Use of Personal Protective Equipment in General Practice and Ambulance settings: a rapid review
Authors: Needham Antonia , Winfield Tom , Elston Lauren , Washington Jenni , Lewis Ruth , Cooper Alison , Edwards Adrian 
Published: March 2023

AbstractThe use of personal protective equipment (PPE) is a cornerstone of infection prevention and control guidelines and was of increased importance during the COVID-19 pandemic. Adherence with prescribed guidelines for the use of PPE and their applicability to the working practices of staff in general practitioner (GP) and ambulance settings have been a growing concern. The aim of this rapid review was to assess the barriers, facilitators, and potential adverse outcomes of the use of PPE in these specific settings.Included studies were published from 2020 to November 2022. We identified four systematic reviews, a rapid review, a retrospective chart review, and a prospective quantitative survey study. Outcome measures were broadly focused on physical adverse outcomes from the use of PPE, but also included barriers and facilitators to the use of PPE in varied healthcare settings. The five reviews covered a broad range of health and care settings, which included GP and ambulance settings, but not as a specific focus. Both the retrospective chart review and the prospective survey study took place in an ambulance or emergency response setting. Overall confidence in the body of evidence is low.Extended use of PPE is associated with an increased occurrence of adverse physiological events, such as pressure ulcers and de novo headaches. Evidence indicates that adherence with PPE guidance is primarily influenced by organisational communication and workplace cultures. In ambulance settings, adherence may also be affected by dispatch codes and indicative symptoms reported during the initial call.Policy implications: As there is evidence to suggest that usage of PPE increases risk of adverse effects in healthcare workers, this should be at the forefront of considerations when developing or reviewing new and existing infection prevention and control measures. If new policy regarding the use and implementation of PPE is to be developed, effective communication and dissemination should be a priority, as this was identified as a barrier to adherence. This review has identified a significant paucity of evidence in the settings of interest and is reliant on examining evidence that represents a large variety of health and care settings. It is important to acknowledge there may be some issues specific to Ambulance and GP settings that are not covered by this review. This does impact the validity of this reviews conclusions.Further high-quality research must be undertaken in the settings of interest to inform and guide policy.Funding statementHealth Technology Wales was funded for this work by the Wales Covid-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government.Rapid Review DetailsReview conducted byHealth Technology Wales (HTW)Review TeamAntonia Needham, Health Technology Wales,antonia.needham@wales.nhs.ukTom Winfield, Health Technology Wales,tom.winfield@wales.nhs.ukLauren Elston, Health Technology Wales,lauren.elston@wales.nhs.ukJenni Washington, Health Technology Wales,jenni.washington@wales.nhs.ukReview submitted to the WCEC on10th February 2023Stakeholder consultation meeting23rdJanuary 2023 [day, month, year]Rapid Review report issued by the WCECFebruary 2023WCEC TeamAdrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal were involved in drafting the Topline summary, review of the report and editingThis review should be cited asRR00046. Wales COVID-19 Evidence Centre. Use of Personal Protective Equipment (PPE) in General Practice and Ambulance settings: a rapid review. February 2023.DisclaimerThe views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest.TOPLINE SUMMARYWhat is a Rapid Review?Our rapid reviews (RR) use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis.Who is this summary for?Wales Ambulance Service NHS Trust and the Royal College of General Practitioners WalesBackground / Aim of Rapid ReviewThe use of personal protective equipment (PPE) is a cornerstone of infection prevention and control guidelines and was of increased importance during the COVID-19 pandemic. Adherence with prescribed guidelines for the use of PPE and their applicability to the working practices of staff in general practitioner (GP) and ambulance settings have been a growing concern. This rapid review aims to assess the barriers, facilitators, and potential adverse outcomes of the use of PPE in these specific settings.Key FindingsExtent of the evidence baseWe identified four systematic reviews (Galanis et al, 2021; Keng et al, 2021; Kunstler et al, 2022), one rapid review (Houghton et al, 2020), a retrospective chart review (McCann-Pineo et al 2022) and a prospective quantitative survey study (Gangaram et al 2022).Outcome measures were broadly focused on physical adverse outcomes from the use of PPE, but also included barriers and facilitators to the use of PPE in varied healthcare settings.In terms of setting, all five systematic and rapid reviews covered a broad range of health and care settings, all of which included GP and ambulance settings, but not as a specific focus – it was deemed that as these settings were included as part of data collection and analysis that the findings would be generalisable.Both the retrospective chart review (McCann-Pineo et al 2022) and the prospective survey study (Gangaram et al 2022) took place in an ambulance or emergency response setting.Recency of the evidence baseStudies included were published from 2020 up until November 2022.Key FindingsThere is a significant lack of evidence in the settings of interest.Extended use of PPE is associated with an increased occurrence of adverse physiological events, such as pressure ulcers and de novo headaches.Evidence indicates that adherence with PPE guidance is primarily influenced by organisational communication and workplace cultures. In ambulance settings, adherence may also be affected by dispatch codes and indicative symptoms reported during the initial call.Quality of the evidenceOf the systematic reviews identified (Galanis et al, 2021; Keng at al, 2021; Kunstler et al, 2022) all are of poor quality, and were determined to have high risk of bias following formal assessment.The rapid review identified (Houghton et al, 2020) is of good quality, with a low risk of bias.Of the primary studies (McCann-Pineo et al, 2022; Gangaram et al, 2022) the retrospective chart review was deemed ‘poor’ quality with high risk of bias, and the prospective quantitative survey study deemed ‘fair’ quality, with undetermined risk of bias.Primary concerns around the evidence base relate to evidence identification, applicability of evidence and methodological limitations.Policy ImplicationsThere is evidence to suggest that usage of PPE increases risk of adverse effects in healthcare workers, and this should be at the forefront of considerations when developing or reviewing new and existing infection prevention and control measures.If new policy regarding the use and implementation of PPE is to be developed, effective communication and dissemination should be a priority, as this was identified as a barrier to adherence.This review has identified a significant paucity of evidence in the settings of interest and is reliant on examining evidence that represents a large variety of health and care settings. It is important to acknowledge there may be some issues specific to Ambulance and GP settings that are not covered by this review. This does impact the validity of this review’s conclusions.Further high-quality research must be undertaken in the settings of interest to inform and guide policy.Strength of EvidenceOverall confidence in the body of evidence is low, and caution should be exercised when drawing conclusions based on this evidence.