Identification and Use of Personal Protective Equipment in the Clinical Setting During the Coronavirus (COVID-19) Pandemic Policy

Applicable to: All Health Service Providers

Description: The purpose of the Identification and Use of Personal Protective Equipment in the Clinical Setting During the Coronavirus (COVID-19) Pandemic Policy is to provide advice on the appropriate use of Personal Protective Equipment (PPE) to assist in the prevention of patient to patient or patient to staff member transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Western Australia (WA) during the COVID-19 pandemic. Additional guidance is provided in Infection Prevention and Control in Western Australian Healthcare Facilities and Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) (external site)

The intent of the Policy is to ensure: 

  • PPE requirements are appropriate to the extent of community transmission in WA during the current phase of the COVID-19 pandemic
  • staff members are trained in the use of PPE so it is used appropriately and supplies are not compromised
  • staff members are provided with PPE that is appropriate for use and provides them with adequate protection.

The use of PPE is only effective when used in conjunction with other prevention strategies as outlined in the National Institute for Occupational Safety and Health (NIOSH) Hierarchy of Controls.

The advice contained in this Policy will be subject to change if significant community transmission is detected in WA. 

The use of PPE for other infective illnesses requiring transmission-based precautions is not outlined in this Policy. Please refer to existing policies and procedures for other situations. 

    This Policy is a mandatory requirement under the Public Health Policy Framework pursuant to section 26(2)(c) of the Health Services Act 2016.


    Type of Amendment  Date of Effect  Description of Amendment 
    Major Amendment  24 April 2020  The following additions and clarifications have been made:
    • Standard and contact precautions are required when managing all at risk patients
    • Standard, contact and airborne precautions must be used when:
      • Managing all critically unwell patients with confirmed or suspected COVID-19
      • Undertaken any aerosol generating procedures in patients with confirmed or suspected COVID-19
    • Standard, contact and airborne precautions should be used, in asymptomatic patients in the setting of limited community transmission, in patients undergoing specific airway or upper digestive tract (aerodigestive) procedures with prolonged risk of aerosol generation. Standard, contact and droplet precautions should be used in remaining patients without confirmed COVID-19 infection or symptoms suggestive of COVID-19 undergoing other aerosol generating procedures
    • Routine pre-operative testing is not routinely recommended, particularly if emergency procedures are required, and does not replace the need to pre-operative screening for symptoms or recent exposures. Testing of asymptomatic patients prior to surgery is only approved for limited number of patients undergoing specific aerodigestive procedures where prolonged aerosol exposure is expected
    • The use of droplet precautions for all clinical encounters is not recommended in the setting of very limited community transmission. Examples of specific encounters involving very close face to face contact for prolonged periods are included. Additional PPE should be considered for those in these specific situations
    • Amendment to section 3.5 Role of COVID-19 testing to include: As at the date of this revision of the Policy, the Chief Health Officer has given approval in writing pursuant to the Directions to the following approved persons:
      • medical practitioners to request a test in respect of patients about to undergo any surgical procedure involving:
        • the upper and lower airway, oral cavity or upper digestive tract where aerosolisation of tissue is expected (by written approval dated 24 April 2020);
        • Category 1 cancers involving mucosal surfaces of the upper airway or aerodigestive tract (by written approval dated 24 April 2020)
      • to conduct a test outside of the requirements of the Directions:
        • none outside the requirements of the Directions.
    The following deletions have been made: 
    • The list of procedures associated with prolonged exposures to aerosols has been removed in favour of a description of the types of procedure where there remains a risk
    • The description of potential SWAT teams has been removed as this will be informed by local resources
    • Donning and Doffing instructions have been replaced by a new Related document.
    Major Amendment  14 May 2020 The following additions, clarifications and deletions have been made in alignment with Australian Health Protection Principle Committee as per the Coronavirus Disease 2019 (COVID-19) CDNA National Guidelines for Public Health Units recommendations:
    • Standard, contact and airborne precautions should only be used in confirmed, probable or suspected cases of COVID-19 who are undergoing AGPs
    • The previous use of airborne precautions for all prolonged AGPs has been removed
    • Further clarity has been provided in the Decision Tree with regard to patients not meeting case definitions (previously referred to as UNKNOWN COVID-19 patient)
    • The list of AGPs has been modified 
    • The previous recommendation for mask use for specific outpatient settings has been removed.
    The following changes have also been made:
    • The role of COVID-19 Testing has been removed from section 3.0 Policy Requirements
    • Definitions populated at section 7.0
    • Inclusion of a new Related document Appendix 1: Requirements for Personal Protective Equipment. Appendix 1 includes Clinical Scenarios for PPE Use, Use of PPE in specific situations and Table 1: Recommended PPE in accordance with the Decision Tree.
    • Inclusion of new Supporting information Donning and Doffing Personal Protective Equipment PPE Video.
    Major Amendment 08 July 2020 The following additions and clarifications have been made:
    • Inclusion of ‘no or limited community transmission’
    Section 3 in policy requirements:
    • Paragraph included advising PPE for consideration if staff are likely to be exposed to potentially infectious materials
    • Use of ‘scenario’ to replace ‘categories’
    • Simplification of Decision Tree
    Section 7 in definitions:
    • Definition of ‘Airborne precautions’ includes accommodation of patient in a negative pressure isolation room where possible
    • Amended ‘COVID-19 Case Definition’ to ‘Confirmed, probable or suspected case of COVID-19’ and addition of consideration of asymptomatic individuals in self-quarantine in WA
    • Addition of definitions for ‘Fit Checked’ and ‘Powered Air Purifying Respirators (PAPR)’
    • Addition of ‘fit-checked’ in relation to a P2 or N95 respirator
    Appendix 1 in requirements for personal protective equipment:
    • Clarification of PPE requirements for confirmed patients that have been cleared of COVID-19 by a Public Health Physician, Infectious Diseases Physician or Clinical Microbiologist
    • Clarification that PAPRs do not provide greater protection than a correctly fit-checked P2 or N95 respirator for patients requiring airborne precautions
    • Addition of ‘and other sites’ in section ‘Use in Emergency Departments’
    • Alignment of Table 1 to scenarios and definitions.
    The following deletions have been made:
    Section 1 in purpose:
    • Dot point ‘patients received appropriate care’ removed
    • Statement ‘Additional PPE requirements will be considered and communicated if sustained or widespread community transmission is detected’ removed
    Appendix 1 in requirements for personal protective equipment:
    • Scenario ‘The symptomatic patient or asymptomatic patient patients in mandatory self-isolation’ has been removed as this point is adequately addressed by Scenario 2
    • Guidance maintenance of distance when performing AGPs on non-COVID-19 patients in the ICU removed as not always practicable
    • Guidance to use aprons or long-sleeve gown where there is a risk of exposure to blood, body substances, and other potentially infectious materials removed as is appropriately addressed in recommended transmission-based precautions
    • Removal of widespread community transmission from Table 1.
    Major Amendment 24 August 2020  The following additions, clarifications and deletions have been made:
    • Pre purpose statement has been removed

    Section 1 Purpose: 

    • It now states that use of PPE is only effective when used in conjunction with other prevention strategies as outlined in the National Institute for Occupational Safety and Health (NIOSH) Hierarchy of Controls (included also as new Supporting information document at section 6)

    Section 3 Policy requirements:

    • The scenarios previously included in Section 3.7 and the Decision tree have been removed
    • Three additional scenarios have been listed at section 3.5 where airborne precautions are required for patients who are confirmed, probable or suspected cases of COVID-19 if they:
      • have severe disease such as those admitted to intensive care units
      • require frequent and/or prolonged episodes of care and adequate physical distancing cannot be maintained during clinical encounters 
      • by nature of their condition, mental state or age exhibit challenging behaviours e.g. aggression, screaming and shouting and adequate physical distancing during clinical encounters cannot be maintained
    • Requirements 3.3 and 3.4 consolidated into 3.5 and requirements 3.8 and 3.9 removed

    Section 7 Definitions:

    • Given the importance of the CDNA case definitions, definitions for a suspected, probable and confirmed case of COVID-19 have now been included. Definitions for prolonged episode of care and significant community transmission have been included 

    Appendix 1 Requirements for Personal Protective Equipment:

    • Under Clinical Scenarios for PPE Use and Table 1 Recommended PPE, reference to specific clinical scenarios previously included in section 3.7 have been replaced with additional requirements in support of section 3.4, 3.5 and 3.6. Additional statements include the predominant mode of COVID-19 spread and detail about the new indications for airborne precautions
    • Requirements under Use in the Intensive Care Units (ICUs), Use in Emergency Departments and other sites, Use in Operating and Procedure Rooms including Endoscopy Suites and Management of aggressive patients (including mental health setting) have been removed as these are now included in the broader policy requirements.
    Major Amendment 3 February 2021 The following additions have been made to the Policy to incorporate the introduction of quantitative fit-test of respirators used by high risk staff at WA public hospitals.

    Section 3 Policy Requirements:

    3.9 Health Service Providers are responsible for ensuring a quantitative fit-test is performed on all staff identified as high risk for exposure to pathogens transmitted by the airborne route or where there may be an increased risk of disease transmission when aerosol generating procedures are performed.

    3.10 Health Service Providers are required to keep a register of all staff tested including date, time, respirator brand, style, size and the result for each respirator tested.

    3.11 Health Service Providers are responsible for ensuring an action plan is initiated i.e. alternative airborne protection via a PAPR or re-deployment if the fit testing process is unsuccessful in identifying a a suitable respirator from available supplies.

    Section 7 Definitions:

    • Definition of a quantitative fit test has been added.
    Major Amendment 19 July 2021 The following modifications have been made to the Policy:
    • CDNA no longer have a 'probable' case definition - Section 7 modified and the term 'probable' removed throughout the Policy.
    • 3.4 modified to stipulate a PFR is to be work for routine care of patients with confirmed or suspect COVID-19.
    • Appendix 1 updated to reflect change in PPE requirement.
    • Table 1 modified to reflect these changes.

    Date of effect: 20 April 2020

    Policy Framework

    Related documents

    Supporting information