 clinical practice guidelines from highly respected organizations, national physiotherapy organizations, and from peer-reviewed studies and transparently report our evidence sources. We represent an international group of physiotherapists, with extensive clinical experience in the ICU and on the wards. We are also academic physiotherapists with experience in the leadership, conduct, and execution of rigorous systematic reviews, clinical studies (including prospective cohort studies and international multi-centre trials), and clinical practice guidelines. We sought endorsement from international physiotherapy organizations.

# LIMITATIONS OF THIS GUIDELINE:
Our guideline also has limitations. Given the recency in presentation of COVID-19, clinical guidance may change as we learn more about the natural history of this disease. We extrapolated our recommendations based on best evidence for current management of critically ill patients and long-term outcomes in critical illness survivors. We did not include a patient in our guideline development group. While our guideline applies to physiotherapy interventions in the acute care setting, longer-term follow-up of survivors is needed.

# SECTION 1: PHYSIOTHERAPY WORKFORCE PLANNING AND PREPARATION RECOMMENDATIONS
COVID-19 is placing significant demands on healthcare resources throughout the world. Table 1 outlines recommendations to assist the physiotherapy workforce to plan and respond to this demand. Tables 2 and 3 provide recommendations for determining whom physiotherapists should treat when patients have presumed or suspected COVID-19. Table 4 provides an example of a resource plan for ICU physiotherapy from Tier 0 (business as usual) through to Tier 4 (large scale emergency). Local context, resources and expertise should be considered when utilising this example resource plan. It is recommended that staff who are pregnant avoid exposure to COVID-19. It is known that pregnant women are potentially at increased risk of complications from any respiratory disease due to the physiological changes that occur in pregnancy.
Presently there is not enough information available about the impacts of COVID-19 on the pregnant mother or their baby.
1.9 Workforce planning should include consideration for pandemic specific requirements, such as additional workload from donning and doffing PPE, and the need to allocate staff to key non-clinical duties such as enforcing infection control procedures .
1.10 Consider organisation of the workforce into teams that will manage COVID-19 versus non-infectious patients. Minimise or prevent movement of staff between teams. Liaise with local infection control services for recommendations.
1.11 Be aware of and comply to relevant international, national, state and/or hospital guidelines for infection control in health care facilities. For example, World Health Organisation (WHO) "Guidelines for Infection prevention and control during health care when novel coronavirus infection is suspected" .
1.12 Senior physiotherapists should be involved in determining the appropriateness of physiotherapy interventions for patients with suspected and/or proven COVID-19 in consultation with senior medical staff and according to a referral guideline.
1.13 Identify hospital-wide plans for allocation / cohorting of patients with COVID-19. Utilise these plans to prepare resource plans that may be required. For example, Table 4 below is an example of a resource plan for ICU physiotherapy.
1.14 Identify additional physical resources that may be required for physiotherapy interventions and how the risk of cross-infection can be minimised (e.g. respiratory equipment; mobilisation, exercise and rehabilitation equipment, equipment storage).
Identify and develop a facility inventory of respiratory, mobilisation, exercise and rehabilitation equipment and determine process of equipment allocation as pandemic levels increase (i.e. to prevent movement of equipment between infectious and non-infectious areas).
It should be recognised that staff will likely have an increased workload with a heightened risk of anxiety both at work and at home . Staff should be supported during and beyond the active treatment phases (e.g. via access to employee assistance programs, counselling, facilitated debriefing sessions).
1.17 Consider and/or promote debriefing and psychological support; staff morale may be adversely affected due to the increased workload, anxiety over personal safety and the health of family members . 
Physiotherapy interventions should only be provided when there are clinical indicators, so that staff exposure to patients with COVID-19 is minimised. Unnecessary review of patients with COVID-19 within their isolation room/areas will also have a negative impact on PPE supplies.
Physiotherapists should meet regularly with senior medical staff to determine indications for physiotherapy review in patients with confirmed or suspected COVID-19 and screen according to set/agreed guidelines (Table 3 provides a suggested framework). 2.6 Physiotherapy staff should not be routinely entering isolation rooms where patients with confirmed or suspected COVID-19 are isolated or cohorted just to screen for referrals.
Options for screening of patients via subjective review and basic assessment whilst not being in direct contact with the patient should be trialled first whenever possible e.g. calling the patients' isolation room telephone and conducting a subjective assessment for mobility information and/or providing education on airway clearance techniques. 

# Use droplet precautions
Use airborne precautions if close contact required or possible aerosol generating procedures.
If not ventilated, patients should wear a surgical mask during any physiotherapy whenever possible. Patients with COVID-19 only allocated to beds with reverse flow isolation rooms.
There is limited availability of reverse flow rooms within most hospitals.
e.g. additional 1 FTE per 4 ICU beds .
1 Senior PT will screen patients with COVID-19 in consultation with an ICU medical Consultant.
Patients will be provided treatment in isolation rooms.
If needed, 1 stretcher chair allocated and quarantined for use. 

# Medical management of COVID-19:
It is important for physiotherapists to be aware of the medical management for patients with COVID-19. For the purposes of this guideline we have summarised some of the recommendations available from medical guidelines developed by professional societies as listed on page 6. Oxygen therapy: Oxygen therapy targets may vary depending on the presentation of the patient.
- For patients presenting with severe respiratory distress, hypoxaemia or shock, SpO2 >94% is targeted  - Once a patient is stable, the target is >90%  in non-pregnant adults and 92-95% in pregnant patients  . - In adults with COVID-19 and acute hypoxaemic respiratory failure, the SpO2 target should not be maintained higher than 96%  Nebulisation: The use of nebulised agents (e.g. salbutamol, saline) for the treatment of non-intubated patients with COVID-19 is not recommended as it increases the risk of aerosolization and transmission of infection to health care workers in the immediate vicinity.
Use of metered dose inhalers / spacers are preferred where possible . If a nebulizer is required, liaise with local guidelines for directions to minimise aerosolization e.g. use of a Pari sprint with inline viral filter.
Use of nebulisers, NIV, HFNO and spirometry should be avoided and agreement to their use sought from senior medical staff . If deemed essential, airborne precautions should be used.
For patients admitted to ICU, additional strategies may be utilised which are summarised below. With increasing acuity, there is an increased risk of dispersion of aerosolised virus into the healthcare environment due to the nature of critical illness, higher viral load and the performance of AGPs. It is recommended that airborne PPE precautions should be used to care for all patients with COVID-19 in ICU .
Intubation and mechanical ventilation: Patients with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability or those with altered mental status should be considered for early invasive mechanical ventilation if appropriate .
The risk of aerosol transmission is reduced once a patient is intubated with a closed ventilator circuit .
Recruitment manoeuvres: Although current evidence does not support the routine use of recruitment manoeuvres in non-COVID-19 ARDS, they could be considered in patients with COVID-19 on a case by case basis .
Prone positioning: Anecdotal reports from international centres dealing with large numbers of critically ill patients with COVID-19 related ARDS suggest that prone ventilation is an effective strategy in mechanically ventilated patients .
In adult patients with COVID-19 and severe ARDS, prone ventilation for 12-16 hours per day is recommended . It requires sufficient human resources and expertise to be performed safely to prevent known complications including pressure areas and airway complications. Physiotherapists also play an integral role in the management of patients with a tracheostomy. 5 outlines recommendations for providing respiratory care to patients with COVID-19. 

# COVID-19 poses significant considerations for respiratory physiotherapy interventions due to their aerosol generating potential. Table
Cough etiquette: Both patients and staff should practice cough etiquette and hygiene.
During techniques which may provoke a cough, education should be provided to enhance cough etiquette and hygiene.
- Ask patient to turn head away during cough and expectoration
- Patients who are able should "catch their cough" with a tissue, dispose of tissue and perform hand hygiene. If patients are unable to do this independently then staff should assist. - In addition, if possible, physiotherapists should position themselves  2m from the patient and out of the "blast zone" or line of cough.
Many respiratory physiotherapy interventions are potentially aerosol generating procedures. While there are insufficient investigations confirming the AGPs of various physiotherapy interventions , the combination with cough for airway clearance makes all techniques potentially AGPs.
These include:
- Cough generating procedures e.g. cough during treatment or huff.
- Positioning / gravity assisted drainage techniques and manual techniques (e.g. expiratory vibrations, percussion, manual assisted cough) that may trigger a cough and the expectoration of sputum Therefore, there is a risk of creating an airborne transmission of COVID-19 during treatments. Physiotherapists should weigh up the risk versus benefit to completing these interventions and use airborne precautions.
Where AGPs are indicated and considered essential, they should be undertaken in a negative-pressure room, if available, or in a single room with the door closed.
Only the minimum number of required staff should be present, and they must all wear PPE as described. Entry and exit from the room should be minimised during the procedure .
This may not be able to be maintained when cohorting is required due to the volume of patients presenting with COVID-19.
BubblePEP is not recommended for patients with COVID-19 because of uncertainty around the potential for aerosolization, similar to the caution the WHO places on bubble CPAP .
There is no evidence for incentive spirometry in patients with COVID-19.
Avoid the use of MI-E, NIV, IPPB devices or HFO devices. However, if clinically indicated and alternative options have not been effective, consult with both senior medical staff and Infection Prevention and Monitoring Services within local facilities prior to use. If used, ensure machines can be decontaminated after use and e.g. protect machines with viral filters over machine and patient ends of circuits.
- Use disposable circuits for these devices.
- Maintain a log for devices that includes patient details for tracking and infection monitoring (if required). - Use airborne precautions.
Where respiratory equipment is used, whenever possible use single patient use, disposable options e.g. single patient use PEP devices.
Re-usable respiratory equipment should be avoided if possible.
Physiotherapists should not implement humidification or NIV or other AGPs without consultation and agreement with a senior doctor (e.g. medical Consultant).
Sputum inductions should not be performed.
Requests for sputum samples. In the first instance, ascertain whether the patient is productive of sputum and able to clear sputum independently. If so, physiotherapy is not required for a sputum sample.
If physiotherapy interventions are required to facilitate a sputum sample then full airborne PPE should be worn. The handling of sputum samples should adhere to local policies. Generally, once a sputum sample has been obtained the following points should be followed:
- All sputum specimens and request forms should be marked with a biohazard label. - The specimen should be double-bagged. The specimen should be placed in the first bag in the isolation room by a staff member wearing recommended PPE. - Specimens should be hand delivered to the laboratory by someone who understands the nature of the specimens. Pneumatic tube systems must not be used to transport specimens.
Saline nebulisation. Do not use saline nebulisation. It should be noted that some UK guidelines allow use of nebulisers, but this is currently not recommended in Australia.
Manual hyperinflation: As it involves disconnection / opening of a ventilator circuit, avoid MHI and utilise ventilator hyperinflation (VHI) if indicated e.g. for suppurative presentations in ICU and if local procedures are in place.
Positioning including gravity assisted drainage: Physiotherapists can continue to advise on positioning requirements for patients.
Prone positioning: Physiotherapists may have a role in the implementation of prone positioning in ICU. This may include leadership within ICU "prone teams", providing staff education on prone positioning (e.g. simulation-based education sessions), or assisting in turns as part of the ICU team.
Tracheostomy management: The presence of a tracheostomy and related procedures are potentially aerosol generating.
- Cuff deflation trials and inner tube changes/cleaning can be aerosol generating - Closed, in-line suction is recommended.
- The use of inspiratory muscle training, speaking valves and leak speech should not be attempted until patients are over the acute infection and the risk of transmission is reduced. - Airborne precautions are recommended with infectious patients with COVID-19 with a tracheostomy.

# Physiotherapy management principlesmobilisation, exercise and rehabilitation interventions:
Physiotherapists are responsible for the provision of musculoskeletal / neurological / cardiopulmonary rehabilitation tasks including:
- Passive, active assisted, active, or resisted joint range of motion exercises to maintain or improve joint integrity and range of motion and muscle strength - Mobilisation and rehabilitation (e.g. bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists, upper limb or lower limb ergometry, exercise programs).
Table 6 outlines recommendations for the implementation of these activities in patients with COVID-19. PPE: Droplet precautions should be appropriate for the provision of mobilisation, exercise and rehabilitation in most circumstances. However, physiotherapists are likely to be in close contact with the patient e.g. for mobilisation, exercise or rehabilitation interventions that require assistance. In these cases, consider use of a high filtration mask (e.g. P2/N95). Mobilisation and exercise may also result in the patient coughing or expectorating mucous or with ventilated patients there may be circuit disconnections.
Refer to local guidelines regarding ability to mobilise patients outside of their isolation room. If mobilising outside of the isolation room, ensure the patient is wearing a surgical mask.
Screening: Physiotherapists will actively screen and/or accept referrals for mobilisation, exercise and rehabilitation.
When screening, discussion with nursing staff, the patient (e.g. via phone) or family is recommended before deciding to enter the patient's isolation room. For example, to try to minimise staff who come in to contact with patients with COVID-19, physiotherapists may screen to determine an appropriate aid to trial. A trial of the aid may then be performed by the nursing staff already in an isolation room, with guidance provided if needed by the physiotherapist who is outside the room.
Direct physiotherapy interventions should only be considered when there are significant functional limitations, e.g. (risk for) ICU-acquired weakness, frailty, multiple comorbidities and advanced age.
Early mobilisation is encouraged. Actively mobilize the patient early in the course of illness when safe to do so .
Patients should be encouraged to maintain function as able within their rooms - Sit out of bed - Perform simple exercises and activities of daily living
Mobilisation and exercise prescription should involve careful consideration of the patients' state (e.g. stable clinical presentation with stable respiratory and haemodynamic function) .
Mobility and exercise equipment: The use of equipment should be carefully considered and discussed with local infection monitoring and prevention service staff before used with patients with COVID-19 to ensure it can be properly decontaminated.
Use equipment that can be single patient use. For example, use Theraband rather than distributing hand weights.
Larger equipment (e.g. mobility aids, ergometers, chairs, tilt tables) must be easily decontaminated. Avoid use of specialised equipment unless necessary for basic functional tasks. For example, stretcher chairs or tilt tables may be deemed appropriate if they can be decontaminated with appropriate cleaning and are indicated for progression of sitting / standing. 

# PPE considerations
It is imperative that physiotherapists understand the measures in place to prevent transmission of COVID-19. Table 7 provides recommendations for this. Patients with presumed or confirmed COVID-19 will be managed with either droplet or airborne precautions . Additionally, they will be placed in isolation. Hospitals are often able to contain patients with droplet or airborne spread within dedicated isolation rooms. However, there are a limited number of negative pressure bays and pods and/or rooms across Australia and New Zealand , so isolation within dedicated rooms may not be possible with COVID-19 due to the large volume of patient admissions.
It is important for physiotherapists to understand the different types of isolation rooms which exist in hospitals. Class S rooms (standard single rooms, no negative pressure capability) which can be used for isolating patients capable of transmitting infection by droplet or contact routes  and Class N rooms (single negative pressure isolation rooms) which are beneficial in isolating patients with transmittable airborne infections . The preference would be for patients with confirmed and/or suspected COVID-19 to be isolated in Class N rooms . If this is not possible then Class S single rooms with clearly designated areas for PPE donning and doffing are recommended . In the event of all single Class N and S rooms being fully occupied, then the recommendation is for patients with COVID-19 to be cohorted separate to patients without COVID-19 within the hospital . In an open ICU or ward cohorted areas with one or more patients with COVID-19, it is recommended that staff members in the whole area are required to use airborne PPE precautions . Table 7 describes how the movement from dedicated isolation rooms to open cohorting might evolve within an ICU. 7.2 "Fit testing" is recommended when available, but the evidence for fit testing effectiveness is limited and the variation in supply of N95 mask types may make any recommendation on fit testing difficult to implement from a practical perspective .
Staff with beards should be encouraged to remove facial hair to ensure good mask fit  7.4 For all suspected and confirmed cases, at a minimum droplet precautions are implemented. Staff will wear the following items:
- Surgical mask - Fluid resistant long-sleeved gown - Goggles/face shield - Gloves  7.5 Recommended PPE for staff caring for COVID-19 infected patients includes added precautions for patients with significant respiratory illness, when AGPs are likely and/or prolonged or very close contact with the patient is likely. In these cases, Airborne precautions are followed including:
- An N95/P2 mask - Fluid resistant long-sleeved gown - Goggles/face shield - Gloves  7.6 In addition, the following can be considered:
- Hair cover for AGPs - Shoes that are impermeable to liquids and can be wiped down Recurrent use of shoe covers is not recommended as repeated removal is likely to increase the risk of staff contamination .
7.7 PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE, particularly masks should not be adjusted during patient care .
7.8 Use a step-by-step process for don/doff PPE as per local guidelines .
Check local guidelines for information on laundering uniforms and/or wearing uniforms outside of work if exposed to COVID-19. For example, changing into scrubs may be recommended in local guidelines  and/or staff may be encouraged to get changed out of their uniform before leaving work and to transport worn uniforms home in a plastic bag for washing at home.  .
Hair should be tied back out of the face and eyes . 7.12 When a unit is caring for a patient with confirmed or suspected COVID-19 it is recommended that all donning and doffing are supervised by an additional appropriately trained staff member .
Avoid sharing equipment. Preferentially use only single use equipment.
Wear an additional plastic apron if high volumes of fluid exposure is expected .
If reusable PPE items are used, e.g. gogglesthese must be cleaned and disinfected prior to re-use .