Part 3: How was clinical guidance developed?

Ministry of Health: Management of personal protective equipment in response to Covid-19.

Media coverage and correspondence we received contained criticism that the Ministry’s guidance about what PPE was needed was too narrow. Many health and disability workers and the people they were caring for felt that they needed a higher level of PPE to feel safe. Frontline workers and those they cared for were concerned about the risk of contracting and spreading Covid-19.

In this Part, we describe the guidance the Ministry issued about the use of PPE, how it prepared and communicated that guidance, and how this affected health workers’ understanding of, and expectations about, the PPE they would need.

For the purposes of this report, we focused mainly on the guidance aimed at community workers. Based on the media coverage and information provided to us, this appeared to be where there was most confusion about what PPE was needed.

What was the guidance on personal protective equipment?

Under the Emergency Plan, the Ministry is responsible for developing clinical guidelines and DHBs are responsible for observing all clinical guidelines, usage policies, and national priorities developed by the Ministry.

In mid-January 2020, the Ministry set up an Infection Prevention Committee to review and sign off on clinical guidance for use in New Zealand. In developing clinical advice, the Ministry closely followed WHO guidance on the appropriate use of PPE.8

On 27 March 2020, the Ministry published guidance for DHBs on prioritising the use of PPE in particular clinical settings (see Appendix 1). On 28 March 2020, it provided specific guidance for community care providers (aged residential care, aged-related community care, disability, hospice, and home care services – see Appendix 2).

By 31 March 2020, a national state of emergency had been declared. New Zealand was under “lockdown” and only essential services remained open. There were cases of community transmission of Covid-19. Levels of concern about the safety of health care and other essential workers were understandably high.

There appears to have been mixed messages about the use of PPE. At the daily Covid-19 media briefing on 31 March 2020, the Director-General of Health acknowledged that staff needed to feel safe as well as be safe. However, he said that this should not contradict clinical guidelines:

I am also conscious that our frontline health workers not only need to be safe, they need to feel safe, and I know that many of them are particularly concerned about elements of that advice. I think it’s very good advice. It’s from infectious diseases specialists, and it’s designed to ensure that they know what PPE to wear in different situations. But I am conscious that many of our frontline healthcare workers are concerned about not having access to masks when they feel they need them to feel safe. (…) So, we’re undertaking a process at the moment of releasing a large number of masks (…). The purpose of this is not to contradict what is in the guidelines, because I think that the advice in the guidelines is very good and it’s based on the best evidence.

One of the DHBs that we spoke to told us that comments made about increased access to PPE led to increased demand from the health and disability sector and a perceived disconnection between what was wanted and what the clinical guidelines said was needed. That DHB said that, in the end, it distributed what people were asking for rather than what the guidelines recommended.

A consistent message from community-based health and disability care providers was that the guidelines did not provide what they felt they needed to feel safe delivering care. Providers also said that, even when they met the criteria, they experienced difficulties accessing PPE through DHBs.

We were also told that many disabled people were concerned that they could be exposed to infection from caregivers who visited their homes and that guidance should have been provided on PPE for caregivers to reduce the perceived risks.

A group from the Ministry met with unions representing different clinical, administrative, and laboratory professions that work in DHBs and in the wider health and disability sector, as well as organisations representing nurses, midwives, and some resident doctors and laboratory/allied health professions, to prepare sector-specific guidance for using PPE.

We have seen a joint statement about PPE dated 22 April 2020, from the New Zealand Public Service Association, E Tū Union, Home and Community Health Association, and DHBs. It said that, where a staff member or client believed it was necessary to wear PPE, a surgical mask and gloves should be provided for each visit.

On 23 April 2020, the Ministry published one page of updated guidance material for PPE use, including care provided in homes.9 This guidance set out what PPE is needed in particular settings and provided some discretion about whether a worker should wear a surgical face mask when caring for patients.

On 5 May 2020, the Ministry added more detailed guidance tailored to the particular work environments of community care providers providing care in residences. It published guidance for disability support and care workers who work in clients’ homes on 7 May 2020 (see Appendix 2).

The Ministry told us that the initial Infection Prevention Committee guidance in March was based on advice from the WHO and other sources of evidence that focused on what was clinically necessary. As guidance from the WHO and other sources changed, the Ministry updated its own guidance.

The Ministry told us that its role was to provide guidance that informs advice on appropriate PPE use, and the DHBs and other providers then could choose to adapt or adopt that advice. The Ministry said that alternative sources of guidance (from unions or DHBs) may have had more of a focus on what PPE employees wanted rather than on what was necessary from an infection control perspective.

We did not see examples where DHBs had adapted the Ministry’s guidelines or issued their own based on their own clinical technical committees. However, if this happened, it may have led to different approaches about what PPE health and disability workers should be provided with.

How were changes to clinical guidance communicated?

The Ministry published guidelines on its website and on the Covid-19 website. It relied on DHBs, primary health organisations, unions, and clinical leadership groups in various sectors (such as the Royal New Zealand College of General Practitioners) to share that guidance.

The Ministry used its networks to disseminate the information further. It emailed Needs Assessment and Service Coordination contacts (agencies that assess what support people with disabilities need), as they had contacts with disability support providers.

We saw examples of communications from DHBs to community care providers, midwives, disability and aged care providers, and primary care services about the clinical guidance and to inform them that PPE would be made available.

Beyond seeing the messages the Ministry sent out, we do not know how effective these channels of communication were.

Our observations

The Ministry was operating in a complex and intense environment and needed to prepare clear and consistent information quickly about what measures were appropriate for health workers to take to reduce the risk of infection. We do not have the clinical expertise to reach a view on the process for developing the clinical guidance on the use of PPE or on the appropriateness of the guidance.

In January and February 2020, the Ministry was monitoring the spread of Covid-19 overseas closely, and it issued the first substantive clinical guidance on PPE at the end of March. It then updated that guidance in late April and early May.

The Ministry’s guidelines on the use of PPE were based on advice from the WHO and focused on what was considered clinically necessary. As guidance from the WHO and other sources changed, the Ministry worked to update its own guidance.

The Ministry responded to health workers’ concerns by working with unions and health professional bodies to refine the guidelines to address the concerns raised, but this took some time.

There appears to have been mixed messages about PPE guidance. At the daily Covid-19 media briefing on 31 March 2020, the Director-General of Health acknowledged that staff needed to feel safe as well as be safe. He also stated that this should not contradict clinical guidelines. That same day the Ministry instructed DHBs to provide PPE to the wider health and disability sector, and told DHBs that it was releasing masks from the Ministry’s national reserve for distribution to DHBs (see paragraph 6.19).

A degree of confusion appears to have arisen after some workers interpreted the Director-General’s comments as meaning that they would be supplied with the PPE they had requested. However, the Ministry’s guidelines at that time set a narrower scope of what PPE should be worn than the subsequent guidance issued in late April and early May, and most DHBs followed those guidelines.

There was always likely to be a tension between people’s personal risk assessments of what they feel they need to keep safe (especially where there was a wide range of opinions on the efficacy of PPE), the view of infection control experts, and the need to prioritise the appropriate use and allocation of PPE.

The Ministry took steps to resolve confusion by publishing additional guidance for PPE use in specific health care settings (maternity, pharmacy, primary care, disability, aged care, and hospice providers) and for non-health workers.10 It modified the original clinical guidelines for community-based health and disability workers after discussions with unions and published revised guidance in the first week of May.

The revised guidance about the circumstances in which PPE should be worn and the expectation that DHBs would provide it appears to have presented difficulties for some DHBs. DHBs did not have relationships with many health and disability providers and may not have had enough PPE supplies to meet the increased demand.

The Ministry mainly relied on DHBs and primary health organisations to disseminate PPE clinical guidance to other parties through their distribution networks. The extent to which this was effective is unclear.

To minimise the risk of confusion in the future, it would be desirable for relevant plans and guidelines to clarify who is eligible to be supplied with PPE from the national reserve.

Recommendation 3
We recommend that the Ministry of Health and district health boards, with appropriate health and disability sector representatives, review how clinical guidelines for personal protective equipment will be prepared or amended and consistently communicated during emergencies. The Ministry needs to ensure that demand forecasting, supply, and procurement are updated to take account of changes to guidance that have an effect on demand.

8: World Health Organization, Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19 March 2020.

9: The Ministry released subsequent guidance for community care providers on 23 April, 5 May, 7 May, 14 May, and 15 May. See Appendix 2 for a list of the guidance published.

10: See Appendix 2 for a list of guidance produced.