GMB Statement and Guidance

PPR, CPR and AGPs

During this unprecedented crisis during which we see our beloved NHS rise to the challenge of keeping our country safe the GMB National Ambulance Committee have taken the decision to issue guidance to our members regarding Covid-19 and the issues of personal protective equipment (PPE).

We consider that the guidance issued by Public Health England and followed by most Ambulance Trusts is confusing and leaves our members at risk and would advise members always to don appropriate PPE for every call based on the information at hand and their own risk assessment. If in doubt always, level up never down. 

Level 3 PPE, Cardiopulmonary Resuscitation (CPR) in relation to chest compressions and Aerosol Generating Procedures (AGP).

As health care professionals (HCP) of all grades we are faced with an influx of confusing and contradictory evidence being produced by highly professional and trusted specialists from all over the world and many of us will have seen the very public spat that has been played out between Public Health England (PHE) and the Resuscitation Council United Kingdom (RCUK).  It is clear that both organisations perceive that their evidence is in the best interest of all HCPs but this has done nothing to alleviate the fear and anxieties being faced by each of us on a daily basis.

The cause for concerns relates to PHE and RCUK not agreeing on CPR not being an AGP.  In short, PHE believes that CPR is not an AGP and RCUK do. It has therefore been reassuring to see that PHE have now amended their guidance to state:

“Based on the NERVTAG evidence review and consensus statement, chest compressions will not be added to the list of AGPs. Healthcare organisations may choose to advise their clinical staff to wear FFP3 respirators, gowns, eye protection and gloves when performing chest compressions but it is strongly advised that there is no potential delay in delivering this life saving intervention.”

GMB has spoken directly with RCUK and confirm that we support their position entirely and their need to balance the chances of survival of the patient with the health and safety of the HCP. 

Many Trusts have issued guidance pertaining to its stance regarding AGP generating procedures and have added a caveat that allows for staff to don level 3 PPE if they wish as long as this does not cause a delay in attending the patient (Pt). Most are, at this time, following guidance from PHE.

We have studied the varying different literary evidence and have determined that at the time of writing we believe that CPR is an AGP and therefore the clinician who embarks on CPR should wear level 3 PPE including a power hood and the reasons are highlighted below.

The RCUK President Professor Jonathan Wyllie in his updated statement on 20th April 2020 wrote about his concerns regarding PHE who insist that CPR was not an AGP procedure and that this may very well place our health at risk.  RCUK Covid 19 guidance categorises CPR as an AGP and that level 3 PPE should be worn prior to undertaking this procedure.  The RCUK reference the World Health Organisation (WHO), the International Liaison Committee on Resuscitation (ILCOR), Centers for Disease Control and Prevention (CDC) and the Australian and New Zealand Intensive Care Society (ANZICS) as evidential departments that also support their view.

Our Paramedics’ own professional body the College of Paramedics (CoP), in a statement released on the 27 March 2020, stated that they recommend the position of the RCUK despite the limited evidence available and state that ‘chest compressions are an AGP and that staff should wear appropriate PPE to deal with such situations’.

Interestingly the National Fire Chiefs Council (NFCC) also support the RCUK and in its guidance state that level 3 PPE should be worn when dealing with CPR and this includes breathing apparatus.

A literary review conducted by Couper et al (2020) titled COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review concluded that it was uncertain if chest compressions or defibrillation caused AGPs and that further study was required into the subject.  The review noted that PPE may be less effective during CPR due to slippage of the face mask leaving the rescuer exposed to harm.

For ambulance staff this would mean withdrawing from the scene to observe hand hygiene and then refit another mask, it also does not mention anything regarding the amount of sweat produced by staff that could also effect the efficacy of the surgical mask.  This point was highlighted by the research whereby they stated that ‘importantly, we found evidence that delivery of chest compressions may reduce the effectiveness of face masks’.

The authors also discuss the process of the generation of AGPs by the thoracic pressure during chest compressions which generate airflow through the small exhaled tidal volume.

Another literature review conducted by Health Protection Scotland and NHS Scotland (2019) concluded that CPR was not classed as an AGP and that the WHO had changed their view that CPR was a AGP, it also importantly states that ‘the list of AGPs may be subject to change as new evidence emerges’.

All the government departments across the UK have jointly produced a document called COVID-19: infection prevention and control guidance, this large document highlights how we should react with regards to PPE and states it believes that chest compressions and defibrillation are not considered an AGP generating technique, however Trusts can request that staff consider donning level 3 PPE respirators.

In section 5.8.1 of the document they also state that the evidence into AGPs will continue to be updated in light of emerging evidence for this new pathogen.

In conclusion, our decision is based in light of the evidence available and the fact that there are too many unknown variables due to COVID-19 that we must support the position of the RCUK and the CoP in that CPR is an AGP technique.

We strongly advocate our membership to wear level 3 PPE including power hoods, if available, whilst preforming CPR.  We are advising that staff begin donning level 3 PPE en route to a suspected cardiac arrest as this should not hinder the time it takes to reach the Pt’s side.  This can be partially done whilst wearing a seat belt and concluded once on scene.

The GMB National Ambulance Committee has taken this stance in the best interests of its membership and using the evidence available.

It would be remiss of us not to believe the guidance and information produced by RCUK, after all, they set the UK standards on resuscitation and these are supported by the CoP.

The position of government departments to maintain a repeating statement that says their advice and guidance may change as more information becomes available is simply not good enough.  Too many of our NHS colleagues have died because of COVID-19 and we will not sit back and comply with a government that has, over the last decade, underfunded the NHS, underappreciated, overworked and underpaid us for their own political means.  As such we will not allow them to use any of us as an experiment to change their guidance as and when it suits them.

We are calling on all ambulance services to amend their local policies in line with RCUK guidance.

Yours sincerely,

Steve Rice – Chair, GMB National Ambulance Committee 

Rachel Harrison – GMB National Officer