Table 1 Challenges, good practice and proposed solutions

Good practice – South Central Ambulance Service (SCAS) senior commander was wearing an easily recognisable tabard and didn’t require level 3 PPE

Only clinicians conducting Aerosol Generating Procedures (AGPs) should be in level 3 Personal Protective Equipment (PPE).

Develop better labelling or supply scene tabards for all clinicians. (see below)

It was difficult to identify clinicians by role and the labels used for identification were insufficient.

In order to distinguish skill levels and grades for clinicians wearing Level 3 PPE it is recommended that a colour coded tabard similar to that used by scene commanders be developed. This would identify Critical Care doctors and Critical Care Paramedics (CCPs) and be standardised across the UK as per the National Ambulance Resilience Unit guidance (Appendix 1) This tabard could either be disposable or washable at 60 °C to facilitate infection control.

Once a fluid repellent suit is donned it makes it impossible to access items in the pockets of clothes underneath. This included radios and car keys.

The senior commander carries a drop box to collect the keys of response vehicles from Critical Care teams as they arrive, allowing these vehicles to be moved as necessary.

Carrying and using radios whilst wearing level 3 PPE is challenging

Use earpieces with a push to talk facility or a belt to carry the radio externally.

The wearing of masks and hoods meant it was difficult to hear verbal instructions

Closed loop communication would be beneficial

It was difficult to send and receive updates from the HEMS desk once level 3 PPE was donned. It was commented that fewer updates from scene were received that would be usual from an non-COVID incident

The teams that arrived at the scene later, when most interventions had already been undertaken, should have one clinician don full level 3 PPE, with at least one other remaining in level 2 PPE to facilitate communication and situational awareness.

A windscreen report is a brief summary of what can be seen immediately on arrival at a large or major incident; they are particularly valuable when taken from a helicopter above the scene and can be done by taking an aerial scene photograph to refer to later. The importance of a windscreen report is increased when later communications may be impaired by the use of PPE.

There are multiple challenges regarding communication and situational awareness

Training. Organisations should train for multi-casualty situations wearing PPE. To-date, the majority of training has focused on individual patient care whilst wearing PPE.

CRM. Individuals should be aware of how PPE compromises recognition and communication. As a result, it takes time to establish what has occurred, who is on the scene and what their role is.

Some teams carried large storage bags containing a variety of sizes of PPE and it was time-consuming to find the correct sizes.

Clinicians could carry one set of PPE of the correct size for the entire shift, with resupply from a stock holdall as required.