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Research in brief

Adapting infection control guidance for pandemic flu affects staff ability to deliver care

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This simulation exercise investigated the impact that adopting pandemic flu infection control guidance would have on care delivery in hospitals

Keywords: Pandemic flu, Swine flu, Personal protective equipment, Infection control


There is limited experience of the effects that adopting UK pandemic flu infection control guidance will have on the use of personal protective equipment (PPE), patients and staff. This study sought to assess these issues by carrying out a live simulation exercise in a hospital.

The study

During this simulation, all staff on an acute general medical ward wore PPE and followed procedures in the UK pandemic flu infection control guidance.

The hospital trust identified an acute medical ward with a mostly respiratory and gastrointestinal case-mix of patients, receiving mainly acute and some elective admissions.

The ward simulated operations at the height of a pandemic, that is, providing cohorted care for patients with flu and flu-like illness. All staff working or visiting the ward had to wear PPE and the amount used was recorded hourly. The ward stock control system was used to quantify usual use of PPE for comparison.

The exercise ran for 24 hours and patients and visitors were not included.

Seventeen infection control nurses (ICNs) acted as observers to monitor staff compliance with guidance. All ward-based staff involved were encouraged to complete a self-administered questionnaire at the end of their shift.

Key findings

Twenty-one ward staff (13 nurses, four HCAs, three domestics and one ward clerk) completed the questionnaire. Of these, only one found wearing a surgical mask comfortable, six expressed no opinion, 12 found them uncomfortable and two found them very uncomfortable.

Seventeen staff said duties took longer; one unforeseen problem was extra time for more frequent emptying of clinical waste bins.         

Nine felt that communication, such as answering the phone or talking with colleagues and patients, was more difficult.

One prominent need was for a ‘holding area’ where staff could put on and remove PPE, carry out hand hygiene and take a break outside of the cohort area.

At least three ICNs were present to observe practice throughout the exercise. Overall, they found good adherence to general infection control measures, although particular aspects of pandemic flu guidance caused some uncertainty among staff.

Use of PPE

The study highlighted issues related to implementing national guidance and quantified the associated use of PPE in a typical UK hospital.

In the worst-case scenario during the height of a pandemic, a cohorted ward could expect to use: up to 5,250 aprons per week compared with 400 normally; 8,400 pairs of gloves compared with 850; 4,550 surgical masks compared with fewer than 10; and 90–100 FFP3 respirators and fluid-repellent gowns, which are not commonly used on wards. This would represent increases in use of up to 13-, 10- and 450-fold for aprons, gloves and surgical masks respectively.

The authors point out these increases have implications not only for cost and procurement but also for storage. They add that the few occasions (13) when high-level PPE was needed was significantly lower than predicted; 500 FFP3 respirators were ordered for the exercise.

There were also large amounts of clinical waste. Normally, the ward produces 4–6 bags over 24 hours, but during the exercise this rose to 18, at least a three-fold increase.

Overall, observers felt that while staff had a good grasp of basic infection control measures, they were unsure about extra ones during a pandemic, despite training.

Many tasks took much longer than usual, despite having extra staff. While it is possible that efficiency would improve as staff become more accustomed to working in a pandemic, it also suggests that working practices may have to change to include cohorting patients needing high levels of PPE and using a task-orientated approach.

Most staff said PPE was uncomfortable and a few reported feeling hot and dry. Staff would therefore need to be encouraged to take frequent breaks during a pandemic.

The authors acknowledge there are limitations to the study, such as the exercise did not take place during a pandemic and the possibility of the Hawthorne effect, in which study participants improve their practice as a result of being observed.


Phin et al (2009) say the results challenge assumptions that large amounts of high-level PPE (such as FFP3 respirators) are needed, adding the emphasis should be on adequate amounts of basic PPE.

They conclude a programme of ongoing infection control education is needed. Health care in a pandemic is not simply a case of applying pandemic flu infection control guidance – hospitals must consider changing the way care and services are delivered. l

Click here to read this study in full


  • Key points
  • Despite pre-exercise training, many staff lacked confidence in using PPE and following infection control measures.
  • Staff found PPE uncomfortable, with even basic tasks taking longer than usual.
  • Increased amounts of clinical waste were generated during the exercise.
  • Staff should be encouraged to take frequent breaks because of discomfort caused by wearing PPE.


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