NIPCM

Responsibilities for the content of this manual

HPS must ensure

• that the content of this manual remains evidence based.

Responsibilities for the adoption and implementation of this manual

Organisations must ensure:

• the adoption and implementation of this manual in accordance with their existing local governance processes
• systems and resources are in place to facilitate implementation and compliance monitoring of infection prevention and control as specified in this manual in all care areas
  • compliance monitoring includes all staff (permanent, agency and where required external contractors)
• there is an organisational culture which promotes incident reporting and focuses on improving systemic failures that encourage safe working practices including near misses

Managers of all services must ensure that staff:

• are aware of and have access to this manual
• have had instruction/education on infection prevention and control through attendance at events and/or completion of training (for example via NHS Education for Scotland (NES) and/or local board or organisation)
• have adequate support and resources available to enable them to implement, monitor and take corrective action to ensure compliance with this manual if this cannot be implemented a robust risk assessment must be undertaken and approved through local governance procedures
• with health concerns (including pregnancy) or who have had an occupational exposure are timeously referred to the relevant agency, for example General Practitioner, Occupational Health or if required Accident and Emergency
• have undergone the required health checks or clearance (including those undertaking Exposure Prone Procedures (EPPs)
• include infection prevention and control as an objective in their Personal Development Plans (or equivalent)

Staff providing care must ensure that they:

• understand and apply the principles of infection prevention and control set out in this manual
• maintain competence, skills and knowledge in infection prevention and control through attendance at education events and/or completion of training, for example NHS Education for Scotland (NES) and/or local board or organisation
• communicate the infection prevention and control practices to be taken by colleagues, those being cared for, relatives and visitors without breaching confidentiality
• have up to date occupational immunisations/health checks/clearance requirements as appropriate
• report to line managers and document any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmission of infection including near misses e.g sharps or PPE failures
• do not provide care while at risk of potentially transmitting infectious agents to others - if in any doubt they must consult with their line manager, Occupational Health Department, Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT)
• contact HPT/IPCT if there is a suspected or actual HAI incident/outbreak

Infection Prevention and Control Teams (IPCTs) and Health Protection Teams (HPTs) must:

• engage with staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of infection prevention and control practices
• provide expert advice on the application of infection prevention and control in all care settings and on individual risk assessments as required including the HIIAT/HIIORT ensuring actions are taken following completion of HIIAT
• have epidemiological or surveillance systems capable of distinguishing patient case or cases requiring investigations and control
• complete documentation when an incident/outbreak or data exceedence is reported

Standard Infection Control Precautions (SICPs), covered in this chapter are to be used by all staff, in all care settings, at all times, for all patients¹ whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care environment.

SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection.

Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated.

The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction and/or the anticipated level of exposure to blood and/or other body fluids.

To be effective in protecting against infection risks, SICPs must be used continuously by all staff. SICPs implementation monitoring must also be ongoing to ensure compliance with safe practices and to demonstrate ongoing commitment to patient, staff and visitor safety.

Further information on using SICPs for Care at Home can be found on the NHS National Education Scotland (NES) website.

 ¹The use of the word 'Persons' can be used instead of 'Patient' when using this document in non-healthcare settings.

1.1 Patient Placement/Assessment for infection risk

Patients must be promptly assessed for infection risk on arrival at the care area (if possible, prior to accepting a patient from another care area) and should be continuously reviewed throughout their stay. This assessment should influence placement decisions in accordance with clinical/care need(s).

Patients who may present a cross-infection risk include those:

• With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.
• Known to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
• Who have been hospitalised outside Scotland in the last 12 months.

For assessment of infection risk see Section 2: Transmission Based Precautions.

Further information can be found in the patient placement literature review.

1.2 Hand Hygiene

Hand hygiene is considered an important practice in reducing the transmission of infectious agents which cause HAIs.

Hand washing sinks must only be used for hand hygiene and must not be used for the disposal of other liquids.  (See Appendix 3 of Pseudomonas Guidance)

Before performing hand hygiene:

• expose forearms (bare below the elbows);
• remove all hand/wrist jewellery* (a single, plain metal finger ring or ring dosimeter (radiation ring) is permitted but should be removed (or moved up) during hand hygiene); bracelets or bangles such as the Kara which are worn for religious reasons should be able to be pushed higher up the arm and secured in place);
• ensure finger nails are clean, short and that artificial nails or nail products are not worn; and
• cover all cuts or abrasions with a waterproof dressing.

 *For health and safety reasons, Scottish Ambulance Service Special Operations Response Teams (SORT) in high risk situations require to wear a wristwatch.

To perform hand hygiene:

Alcohol Based Hand Rubs (ABHRs) must be available for staff as near to point of care as possible. Where this is not practical, personal ABHR dispensers should be used.

Perform hand hygiene:

1. before touching a patient;
2. before clean/aseptic procedures. If ABHR cannot be used then antimicrobial liquid soap should be used;
3. after body fluid exposure risk;
4. after touching a patient; and
5. after touching a patient’s immediate surroundings

 

Some additional examples of hand hygiene moments include:

• Before handling medication
• Before preparing food
• After visiting the toilet
• After removing PPE
• Between carrying out different care activities on the same patient

Download and print the 5 moments of hand hygiene poster.

Download and print the 4 moments poster for residential and care home settings.

Wash hands with non-antimicrobial liquid soap and water if:

• hands are visibly soiled or dirty;
• caring for patients with vomiting or diarrhoeal illnesses; or
• caring for a patient with a suspected or known gastro-intestinal infection e.g. norovirus or a spore forming organism such as Clostridioides difficile.

In all other circumstances use ABHRs for routine hand hygiene during care.

(The video above demonstrating Hand Washing and Drying Technique was produced by NHS Ayrshire and Arran)

Where there is no running water available or hand hygiene facilities are lacking, staff may use hand wipes followed by ABHR and should wash their hands at the first available opportunity.

For how to:

• wash hands see Appendix 1
• hand rub see Appendix 2

Skin care:

• Warm/tepid water should be used to reduce the risk of dermatitis; hot water should be avoided.
• Pat hands dry thoroughly after hand washing using disposable paper towels; avoid rubbing which may lead to skin irritation/damage.
• Use an emollient hand cream during work and when off duty.
• Do not use refillable dispensers or provide communal tubs of hand cream in the care setting.
• Staff with skin problems should seek advice from Occupational Health or their GP.

Surgical Hand Antisepsis

Surgical scrubbing/rubbing: (applies to persons undertaking surgical and some invasive procedures)

Perform surgical scrubbing/rubbing before donning sterile theatre garments or at other times e.g. prior to insertion of central vascular access devices.

• Remove all hand/wrist jewellery.
• Nail brushes should not be used for surgical hand antisepsis.
• Nail picks (single-use) can be used if nails are visibly dirty.
• Soft, non-abrasive, sterile (single-use) sponges may be used to apply antimicrobial liquid soap to the skin if licensed for this purpose.
• Use an antimicrobial liquid soap licensed for surgical scrubbing or an ABHR licensed for surgical rubbing (as specified on the product label).
• ABHR can be used between surgical procedures if licensed for this use or between glove changes if hands are not visibly soiled.
  
  
• For surgical scrubbing technique see Appendix 3.
• For surgical rubbing technique see Appendix 4. 

Hand Hygiene posters/leaflets can be found at Wash Your Hands of Them Resources.

Further information can be found in the Hand Hygiene literature reviews:

• Hand washing, hand rubbing and indications for hand hygiene
• Hand hygiene products
• Skin care
• Surgical hand antisepsis in the clinical setting

  (The video above demonstrating Surgical Scrubbing using ABHR was produced by Golden Jubilee National Hospital)

1.3 Respiratory and Cough Hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of respiratory illness (pathogens):

• Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose.
• Dispose of all used tissues promptly into a waste bin.
• Wash hands with non-antimicrobial liquid soap and warm water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions.
• Where there is no running water available or hand hygiene facilities are lacking, staff may use hand wipes followed by ABHR and should wash their hands at the first available opportunity.
• Keep contaminated hands away from the eyes nose and mouth.

Staff should promote respiratory and cough hygiene helping those (e.g. elderly, children) who need assistance with this e.g. providing patients with tissues, plastic bags for used tissues and hand hygiene facilities as necessary.

Further information can be found in the cough etiquette/respiratory hygiene literature review.

1.4 Personal Protective Equipment

Before undertaking any procedure staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

All PPE should be:

• located close to the point of use;
• stored to prevent contamination in a clean/dry area until required for use (expiry dates must be adhered to);
• single-use only items unless specified by the manufacturer;
• changed immediately after each patient and/or following completion of a procedure or task; and
• disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.

Reusable PPE items, e.g. non-disposable goggles/face shields/visors must have a decontamination schedule with responsibility assigned.

Further information on best practice for PPE use for SICPs can be found in Appendix 16.

Gloves must be:

• worn when exposure to blood and/or other body fluids is anticipated/likely;²
• changed immediately after each patient and/or following completion of a procedure or task;
• changed if a perforation or puncture is suspected;
• appropriate for use, fit for purpose and well-fitting.

Double gloving is recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and gynaecological operations or when attending major trauma incidents.

For appropriate glove use and selection see Appendix 5.

Further information can be found in the Gloves literature review.

Aprons must be:

• worn to protect uniform or clothes when contamination is anticipated/likely e.g. when in direct care contact with a patient;
  and
• changed between patients and/or following completion of a procedure or task.

Full body gowns/Fluid repellent coveralls must be:

• worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in the operating theatre;
  
  
• worn when a disposable apron provides inadequate cover for the procedure/task being performed;
  
  
• changed between patients and immediately after completion of a procedure or task.

The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure.

Sterile surgical gowns must be:

• worn by all scrubbed members of the operating theatre surgical team;
• worn for insertion of central venous catheters, insertion of peripherally inserted central catheters, insertion of pulmonary artery catheters and spinal, epidural and caudal procedures.

Reusable gowns must:

• not be worn in the operating theatre environment or for aseptic surgical procedures;
• be appropriately processed between uses based on manufacturer’s instructions.

If hand hygiene with soap and water is required, this should not be performed whilst wearing an apron/gown in line with a risk of apron/gown contamination; hand hygiene using ABHR is acceptable.

Further information can be found in the Aprons/Gowns literature review.

Eye/face protection must:

• be worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely  and always during Aerosol Generating Procedures.
  
  
• be worn by all scrubbed members of the surgical team for all surgical procedures;
  
  
• not be impeded by accessories such as piercings/false eyelashes;
  
  
• not be touched when worn;
  
  
• cover the full peri-orbital region and wrap around the sides of the face;
  
  
• be removed or changed in accordance with manufacturer’s instructions, if vision is compromised through contamination with blood or body fluids, if the integrity of the equipment is compromised, at the end of a clinical procedure/task and/or prior to leaving the dedicated clinical area.

Regular corrective spectacles and safety spectacles are not considered eye protection.

Further information can be found in the eye/face protection literature review.

Fluid Resistant Type IIR surgical face masks must be:

• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated/likely;
  (as part of SICPs a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray.)

• worn in combination with a full face shield, integrated half face shield or goggles for AGPs on non-infectious patients;
  
  
• worn to protect patients from the operator as a source of infection when performing invasive spinal procedures such as myelography, lumbar puncture and spinal anaesthesia ,inserting a Central Vascular Catheter (CVC), performing intra-articular (joint) injections;
  
  
• worn by all scrubbed members of the theatre surgical team for all surgical procedures;
  
  
• worn by non-scrubbed members of the theatre surgical team if deemed necessary following a risk assessment of exposure to blood and/or body fluids;
  
  
• well fitting and fit for purpose (fully covering the mouth and nose);
  
  
• removed or changed;
  • at the end of a procedure/task;
    
    
  • if the integrity of the mask is breached, e.g. from moisture build-up after extended use or from gross contamination with blood or body fluids;
    and
  • in accordance with specific manufacturers’ instructions.

Further information can be found in:

• aerosol generating procedures literature review
• surgical face masks literature review
• section 2.4 of the NIPCM
• appendix 11 of the NIPCM

Footwear must be:

• able to either withstand machine washing at 40°C or disinfection with a chlorine releasing agent. 
• non-slip, clean and well maintained, and support and cover the entire foot to avoid contamination with blood or other body fluids or potential injury from sharps; and
• removed before leaving a care area where dedicated footwear is used e.g. theatre, in these areas have a decontamination schedule with responsibility assigned.

Further information can be found in the footwear literature review.

Headwear must be:

• worn in theatre settings/clean rooms e.g. Central Decontamination Unit (CDU);
• well fitting and completely cover the hair; and
• changed/disposed of between clinical procedures/tasks or if contaminated with blood and/or body fluids;
• removed before leaving the theatre/clean room.

Further information can be found in the headwear literature review

For the recommended method of putting on and removing PPE see video below and Appendix 6.

If you are experiencing issues accessing the above video via YouTube please try the alternative version that can be accessed on Vimeo.

²Scottish National Blood Transfusion Service (SNBTS) adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

1.5 Safe Management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents. Consequently it is easy to transfer infectious agents from communal care equipment during care delivery.

Care equipment is classified as either:

• Single-use – equipment which is used once on a single patient and then discarded. Must never be reused even on the same patient. The packaging carries the symbol below.
  • Needles and syringes are single use devices. They should never be used for more than one patient or reused to draw up additional medication.
  • Never administer medications from a single-dose vial or intravenous (IV) bag to multiple patients.
• Single patient use – equipment which can be reused on the same patient.
• Reusable invasive equipment - used once then decontaminated e.g. surgical instruments.
• Reusable non-invasive equipment (often referred to as communal equipment) - reused on more than one patient following decontamination between each use e.g. commode, patient transfer trolley.

Before using any sterile equipment check that:

• the packaging is intact
• there are no obvious signs of packaging contamination
• the expiry date remains valid

Decontamination of reusable non-invasive care equipment must be undertaken:

• between each use
• after blood and/or body fluid contamination
• at regular predefined intervals as part of an equipment cleaning protocol
• before inspection, servicing or repair

Adhere to manufacturers’ guidance for use and decontamination of all care equipment.

All reusable non-invasive care equipment must be rinsed and dried following decontamination then stored clean and dry.

Decontamination protocols should include responsibility for; frequency of; and method of environmental decontamination.

An equipment decontamination status certificate will be required if any item of equipment is being sent to a third party e.g for inspection, servicing or repair.

Guidance may be required prior to procuring, trialling or lending any reusable non-invasive equipment. 

Further information can be found in the management of care equipment literature review.

For how to decontaminate reusable non-invasive care equipment see Appendix 7.

1.6 Safe Management of Care Environment

It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean, free from non-essential items and equipment to facilitate effective cleaning
• well maintained and in a good state of repair
• routinely cleaned in accordance with the Health Facilities Scotland (HFS) National Cleaning Specification:
  • A fresh solution of general purpose neutral detergent in warm water is recommended for routine cleaning. This should be changed when dirty or at 15 minutes intervals or when changing tasks.
  • Routine disinfection of the environment is not recommended. However, 1,000ppm available chlorine should be used routinely on sanitary fittings.

Staff groups should be aware of their environmental cleaning schedules and clear on their specific responsibilities.

Cleaning protocols should include responsibility for; frequency of; and method of environmental decontamination.

Further information can be found in the routine cleaning of the environment in hospital setting literature review.

1.7 Safe Management of Linen

Clean linen

• Should be stored in a clean, designated area, preferably an enclosed cupboard.
• If clean linen is not stored in a cupboard then the trolley used for storage must be designated for this purpose and completely covered with an impervious covering that is able to withstand decontamination.

Linen used during patient transfer

• Any linen used during patient transfer e.g. blankets, should be categorised at the point of destination.

For all used linen (previously known as soiled linen):

• Ensure a laundry receptacle is available as close as possible to the point of use for immediate linen deposit.
• Do not:
  • rinse, shake or sort linen on removal from beds/trolleys;
  • place used linen on the floor or any other surfaces e.g. a locker/table top;
  • re-handle used linen once bagged;
  • overfill laundry receptacles; or
  • place inappropriate items in the laundry receptacle e.g. used equipment/needles.

For all infectious linen (this mainly applies to healthcare linen) i.e. linen that has been used by a patient who is known or suspected to be infectious and/or linen that is contaminated with blood and/or other body fluids e.g. faeces:

• Place directly into a water-soluble/alginate bag and secure; then place into a plastic bag e.g. clear bag and secure before placing in a laundry receptacle. This applies also to any item(s) heavily soiled and unlikely to be fit for reuse.
• Used and infectious linen bags/receptacles must be tagged e.g. ward/care area and date.
• Store all used/infectious linen in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of linen receptacles.

Local guidance regarding management of linen may be available.  

All linen that is deemed unfit for re-use e.g torn or heavily contaminated, should be categorised at the point of use and returned to the laundry for disposal. 

Further information can be found in the safe management of linen literature review and National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution.

Further information about linen bagging and tagging can be found in Appendix 8.

1.8 Safe Management of Blood and Body Fluid Spillages

Spillages of blood and other body fluids may transmit blood borne viruses.

Spillages must be decontaminated immediately by staff trained to undertake this safely.

Responsibilities for the decontamination of blood and body fluid spillages should be clear within each area/care setting.

If superabsorbent polymer gel granules for containment of bodily waste are used these should be used in line with national guidance. In Scotland refer to http://www.hfs.scot.nhs.uk/publications/1575969155-SAN(SC)1903.pdf.  In England refer to https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102937.

For management of blood and body fluid spillages see Appendix 9.

Further information can be found in the management of blood and body fluid in health and social care settings literature review.

 

 

 

1.9 Safe Disposal of Waste (including sharps)

Scottish Health Technical Note (SHTN) 3: NHSScotland Waste Management Guidance contains the regulatory waste management guidance for NHSScotland including waste classification, segregation, storage, packaging, transport, treatment and disposal.

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to the safe disposal of sharps.

Categories of waste:

• Healthcare (including clinical) waste – is produced as a direct result of healthcare activities e.g. soiled dressings, sharps.
• Special (or hazardous) waste – arises from the delivery of healthcare in both clinical and non-clinical settings. Special waste includes a range of controlled wastes, defined by legislation, which contain dangerous or hazardous substances e.g. chemicals, pharmaceuticals.
• Domestic waste – must be segregated at source into:
  • Dry recyclates (glass, paper and plastics, metals, cardboard).
  • Residual waste (any other domestic waste that cannot be recycled).

Waste Streams:

• Black – Trivial risk:
  • Domestic waste or yellow and black stripes (small quantities of hygiene waste).
  • Final disposal to Landfill.
  • Clear/opaque receptacles may also be used for domestic waste at care area level.
• Orange, Light Blue (laboratory) – Low risk
  • Orange - consists of items which are contaminated or likely to be contaminated with blood and/or body fluids. Final disposal following heat disinfection is to landfill.
  • Light Blue – laboratory/microbiological waste that must be autoclaved before disposal via the orange stream.

• Yellow– High risk:
  • Waste which poses ethical, highly infectious or contamination risks.
  • This includes anatomical and human tissue which is recognisable as body parts, medical devices and sharps waste boxes that have red, purple or blue lids.
  • Disposal is by specialist incineration.

• Red – Special waste
  • Chemical waste.

For care/residential homes waste disposal may differ from the categories described above and guidance from local contractors will apply. Refer to SEPA guidance.

Safe waste disposal at care area level:

Always dispose of waste:

• immediately and as close to the point of use as possible; and
• into the correct segregated colour coded UN 3291 approved waste bag (either orange/yellow for healthcare waste or black/clear/opaque for domestic) or container (sharps box).

Liquid waste e.g. blood must be rendered safe by adding a self-setting gel or compound before placing in an orange lidded leak-proof bin.

Waste bags must be no more than 3/4 full or more than 4 kgs in weight; and use a ratchet tag/or tape (for healthcare waste bags only) using a ‘swan neck’ to close with the point of origin and date of closure clearly marked on the tape/tag.

Store all waste in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of waste receptacles.

Sharps boxes must:

• have a dedicated handle;
• have a temporary closure mechanism, which must be employed when the box is not in use;
• be disposed of when the manufacturers’ fill line is reached; and
• be labelled with point of origin and date of closure.

Local guidance regarding management of waste at care level may be available. 

Further information can be found in the safe disposal of waste literature review.

1.10 Occupational Safety: Prevention and Exposure Management (including sharps)

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to:

• arrangements for the safe use and disposal of sharps
• provision of information and training to employees
• investigations and actions required in response to work related sharps injuries

Sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices.

Manufacturers’ instructions for safe use and disposal must be followed.

Needles must not be re-sheathed/recapped.⁴

Always dispose of needles and syringes as 1 unit.

If a safety device is being used safety mechanisms must be deployed before disposal.

A significant occupational exposure is:

• a percutaneous injury e.g. injuries from needles, instruments, bone fragments, or bites which break the skin; and/or
• exposure of broken skin (abrasions, cuts, eczema, etc); and/or
• exposure of mucous membranes including the eye from splashing of blood or other high risk body fluids.

There is a potential risk of transmission of a Blood Borne Virus (BBV) from a significant occupational exposure and staff must understand the actions they should take when a significant occupational exposure incident takes place. There is a legal requirement to report all sharps injuries and near misses to line managers/employers.  

For the management of an occupational exposure incident see Appendix 10

Further information can be found in the occupational exposure management (including sharps) literature review.

⁴  A local risk assessment is required if re-sheathing is undertaken using a safe technique for example anaesthetic administration in dentistry.

SICPs may be insufficient to prevent cross transmission of specific infectious agents. Therefore additional precautions TBPs are required to be used by staff when caring for patients with a known or suspected infection or colonisation.

Clinical judgement and decisions should be made by staff on the necessary precautions.  This must be based on the:

• suspected or known infectious agent
• severity of the illness caused
• transmission route of the infectious agent
• care setting and procedures undertaken

TBPs are categorised by the route of transmission of infectious agents (some infectious agents can be transmitted by more than one route): Appendix 11 provides details of the type of precautions, optimal patient placement, isolation requirements and respiratory precautions required.  Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

Contact precautions

Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of cross-infection transmission.

Droplet precautions

Used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.

Airborne precautions

Used to prevent and control infections spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.

Further information on Transmission Based Precautions can be found in the definitions of Transmission Based Precautions literature reviews.

2.1 Patient Placement/Assessment for Infection Risk

The potential for transmission of infection must be assessed at the patient’s entry to the care area.  If hospitalised or in a care home setting this should be continuously reviewed throughout the stay/period of care. The assessment should influence placement decisions in accordance with clinical/care need(s).

Patients who may present a cross-infection risk in any setting includes those:

• With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.
• Known to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
• Who have been hospitalised (inpatient) outside Scotland in the last 12 months.

Isolation facilities should be prioritised depending on the known/suspected infectious agent (refer to Aide Memoire - Appendix 11).  All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.

The clinical judgement and expertise of the staff involved in a patient's management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought particularly for the application of TBPs e.g. isolation prioritisation when single rooms are in short supply. 

Hospital settings:

• Isolation of infectious patients can be in specialised isolation facilities, single room isolation, cohorting of infectious patients where appropriate, ensuring that they are separated by at least 3 feet (1 metre) with the door closed.
• Signage should be used on doors/areas to communicate isolation requirements and prevent entry of unnecessary visitors and non-essential staff.
• Infectious patients should only be transferred to other departments if medically necessary.  If the patient has an infectious agent transmitted by the airborne/droplet route then if possible/tolerated the patient should wear a surgical face mask during transfer.
• Receiving department/hospital and transporting staff must be aware of the necessary precautions.

Care home settings:

• Residents should remain in their bedroom whilst considered infectious (as described above) and the door should remain closed (if unable to isolate this should be documented).
• If transfer to hospital is required the ambulance service should be informed of the infectious status of the resident.
• Advice on resident’s clinical management should be sought from GP,  and infection prevention and control management sought from the HPT.
• Avoid unnecessary transfer of residents within/between care areas.

Staff cohorting; consider assigning a dedicated team of care staff to care for patients in isolation/cohort rooms/areas as an additional infection control measure during outbreaks/incidents. This can only be implemented if there are sufficient levels of staff available (so as not to have a negative impact on non-affected patients’ care).

Before discontinuing isolation; individual patient risk factors should be considered (e.g. there may be prolonged shedding of certain microorganisms in immunocompromised patients).

Primary care/out-patient settings:

• Patients attending these settings with suspected/known infection/colonisation should be prioritised for assessment/treatment e.g. scheduled appointments at the start or end of the clinic session. Infectious patients should be separated from other patients whilst awaiting assessment and during care management by at least 3 feet (1m). 
• If transfer from a primary care facility to hospital is required the ambulance service should be informed of the infectious status of the patient.

Further information can be found in the patient placement literature review.

2.2 Safe Management of Patient Care Equipment in an Isolation Room/Cohort Area

• Use single-use items if possible.
• Reusable non-invasive care equipment should be dedicated to the isolation room/cohort area and decontaminated prior to use on another patient Section 1.5. Safe Management of Care Equipment
• An increased frequency of decontamination should be considered for reusable non-invasive care equipment when used in isolation/cohort areas.

For how to decontaminate non-invasive reusable equipment see Appendix 7.

Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

2.3 Safe Management of the Care Environment

Routine environmental decontamination

Hospital/Care home setting:

Patient isolation/cohort rooms/area must be decontaminated at least daily, this may be increased on the advice of IPCTs/HPTs. These areas must be decontaminated using either:

• a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.)); or
• a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .

Increased frequency of decontamination/cleaning schedules should be incorporated into the environmental decontamination schedules for areas where there may be higher environmental contamination rates e.g.

• toilets/commodes particularly if patients have diarrhoea; and
• “frequently touched” surfaces such as door/toilet handles and locker tops, over bed tables and bed rails.

Vacated rooms should also be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. In an isolation room with 10-12 air changes per hour (ACH) a minimum of 20 minutes is considered pragmatic; in a side room with 6 ACH this would be approximately one hour. Advice should be sought from IPCT.

Patient rooms must be terminally cleaned following resolution of symptoms, discharge or transfer. This includes removal and laundering of all curtains and bed screens.

Primary care/Out-patient settings:

The extent of decontamination between patients will depend on the duration of the consultation/assessment, the patients presenting symptoms and any visible environmental contamination. 

Equipment used for environmental decontamination must be either single-use or dedicated to the affected area then decontaminated or disposed of following use e.g. cloths, mop heads.

Terminal decontamination

Following patient transfer, discharge, or once the patient is no longer considered infectious:

Remove from the vacated isolation room/cohort area, all:

• healthcare waste and any other disposable items (bagged before removal from the room);
• bedding/bed screens/curtains and manage as infectious linen (bagged before removal from the room); and
• reusable non-invasive care equipment (decontaminated in the room prior to removal) Appendix 7.

The room should be decontaminated using either:

• a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.); or
• a general purpose neutral detergent clean in a solution of warm water followed by disinfection solution of 1,000ppm av.cl..

The room must be cleaned from the highest to lowest point and from the least to most contaminated point.

Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .

Unless instructed otherwise by the IPCT there is no requirement for a terminal clean of an outpatient area or theatre recovery.

Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

2.4 Personal Protective Equipment (PPE)

Surgical masks

A type IIR fluid resistant surgical mask should be worn when caring for a patient with a suspected/confirmed infectious agent spread by the droplet route.

Surgical masks worn by patients with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control, should meet type II or IIR standards.

Eye/face protection

A face visor or goggles should be used in combination with a fluid resistant type IIR surgical mask when caring for symptomatic patients infected with droplet transmitted infectious agents.

A face visor or goggles should be used in combination with a fluid resistant FFP3 respirator when caring for symptomatic patients infected with an airborne transmitted infectious agent.

Eye/face protection should be worn

• by all of those in the room when potentially infectious AGPs are conducted
• for the care of patients with novel infectious agents including pandemic influenza

Aprons/Gowns

An apron/gown should be worn when caring for patients known or suspected to be colonised/infected with antibiotic resistant bacteria including contact with the patient’s environment.

Plastic aprons and/or fluid repellent gowns should be used in health and social care settings for protection against body fluid splash and spray.

A full body fluid repellent gown should be worn when conducting AGPs on patients known or suspected to be infected with a respiratory infectious agent.

Further information can be found in the Aprons/Gowns literature review.

 

RPE

PPE must still be used in accordance with SICPs when using Respiratory Protective Equipment. See Chapter 1.4 for PPE use for SICPs. 

Further information on best practice for PPE use for TBPs can be found in Appendix 16.

Where it is not reasonably practicable to prevent exposure to a substance hazardous to health (as may be the case where healthcare workers are caring for patients with suspected or known airborne micro-organisms) the hazard must be adequately controlled by applying protection measures appropriate to the activity and consistent with the assessment of risk. If the hazard is unknown the clinical judgement and expertise of IPC/HP staff is crucial and the precautionary principle should apply.

Respiratory Protective Equipment (RPE) i.e. FFP3 and facial protection, must be considered when a patient is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route and when carrying out aerosol generating procedures (AGPs) on patients with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

The following risk categorisation is the minimum requirement for staff groups that require FFP3 fit testing. NHS Boards can add to this for example where high risk units are present. This categorisation is inclusive of out of hours services.

National Priority Risk Categorisation for face fit testing with FFP3

Level 1 – Preparedness for business as usual

Staff in clinical areas most likely to provide care to patients who present at healthcare facilities with an infectious pathogen spread by the airborne route; and/or undertake aerosol generating procedures i.e. A&E, ICU, paediatrics, respiratory, infectious diseases, anaesthesia, theatres, Chest physiotherapists, Special Operations Response Team (Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams, mortuary staff.

Level 2 – Preparedness in the event of emerging threat

Staff in clinical setting likely to provide care to patients admitted to hospital in the event of an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all other ambulance transport staff.

In the event of an ‘Epidemic/Pandemic’ Local Board Assessment as per their preparedness plans will apply.

The decision to wear an FFP3 respirator/hood should be based on clinical risk assessment e.g task being undertaken, the presenting symptoms, the infectious state of the patient, risk of acquisition and the availability of treatment.

For a list of organisms spread wholly or partly by the airborne (aerosol) or droplet routes see Appendix 11.

Further information can be found in the aerosol generating procedures literature review.

All tight fitting RPE i.e FFP3 respirators must be:

• Single use (disposable) and fluid-resistant.NB. Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated.
• Compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection. If wearing a valved, non-shrouded FFP3 respirator a full face shield/visor must be worn.
• Changed after each use. Other indications that a change in respirator is required include: if breathing becomes difficult; if the respirator becomes wet or moist, damaged; or obviously contaminated with body fluids such as respiratory secretions.
• Fit tested (by a competent fit test operator) on all healthcare staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance.
• Fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved.

The poster below gives further information on compatibility of facial hair and FFP3 respirators and can be used when fit testing and fit checking.

Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.

In the absence of an anteroom/lobby remove FFP3 respirators in a safe area (e.g. outside the isolation/cohort room/area).

All other PPE should be removed in the patient care area.

Powered respirator hoods are an alternative to FFP3 respirators for example when fit testing cannot be achieved.

Powered hoods must be:

• single use (disposable) and fluid resistant;
• the filter must be enclosed with the exterior and the belt able to withstand disinfection with 10,000ppm av.cl.

FFP3 respirator or powered respirator hood:

• may be considered for use by visitors if there has been no previous exposure to the infected person or infectious agent; but
• must never be worn by an infectious patient(s) due to the nature of the respirator filtration of incoming air not expelled air.

Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) literature review.

Frameworks to support the assessing and recording of staff competency in PPE for HCID are available in the resources section of the NIPCM.

2.5 Infection Prevention and Control during care of the deceased

The principles of SICPs and TBPs continue to apply whilst deceased individuals remain in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living patients.

Washing and/or dressing of the deceased should be avoided if the deceased is known or suspected to have an invasive streptococcal infection, viral haemorrhagic fevers or other Group 4 infectious agents. See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased.

Staff should advise relatives of the precautions following viewing and/or physical contact with the deceased and also when this should be avoided.

Deceased individuals known or suspected to have a Group 4 infectious agent should be placed in a sealed double plastic body bag with absorbent material placed between each bag. The surface of the outer bag should then be disinfected with 1000ppm av.cl before being placed in a robust sealed coffin.

Post mortem examination should not be performed on a deceased individual known or suspected to have Group 4 infectious agents.  See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased”. Blood sampling can be undertaken in the mortuary by a competent person to confirm or exclude this diagnosis.  Refer to Section 2.4 for suitable PPE. 

 

The purpose of this chapter is to support the early recognition of potential infection incidents and to guide IPCT/HPTs in the incident management process within care settings; (that is, NHSScotland, independent contractors providing NHS services and private providers of care).

This guidance is aligned to the Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams (2017)

Built environment incidents/outbreaks

HPS are currently working towards delivery of comprehensive evidence-based guidance which will form Chapter 4 of the National Infection Prevention and Control Manual (NIPCM) on the built environment and decontamination. 

In the interim two Aide-Memoires have been produced to provide best practice recommendations to be implemented in the event of a healthcare water-associated or healthcare ventilation-associated infection incident/outbreak.  These will ensure clinical staff, estates and facilities staff, and Infection Prevention and Control Teams (IPCT) have an understanding of the preventative measures required and the appropriate actions that should be taken.

Prevention and management of healthcare water-associated infection incidents/outbreaks

Prevention and management of healthcare ventilation-associated infection incidents/outbreaks

 

 

3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance

The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover both incidents and outbreaks

A healthcare infection incident may be:

An exceptional infection episode

• A single case of any serious illness which has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high consequence such as VHF or XDR-TB.

See literature review for Infectious Diseases of High Consequence (IDHC)

A healthcare associated infection outbreak

• Two or more linked cases with the same infectious agent associated with the same healthcare setting over a specified time period.

or

• A higher than expected number of cases of HAI in a given healthcare area over a specified time period.

A healthcare infection exposure incident

• Exposure of patients, staff, public to a possible infectious agent as a result of a healthcare system failure or a near miss e.g. ventilation, water or decontamination incidents.

A healthcare infection data exceedance

• A greater than expected rate of infection compared with the usual background rate for that healthcare location.

Further information can be found in the literature review Healthcare infection incidents and outbreaks in Scotland.

3.2 Detection and recognition of a Healthcare Infection incident/outbreak or data exceedance

An early and effective response to an actual or potential healthcare incident, outbreak or data exceedance is crucial. The local Board IPCT and HPT should be aware of and refer to the national minimum list of alert organisms/conditions. See Appendix 13.

3.2.1 Assessment

Following detection/recognition of an incident a member of IPCT or HPT will:

• Undertake an initial assessment, utilising the Healthcare Infection Incident Assessment Tool (HIIAT) - Appendix 14, gather epidemiological data and clinical assessment information on the patients condition as per:
  • Section 1.1
  • Section 2.1

• Based on this initial assessment the IPCT/HPT may choose to convene a Problem Assessment Group (PAG) to further assess and determine if an IMT is required.
  • If the HIIAT is assessed as Green and there is no HPS support required then this should be reported as per DL(2019)23. If support is required this should be communicated to HPS. The HIIAT Green reporting protocol, procedure and template is available from the resources section.
  • If the HIIAT is assessed Amber or Red report to HPS. Healthcare Infection Incident and Outbreak Reporting Template (HIIORT) - Appendix 15 should be completed.

3.2.2 Investigation

The IPCT/HPT will establish an IMT if required.

• In the NHS hospital setting the ICD will usually chair the IMT and lead the investigation of healthcare incidents.  Where there are implications for the wider community e.g. TB or measles, or rare events such as CJD or a Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the hospital service, the CPHM may chair the IMT. A draft agenda for the IMT is available.
• The membership of the IMT will vary depending on the nature of the incident.
• A case definition for the purpose of the incident will be agreed. A case definition should include the following: the people involved (e.g. patients, staff); the symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s) involved); and a limit of time (e.g. between January and March year/date). The case definition(s) should be regularly reviewed and refined (if required) throughout the incident investigation as more information becomes available.
• The investigation of the incident should include: an ongoing epidemiological investigation; the nature and characteristics of the incident e.g. a microbiological investigation; and how cases were exposed to the infective agent or other hazard to inform control measures.
• Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
• Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
• The IMT should receive and discuss all information gathered and epidemiological outputs e.g. an epidemiological (epi) curve, a timeline and a ward map to:
  • Generate hypotheses as to which cross-transmission pathways and clinical procedures may be involved.
  • Determine whether additional case finding and control measures may be necessary.
  • Confirm that all incident control measures are being applied effectively and are sufficient.
• If staff screening is being considered as part of the investigation DL (2020)1 must be followed.
• HAI deaths, which pose an acute and serious public health risk, must be reported to the Procurator Fiscal, refer to SGHD/CMO(2014)27.
• If no new cases arise and any remaining cases are considered to no longer pose a risk, the IMT should agree on actions prior to resumption of normal service.
• Once the incident is over the IMT/NHS Board should evaluate and report on the effectiveness and efficiency of incident management using the Hot Debrief Tool.This is not a mandatory requirement but for the purpose of sharing lessons learned across Scotland.

The IMT Chair, in discussion with the IMT, should determine whether further reporting on the incident and the incident management is required i.e. SBAR Report and full IMT report template are available in the resources section of the NIPCM website.  

3.3 COVID-19 Definition of confirmed and suspected case

COVID-19 case definitions are regularly reviewed and can be found in the guidance for secondary care and are defined as:

Confirmed 

A laboratory confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19. 

Suspected 

An individual meeting one of the following case criteria taking into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and patients who are immunocompromised;

Community definition:

recent onset new continuous cough

or

fever

or

loss of/change in sense of taste or smell (anosmia)

Definition for individuals requiring hospital admission:

clinical or radiological evidence of pneumonia

or

Acute Respiratory Distress Syndrome

or

influenza-like illness (fever greater than or equal to 37.8֯C and at least one of the following respiratory symptoms, which must be of acute onset – persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)

or

a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms

 

 

 

3.4 COVID-19 Notification of positive cases

It is essential that NHS Boards have systems in place to ensure that laboratory confirmed cases of SARS-CoV-2 isolated from patients are reported to Infection Prevention and Control Teams (IPCTs) as promptly as possible to allow any inappropriately placed patients to be identified and isolated. 

Reporting systems should also be in place to alert the relevant teams of any positive staff cases.  There must be a robust and clear process in place for recording and communication of results to staff members.

The Occupational Health Service (OHS) will be key to this process. Staff who have a positive result may require advice, counselling and support.  Staff confidentiality and records of test results must be maintained securely.  It is recognised that staff in some organisations such as Scottish Ambulance Service, do not fall under the remit of OHS but will be captured under the test and protect service. 

COVID-19 is a notifiable disease and as such, directors of diagnostic laboratories must inform their health board, the common services agency and Public Health Scotland of all COVID-19 isolates.  This is a requirement of the Public Health etc (Scotland) Act 2008 and notification of infectious disease or health risk forms are available.

3.4.1 Communicating results

On confirmation of a positive COVID-19 patient isolate, the ward staff should be informed by the reporting laboratory or IPCT if the patient is still an inpatient. There must be agreed processes in place for communicating results and IPC advice out of hours when IPCTs are not available.

IPCTs should agree local notification process for any patients who have been discharged home since the COVID-19 test was undertaken to ensure that the patient is contacted at home and provided with the appropriate self-isolation advice.

There should be processes in place to ensure that IPCTs and OHS share intelligence which may indicate an outbreak is occurring in a specific ward/department.

3.4.2 Communication with other care facilities and NHS boards

Where a confirmed case or an identified contact has been transferred to another care facility (care home, hospice, mental health facility), the facility must be notified as soon as possible to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented.  There should be a local agreement in place to determine whether clinical teams or IPCTs will notify the facility and HPTs where required.  Local agreements should include reporting arrangements out of hours.

If a confirmed case or an identified contact has been transferred to another NHS board,
the receiving NHS board must be notified by the IPCT or clinical team and alert them to the positive COVID-19 status or exposure to ensure the appropriate control measures are implemented as per the Scottish COVID-19 IPC addendum.

Similarly, if a confirmed case has transferred from another board within 48 hours of symptom onset or positive test, the IPCT must inform the NHS board from which the patient transferred to allow risk assessment to be undertaken and contacts to be identified.

3.4.3 Surveillance

Active surveillance should be undertaken by IPCTs to allow outbreaks to be detected at the earliest possible opportunity.

 

3.5 COVID-19 Outbreak definitions

The definitions below should be applied to determine if a COVID-19 outbreak within a healthcare setting is occurring and determine when it can end. When assessing patient and staff clusters to determine if an outbreak is occurring, a high degree of suspicion should be applied.

3.5.1 Criteria to declare a COVID-19 outbreak in an inpatient setting

Two or more patient or staff cases of COVID-19 within a specific setting where nosocomial infection and ongoing transmission is suspected. For the purposes of this reporting, a high degree of suspicion should be applied and should be completed for any non-COVID-19 ward where there are unexpected cases of suspected or confirmed COVID-19. e.g. any cases that were not confirmed or suspected on admission. No time limit should be applied to determining whether a case is nosocomial e.g. 48 hours.

or

In High Risk Pathway where two or more staff cases of suspected or confirmed COVID-19 are identified.

Note: If there is a single suspected or confirmed case in a patient who was not suspected as having COVID-19 on admission, this should initiate further investigation and risk assessment This single case may constitute a possible cluster or an outbreak depending on the contacts and exposures identified.  Where patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.

3.5.2 Criteria to determine that a COVID-19 outbreak in an inpatient setting has ended

No new test-confirmed or suspected cases with illness onset date 14 days following the last new confirmed case (from date of symptom onset or date of positive test if case has remained asymptomatic), within the affected ward or department.  The outbreak can be declared closed provided that these criteria are met.  Stepdown guidance and further information on isolation periods can be accessed .

 

 

3.6 COVID-19 Roles and Responsibilities

NHS Boards should have a COVID-19 outbreak response plan which details the roles and responsibilities of Infection Prevention and Control Teams (IPCTs) ,Health Protection Teams (HPTs) and the occupational health services (OHS) within their board when responding to COVID-19 outbreaks. 

3.6.1 Convening an Incident Management Team (IMT)/Problem Assessment Group (PAG)

In a healthcare setting, the CPH(M) or the Infection Prevention and Control Doctor (IPCD) will chair the IMT depending on the circumstances and this should be agreed in advance and documented in the COVID-19 outbreak response plan. The ICD will usually chair the IMT, lead the investigation and management of incidents limited to the healthcare site, where no external agencies are involved and where there are no implications for the wider community. The CPH(M) would normally chair the IMT where there are implications for the wider community.

More information on IMTs and PAGS can be found in the Management of Public Health incidents: guidance on the roles and responsibilities of NHS led Incident Management Teams

An IMT generic COVID-19 agenda  and a supporting agenda aide memoire in for use by the chair or wider IMT members to support consistency in discussion points during COVID-19 IMTs across NHS Scotland are available.

 

3.6.2 Contact tracing responsibilities

The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing and follow up amongst the following groups of individuals:

• Inpatients
• Outpatients
• Community contacts of an inpatient prior to admission
• Visitors
• Healthcare workers and wider staff groups

Typically, IPCTs will follow up inpatient contacts, OHS will follow up staff contacts and HPTs will follow up any contacts in the exposure period prior to hospital admission and visitors.

3.6.3 Case definition for the incident

A case definition for the purpose of the incident must be agreed by the IMT and should include the following:

• the people involved (patients, staff, visitors);
• the pathogen (SARS-CoV-2);
• the place (the ward and hospital);
• a time period (commencing 48 hours prior to index case symptom onset or positive test if asymptomatic). 

Suggested case definitions for COVID-19 as follows;

• Confirmed case (Recorded as confirmed case in reporting tool): PCR positive COVID-19 test in anyone associated with ward ** during a specified time period
• Probable case (Recorded as suspected (symptomatic) case in reporting tool): Anyone on ward ** with symptoms of COVID-19 during a specified time period
• Possible case (Recorded as contacts (asymptomatic) in reporting tool): Anyone who has been exposed to COVID-19 on ward ** during a specified time period but not yet developed symptoms

 

 

3.7 COVID-19 Investigations

3.7.1 Epidemiological data/timelines

3.7.2 Identifying missed opportunities to isolate

3.7.3 IPC practice and compliance (including AGPs)

3.7.4 Review of visiting

3.7.5 Testing during an outbreak

3.7.6 Whole Genome Sequencing

3.7.7 Contact tracing

3.7.8 Ventilation considerations

3.7.9 Bed spacing

3.7.10 Review of physical distancing

3.7.11 COVID-19 messaging

 

The extent of the outbreak investigations should be decided by the IMT with an emphasis on active case finding and identifying any factors which have contributed towards the development of the outbreak.  Investigations undertaken and subsequent findings should be  documented by the IMT.

3.7.1 Epidemiological data/Timelines

A basic epidemiological investigation characterising the outbreak in time, place and person should be undertaken.  This process will help identify potential sources and mode of transmission. 

3.7.2 Identifying missed opportunities to isolate

Review of patient cases should consider any potential missed opportunities to isolate a patient, a delay in which may have resulted in onward transmission.  In particular, consider any missed atypical presentation of COVID-19.  Any learning should be widely communicated to all clinical staff in the board.

3.7.3 IPC practice and compliance (including AGPs)

Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission.  Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed. 

Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the correct fallow times are being observed prior to other patients using the room in which the AGP was undertaken.  The IMT may choose to repeat audits as part of the outbreak investigation. 

Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within the Scottish COVID-19 addendum.

Ensure that patients are wearing face masks appropriately as per the Scottish COVID-19 addendum.

3.7.4 Review of visiting

When investigating an outbreak of COVID-19, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic, declining to wear face coverings or non compliance with physical distancing.  Consider what, if any, measures need to be introduced to mitigate any risks identified.

3.7.5 Testing during an outbreak

Proactive case finding should be supported through selected testing of any suspected symptomatic cases and when indicated, asymptomatic testing as determined by the IMT.  The highest level of benefit in terms of reducing transmission will be from identifying those most likely to have been infected.  The highest level of benefit in terms of reducing harm will be from detecting asymptomatic positive cases who may transmit the infection.

LFD testing may be undertaken to enable early detection of cases during an outbreak however, regardless of LFD result, a confirmatory follow up PCR test must also be undertaken.

• Patients: All patients symptomatic of COVID-19 should be tested.
  
  
• Staff: All staff who are symptomatic of COVID-19 must be tested and excluded from work. Follow COVID-19: Management of exposed healthcare workers and patients in hospital settings.

3.7.6 Whole Genome Sequencing

Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions.

3.7.7 Contact tracing

This is a 2 step process involving identification of contacts and then risk assessing which contacts will require self-isolation.

Anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact. 

The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors.  IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact and avoid the need for these staff having to be excluded from work.

Case definitions for contacts

A contact is defined as a person who, in the period 48 hours prior to and 10 days after the confirmed case’s symptom onset, or date a positive test was taken if asymptomatic and had at least one of the exposures listed below. 

Household contact:

• Those that are living in the same household as a case for example those that live and sleep in the same home, or in shared accommodation such as university accommodation that share a kitchen or bathroom.
• Those that do not live with the case but have contact within the household setting.
• Those that have spent a significant time in the home (cumulatively equivalent to an overnight stay and without social distancing e.g. 8 hours or more) with a case during the infectious period.
• Sexual contacts who do not usually live with the case.
• Cleaners (without protective equipment) of household settings during the infectious period, even if the case was not present at the time.

Non-household contact

Direct contact:

• Face to face contact with a case within 1 metre for any length of time, including: being coughed on.
• Having a face-to-face conversation.
• Having skin-to-skin physical contact.
• Any contact within 1 metre for one minute or longer without face-to-face contact.
• A person who has travelled in a small vehicle with someone who has tested positive for coronavirus (COVID-19); or in a large vehicle near someone who has tested positive for coronavirus (COVID-19).

Proximity contact:

• A person who has been between 1 and 2 metres of someone who has tested positive for coronavirus (COVID-19) for more than 15 minutes, cumulatively, during the period defined above.

Contact tracing patients

Typically, any patients in the same bed bay as a confirmed case should be considered household contacts.  For larger open bedded areas such as ITUs or nightingale wards the proximity contact definition may be used however, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures such as:

• Whether or not all the patients were bed bound (e.g in an ITU area).
• Whether or not the confirmed case had an AGP performed during the exposure period.
• The patient population and patients who may mobilise between bed spaces including the confirmed case.
• Any reported suspected COVID-19 symptomatic cases in other parts of the ward or department.
• Ventilation; is the area poorly ventilated?  i.e only natural ventilation and windows have been closed?

Depending on the findings of the considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.

For cases who have been in a single side room for the exposure period, only staff, patients and visitors who have entered the room of the confirmed case should be considered potential contacts.  If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.

IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g radiology, shops, other wards and consider any potential contacts in these areas.

Contact tracing staff

The flow chart in appendix 1 should be used to assess staff contacts in the healthcare setting and assumes that staff who have worn PPE have had training in its use and that the PPE worn at the time of contact met technical and quality standards.

Contact tracing visitors

It is essential that ward staff keep comprehensive lists of all visitors who have come into the ward.  These lists should be provided to Test and Protect teams when an outbreak is recognised to enable contact tracing of visitor contacts.  Teams should take into account the PPE worn by visitors when considering them as possible contacts requiring self-isolation.  Details of visitor PPE can be found within the Scottish COVID-19 addendum . 

It should be noted that whilst visitors may have worn PPE as advised by staff, they are not trained in donning and doffing and therefore there remains a higher risk of exposure.

3.7.8 Ventilation considerations

Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation.  It is important to consider best practice on ventilation and FAQs developed specifically in response to the COVID-19 pandemic.  The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated. 

The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;

• Is the planned preventative maintenance (PPM) programme up to date?
• When was the last PPM check performed?
• Is ventilation system functioning within normal set parameters?
• Are ventilation grilles, AHU, ductwork etc clean and free from dust/debris?
• Is cleaning schedule for the above up to date?
• Does the ventilation system meet current specification?

3.7.9 Bed spacing

Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing are adequate. See section 5.12.1 of COVID-19 addendum.

3.7.10 Review of physical distancing

Physical distancing amongst patients and staff should be reviewed by the IMT. 

Non-compliance with physical distancing by staff, particularly during breaks, when car sharing and outside of work, has been regularly reported as a factor in the development of outbreaks in the healthcare setting.  Review of staff meeting rooms, changing rooms, break facilities, and other non clinical meeting areas are important to detect and control transmission between staff. 

Patients must be reminded of the importance of physical distancing and refraining from entering the bed space/zone of other patients.  

Organisations should ensure there are engineering and administrative measures in place wherever possible to support physical distancing such as floor markings, physical barriers, staggered tea breaks and promotional signage.

3.7.11 COVID-19 messaging

IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate.  COVID-19 messaging should be in place to promote;

• Physical distancing
• Hand hygiene
• Appropriate use of face masks and face coverings
• Awareness of COVID19 symptoms & requirement for patients/staff/visitors to report symptoms to staff
• No visiting if symptomatic
• Staff testing

Every opportunity to promote this messaging should be considered.

3.8 COVID-19 Formulate hypothesis

A hypothesis or hypotheses should be generated at the first IMT.  The hypothesis should address the potential source and mode of transmission.  The hypothesis should be re-visited at every IMT and consideration given as to whether it remains to be the most probable cause of the outbreak.

3.9 COVID-19 Control Measures

3.9.1 Patient placement

3.9.2 Hand hygiene

3.9.3 Personal Protective Equipment

3.9.4 Safe Management of care Equipment

3.9.5 Safe Management of Care Environment

3.9.6 Waste and Linen

3.9.7 Staff

3.9.8 Management of staff exposed to a case

3.9.9 Closure of the ward/unit

3.9.10  Other control measures which may be considered by the IMT

3.9.11 Conversion of outbreak ward to high risk pathway

 

Control measures should be implemented immediately to prevent onward transmission of COVID-19.  These must include:

3.9.1 Patient placement

• The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified.
• Ideally, those who are confirmed cases of COVID-19 should be transferred to the High Risk (Red) Pathway as soon as possible.
• Cohort areas may be established where required and may consist of the following;
  • Confirmed positive COVID-19
  • Asymptomatic contacts of COVID-19
• Suspected cases (symptomatic) should be isolated on the ward and tested for COVID-19 as soon as possible. Symptomatic patients should not be cohorted together.  The cohorting of symptomatic patients’ risks transmission of other respiratory viruses whilst the causative pathogen remains unknown.
• Doors to isolation rooms and cohorts should be closed and signage clear.
• Patient placement is regularly reviewed and documented in patient case notes.
• Restrict transfers to any other ward or department unless essential.
• Depending on the degree of exposure to the index case/s, the number of patients exposed, type of department in which the outbreak has occurred, the clinical needs of the patients and where staffing allows, it may be necessary to leave the contacts in the low or medium risk COVID-19 pathway and apply cohort nursing – a local risk assessment should be undertaken by the IMT and take account of whether the ward will remain open or closed.

Any asymptomatic contacts should be isolated or remain cohorted together until the 14 day isolation period has elapsed. 

During the isolation period, contacts must be managed in the same manner as a confirmed case on the High risk pathway.

• If a contact develops symptoms during the 14 day isolation period, testing should be performed as soon as possible. If a contact tests positive for COVID-19 they should be transferred to the High Risk (Red) pathway as soon as possible to complete their isolation period which should be reset to commence from the day of symptom onset.
• All efforts should be made to dedicate staff to the management of the cohort and ideally those staff must not then go between the case and contacts and all other unaffected patients on the ward. These staff cohorts should be maintained wherever possible for the duration of the isolation period.

3.9.2 Hand hygiene

• Reinforce hand hygiene techniques and opportunities to all staff groups and ensure hand hygiene signage is in place
• Adequate supplies of ABHR and plain liquid soap is available.
• Ensure patients are supported with hand hygiene where required and symptomatic patients are provided with disposable tissues and waste bag for disposal.

3.9.3 Personal Protective Equipment

• Reinforce appropriate PPE use as per COVID-19 IPC addendum (general use and AGP) to all staff groups
• Ensure adequate PPE supplies are available

3.9.4 Safe Management of care Equipment

• All non essential items of equipment and any clutter removed from ward to aid cleaning.
• Dedicated equipment for the affected areas where possible.  Ensure equipment is cleaned as per appendix 7 of NIPCM.

3.9.5 Safe Management of Care Environment

• As a minimum, twice daily cleaning with chlorine based detergent is in place throughout the ward paying close attention to touch surfaces
• Terminal clean is undertaken following a patient transfer, discharge, once the patient is no longer considered infectious and prior to ward reopening.

3.9.6 Waste and Linen

• Waste associated with the affected area is disposed of as category B waste and in line with COVID-19 addendum.
• All linen used by patients in the affected area should be managed as infectious linen in line with COVID-19 addendum.
• When a bed is vacated and the linen removed, new linen should not be put in place until the ward or bed bay has been terminally cleaned and is ready to re-open to admissions and transfers.

3.9.7 Staff

• Ward staff provided with regular updates and support regarding outbreak management.
• The number of staff entering the ward should be restricted as far as possible. The number of staff on wards rounds should be reduced to essential staff only.  Non-essential patient assessments by staff external to the ward should be postponed until the outbreak is closed.
• Staff should be cohorted to the symptomatic patients and any contacts and avoid caring for other unaffected patients on the ward wherever possible.
• Regular symptom vigilance must be in place at all times especially during outbreaks and arrangements made for staff to leave the ward if symptoms develop during a shift.

3.9.8 Management of staff exposed to a case

• IMTs should refer to the COVID-19: Management of HCW and exposed patients or residents in health and social care settings when managing staff identified as contacts.
• Staff members who have a positive test must inform their line manager and arrangements should be made for them to stop work immediately and return home, avoiding the use of public transport. Local arrangements for transport of infected patients should be followed.
• NHS Boards should have arrangements in place to backfill staff who test positive.
• The staff member who tests positive will need to self-isolate for a period of 10 days, and their households also need to isolate for a period of 10 days as described by NHS Inform in Coronavirus (COVID-19): Guidance for households with possible coronavirus infection.
• In addition, staff who test positive will be contacted by the contact tracing team as part of the Test and Protect programme.
• More information can be found in the healthcare worker testing guidance on the Scottish Government website.

3.9.9 Closure of the ward/unit

• There should be a low threshold for ward closure.
• If cases have limited patient contacts which can all be isolated or cohorted in a closed bed bay, the IMT may decide that it is appropriate to keep the ward open taking account of bed availability and any specialist services provided in the affected ward.  This must be reviewed regularly (at least twice daily) and where there is any other symptom onset identified in staff, patients or visitors outside of the affected bay, the ward should be closed to admissions and transfers.
• Where all contacts and subsequent cases are unable to be cohorted, isolated or transferred to the high risk pathway, the ward should be closed to admissions and transfers wherever possible.

3.9.10  Other control measures which may be considered by the IMT

• Visiting restrictions
• Education sessions for staff if knowledge gaps identified
• Wider screening of patients and staff during the outbreak period

3.9.11 Conversion of outbreak ward to high risk pathway

Where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a high risk pathway ward to allow confirmed COVID-19 cases to be transferred/admitted to the area and utilise bed capacity within the ward.  This is an operational decision which must be carefully considered, documented and undertaken as a last resort.  The following must apply;

• If there are contacts on the ward who remain asymptomatic and do not have a confirmed COVID-19 positive test, these may be moved to other wards for the conversion to take place.  However, these contacts must be placed in single side rooms on transfer and must be managed as a high risk patient until the 14 day isolation period is complete
• There must be no patients remaining on the outbreak ward who have not yet tested positive for COVID-19 – all patients on the ward must be confirmed COVID-19 before the conversion takes place.
• The incident must remain open on the boards reporting dashboard to ensure all contacts are monitored regardless of where they are placed until the ‘ending an outbreak’ criteria is met.

In choosing to convert the outbreak ward to a high risk pathway ward, IMTs alongside hospital management must weigh up the risk associated with transferring contacts to other wards and the demand for patient beds to accommodate emergency admissions.

 

 

 

 

 

3.10 COVID-19 Communications

• Internal outbreak communication plans should be agreed for each NHS board and this should include senior managers within the board, department leads for visiting staff such as clinical teams, phlebotomists, pharmacists, physiotherapists, all support staff, including porters, cleaners, volunteers.
• Regular updates should be reported to ARHAI in line with section 3.11.
• COVID-19 test results should be documented in individual case notes including any IPC advice issued.
• Where guidance can not be followed, this should be risk assessed and documented by the clinical team or IMT.
• Media statements should be prepared by the IMT ready for release should it be required.
• Patients and carers where applicable should be kept informed of all screening investigations and provided with information leaflets where available or advice provided from NHS Inform.

3.11 COVID-19 Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) reporting requirements

Reporting should be led by the IPCT.  Reporting of COVID-19 should occur on recognition of a COVID-19 cluster

COVID-19 Cluster (possible COVID-19 outbreak as defined in section 3.5)

• A cluster should be assessed using the Healthcare Infection Incident Assessment Tool (HIIAT) as per Appendix 14 of the NIPCM. 
• All confirmed clusters/possible outbreaks, must be reported to ARHAI. 
• A Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Too (HIIORT). should be completed for any HIIAT score of Red or Amber and for any HIIAT Green incident where support from ARHAI Scotland is required/requested. 
• HIIORTs must be submitted using the Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Tool. 
  
• The data submitted above is reported through ARHAI to the Scottish Government Healthcare Associated Infection Policy Unit and it is essential that all fields within the tools are completed to enable reporting requirements to be met. 
• Any media statements prepared by the IMT in response to the incident should be shared with ARHAI.

 

3.12 COVID-19 Learning from the outbreak

As the COVID-19 pandemic continues, it is essential that NHS Boards record and disseminate learning from outbreaks internally and with ARHAI for sharing nationally. 

An evaluation of the effectiveness and efficiency of outbreak investigations and control measures will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.

3.13 COVID-19 Outbreak Resources

• Outbreak checklist
• Outbreak data collection tool
• IMT generic COVID-19 Agenda
• IMT generic COVID-19 Agenda Aide-memoire

 

 

COVID-19 Appendix 1 - Assessing staff contacts in Acute Settings

This appendix should be used by Health Protection Teams (HPTs), Occupational Health Services (OHS) and Infection Preventon and Control Teams (IPCTs) aiming to apply some consistency in approach to assessment of staff contacts within healthcare and state health and care settings. 

Appendix 1 - Assessing staff contacts in Acute Settings

This addendum has been developed in collaboration with NHS boards to provide Scottish context to the UK COVID-19 IPC remobilisation guidance, some deviations exist for Scotland and these have been agreed through consultation with NHS Boards and approved by the CNO Nosocomial Review Group.  These processes deviate from the National Infection Prevention and Control Manual normal process for sign off due the timescales for COVID-19 guidance approval.

When an organisation adopts practices that differ from those recommended/stated in this national guidance, that individual organisation is responsible for ensuring safe systems of work, including the completion of a risk assessment(s) approved through local governance procedures.

Version control

26 October 2020
Version 1.0
First publication.

28 October 2020
Version 1.1
Update to section 5.7 'Safe Management of the Care Environment' to reflect detail of 2nd daily clean. Update to section 5.5 'Personal Protective Equipment' to be more explicit.

6 November 2020
Version 1.2
Update to align references to changing of facemasks between pathways.

20 November 2020
Version 1.3
5.2 New section on communications when transferring a suspected/confirmed case
5.11 New section on car sharing
5.13 New section on visiting
Update to definition of recovered patient

9 December 2020
Version 1.4
5.5.8 New section on PPE requirements for delivery of vaccinations
5.14 New section on outbreaks

18 December 2020
Version 1.5
5.1 Link to RCPCH paediatric guidance for pre-operative admission assessment and testing requirements
5.2 New section on COVID-19 testing
5.3.7 New section on Patients returning from weekend/day pass
5.6.3 New FRSM poster (ways to improve fit)
5.15.1 New section on Whole Genome Sequencing (WGS)

23 December 2020
Version 1.6
5.1.3 Updated to reflect changes in stepdown guidance
5.2  Inclusion of SG link to asymptomatic staff testing information
5.3.5 New section Transferring non-COVID-19 patient between different wards and hospitals.

22 January 2021
Version 1.7
5.2 Update to the COVID-19 testing section and associated testing table
5.3.9 New section on guidance for the Discontinuation of Infection control precautions and discharging COVID-19 patients from hospital
5.6 Update to PPE guidance specifically in relation to visors
5.13 New section on the hierarchy of controls

18 February 2021
Version 1.8
Update to resources and Rapid reviews content
5.1.2  Additional wording added to definition of suspected case section to reflect wide variety of presenting symptoms
5.1.3 Strengthening of triage question relating to travel history
5.6 Additional paragraph in PPE section reinforcing need for visiting staff to seek clarity on patient pathway and PPE requirements prior to patient contact

26 March 2021
Version 1.9
5.3.9 Update to stepdown requirement for inpatient table to recognise need for clinical assessment
5.6.7 Sessional PPE use no longer accepted beyond eye protection in the high risk pathway and FRSMs across all pathways.
5.21 Useful tools section added

5.1 COVID-19 case definitions and triage

5.1.1 Definition of a confirmed case

5.1.2 Definition of a suspected case

5.1.3 Triaging patients

 

5.1.1 Definition of a confirmed case

A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.

5.1.2 Definition of a suspected case

A wide variety of clinical symptoms have been associated with COVID-19: headache, loss of smell, nasal obstruction, lethargy, myalgia (aching muscles), rhinorrhea (runny nose), taste dysfunction, sore throat, diarrhoea, vomiting and confusion; fever may not be reported in all symptomatic individuals. Patients may also be asymptomatic

The definition of a suspected case is as follows;

An individual meeting one of the following case criteria taking into account atypical and
non-specific presentations in older people with frailty (further information on presentations and management of COVID-19 in older people and Scottish Government and Appendix 1 :Think COVID:Covid-19 Assessment in the Older Adult - Checklist), those with pre-existing conditions and patients who are immunocompromised;

Community definition:

• Recent onset new continuous cough

or

• fever

or

• loss of/change in sense of taste or smell (anosmia)

Definition for individuals requiring hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

• influenza-like illness (fever greater than or equal to 37.8֯C and at least one of the following respiratory symptoms, which must be of acute onset – persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)

or

• a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms

Patients must be assessed for bacterial sepsis or other causes of symptoms as appropriate.

5.1.3 Triaging patients

Triaging of patients within all healthcare facilities must be undertaken to enable early recognition of COVID-19 cases.  Wherever possible, triage questions should be undertaken prior to arrival at the healthcare facility.  For emergency admissions, triage questions should be completed immediately on arrival where it is safe to do so without delaying any necessary immediate life-saving interventions. With the emergence of new variants of concern (VOC) it is essential that a travel history is sought and recorded.

The following are examples of triage questions:

• Do you or any member of your household/family have a confirmed diagnosis of COVID-19?

If yes, wait until 10 day self-isolation period is complete before treatment or if urgent care is required, follow the high-risk pathway and isolate for 14 days.

• Are you or any member of your household/family waiting for a COVID-19 test result?

If yes, ascertain if treatment can be delayed until results are known.  If urgent care is required, follow the high risk pathway and isolate for 14 days.

• Have you travelled internationally to any country which isn’t exempt from self-isolation rules in the last 14 days?

If yes, wait until 10 days self isolation period is complete before treatment.

Only urgent care should be provided during the self-isolation period. The patient should be placed in a single side room on the amber or red pathway depending on a clinical and individual assessment – see footnote 1 in section 5.1 (see Scottish Government COVID-19 international travel and quarantine  for the list of countries exempt from self-isolation) and will require 14 days self isolation.

Single side room placement is essential to prevent onward transmission of new VOC within healthcare settings.

• Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 14 days?

If yes, wait until 10 days self-isolation period is complete before treatment or if urgent care is required, follow the high-risk pathway and isolate for 14 days unless COVID-19 test is negative and COVID-19 is clinically ruled out .

• Do you have any of the following symptoms?
  • high temperature or fever
  • new, continuous cough
  • loss or alteration to taste or smell

If yes, provide advice on who to contact (GP/NHS111) or, if admission required, follow high-risk pathway and isolate for 14 days.

• Is there any reason why you are unable to wear a face covering when attending for your appointment or admission?

If no, remind patient to wear face covering on arrival or supply facemask.

A word version of these questions for triage is available to download.

5.2 COVID-19 Testing

All planned adult elective surgical admissions should be tested in line with SIGN Guidance for Reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery and elective surgical paediatric admissions must be tested in line with RCPCH guidance. 

A letter was also issued to NHS Scotland Chief Executives on 27^th November detailing the staged roll out of the admission testing expansion plan to include;

• All emergency admissions
• All planned admissions to hospitals
• Routine testing of asymptomatic, patient facing healthcare workers

A table containing a summary of testing requirements in NHSScotland is available.  When using this table the following applies;

• Screening undertaken outwith national programmes which are detailed at the links above should be based on decision of clinical services e.g screening in critical care settings.
• Any patient who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested within a period of 90 days from their initial symptom onset, unless they develop new possible COVID-19 symptoms. This is because fragments of inactive virus can be persistently detected by PCR in respiratory tract samples for some time following infection. The exception to this is:
  
  • Discharge to care home/residential facilities where 2 negative tests must be achieved 24 hours apart prior to transfer
• It is recognised that a patient may meet different criteria for testing multiple times in a short period of time (admission screening, transfers to another ward, contact of a case, outbreak management). If an inpatient has undergone a COVID-19 test in the previous 24 hours, there is no need to repeat it and the result can be accepted for any of the testing requirements with the exception of
  • New symptoms onset – a new test should be performed as soon as symptoms are recognised
  • Pre elective screening – where the requirement for a negative test must be within a set time period (48 or 72 hours)

5.3 Patient placement/assessment of risk

5.3.1 Critical care units

5.3.2 Split pathways

5.3.3 Staff cohorting

5.3.4 Moving patients between pathways

5.3.5  Patient transfers

5.3.6 Single side room prioritisation

5.3.7 Patients returning from day or overnight pass

5.3.8 Local and National prevalence data

5.3.9 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

Table 1 - Stepdown requirements for hospital inpatients and positive staff remaining in hospital

Table 2 - Stepdown requirements for patients being discharged from hospital 
Table 3 - Stepdown requirements for outpatients

Defined pathways must be established to ensure segregation of patients determined by their risk of COVID-19.  Any other known or suspected infections and the need for any Aerosol Generating Procedures (AGPs) must be considered before patient placement within each of the pathways.

Examples of pathways are described here.  Your board may use different names for each of the pathways from those described and you should familiarise yourself with the pathways in your clinical area that align with those described here.

High-risk COVID-19 pathway

Known as the high-risk COVID-19 pathway in the UK IPC remobilisation guidance. It is more commonly known as the red pathway in many boards within Scotland.

1. Confirmed COVID-19 individuals.
2. Symptomatic or suspected COVID-19 individuals (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
3. Those who are known to have had contact with a confirmed COVID-19 individual and are still within the 14 day self-isolation period and those who have been tested and results are still awaited.
4. See footnote 1.

Low-risk COVID-19 pathway

Known as the low-risk COVID-19 pathway in the UK IPC remobilisation guidance. Commonly known as the green or super green pathway in many boards within Scotland.

1. Patients who have been triaged and meet the following criteria – asymptomatic and no known contact with a COVID-19 case and meet isolation and testing criteria as per SIGN Guidance for for Reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery.

   NB: Paediatric services refer to RCPCH guidance for pre-operative admission assessment and testing requirements only.  All other IPC guidance should be followed as per this addendum.

Medium-risk COVID-19 pathway

Known as the medium-risk COVID-19 pathway in the UK IPC remobilisation guidance. Commonly known as the amber pathway in many boards within Scotland.

1. All other patients who have been triaged and who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic individuals who refuse testing or for whom testing cannot be undertaken for any reason.
3. See footnote 1
4. Recovered COVID-19 patients – see Discontinuation of IC precautions in section 5.3.9

5.3.1 Critical care units

Where facilities allow, boards may allocate separate critical care units to each of the defined pathways.  It is accepted however that critical care units in some NHS boards may have to house patients from each of the three pathways on the one unit. Pathways must be clearly signposted. 

Where all COVID-19 patients requiring Aerosol Generating Procedures (AGPs) on the high and medium risk pathways can be isolated in a single side room the whole unit does not need to be considered a 'High Risk' area and no longer requires unit-wide airborne precautions to be applied. 

However, consideration may need to be given to unit-wide application of airborne precautions where the number of cases of high and medium-risk pathway patients requiring AGPs increases and all such patients cannot be managed in a single side room.

Where AGPs on any medium and high risk patient is required on the main unit, this presents a risk to the surrounding patients and staff and unit-wide airborne precautions would be required. Segregation of patient pathways must continue to reduce exposure risk to medium risk pathway way patients from those in the high risk pathway.

Bed management needs to be considered preoperatively in the event that a critical care bed is required postoperatively to ensure there is a bed available on the correct pathway.

Further information can be found in Frequently Asked Questions (FAQs) for critical care units.

5.3.2 Split pathways

Where necessary, hospital care areas may designate self-contained areas on the same ward for the treatment and care of patients at high and medium risk or patients at medium and low risk of COVID-19 following a risk assessment undertaken in conjunction with the local IPCT and taking into account considerations such as the type of clinical area, the patient group, the ward environment (including single side room capacity) staffing levels and overall bed capacity and demand.  

Patients on the high and low risk pathways should not be on the same ward unless this is a critical care or regional specialist centre where clinical care cannot be provided anywhere else. This may require discussion with the IPCT. There should be clear physical segregation of pathways with signage in place to support this and staff should be cohorted to the different pathways within the same ward wherever possible. 

5.3.3 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for patients in each of the different pathways.

There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between pathways. 

Rotas should be planned in advance wherever possible, to take account of different pathways and staff allocation.

For staff groups who need to go between pathways, efforts should be made to see patients on the low risk pathways first, then the medium risk pathway, then the high risk pathway.  

FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogens and when leaving high-risk (red) pathway areas

5.3.4 Moving patients between pathways

Any patient on the medium or low pathways who develop symptoms of COVID-19 should be isolated immediately and tested for COVID-19. 

Any patient who goes on to test positive for COVID-19 (whether symptomatic or asymptomatic) should be transferred to the high risk pathway. 

Patients may only move from the medium pathway to the low risk pathway where they have been isolated in a side room for the full 14 days and staff can document that there have been no recorded PPE breaches by staff or visitors who have entered the patient’s room during the 14 day period. 

A high level of suspicion should be applied so as not to expose patients on the low risk pathway to a patient who may potentially be incubating COVID-19.

Patients who have been on the high risk pathway having had confirmed COVID-19, may be moved to the Medium risk pathway after they meet the definition for a ‘recovered patient’.

5.3.5 Patient transfers (please also refer to testing table for testing requirements on transfer)

Non-COVID-19 patient transfers between wards and departments in the same hospitals

• Patient movement between different bed bays and transfers between different wards should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both wards/departments is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort. Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.
• Patients should continue to be tested immediately if clinically indicated. A clinical or a public health professional may consider testing even if the definition of a possible case is not met.

Non-COVID-19 patient transfers to a new hospital (either within the same Board or new Board

• Patient movement between hospitals should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both hospitals is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort.  Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• Patients who are transferred to a new hospital should follow the medium pathway. 
• If patient is a planned transfer to a clinically vulnerable area, then pre-transfer testing must be built into the pre-transfer testing must be built into the transfer plan and a test undertaken pre-transfer wherever possible.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.

NB: A negative test does not mean that the patient is not incubating the virus. Staff should practice vigilance in monitoring for any symptom onset in the patient after transfer and reinforce the importance of COVID-19 measures. This includes physical distancing, hand hygiene, wearing of facemasks and respiratory etiquette.

Transferring suspected/confirmed COVID-19 patients between wards, departments or hospitals during infectious period

Wherever possible, patients who are confirmed or suspected to have COVID-19 should not be moved from the high risk pathway ward until they have completed 14 days of isolation and meet the definition for a recovered patient as described in footnote 1 and criteria contained within section 5.3.9. There may however be instances where it is necessary to transfer a patient prior to completion of their 14 day isolation period such as;

• The patient no longer requires critical care and the critical care bed is required for another patient
• The patient requires escalation of care to a critical care unit
• The patient requires urgent treatment in a regional specialist unit and postponement would have a detrimental effect on the patient and the care cannot be provided on the ward they currently reside in
• The patient requires an urgent procedure or investigation to be undertaken and postponement would have a detrimental effect on the patient

The local IPCT should be notified of any patient transfer out of a high risk ward where the patient has not yet completed their 14 day isolation period.

Communication with the receiving department/NHS Board is vital to ensure appropriate IPC measures are continued during and after transfer.  The patient must continue to be managed as a high risk pathway patient. Communications must include;

• Patient symptom onset date
• Patient positive test date (if confirmed)
• Date when patient will have completed 14 days in isolation
• Current symptom status and any test results still awaited
• Any patient details which prevent or impact on the necessary transmission based precautions required for COVID-19 i.e. falls risk requiring door to remain open, patient does not adhere to isolation
• Confirm if local IPC team has been informed of transfer

Ensure transferring ambulance or portering staff are advised of the necessary precautions required for PPE and decontamination of transfer equipment.

There is no need to test the patient again on transfer provided symptomatic cases have already had a test taken.

5.3.6 Single side room prioritisation

Any patient who has a co-infection with COVID-19 and any other known or suspected infectious pathogen must not be cohorted with other COVID-19 patients.

Any patient who is required to quarantine following arrival to Scotland from overseas should be prioritised for a single side room to reduce the transmission risk of new variants of concern (VOC).

5.3.7 Patients returning from day or overnight pass

Patients who have been allowed to leave the healthcare facility for the day or for an overnight stay should be triaged in advance of their immediate return to the facility and again on arrival at the facility to determine which pathway they should be placed on.  Patients should not return to the low risk pathway and as a minimum should be placed on the medium risk pathway.

5.3.8 Local and National prevalence data

Boards must have an escalation action plan in place ready to deploy should prevalence increase triggering a potential cessation of elective services and an increase in high risk pathway cases. 

Local and national prevalence and incidence data as advised by country-specific public health organisations should be used to inform the pandemic plan which should include local systems for monitoring prevalence, triggers and a defined escalation process which takes account of bed capacity, COVID-19 cluster data and risks associated with disruption to elective services.  These considerations may be site-specific or board-wide.  

As case numbers of COVID-19 fluctuate, so too will the volume of patients on each of the pathways.  Where critical care units need to expand, this action plan should include allocated areas for additional ITU beds and sufficient staffing and equipment to support the expansion.

Footnote 1

When deciding patient placement for untriaged individuals where symptoms are unknown – for example, where the patient is unconscious – or individuals who have returned from a country on the quarantine list in the last 14 days, a full clinical and individual assessment of the patient should be carried out prior to placement in a side room on the red or amber pathway.  This assessment should take account of risk to the patient (immunosuppression, frailty) and clinical care needs (treatment required in specialist unit). 

5.3.9 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

It is important to note that patients deemed clinically fit for discharge can and should be discharged before resolution of symptoms and should continue to self isolate in the community for a total of 14 days.

Before control measures are stepped down for COVID-19, clinical teams must first consider any ongoing need for transmission based precautions (TBPs) necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or patients with ongoing diarrhoea.

Patient discharge advice leaflets are available 

Key notes below to be referred to in conjunction with tables 1-3;

• Number of isolation days required– All patients who have been in hospital must complete 14 days isolation if remaining in hospital or being discharged to a residential setting or care home.  This is because, in general, those with COVID-19 who are admitted to hospital will have more severe disease than those who remain in the community, especially if they require critical care. In addition, those admitted are more likely to have pre-existing conditions such as severe immunosuppression. In healthcare settings, including residential care facilities, there are considerable numbers of immunocompromised and vulnerable patients who will be at risk of nosocomial infection.

Other household members should complete their 10 day stay at home period (as described in Stay at Home guidance). If this did not start before the patient was admitted to hospital, then it should commence from the day the patient returns to the household, unless the patient has already completed their appropriate period of isolation within hospital.

• COVID-19 clinical requirements for stepdown – This can be done when the patient’s clinical status is appropriate for discharge and ongoing care needs can be met at home or in the facility to which they will be transferred.  Those with COVID-19 additionally require the following; Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some individuals, and is not an indication of ongoing infection when other symptoms have resolved. If inpatient is being discharged home, they must be given clear advice directing them what to do if their symptoms worsen.

 

• Testing required for stepdown –some inpatients may require testing and this should be undertaken as per tables 1-3 below unless there are overriding clinical reasons where this is not appropriate.  Where testing is not possible (e.g. patient doesn’t consent or it would cause distress) and if discharged to care facility within the 14-day isolation period then there must first must be a risk assessment of the discharge location and the ability of the individual being discharged to adhere with the required isolation measures in the care facility for the remaining 14 day isolation period. 

For severely immunocompromised individuals or those at extremely high risk of severe illness (as determined by an individual assessment by the clinician), one negative test is acceptable for stepdown. If repeat testing is carried out and patients remains positive after 14 days, further testing should be considered after a further 7 days if the patient remains in hospital, or at intervals of 2 weeks in the community, e.g. if attending hospital for another pressing indication. Further testing should be determined by the senior clinician in conjunction with the local laboratory. For example, if the patient is being transferred to an inpatient environment containing severely immunosuppressed patients (e.g. Bone Marrow Transplant unit) 2 negative tests 24 hours apart may be considered.

Table 1 - Stepdown requirements for hospital inpatients and positive staff remaining in hospital

Inpatient cohorts	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Inpatients - General	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Not routinely required
Inpatients - Severely Immunocompromised as determined by Chapter 14a of the Green Book	14 days from symptom onset (or first positive test i symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics. Individual risk assessment by clinical teams taking account of symptoms, clinical presentation, intended setting for stepdown.	Local clinical teams may consider testing as part of the stepdown process and where undertaken, 1 negative test would be  acceptable for stepdown.
Inpatients with severe COVID-19 (requiring ITU/HDU for COVID-19 treatment)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever for 48 hours without use of antipyretics. Individual risk assessment by clinical teams taking account of symptoms, clinical presentation, intended setting for stepdown.	Local clinical teams may consider testing as part of the stepdown process and where undertaken, 1 negative test would be  acceptable for stepdown.
Staff working in healthcare	10 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Not routinely required. Resume routine testing after 90 days from first positive isolate unless symptoms develop before then in which case test should be repeated.

Table 2 - Stepdown requirements for inpatients being discharged from hospital

Discharge cohort	Number of isolation days required	Does isolation need to be completed in hospital?	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Patient discharging to a care facility including nursing homes and residential homes	14 days from symptom onset (or first positive test if symptom onset undetermined)	No – patient may be discharged to care home but only after 2 negative tests achieved and must be placed in a single room facility on discharge until 14 day isolation complete.  Provide care as per NIPCM COVID-19 Care Home addendum	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	2 negative tests required commencing on day 8 & taken 24 hrs apart
Patient discharging to their own home - General	14 days from symptom onset (or first positive test i symptom onset undetermined)	May complete at home and follow Stay at home guidance .  Must be given clear advice for what to do if their symptoms worsen	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Not routinely required
Patient discharging to their own home – someone in household is severely immunocompromised or at risk of severe illness	14 days from symptom onset (or first positive test if symptom onset undetermined)	Wherever possible, patient should be discharged to a different household from anyone immunocompromised or at severe risk of infection.  If not possible – see ‘testing required’	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Testing for clearance is encouraged.

Table 3 - Stepdown requirements for outpatients

Discharge cohort	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Outpatient	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	Virological clearance is encouraged for those severely immunocompromised, at high risk of severe disease and those discharged from critical care. If  required to help inform actions at next OP appointment

Other than the limited scenarios described above which indicate testing prior to discontinuation of IPC precautions, any patient who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested within a period of 90 days  from their initial symptom onset, unless they develop new possible COVID-19 symptoms. This is because fragments of inactive virus can be persistently detected by PCR in respiratory tract samples for some time following infection.   If testing is undertaken within those 90 days despite this, and the result is COVID-19 positive in the absence of any symptoms, there is no requirement to isolate the patient or place them back on the high risk pathway unless a discussion between clinicians and the IPCT indicates that this is necessary.

Transferring between pathways on stepdown

Regardless of stepdown location remaining in hospital, care facility, home (receiving care at home or attending OPDs) all patients must remain on the high risk pathway until stepdown criteria is met at which point they may be transferred to the medium risk pathway.

Transporting COVID-19 patients home safely when still within the self-isolation period

On discharge, patients should be transferred home by the safest method possible to prevent onward transmission of COVID-19.  Transport home can be arranged via a variety of routes, e.g. if the patient has their own car at the hospital, and is well enough, they may drive home. If they are taking shared transport, the need for further isolation of discharged patients with COVID-19  who have not completed  their self isolation period and who do not have virological evidence of clearance should be communicated with transport staff (e.g. ambulance crews or relatives). Those transporting them should not themselves be at greater risk of severe infection.

The following guidelines apply to all methods of transport:

• the patient should be given clear instructions on what to do when they leave the ward to minimise risk of exposure to staff, patients and visitors on their way to their transport
• the patient should wear surgical face masks for the duration of the journey, and advised that this should be left on for the entire time if tolerated (not pulled up and down)
• the patient should sit in the back of the vehicle with as much distance from the driver as possible (e.g. the back row of a multiple passenger vehicle), and where possible use vehicles that allow for optimal implementation of physical distancing measures such as those that have a partition between the driver and the passenger, or larger vehicles that allow for a greater distance between the driver and the passenger
• vehicle windows should be (at least partially) open to facilitate a continuous flow of air
• vehicles should be cleaned appropriately at the end of the journey using a household detergent active against viruses and bacteria
• ensure the patient has a supply of tissues and a waste bag for disposal for the duration of the journey. The waste bag should then be taken into their house and held for a period of 72 hours before disposal with general household waste

 

5.4 Hand hygiene

Hand hygiene is considered one of the most important practices in preventing the onward transmission of any infectious agents including COVID-19. 

Hand hygiene should be performed in line with section 1.2 of SICPs.

5.5 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19. 

The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

5.6 Personal Protective Equipment (PPE)

5.6.1 Extended use of face masks for staff, visitors and outpatients

5.6.2 Face masks for inpatients

5.6.3 PPE determined by COVID-19 care pathway

Table 4: PPE for direct patient care determined by pathway

5.6.4 Aerosol Generating procedures (AGPs)

5.6.5 PPE for Aerosol Generating Procedures (AGPs)

Table 5: PPE for AGPs determined by pathway

5.6.6 Post AGP Fallow Times (PAGPFT)

Table 6: PAGPFT calculation

5.6.7 Sessional use of PPE

5.6.8 PPE for delivery of COVID-19 Vaccinations

 

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. 

PPE requirements as per standard infection prevention and control are detailed in section 1.4 SICPs.   

PPE requirements during the COVID-19 pandemic are determined by the care pathways and are detailed in 5.6.3.

PPE must not be used inappropriately.  It is of paramount importance that PPE is worn at the appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

PPE is the least effective control measure for COVID-19 and other mitigation measures as per the hierarchy of controls must be implemented and adhered to wherever possible.  More details on the hierarchy of controls can be found in section 5.13.

5.6.1 Extended use of face masks for staff, visitors and outpatients

New and emerging scientific evidence suggests that COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or
pre-symptomatic). 

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and patients.

• View further Scottish Government guidance and associated FAQs.
• View a poster detailing the ‘Dos and don’ts’ of wearing a face mask.

In Scotland, staff are provided with Type IIR masks for use as part of the extended wearing of facemasks.

• View a poster that supports the wearing of a non-medical face mask/face covering.

5.6.2 Face masks for inpatients

A surgical facemask should be worn by all inpatients across all pathways where it can be tolerated and does not compromise their clinical care for example when receiving oxygen therapy. All patients should be encouraged to adhere to this COVID-19 control measure.The purpose of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination.  This should be actively promoted throughout the healthcare setting

It is recognised that it will be impractical for patients to wear facemasks at all times and these will have to be removed for reasons such as eating and drinking or showering. There is no need for patients to wear a facemask when sleeping provided the beds are at least 2 metres apart.

A surgical facemask should be worn by all patients across all pathways during transfer between departments within the hospital. 

Where a patient is isolated in a side room, they do not need to wear a surgical facemask. However, the patient must be asked to don their mask when any staff or visitors enter the room and before they are within a 2 metre distance of the patient.

A poster promoting patient facemask use is available.

More information on physical distancing in inpatient settings can be found in section 5.14.

5.6.3 PPE determined by COVID-19 care pathway

The PPE worn for direct patient care differs depending on the COVID-19 care pathway and the task being undertaken.  It is important that the need for PPE required for any other known or suspected pathogens is also risk assessed.

Table 4 details the PPE which should be worn when providing direct patient care in each of the COVID-19 care pathways.

Type IIR facemasks should be worn for all direct patient care regardless of the pathway.  This measure has been implemented alongside physical distancing specifically for the COVID-19 pandemic.

FRSMs can be worn sessionally when going between patients on the medium (amber) and low (green) risk pathways however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogens and when leaving high-risk (red) pathway areas’.

It is recommended that surgical masks should be well fitting and fit for purpose, covering the mouth and nose in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask).  A poster provides some suggested ways to wear facemasks to help improve fit.

Healthcare staff entering different pathways to provide patient consultations (AHPs) or undertake patient transfers (portering and theatre staff) throughout the course of their working day must ensure they first clarify with nurse in charge on named nurse what pathway the patient they are attending to is on and what PPE is required.

 

Table 4: PPE for direct patient care determined by pathway

PPE used	Low-risk pathway (green)	Medium-risk pathway (amber)	High-risk pathway (red)
Gloves	If contact with blood and body fluid (BBF) anticipated, then single-use.	If contact with BBF is anticipated, then single-use.	Worn for all direct patient care. Single use.
Apron or gown	If direct contact with patient, their environment or BBF  is anticipated, (Gown if extensive splashing  anticipated), then single use	If direct contact with patient, their environment or BBF  is anticipated, (Gown if extensive splashing anticipated), then Single use.	Always within 2 metres of a patient (Gown if exensive splashing  anticipated). Single-use.
Face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask
Eye and face protection	If splashing or spraying with BBF including coughing/sneezing anticipated.  Single-use or reusable following decontamination.	If splashing or spraying with BBF includuing coughing/sneezing anticipated Single-use or reusable following decontamination.	Always within 2 metres of a patient Single-use, sessional or reusable following decontamination.

5.6.4 Aerosol Generating procedures (AGPs)

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

Below is the list of medical procedures for COVID-19 that have been reported to be aerosol-generating and are associated with an increased risk of respiratory transmission:

• tracheal intubation and extubation
• manual ventilation
• tracheotomy or tracheostomy procedures (insertion or removal)
• bronchoscopy
• dental procedures (using high-speed devices, for example, ultrasonic scalers/high-speed drills)
• non-invasive ventilation (NIV): Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• respiratory tract suctioning (see note 1)
• upper ENT airway procedures that involve respiratory suctioning
• upper gastrointestinal endoscopy where open suction of the upper respiratory tract occurs
• high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

Note 1: The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.    It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  The evidence on respiratory tract suctioning is currently being reviewed by the AGP Panel. 

Other procedures

Certain other procedures or equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk for COVID-19. Procedures in this category include administration of humidified oxygen, administration of Entonox or medication via nebulisation.

The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks. In addition, the current expert consensus from NERVTAG is that chest compressions are not considered to be procedures that pose a higher risk for respiratory infections including COVID-19.

An SBAR specific to AGPs during COVID-19 was produced by Health Protection Scotland (HPS) and agreed by NERVTAG.

The NERVTAG consensus view is that the HPS document accurately presents the evidence base concerning medical procedures and any associated risk of transmission of respiratory infections and whether these procedures could be considered aerosol-generating. NERVTAG supports the conclusions within the document and supports the use of the document as a useful basis for the development of UK policy or guidance related to COVID-19 and
aerosol-generating procedures (AGPs).

5.6.5 PPE for Aerosol Generating Procedures (AGPs)

Airborne precautions are not required for AGPs on patients or individuals in the low-risk pathway provided the patient has no other infectious agent transmitted via the droplet or airborne route.

However, we recognise that some staff remain anxious about performing AGPs on patients during this COVID-19 pandemic and therefore when prevalence is high, and where staff have concerns about potential exposure to themselves, they may choose to wear an FFP3 respirator rather than an FRSM when performing an AGP on a low-risk pathway patient.  This is a personal PPE risk assessment.  

Airborne precautions are required for the medium and high-risk pathways where AGPs are undertaken and the required PPE is detailed in table 5.

**Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators, including powered respirators, for decontamination.  This literature review will be updated to incorporate recommendations from this group when available.  In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.

Table 5: PPE for aerosol-generating procedures, determined by pathway

PPE used	Low-risk pathway (green)1	Medium-risk pathway (amber)	High-risk pathway (red)
Gloves	Single-use.	Single-use.	Single-use.
Apron or gown	Single-use apron. Gown if If splashing or spraying anticipated.	Single-use gown.	Single-use gown.
Face mask or respirator	Type IIR.2	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.	Single-use or reusable.

¹The low risk or green pathway can be used provided that the individual has no other known or suspected infectious agent transmitted via the droplet or airborne route.

² FFP3 masks must be fluid resistant.  Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated.

5.6.6 Post AGP Fallow Times (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted.  This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate. 

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 3 and clinical teams will need to undertake a risk assessment in conjunction with estates colleagues and the IPCT for rooms in which AGPs are performed. The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  it is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.  

During the PAGPFT staff should not enter this room without FFP3 masks.  Patients, other than the patient on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately as per NHS Scotland Cleaning Standards. 

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 3). Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Table 6: Post AGP fallow time calculation

Duration of AGP (minutes)	1 AC/h	2 AC/h	4 AC/h	6 AC/h	8 AC/h	10 AC/h	12 AC/h	15 AC/h	20 AC/h	25 AC/h
3	230	114	56	37	27	22	18	14	10	8 (10)*
5	260	129	63	41	30	24	20	15	11	8 (10)*
7	279	138	67	44	32	25	20	16	11	9 (10)*
10	299	147	71	46	34	26	21	16	11	9 (10)*
15	321	157	75	48	35	27	22	16	12	9 (10)*

* Note that for duration of 25 air changes per hour the minimum fallow time (to allow for droplet settling time) is 10 minutes.

Post AGP fallow times are not required for AGPs undertaken on patients in the low-risk pathway provided the patient has no other infectious agent transmitted via the droplet or airborne route.

For more information specific to theatre settings, please see the operating theatre frequently asked questions.

It is often difficult to calculate air changes in areas that have natural ventilation only.  Natural ventilation, particularly when reliant on open windows can vary depending on the climate. An arbitrary air change rate in these circumstances has been agreed as one to two air changes per hour.

If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.

5.6.7 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between patients and for a period of time where a healthcare worker was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is no longer required other than when wearing a visor or eye protection in a communal bay on the high-risk pathway and when wearing a fluid-resistant surgical face mask (FRSM) across all pathways. Sessional use of all other PPE is associated with transmission of infection amongst patients and is considered bad practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) pathway areas. 

Visors/eye protection must be changed if damaged, soiled, compromised or uncomfortable or after having provided care for a patient isolated with any other suspected/known infectious pathogens and when leaving the high risk (red) pathway.

Unit wide Airborne precautions will require sessional use of FFP3 masks throughout the unit however all other AGP PPE should be removed when no longer within 2 metres of a patient or, if still within 2 metres of the patient, then after the AGP is complete and fallow time has elapsed. It is not necessary to wear sessional gowns moving around a unit or department.  Gowns protect against excessive splash and spray which is associated with AGPs and other direct patient care procedures.

5.6.8 PPE for delivery of COVID-19 Vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct patient contact and where 2 metre physical distancing cannot be maintained.  This will protect both the HCWs and patient from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
  
  
• perform hand hygiene regularly including before and after each patient/individual. contact and as per 5 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
  
  
• wear a visor where there is anticipated splash or spraying to the face.  For example, where nasal vaccinations induce sneezing, HCWs may choose to wear a visor to prevent droplet contamination to the face following risk assessment. 

The individual on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance. 

 

• As per SICPs;
  • Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
  • Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

 

5.7 Safe management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents.

It is easy to transfer infectious agents from communal care equipment during care delivery. 

All care equipment should be decontaminated as per Table 7.

Table 7: Equipment cleaning determined by pathway

Pathway	Product
Low-risk pathway (green)	General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids or it has been used on a patient with a known or suspected infectious pathogen.
Medium-risk pathway (amber)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.
High-risk pathway (red)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

5.8 Safe Management of the Care Environment

During this ongoing pandemic, cleaning frequency of the environment should be increased across all pathways. A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean.  Where a room has not been occupied by any staff or patients since the first daily clean was undertaken, a second daily clean is not required.

It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean, free from non-essential items and equipment to facilitate effective cleaning
• well maintained and in a good state of repair

The use of general purpose detergent for cleaning in the Low Risk pathway is sufficient with the exception of isolation/cohort areas where patients with a known or suspected infectious agent are being nursed.  These areas require to be cleaned twice daily with a chlorine releasing agent containing 1000ppm av chlorine. 

Environmental cleaning in the Medium and High Risk COVID-19 Pathways should be undertaken using either a combined detergent/disinfectant solution at a dilution of
1000 ppm available chlorine or a general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000 ppm.

Cleaning across the pathways is summarised in table 8. It is recognised that NHS boards will have local protocols in place to determine the staff groups who have responsibility for cleaning different items and areas. 

Table 8: Environmental cleaning determined by pathway

	Low risk pathway (green)	Medium risk pathway (amber)	High risk pathway (red)
First daily clean	Full clean	Full clean	Full clean
Second daily clean	High Risk Touch Surfaces* within clinical inpatient areas	High Risk Touch Surfaces within clinical inpatient areas	High Risk Touch Surfaces within clinical inpatient areas
Product	General-purpose detergent. Note that cleaning in the low-risk pathway should be carried out with chlorine-based detergent for patient rooms where the patient is known to have any other known or suspected infectious agent.	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

*High risk touch surfaces as a minimum should include door handles/push pads, taps, bed heads/bed ends, cotsides, light switches, lift buttons.  Clinical inpatient areas should include the patient bedroom and treatment areas and staff rest areas.

Any areas contaminated with blood and body fluids across any of the three pathways require to be cleaned as per Appendix 9.

5.9 Safe Management of Linen

All linen should be handled as per section 1.7 of SICPs – Safe Management of Linen.

Linen used on patients in the high and medium-risk pathway should be treated as infectious

5.10 Safe Management of Blood and Body Fluid Spillages

All blood and body fluid spillages across the three pathways should be managed as per section 1.8 of SICPs – Safe management of Blood and Body Fluid Spillages and Appendix 9.

5.11 Safe Disposal of waste (including sharps)

Safe Disposal of waste (including sharps)

Waste should be handled in accordance with Section 1.9 of SICPs. Waste generated in patient bedroom and treatment  areas within the High and Medium Risk pathway should be treated as infectious (category B) where clinical waste contracts are in place.

Care home and community settings

If the facility does not have a clinical waste contract, ensure all waste items that have been in contact with the individual – for example, used tissues and disposable cleaning cloths – are disposed of securely within disposable bags.

When full, the plastic bag should then be placed in a second bin bag and tied.

These bags should be stored in a secure location (not an individual’s bedroom) for 72 hours before being put out for collection.

Note: FRSMs worn as part of the extended use of facemasks policy should be disposed of as clinical waste.

 

 

5.12 Occupational Safety

• Section 1.10 of SICPs remains applicable to COVID-19 patients.
• View occupational risk assessment guidance specific to COVID-19.

PPE is provided for occupational safety and should be worn as per table 1 and table 2.

5.12.1 Car sharing for Healthcare professionals including trainees/students

Wherever possible, car sharing should be avoided with anyone outside of your household or your support bubble.   This is because the close proximity of individuals sharing the small space within the vehicle increases the risk of transmission of COVID-19.  All options for travelling separately should be explored and considered such as;

• Healthcare staff travelling separately in their own cars
• Geographical distribution of visits – can these be carried out on foot or by bike?
• Use of public transport where social distancing can be achieved via use of larger capacity vehicles

However, it is recognised that there are occasions where car sharing is unavoidable such as;

• Healthcare staff who carry out community visits
• Healthcare staff who are commuting with students as part of supported learning/mentorship
• Healthcare staff working in emergency response vehicles
• Healthcare staff living in areas where public transport is limited and car sharing is the only means of commuting to and from the workplace

Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;

• Staff (and students) must not travel to work/car share if they have symptoms compatible with a diagnosis of COVID-19.
• Ideally, no more than 2 people should travel in a vehicle at any one time
• Use the biggest car available for car sharing purposes
• Car sharing should be arranged in such a way that staff share the car journey with the same person each time to minimise the opportunity for exposure. Rotas should be planned in advance to take account of the same staff commuting together/car sharing as far as possible
• The car must be cleaned regularly (at least daily) and particular attention should be paid to high risk touch points such as door handles, electronic buttons and seat belts. General purpose detergent is sufficient unless a symptomatic or confirmed case of COVID-19 has been in the vehicle in which case a disinfectant should be used.
• Occupants should sit as far apart as possible, ideally the passenger should sit diagonally opposite the driver.
• Windows in the car must be opened as far as possible taking account of weather conditions to maximise the ventilation in the space
• Occupants in the car, including the driver, should wear a fluid resistant surgical mask (FRSM) provided it does not compromise driver safety in any way.
• Occupants should perform hand hygiene using an alcohol based hand rub (ABHR) before entering the vehicle and again on leaving the vehicle. If hands are visibly soiled, use ABHR on leaving the vehicle and wash hands at the first available opportunity
• Occupants should avoid eating in the vehicle
• Passengers in the vehicle should minimise any surfaces touched – it is not necessary for vehicle occupants to wear aprons or gloves
• Keep the volume of any music/radio being played to a minimum to prevent the need to raise voices in the car

Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.

5.13 Hierarchy of Controls

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below is a graphic specifying the general principles of prevention legislated in the Management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1. It details the most to the least effective hierarchy of controls and can be used to help implement effective controls in preventing the spread of COVID-19 within healthcare settings.  NHS boards and NHS staff should employ the most effective method of control first.  Where that is not possible, all others must be considered.  PPE is the last in the hierarchy of controls.

Hierarchy of Risk Controls graphic //commons.wikimedia.org/index.curid=90190143 (original version: NIOSH Vector version: Michael Pittman)

Application of the hierarchy of control in health and social care settings is as follows;

1. Elimination
   • Patients must not attend for an appointment if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff who can work from home should be supported to do so
   • Consideration should be given to non clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible
2. Substitute
   • Patient consultations over phone as far as possible rather than in person
3. Engineering controls
• Installations of partitions at appropriate places (e.g reception desks)
• 2 metre physical distancing on the premises (see section 5.14) 
• Efforts made to reduce number of people on premises at any one time
• reduce waiting time for individuals in clinic and radiology departments
• improve ventilation by opening windows on the premises 
• Optimal bed spacing and chair spacing (see section 5.14.1)
4. Administrative Controls (more detail in section 5.14.2) 
• Working from behind or at the side of the individual (no face to face close contact)
• development of pathways/one way systems on the premises
• use of various COVID-19 related signage
• provision of additional hand hygiene stations
• increased cleaning. 
5. PPE
• Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask
• PPE when a risk assessment indicates this (see PPE section of this addendum)

 

 

 

 

 

5.14 Physical distancing

All staff working with NHS Scotland healthcare facilities must maintain 2 metres physical distancing wherever possible.  This does not apply to the provision of direct patient care where appropriate PPE should be worn in line with section 5.6. 

Outbreaks amongst staff have been associated with a lack of physical distancing in recreational areas during staff breaks and when car sharing.

There are many areas within healthcare facilities where maintaining 2 metres physical distancing is a challenge due to the nature of the work undertaken.  Where 2 metres physical distancing cannot be maintained, staff must ensure they are wearing face masks in line with the extended use of facemasks section 5.6.1.

Staff must adhere to physical distancing as much as possible and should:

• stagger tea breaks to reduce the number of staff in recreational areas at any one time
• maintain 2-metre physical distancing when removing FRSMs to eat and drink
• not car share when commuting to and from work unless absolutely necessary – where this is absolutely necessary, staff should sit as far apart as possible, wear a face covering or face mask and keep windows open in the car to improve ventilation

5.14.1 Inpatient bed spacing and OPD chair spacing

Health Facilities Scotland have undertaken an assessment of bed and chair spacing within NHS Scotland facilities taking into account compounding factors applied in conjunction with physical distancing (patient placement, ventilation, hand hygiene, face coverings, environmental cleaning).  The purpose of this document aims to help support boards in reviewing bed spacing to ensure 2 metre physical distancing, or as close to it as possible, can be maintained for inpatient beds and treatment chairs.

Note: This assessment will be added to the addendum in the near future.

Existing SHPN 04-01 guidance relating to bed spacing can be found here and recognises that spacing requirements are in place to contribute towards the control of healthcare associated infections.  Published in 2010 it stipulates that dimensions of bed spacing in any new builds should meet 3.6m (width) x 3.7m (depth).  To achieve 3.6m between bed spaces, measurements should be taken from bed centre to bed centre.

5.14.2 Engineering and Administration control measures in healthcare settings

Boards and departments should apply administrative controls to establish separation of patient pathways and minimise contact between the pathways.  Due to the wide variance in the layout, structure and fabric of NHS facilities across Scotland it is not possible to be descriptive in exactly how these should be applied and full assessment should be undertaken locally.  The following bullet points provide guidance which boards and departments may use when considering how best to develop pathways and promote 2-metre physical distancing.

• Signage on entry to buildings, wards and departments advising of the necessary precautions to take (face coverings, hand hygiene, physical distancing) including advice for visitors not to enter the premises if symptomatic of COVID-19.
• Ensure signage is clearly displayed to clearly identify pathways. Floor markings may also be used.  Physical barriers may be used where appropriate to prevent cross over of pathways.
• Ensure there are adequate hand hygiene facilities (wash hand basins or alcohol-based hand rub stations) available including the use of posters promoting hand hygiene and detailing the effective method for doing so. Appendix 1 how to handwash and Appendix 2 how to handrub.
• Where required, facilitate the use of screens to reduce exposure risk, for example at admission desks or help desks. Screens may be used in clinical care areas to help segregate patients however installation of these must not hinder the ability of staff to observe their patients and must be assessed by fire officers and health and safety teams first to ensure all other regulations remain compliant. There is limited evidence supporting the use of partitions for face-to-face interactions or between bed spaces, but it appears logical that a physical barrier can reduce contact between individuals and reduce the spread of infected particles from an infective source.
  • Full bed length, floor to ceiling partitions are likely to be the most efficacious in preventing transmission of COVID-19.  Partitions for face-to-face interactions, as a minimum, should cover both individuals breathing zone which encompasses a radius of 30cm from the middle of the face.
• Consider remote consultations where possible rather than face to face.
• Ensure areas are well ventilated where possible – open windows if temperature/weather conditions allow. Note that specific guidance applies to specialist ventilation areas such as theatres and endoscopy suites.

5.15 Visiting

The Scottish Government have produced hospital visiting guidance to support the safe reintroduction of visitors into hospital settings and NHS boards should familiarise themselves with the content to ensure patient, staff and visitor safety.  Visitors must;

• Not visit if they have suspected or confirmed COVID-19 or if they have been advised to self-isolate for any reason
• Wear a face covering on entering the hospital
• Be provided with appropriate PPE (see table 6)
• Perform hand hygiene at the appropriate times;     
• on entry to the hospital and when leaving the patient’s room/ward.
• Prior to putting on PPE
• After removing PPE
• Observe physical distancing
• Not move around the ward and should stay at the bedside of the person they are visiting.
• Not visit other patients in the hospital
• Not touch their face or face covering/mask once in place
• Not eat whilst visiting
• Avoid sharing mobile phone devices with the patient unnecessarily – if mobile devices are shared to enable communications with other friends and family members, the phone should be cleaned between uses using manufacturer’s instructions

 

Table 9: PPE for Visitors

PPE used	Low-risk pathway (green)	Medium-risk pathway (amber)	High-risk pathway (red)	Unit wide AGP Zone
Gloves	Not required1	Not required1	Not required1	Not required1
Apron or gown	Not required2	Not required2	If within 2 metres of patient	Apron Required
Face mask	Face covering or provide with FRSM if visitor arrives without a face covering	Face covering or provide with FRSM if visitor arrives without a face covering	FRSM	FRSM4
Eye and face protection	Not required3	Not required3	If within 2 metres of patient	Required to be worn alongside FRSM (or FFP3 where NHS Boards can fit test) on entry to area

¹ unless providing direct care to the patient which may expose the visitor to blood and/or body fluids i.e toileting.

² unless providing care to the patient resulting in direct contact with the patient, their environment or blood and/or body fluid exposure i.e toileting, bed bath.

³ Unless providing direct care to the patient and splashing/spraying is anticipated.

⁴ Patients should not receive visitors whilst undergoing an AGP or during the Post AGP fallow time that follows the procedure.  Where a unit has unit wide airborne precautions in place, visitors may be allowed to enter the room but must be informed that there is a higher degree of risk due to the potential exposure to infectious aerosols.  The following additional mitigation measures should be in place;

• Visitor should not enter whilst the individual they are visiting is undergoing an AGP or during the post AGP fallow time.
• Ask visitor to remain 2 metres from all other patients
• Provide the visitor with PPE as described in the table above
• Guide and supervise visitors when donning and doffing PPE and remind them of the appropriate times when hand hygiene should be undertaken.
• Ensure visitors perform hand hygiene on leaving the ward

5.16 Outbreaks

It is essential that staff remain vigilant and report any concern that there may be a possible outbreak of COVID-19 developing in their clinical area.  Where two or more patients or staff members in the low or medium risk pathways develop symptoms of suspected COVID-19 or test positive for COVID-19 (regardless of symptom status) and where the cases were not confirmed or suspected COVID-19 on admission, there may be a possible outbreak occurring.  A high degree of suspicion should be applied and staff should contact their local IPCT if they suspect an outbreak may be occurring in their area. 

Further COVID-19 outbreak guidance can be found within Chapter 3 of the NIPCM.

5.15.1 Whole Genome Sequencing

Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions. 

 

 

 

5.16 Resources

This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.

PPE

• PPE poster – low-risk pathway
• PPE poster – medium-risk pathway
• PPE poster – high-risk pathway
• PPE poster - PPE for unit wide airborne precautions
• COVID-19 Wearing a facemask poster (staff)
• Wearing a face mask - information for patients poster
• Poster suggested ways of wearing a face mask
• PPE for COVID-19 vaccination (staff) 
• PPE for COVID-19 vaccination (public)

FAQs

• COVID-19 Frequently Asked Questions for critical care
• COVID-19 Frequently asked questions for operating theatres
• COVID-19 Frequently asked questions for endoscopy services

 

• COVID-19 Outbreak checklist
• Key messages in the workplace poster
• COVID-19 Hospital testing summary table
• Stop the Spread – COVID-19 Good Practice Points
• COVID-19 Safe practice in acute healthcare settings poster

 

 

5.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Review of the National and International Guidance on Infection Prevention and Control Measures for Personal Protective Equipment (PPE) and Aerosol Generating Procedures (AGPS) for COVID-19
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• Provision of gloves for COVID-19 in health and care settings
• Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature - SARS-CoV-2 variants VOC-202012/01 (B.1.1.7) and 501Y.V2 (B.1.351) – implications for infection control within health and care settings
• Rapid review of the literature – Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature – Ultraviolet light technology for decontamination of health and care settings in the context of COVID-19
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

5.18 COVID-19 Education resources

This section contains a number of educational resources to support the COVID-19 response in partnership with a range of stakeholders

The following hand hygiene short films are available on Vimeo and are existing NES resources.

• Correct use of alcohol-based hand rub
• Correct hand hygiene technique using soap and water
• Correct order for donning and doffing PPE for healthcare workers in a primary care setting
• Safe use of fluid-resistant surgical masks

 

 

5.20 COVID-19 Compendium

This section contains links to current national and international policy, guidance and resources on COVID-19 from key organisations.

• COVID-19 compendium

 

5.21 Useful tools for IPCTs

Below is a list of tools in use by IPCTs in NHS Boards across NHS Scotland in the context of COVID-19.  NHS Boards have given permission for these to be shared here however these documents are not endorsed by ARHAI Scotland, nor do ARHAI Scotland hold any responsibility for updating these documents.  It is recognised that development of national tools are beneficial and as such, COVID19 tools will be developed as requested via the NPGO programme going forward.

• NHS A&A – COVID19 de-escalation checklist (added 26/3/21)
• NHS Grampian – Coronavirus Anxiety Workbook (added 26/3/21)
• NHS Tayside – COVID19 Incidents Reporting Template (added 26/3/21)
• NHS Tayside – COVID19 PAG IMT checklist (added 26/3/21)
• NHS Tayside – COVID19 Protocols (added 26/3/21)
• NHS Tayside – IPC COVID19 Assurance Audit Tool (added 26/3/21)
• NHS Tayside – Scoring proposals for COVID19 Impact (added 26/3/21)

Appendix 1: Think COVID. COVID-19 assessment in the older adult checklist

Think COVID: COVID-19 assessment in the older adult checklist

The purpose of this addendum is to provide COVID-19 specific infection and prevention control (IPC) guidance for care home staff and providers on a single platform to improve accessibility.

When an organisation adopts practices that differ from those recommended/stated in this national guidance, that individual organisation is responsible for ensuring safe systems of work, including the completion of a risk assessment(s) approved through local governance procedures.

 

Version control

16 December 2020
Version 1.0
First publication.

25 January 2021
Version 1.1
Inclusion of new section 6.2.4 'Discontinuing IPC precautions in care homes for residents who are COVID-19 positive'

31 March 2021
Version 1.2

6.1.2 Definition of suspected case; Additional information and links included.

6.1.3   Triaging of residents being admitted to a care home. International travel isolation changed to reflect current guidance

6.2 Resident Placement/Assessment of Infection Risk section updated.

6.2.5 Residents returning from overnight stay included

6.2.4 Stepdown table renamed (Discontinuation of IPC) to be consistent with Acute Addendum. Discontinuing IPC precautions in care homes for residents who are COVID-19 positive information clarified. Residents discharged from hospital to care homes – additional information included to clarify 14 day isolation requirements.

6.2.4 Links have been removed that are no longer available.

6.5 Additional information included on PPE & link to hierarchy of control.

6.5.1 New FRSM poster (ways to improve fit) link included

6.5.2   Face masks for residents, additional advice on wearing masks when moving around the care home

6.5.3 Table 2 PPE for direct resident care determined by risk category. Update to PPE guidance specifically in relation to visors.

6.5.4 PPE – Putting on (Donning) and Taking off (Doffing) further detailed information included

6.5.5 Aerosol Generating procedures (AGPs) Additional information added under table on requirements for respirators/fluid resistant requirement.

6.5.8 Additional section added on delivery of COVID-19 vaccinations.

6.7 Safe Management of the Care Environment. Additional detail provided where items cannot stand application of chlorine releasing agents. Also additional information if an organisation adopts practices that differ from those recommended/stated.

6.8 Wording amended to clarify linen categorisation where no outbreak.

6.10 Safe disposal of waste. Wording amended to provide clarity.

6.11.2 Engineering and Administration control measures added.

6.12 New section on hierarchy of controls

6.14 Visiting in care homes updated following publication of ‘Open with Care’

6.16 Resources and Tools section updated.

6.17 Rapid reviews section added

6.18 Education resources added.

6.1 COVID-19 case definitions and triage

6.1.1 Definition of a confirmed case

A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.

6.1.2 Definition of a suspected case

An individual meeting one of the following case criteria taking into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and residents who are immunocompromised; (further information on presentations and management of COVID-19 in older people and Scottish Government and Appendix 1 :Think COVID:Covid-19 Assessment in the Older Adult - Checklist).

Community definition:

• Recent onset new continuous cough

or

• fever

or

• loss of/change in sense of taste or smell (anosmia)

 

Definition for residents who may require hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

• influenza-like illness (fever greater than or equal to 37.8֯C and at least one of the following respiratory symptoms, which must be of acute onset – persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)

or

• a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms

6.1.3 Triaging of residents being brought into a care home

Residents being admitted to the care home must complete a total of 14 days of isolation either starting on or including the date of transfer. Screening of residents for transfer purposes may only provide partial reassurance as infection may still develop subsequently at any time during the incubation period. See section 6.2.4 for discontinuation of IPC precautions in care homes for residents who are COVID-19 positive.

To aid single room prioritisation for residents who may be at most risk, admission triage should be undertaken to enable early recognition of potential COVID-19 cases. 

Wherever possible, triage questions should be undertaken prior to arrival at the care home. 

If the resident has capacity issues this should be undertaken with the individual’s guardian or power of attorney.

The following are examples of triage questions:

• Do you or any member of your household/family have a confirmed diagnosis of COVID-19?

If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.

• Are you or any member of your household/family waiting for a COVID-19 test result?

If yes, follow the high-risk category.

• Have you been an inpatient in hospital in the past 14 days?

If yes, follow the high-risk category.

• Have you travelled internationally to any country which isn’t exempt from self-isolation rules in the last 14 days?

If yes, should wait for 10-day quarantine before admission to care home, or if urgent transfer is required, follow high risk category.

The Scottish Government website details quarantine (self- isolation) rules and information on the process for people entering the UK.

• Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 14 days?

If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.

• Do you have any of the following symptoms?
  • high temperature or fever
  • new, continuous cough
  • loss or alteration to taste or smell

If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.

6.2 Resident placement/assessment of risk

6.2.1 Staff cohorting

6.2.2 Requirements for risk categories

6.2.3 Resident Cohorting

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

6.2.5 Residents returning from day visit or overnight stay

Defined risk categories have been agreed at UK level to inform resident placement and the precautions required. Any other known or suspected infections must be taken into consideration before resident placement within each of the risk categories.

Examples of risk categories for care homes are described below and staff should familiarise themselves with these.

Details of the Low Risk Category are not included here however it is expected that all residents in care home settings will fall into the Medium (Amber) or High (Red) risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

1. Known as the High Risk COVID-19 risk category in the UK IPC remobilisation guidance and is more commonly known as the red risk category.

1. Confirmed COVID-19 residents within the first 14 days of onset (or test date if asymptomatic). Symptomatic or suspected COVID-19 residents (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
2. Those who are known to have had close contact with a confirmed
   COVID-19 individual and are still within the 10-day self-isolation period.
3. Residents who are symptomatic or suspected COVID-19 but who decline testing or who are unable to be tested for any reason.

2. Known as the Medium Risk COVID-19 risk category in the UK IPC remobilisation guidance and may be commonly known as the amber risk category.

1. All residents who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic residents who refuse testing or for whom testing cannot be undertaken for any reason.

6.2.1 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for residents in each of the high and medium risk categories.  There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between risk categories.  Rotas should be planned in advance wherever possible, to take account of different risk categories and staff allocation.  For staff groups who need to go between risk categories, efforts should be made to see residents on the medium risk categories, then the high risk category.   Facemasks should be changed between risk categories.

6.2.2 Requirements for risk categories

Any resident on the medium risk category who develops symptoms of COVID-19 should be isolated on the high risk category immediately and tested for COVID-19 and notify your local Health Protection Team (HPT). Any resident who is asymptomatic and tests positive for COVID-19 should be then cared for as per the high-risk category.

Care homes are likely to have residents with dementia and/or cognitive impairment and so staff are advised to conduct a local risk assessment to ascertain appropriate placement. This does not mean resident needs to move their room or be moved to a different area but advises of the relevant risk category precautions that require to be put in place.

6.2.3 Resident Cohorting

Any resident who has a coinfection with COVID-19 and any other known or suspected infectious pathogen must not be cohorted with other COVID-19 residents.

Cohorting in care homes should be undertaken with care. Residents who are shielding (extremely high risk of severe illness) must not be placed in cohorts and should be prioritised for single occupancy rooms.

Where all single room facilities are occupied and cohorting is unavoidable, then cohorting could be considered whilst ensuring that:

• Confirmed COVID-19 residents are placed in multi-occupancy rooms together.
• Suspected COVID-19 residents are placed in multi occupancy rooms together.
• Confirmed and suspected residents should not be cohorted together.

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

Before IPC control measures are stepped down for COVID-19, it is essential to first consider the ongoing need for transmission based precautions (TBPs) necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or patients with ongoing diarrhoea.

Key notes to be referred to in conjunction with table 1;

• Completing the 14 day isolation period - – In care homes residents must complete 14 days isolation.  This is because there are considerable numbers of immunocompromised and vulnerable residents who will be at risk of nosocomial infection.
• COVID-19 clinical requirements for stepdown – Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some residents, and is not an indication of ongoing infection when other symptoms have resolved.
• Testing required for stepdown – No testing is required routinely to stepdown IPC precautions in a care home unless discharged from hospital. .

Table 1 - Stepdown requirements for care homes

Group	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown	Transferring between risk  categories on stepdown
Care home current residents (known COVID-19 positive)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever  for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required unless being discharged from hospital	Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category
Care home residents, being admitted from hospital	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics & at least some  respiratory recovery	2 negative tests required commencing on day 8 & taken 24 hrs apart	Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category
Care home staff	10 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required.	Staff can return to work as normal once criteria is met

Residents discharged from hospital to care homes

COVID-19 residents being discharged from hospital into a care home should have 2 negative tests prior to transfer back to the care home, unless there are overriding clinical reasons where this is not appropriate, prior to discharge.  They do not require to spend all 14 days’ isolation period in hospital but should have 2 negative tests before discharge from hospital to the care home (testing can be commenced on day 8).

Tests should be taken at least 24 hours apart and preferably within 48 hours of discharge. Where it is in the clinical interest of the resident and negative testing is not possible (e.g. resident doesn’t consent, detrimental consequences or it would cause distress) a risk assessment and a care plan for the remaining period of isolation up to 14 days in the home must be agreed and documented. On return to the care home, the resident must be managed as per the high risk category until the 14-day self-isolation period (day 14 from date of symptom onset or date of positive test if asymptomatic) is complete.

Note: the 14-day total isolation period for admission to a care home from hospital and any isolation days completed as an in-patient should be taken into consideration on admission to the care home i.e. 14 days in total only and not 14 days commencing on admission to the care home.

Note: an admission to hospital is considered to include only those patients who are admitted to a ward. An attendance at A&E that didn’t result in an admission would not constitute an admission.

6.2.5 Residents returning from day visit or overnight stay

Residents who leave care home for the day or for an overnight stay should be triaged in advance of their immediate return to the care home and again on arrival at the care home to determine which category they should be placed on. 

6.3 Hand hygiene

Hand hygiene is considered one of the most important practices in preventing the onward transmission of any infectious agents including COVID-19.  Hand hygiene should be performed in line with section 1.2 of SICPs.

Hand hygiene is essential to reduce the transmission of infection in care home settings. All staff, residents and visitors should clean their hands with soap and water or, where this is unavailable, alcohol-based hand rub (ABHR) when entering and leaving the care home and when entering and leaving areas where care is being delivered.

Hand hygiene must be performed immediately before every episode of direct care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination and waste handling.

Before performing hand hygiene:

• expose forearms (bare below the elbows)
• remove all hand and wrist jewellery (a single, plain metal finger ring is permitted but should be removed (or moved up) during hand hygiene)
• ensure finger nails are clean, short and that artificial nails or nail products are not worn
• cover all cuts or abrasions with a waterproof dressing

If wearing an apron rather than a gown (bare below the elbows), and it is known or possible that forearms have been exposed to respiratory secretions (for example cough droplets) or other body fluids, hand washing should be extended to include both forearms. Wash the forearms first and then wash the hands.

Staff should support any residents with hand hygiene regularly where required.

6.4 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19.  The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

Residents, staff and visitors should be encouraged to minimise potential COVID-19 transmission through good respiratory hygiene measures which are:

• disposable, single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose – used tissues should be disposed of promptly in the nearest waste bin;
• tissues, waste bins (lined and foot operated) and hand hygiene facilities should be available for residents, visitors and staff;
• hands should be cleaned (using liquid soap and water if possible, otherwise using alcohol based hand rub (ABHR) after coughing, sneezing, using tissues or after any contact with respiratory secretions and contaminated objects;
• encourage residents to keep hands away from the eyes, mouth and nose.

Some residents may need assistance with containment of respiratory secretions; those who are immobile will need a container (for example a plastic bag) readily at hand for immediate disposal of tissues.

6.5 Personal Protective Equipment (PPE)

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. 

PPE requirements as per standard infection prevention and control are detailed in section 1.4 SICPs.   

PPE requirements during the COVID-19 pandemic are determined by the care categories and are detailed in 6.5.1.

It is of paramount importance that PPE is worn only at the recommended appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

PPE is the least effective control measure for COVID-19 and other mitigation measures as per the hierarchy of controls must be implemented and adhered to wherever possible.  More details on the hierarchy of controls can be found in section 6.12.

6.5.1 Extended use of face masks for staff and visitors

New and emerging scientific evidence suggests that COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or pre-symptomatic). 

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and residents.  The guidance and FAQs are available Scottish Government guidance and associated FAQs.

A poster detailing the ‘Dos and don’ts’ of wearing a face mask is available.

Extended use of face masks relates to the specific guidance that staff should wear Fluid Resistant (Type IIR) Surgical Mask (FRSM) at all times for the duration of their shift in the care home setting.  Face masks must be removed and replaced as necessary (observing hand hygiene before the mask is removed and before putting another mask on).

In Scotland, staff are provided with Type IIR masks for use as part of the extended wearing of facemasks.

It is recommended that FRSMs should be well fitting and fit for purpose, covering the nose and mouth in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask). A ‘How to wear facemasks’ poster suggests ways to wear facemasks to help improve fit.

6.5.2 Face masks for residents

Residents in the medium or high risk category should be encouraged to wear a FRSM, if these can be tolerated and do not compromise care, when moving around the care home and when individuals enter the room.

Appropriate physical distancing and wider IPC measures are critical, with the use of face masks being a further line of defence.

Scottish Government guidance is available on the extended use of face masks in hospitals and care homes.  

Where clinical waste disposal is not available, used face masks should be double bagged and disposed of in domestic waste.

6.5.3 PPE determined by COVID-19 care pathway

Table 2 details the PPE which should be worn when providing direct resident care in each of the COVID-19 care risk categories.

Type IIR facemasks should be worn for all direct care regardless of the risk category.  This is a measure which has been implemented alongside physical distancing specifically for the COVID-19 pandemic. FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a resident isolated with a suspected or known infectious pathogen and when leaving resident areas on high risk categories.

Further guidance on glove use can be found in Appendix 5

Table 2: PPE for direct resident care determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	If contact with BBF is anticipated. Single use.	Worn for all direct care. Single use.
Apron or gown	If direct contact with resident, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated). Single use.	Always within 2 metres of resident (Gown if splashing spraying anticipated). Single-use.
Face mask	Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask	Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask
Eye and face protection	If splashing or spraying with BBF anticipated. Single-use or reusable following decontamination.	Always within 2 metres of a resident Single-use, *sessional or reusable following decontamination.

*Sessional use see section 6.5.7  

6.5.4 PPE - putting on (donning) and taking off (doffing)

All staff must be trained in how to put on and remove PPE safely.  A short film showing the correct order for putting on and the safe order for removal of PPE is available.  The video will also describe safe disposal of PPE.  A poster describing the donning and doffing of PPE is available in the NIPCM Appendix 6 .

Putting on PPE

Before putting on PPE:

• Check what the required PPE is for the task/visit
• Select the correct size of PPE
• Perform hand hygiene

PPE should be put on before entering the room.

• The order for putting on is apron, surgical mask, eye protection (if required) and gloves – you may require some of these items or all of them
• When putting on mask, the mask should be well fitting, position the upper straps on the crown of head and the lower strap at the nape of the neck. Mould the metal strap over the bridge of the nose using both hands.  Further link to a poster on fitting masks can be found in section 6.5.1.

When wearing PPE:

• Keep hands away from face and PPE being worn.
• Change gloves when torn or heavily contaminated.
• Limit surfaces touched in the care environment.
• Always perform hand hygiene after removing gloves

Removal of PPE

PPE should be removed in an order that minimises the potential for cross-contamination.

Gloves

• Grasp the outside of the glove with the opposite gloved hand; peel off.
• Hold the removed glove in gloved hand.
• Slide the fingers of the un-gloved hand under the remaining glove at the wrist.
• Peel the glove off and discard appropriately.

 Gown

• Unfasten or break ties.
• Pull gown away from the neck and shoulders, touching the inside of the gown only.
• Turn the gown inside out, fold or roll into a bundle and discard.

Eye Protection (if worn)

• To remove, handle by headband or earpieces and discard appropriately.

Fluid Resistant Surgical facemask

• Remove after leaving care area.
• Untie or break bottom ties, followed by top ties or elastic and remove by handling the ties only (as front of mask may be contaminated) and discard as clinical waste.
• For face masks with elastic, stretch both the elastic ear loops wide to remove and lean forward slightly. Discard as clinical waste.

To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.

Perform hand hygiene immediately after removing all PPE.

6.5.5 Aerosol Generating procedures (AGPs)

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

Below is the list of medical procedures for COVID-19 that have been reported to be aerosol-generating and are associated with an increased risk of respiratory transmission:

• respiratory tract suctioning*
• dental procedures (using high-speed devices, for example, ultrasonic scalers/high-speed drills)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• non-invasive ventilation (NIV): Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
• Tracheal intubation and extubation
• Upper ENT airway procedures that involve respiratory suctioning

*Note : The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.    It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  The evidence on respiratory tract suctioning is currently being reviewed by the AGP Panel. 

Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres. On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

This recommendation comes from Public Health England and the New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG).  The published evidence view and consensus opinion can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp--2

Certain other procedures/equipment may generate an aerosol from material other than an individual’s secretions but are not considered to represent a significant infection risk and do not require AGP PPE. Procedures in this category include:

• administration of humidified oxygen;
• administration of medication via nebulisation.

Note: During nebulisation, the aerosol derives from a non-resident source (the fluid in the nebuliser chamber) and does not carry resident-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol.

Staff should use appropriate hand hygiene when helping residents to remove nebulisers and oxygen masks.

For residents with suspected/confirmed COVID-19, any of the potentially infectious AGPs listed above should only be carried out when essential. The required PPE for AGPs should be worn by those undertaking the procedure and those in the room, as detailed above. Where possible, these procedures should be carried out in a single room with the doors shut. Only those staff who are needed to undertake the procedure should be present.

It is the responsibility of care home providers to ensure that all staff have been fit tested for FFP3 respirators, when appropriate. If you do not anticipate the need for FFP3 respirators and are not caring for anyone currently receiving AGPs such as CPAP, these should not be ordered or stockpiled and any surplus stock should be returned.

A Situation, Background, Assessment and Recommendations  (SBAR ) has been produced by Health Protection Scotland (HPS)/ARHAI Scotland and agreed by New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) specific to AGPS during COVID-19.

The NERVTAG consensus view is that the HPS document accurately presents the evidence base concerning medical procedures and any associated risk of transmission of respiratory infections and whether these procedures could be considered aerosol-generating. NERVTAG supports the conclusions within the document and supports the use of the document as a useful basis for the development of UK policy or guidance related to COVID-19 and
aerosol-generating procedures (AGPs).

Airborne precautions are required for the medium and high-risk categories where AGPs are undertaken and the required PPE is detailed in table 3 below.

**Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators, including powered respirators, for decontamination. This literature review will be updated to incorporate recommendations from this group when available. In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.

Table 3: PPE for aerosol-generating procedures, determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	Single-use.	Single-use.
Apron or gown	Single-use gown.	Single-use gown.
Face mask or respirator**	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.

**FFP3 masks must be fluid resistant. Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated

6.5.6 Post AGP Fallow Times (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted.  This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate. 

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 4. It is often difficult to calculate air changes in areas that have natural ventilation only.  All point of care areas require to be well ventilated. Natural ventilation, provides an arbitrary 1-2 air changes per hour. To increase natural ventilation in many community health and social care settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  it is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.  

During the PAGPFT staff should not enter this room without FFP3 masks.  Residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately as per NHS Scotland Cleaning Standards. 

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 4). Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Table 4: Post AGP fallow time calculation

Duration of AGP (minutes)	1 AC/h	2 AC/h	4 AC/h	6 AC/h	8 AC/h	10 AC/h	12 AC/h	15 AC/h	20 AC/h	25 AC/h
3	230	114	56	37	27	22	18	14	10	8 (10)*
5	260	129	63	41	30	24	20	15	11	8 (10)*
7	279	138	67	44	32	25	20	16	11	9 (10)*
10	299	147	71	46	34	26	21	16	11	9 (10)*
15	321	157	75	48	35	27	22	16	12	9 (10)*

* Note that for duration of 25 air changes per hour the minimum fallow time (to allow for droplet settling time) is 10 minutes.

6.5.7 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between residents and for a period of time where a member of staff was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is no longer recommended other than when wearing a visor or eye protection in a communal area where the resident is on the high-risk pathway and when wearing a fluid-resistant surgical face mask (FRSM) across all pathways. Sessional use of all other PPE is associated with transmission of infection amongst residents and is considered poor practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) pathway areas.

The same principles should be observed for staff post toilet and meal breaks, when a new face mask should be put on, once removed the FRSM must never be reused.

Employers are encouraged to plan breaks in such a way that allows 2 metre physical distancing and therefore staff not having to wear a face mask, with natural ventilation where possible.

6.5.8   PPE for delivery of COVID-19 vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct contact and where 2 metre physical distancing cannot be maintained.  This will protect both the HCWs and resident from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
• perform hand hygiene regularly including before and after each resident /individual contact and as per 4 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
• wear a visor where there is anticipated splashing to the face.  For example, where nasal vaccinations induce sneezing, HCWs may choose to wear a visor to prevent droplet contamination to the face following risk assessment. 

The resident on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance.

As per SICPs;

• Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
• Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

6.6 Safe management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents.

It is easy to transfer infectious agents from communal care equipment during care delivery. 

All care equipment should be decontaminated as per Table 5.

Table 5: Equipment cleaning determined by risk category

Risk category	Product
Medium-risk category (amber)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.
High-risk category (red)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

6.7 Safe Management of the Care Environment

There are many areas in care homes that become easily contaminated with micro-organisms (germs) for example toilets, waste bins, kitchen surfaces.

Furniture and floorings in a poor state of repair can harbour micro-organisms (germs) in hidden cracks or crevices.

To reduce the spread of infection, the environment must be kept clean and dry and where possible clear from litter or non-essential items and equipment.

Maintaining a high standard of environmental cleanliness is important in care homes as residents living there are often elderly and vulnerable to infections.

During this ongoing pandemic, cleaning frequency of the environment should be increased across all categories. A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean.  Where a room has not been occupied by any staff or residents since the first daily clean was undertaken, a second daily clean is not required.

It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean, free from non-essential items and equipment to facilitate effective cleaning
• well maintained and in a good state of repair

Environmental cleaning in the Medium and High Risk COVID-19 categories should be undertaken using either a combined detergent/disinfectant solution at a dilution of 1000 ppm available chlorine or a general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000 ppm.

Cleaning across the risk categories is summarised in table 6.

Table 6: Environmental cleaning determined by risk category

	Medium risk category (amber)	High risk category (red)
First daily clean	Full clean	Full clean
Second daily clean	High Risk Touch Surfaces*	High Risk Touch Surfaces
Product	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

*High risk touch surfaces as a minimum should include door handles/push pads, taps, light switches, lift buttons.  Resident areas should include the bedroom and treatment areas and staff rest areas.

Any areas contaminated with blood and body fluids across any of the two pathways require to be cleaned as per Appendix 9.

Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated, you may have to discard it. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.

If the item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning. However, when an organisation adopts practices that differ from those recommended/stated in this national guidance with regards to cleaning agents, the individual organisation is fully responsible for ensuring safe systems of work, including the completion of local risk assessment(s) approved and documented through local governance procedures.

6.8 Safe Management of Linen

All linen should be handled as per section 1.7 of SICPs – Safe Management of Linen.

Linen used on residents who are known to be COVID positive or suspected or where there is a confirmed outbreak should be treated as infectious. Following local risk assessment/ if no outbreaks in the care home laundry can be processed as normal.

Care homes with their own in-house laundries may also refer to National Guidnce for Safe Management of Linen in NHSScotland for more information. 

6.9 Safe Management of Blood and Body Fluid Spillages

All blood and body fluid spillages across the three pathways should be managed as per section 1.8 of SICPs – Safe management of Blood and Body Fluid Spillages and Appendix 9.

6.10 Safe Disposal of waste (including sharps)

Waste should be handled in accordance with Section 1.9 of SICPs.

Waste generated from patients/individuals who are known to be COVID positive, or suspected or where there is a confirmed outbreak, should be disposed of as clinical waste where clinical waste contracts are in place.   

NB: Type IIR facemasks worn as part of the extended use of facemasks policy should be disposed of as clinical waste.

If the community health and care setting does not have a clinical waste contract, or for care at home, ensure all waste items that have been in contact with the patient/ individual (e.g. used tissues and disposable cleaning cloths) are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.

 

6.11 Occupational Safety

Section 1.10 of SICPs remains applicable to COVID-19 residents.

Occupational risk assessment guidance specific to COVID-19 is available.

PPE is provided for occupational safety and should be worn as per Tables 2 and table 3.

6.11.1 Car/vehicle sharing for staff

Wherever possible, car sharing should be avoided with anyone outside of your household or your support bubble.   This is because the close proximity of individuals sharing the small space within the vehicle increases the risk of transmission of COVID-19.  All options for travelling separately should be explored and considered such as;

• Staff travelling separately in their own cars
• Geographical distribution of visits – can these be carried out on foot or by bike?
• Use of public transport where social distancing can be achieved via use of larger capacity vehicles

However, it is recognised that there are occasions where car sharing is unavoidable such as:

• Staff who carry out community visits;
• Staff who are commuting with residents as part of supported care;
• Staff who are commuting with students as part of supported learning/mentorship;
• Staff living in areas where public transport is limited and car sharing is the only means of commuting to and from the workplace;

Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;

Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;

• Staff (and students) must not travel to work/car share if they have symptoms compatible with a diagnosis of COVID-19.
• Ideally, no more than 2 people should travel in a vehicle at any one time
• Use the biggest car available for car sharing purposes
• Car sharing should be arranged in such a way that staff share the car journey with the same person each time to minimise the opportunity for exposure. Rotas should be planned in advance to take account of the same staff commuting together/car sharing as far as possible
• The car must be cleaned regularly (at least daily) and particular attention should be paid to high risk touch points such as door handles, electronic buttons and seat belts. General purpose detergent is sufficient unless a symptomatic or confirmed case of COVID-19 has been in the vehicle in which case a disinfectant should be used.
• Occupants should sit as far apart as possible, ideally the passenger should sit diagonally opposite the driver.
• Windows in the car must be opened as far as possible taking account of weather conditions to maximise the ventilation in the space
• Occupants in the car, including the driver, should wear a fluid resistant surgical mask (FRSM) provided it does not compromise driver safety in any way.
• Occupants should perform hand hygiene using an alcohol based hand rub (ABHR) before entering the vehicle and again on leaving the vehicle. If hands are visibly soiled, use ABHR on leaving the vehicle and wash hands at the first available opportunity
• Occupants should avoid eating in the vehicle
• Passengers in the vehicle should minimise any surfaces touched – it is not necessary for vehicle occupants to wear aprons or gloves
• Keep the volume of any music/radio being played to a minimum to prevent the need to raise voices in the car

Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.

6.11.2   Engineering and administration control measures in care home settings

Care homes should apply administrative controls to establish separation of resident categories and minimise contact.  Due to the wide variance in the layout, structure and fabric of care homes across Scotland it is not possible to be descriptive in how these should be applied and full risk assessment should be undertaken locally.  The following bullet points provide guidance which may use when considering how best to develop pathways and promote 2-metre physical distancing.

• Signage on entry to the care home advising of the necessary precautions to take (face coverings, hand hygiene, physical distancing) including advice for visitors not to enter the premises if symptomatic of COVID-19.
• Ensure signage is clearly displayed to clearly identify resident category. Floor markings may also be used, if considered appropriate.  Physical barriers may be used where appropriate to prevent cross over of categories.
• Ensure there are adequate hand hygiene facilities (wash hand basins or alcohol-based hand rub stations) available including the use of posters promoting hand hygiene and detailing the effective method for doing so. Appendix 1 how to hand wash and Appendix 2 how to hand rub.
• Where required, facilitate the use of screens to reduce exposure risk, for example at reception desks.
• Ensure areas are well ventilated where possible, open windows if a local risk assessment and temperature/weather conditions allow.

6.12 Hierarchy of Controls

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below is a graphic specifying the general principles of prevention legislated in the Management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1. It details the most to the least effective hierarchy of controls and can be used to help implement effective controls in preventing the spread of COVID-19 within healthcare settings.  NHS boards and NHS staff should employ the most effective method of control first.  Where that is not possible, all others must be considered.  PPE is the last in the hierarchy of controls.

Hierarchy of Risk Controls graphic //commons.wikimedia.org/index.curid=90190143 (original version: NIOSH Vector version: Michael Pittman)

Application of the hierarchy of control in health and social care settings is as follows;

1. Elimination
   • Patients must not attend for an appointment if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff who can work from home should be supported to do so
   • Consideration should be given to non clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible
2. Substitute
   • Patient consultations over phone as far as possible rather than in person
3. Engineering controls
• Installations of partitions at appropriate places (e.g reception desks)
• 2 metre physical distancing on the premises (see section 6.15) 
• Efforts made to reduce number of people on premises at any one time
• reduce waiting time for individuals in clinic and radiology departments
• improve ventilation by opening windows on the premises 
• Optimal bed spacing and chair spacing (see section 6.11.2) 
4. Administrative Controls (more detail in section 6.11.2) 
• Working from behind or at the side of the individual (no face to face close contact)
• development of pathways/one way systems on the premises
• use of various COVID-19 related signage
• provision of additional hand hygiene stations
• increased cleaning. 
5. PPE
• Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask
• PPE when a risk assessment indicates this (see PPE section of this addendum).

6.13 Caring for someone who has died

The IPC measures described in this document continue to apply whilst the individual who has died remains in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living individuals. Where the deceased was known or suspected to have been infected with COVID-19, there is no requirement for a body bag, and viewing, hygienic preparations, post-mortem and embalming are all permitted. Body bags may be used for other practical reasons such as maintaining dignity or preventing leakage of body fluids.

For further information, please see the following guidance produced by Scottish Government Coronavirus (COVID-19): guidance for funeral directors on managing infection risks.

 

6.14 Visiting

The Scottish Government has published new visiting guidance, Open with Care: supporting meaningful contact in care homes. 

Care homes should familiarise themselves with the content of this guidance to ensure resident, staff and visitor safety. The guidance also includes information leaflets for family and friends, as well as a Frequently Asked Questions (FAQs) which are intended for everyone involved in resuming meaningful contact in care homes, whether a resident, family member, a visiting professional, care home provider or other partner. 

Open with Care sets out how indoor contact in care homes will gradually increase while minimising COVID-19 risks to residents, staff and visitors. Continued attention to safety measures in relation to the pandemic are essential for everyone. This includes hand hygiene, PPE as appropriate, ensuring good airflow (as far as reasonably comfortable), and rigorous cleaning of surfaces before and after visits. 

Visitors must be informed of and adhere to IPC measures in place, including FRSM, hand hygiene, physical distancing and not attending with COVID-19 symptoms or before a period of self-isolation has ended, whether identified as a case of COVID-19 or as a contact.  

A log of all visitors must be kept, which may be used for Test and Protect purposes.

6.15 Physical distancing

All staff working in the care home must maintain 2 metres physical distancing wherever possible.  This does not apply to the provision of direct resident care where appropriate PPE should be worn in line with section 6.5.  Outbreaks amongst staff have been associated with a lack of physical distancing in recreational areas during staff breaks and when car sharing.  There are many areas within a care home where maintaining 2 metres physical distancing is a challenge due to the nature of the work undertaken.  Where 2 metres physical distancing cannot be maintained, staff must ensure they are wearing face masks/coverings in line with the extended use of facemasks guidance. See section 6.5.1.

Staff must adhere to physical distancing as much as possible and should;

• stagger tea breaks to reduce the number of staff in recreational areas at any one time.
• maintain 2 metre physical distancing when removing FRSMs to eat and drink.
• not care share with colleagues when commuting to and from work unless absolutely necessary. Where this is absolutely necessary, staff should sit as far apart as possible, wear a face covering or FRSM and keep windows open in the car to improve ventilation. 

6.16Resources and tools

• PPE poster – Low Risk Pathway
• PPE poster - Medium Risk Pathway
• PPE poster - High Risk pathway
• PPE COVID-19 Vaccinations (Staff)
• PPE for COVID-19 vaccinations (public)
• COVID-19 Safe Practice in acute healthcare settings poster
• COVID-19 Wearing a facemask poster (staff)
• Wearing a non-medical face mask or face covering
• Suggested ways of wearing a FRSM poster
• Key messages in the workplace poster
• Stop the spread: COVID-19 good practice points poster
• 4 moments for hand hygiene poster – residential and care home settings
• How to wash hands – Appendix 1 - NIPCM
• How to use alcohol based hand rub – Appendix 2 - NIPCM
• PHS Primary Care COVID-19 guidance
• PHS Social Care and Residential Care settings COVID-19 guidance
• COVID-19 Outbreak Checklist

6.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Review of the National and International Guidance on Infection Prevention and Control Measures for Personal Protective Equipment (PPE) and Aerosol Generating Procedures (AGPS) for COVID-19
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• Provision of gloves for COVID-19 in health and care settings
• Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature - SARS-CoV-2 variants VOC-202012/01 (B.1.1.7) and 501Y.V2 (B.1.351) – implications for infection control within health and care settings
• Rapid review of the literature – Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature – Ultraviolet light technology for decontamination of health and care settings in the context of COVID-19
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

6.18COVID-19 Compendium

This section contains links to current national and international policy, guidance and resources on COVID-19 from key organisations.

• COVID-19 compendium

 

This addendum has been developed in collaboration with a wide range of stakeholders to provide Scottish context to the UK COVID-19 IPC remobilisation guidance in community settings. Some deviations from the UK COVID-19 IPC remobilisation guidance exist for Scotland and these have been agreed through consultation with NHS Boards and approved by the CNO Nosocomial Review Group.  These processes deviate from the National Infection Prevention & Control Manual normal process for sign off due the timescales for COVID-19 guidance approval.

The purpose of this addendum is to provide COVID-19 specific IPC guidance for community health and care settings on a single platform improving accessibility for users.  The guidance within this addendum is in line with the UK IPC remobilisation guidance however some deviations for NHS Scotland exist.

When an organisation adopts practices that differ from those recommended/stated in this national guidance, that individual organisation is responsible for ensuring safe systems of work, including the completion of a risk assessment(s) approved through local governance procedures.

This guidance if for use within the following settings;

• GP practices
• Health centres
• Health and social care services provided in peoples own homes 
• Community based settings for people with mental health needs
• Community based settings for people with learning disabilities
• Community based settings for people who misuse substances
• Supported accommodation settings
• Rehabilitation services
• Residential children's homes
• Stand-alone residential respite for adults (settings not registered as a care home)
• Stand-alone residential respite/short break services for children
• Sheltered housing
• Hospice settings
• Community Optometry
• Community Pharmacy
• Specialist palliative care in-patients units/hospices
• Prison and detention settings

Within this document, service users are referred to as patients and/or individuals depending on the facility/setting in which care is provided.

 

Version Control

7 January 2021
Version 1.0
First publication

25 January 2021
Version 1.1
Addition of section 7.2.5 'Discontinuing IPC control measures in community health and care settings for COVID-19 individuals'

31 March 2021
Version 1.2

Health Centres included in list

Additional paragraph added clarifying position when organisations adopts practices that differ from those in this national guidance.

7.1.2 Definition of suspected case; Additional information and links included

7.1.4 Triaging individuals. International travel isolation changed to reflect current guidance

7.2    Individual placement/Assessment of Infection Risk section updated.

7.2.3 Individuals returning from day or overnight stay, new section included.

7.2.4 Providing care at home; Title amended

7.2.6 Table 1 Stepdown requirements for community health and care settings amended.

7.5.1 Extended use of Face Masks for staff, visitors and outpatients; additional information with link to new FRSM poster (ways to improve fit) link included.

7.5.2 Table 2: PPE for direct patient/individual care determined by pathway; Eye/face protection updated to include coughing & sneezing in medium pathway.

7.5.7 Table 3: PPE for Aerosol Generating Procedures determined by category; additional information below table included on respirators.

7.5.10 New section on PPE for delivery of COVID-19 Vaccinations

7.7 Safe Management of the Care Environment; Additional detail provided where items cannot stand application of chlorine releasing agents. Also additional information if an organisation adopts practices that differ from those recommended/stated.

7.7.1 Cleaning practice points; Additional detail also included where items cannot stand application of chlorine releasing agents. Additional information if an organisation adopts practices that differ from those recommended/stated.

7.8 Safe management of linen amended to clarify linen categorisation where no outbreak.

7.10 Safe Disposal of waste (including sharps). Wording amended to provide clarity.

7.11.1 Vehicle sharing for all staff; title amended

7.12 New section on hierarchy of controls added.

7.1.6 Resources and tools section updated

7.1 COVID-19 case definitions and triage

7.1.1 Definition of a confirmed case

7.1.2 Definition of a suspected case

7.1.3 Testing

7.1.4 Triaging individuals

 

7.1.1 Definition of a confirmed case

A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.

7.1.2 Definition of a suspected case

The case definition being used across the UK reflects current understanding from the epidemiology available and may be subject to change.  Case definitions can be found within Public Health Scotland (PHS) primary care guidance and below.

An individual meeting one of the following case criteria taking into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and patients who are immunocompromised; (further information on presentations and management of COVID-19 in older people and Scottish Government and Appendix 1 :Think COVID:Covid-19 Assessment in the Older Adult - Checklist).

Community definition:

• Recent onset new continuous cough

or

• fever

or

• loss of/change in sense of taste or smell (anosmia)

Definition for individual who may require hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

• influenza-like illness (fever greater than or equal to 37.8֯C and at least one of the following respiratory symptoms, which must be of acute onset – persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)

or

• a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms

Individuals must be assessed for bacterial sepsis of other causes of symptoms as appropriate

7.1.3 Testing

Clinicians should test all individuals who meet either of the case definitions described in section 7.1.1.  Further information on testing can be found in the PHS Primary Care guidance.

Guidance for coronavirus testing including who is eligible for a test, how to get tested and the different types of test are available on the Scottish Government web site.

7.1.4 Triaging individuals

The mechanism for triage will vary dependant on both the geographical location and service within primary care but wherever possible, triage questions should be undertaken by telephone prior to an arranged arrival at the facility.   

To enable early detection of suspected or confirmed COVID-19, triage questions should be undertaken again on arrival at community health facilities. 

For unplanned arrivals, triage questions should be completed immediately on arrival where it is safe to do so without delaying any necessary immediate lifesaving interventions. 

Individuals with symptoms consistent with COVID-19 could present to your facility. Information posters for NHS settings should be displayed so they can be seen before individuals enter the premises, encouraging them to return home and be advised to contact NHS24. Posters are available on NHS Inform.

If providing a home visit, staff should contact the patient/individual by telephone at home prior to the visit to undertake the triage questions.  These should be repeated on arrival at the patient/individual’s home. 

If patient lacks capacity to answer these questions by telephone, an assessment should be made on arrival keeping 2 metres from the individual where possible.  If this is not possible, treat as medium risk category or high risk category if COVID-19 symptoms can be observed.

If it is an emergency and you need to call an ambulance for an individual, dial 999 and inform the ambulance call handler of the concerns about COVID-19 infection. While awaiting ambulance transfer, show the individual into a room and ask that they wear a fluid resistant surgical mask where it can be tolerated. Leave the room if safe to do so. If you have to enter the room, stay at least 2 metres away from the individual if possible and if not, wear PPE in line with section 7.5.  The room should be cleaned as per section 7.7 once the patient safely leaves the premises.

Staff within residential and detention settings must ensure individuals are monitored for new onset of any symptoms and action taken at the earliest opportunity.

The following are examples of triage questions:

• Do you or any member of your household/family have a confirmed diagnosis of COVID-19?

If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.

• Are you or any member of your household/family waiting for a COVID-19 test result?

If yes, ascertain if appointment/consultation/home visit can be delayed until results are known.  If urgent care is required, follow the high risk category.

• Have you travelled internationally to any country which isn’t exempt from self-isolation rules in the last 14 days?

If yes, 10 days’ self-isolation will apply.  Only urgent care should be provided during the self-isolation period.  The individual should be placed on the medium or high risk category depending on a clinical and individual assessment – see footnote 1 in section 7.2 (See Scottish Government list of countries exempt from self-isolation).

• Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 14 days?

If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.

• Do you have any of the following symptoms?
  • high temperature or fever
  • new, continuous cough
  • loss or alteration to taste or smell

If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.

• Is there any reason why you are unable to wear a face covering when attending for your appointment/when your care provider visits?

If No, remind individual to wear face covering on arrival or supply facemask.

A word version of these questions for triage is available to download.

7.2 Individual placement/assessment of infection risk

7.2.1 Category implementation and the surrounding environment

7.2.2 Managing individual placement in self-contained residential settings

7.2.3 Individuals returning from day or overnight stay

7.2.4 Providing care at home

7.2.5 Staff cohorting

7.2.6 Discontinuing IPC control measures in community health and care settings for COVID-19 individuals

Table 1: Stepdown requirements for community health and care settings

Risk categories must be established to ensure segregation of individuals determined by their risk of COVID-19. 

Any other known or suspected infections and the need for any Aerosol Generating Procedures (AGPs) must be considered before individual placement within each of the category areas.

Establishing which category an individual is in will determine Personal Protective Equipment (PPE) and decontamination requirements.

Examples of categories are described below.  Your setting may use different names for each of the categories from those described below and you should familiarise yourself with the categories in your setting that align with those described here. 

Any services providing care at home should phone ahead to the individual prior to a visit and ask the triage questions in (examples in section 7.1) to determine what category they will be on.

Within Acute care settings there is an additional low risk pathway which can be found in the Scottish Acute Care COVID-19 Addendum however it is expected that all individuals in community and care at home settings will fall into the Medium or High risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

1. Known as the High Risk COVID-19 risk category in the UK IPC remobilisation guidance and is more commonly known as the red risk category.

1. Confirmed COVID-19 patients/individuals.
2. Symptomatic or suspected COVID-19 patients/individuals (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
3. Those who are known to have had contact with a confirmed COVID-19 individual and are still within the 14-day self-isolation period and those who have been tested and results are still awaited.
4. Individuals who are symptomatic or suspected COVID-19 but who decline testing or who are unable to be tested for any reason.
5. See footnote 1.

2. Known as the Medium Risk COVID-19 risk category in the UK IPC remobilisation guidance and may be commonly known as the amber risk category.

1. All other patients/individuals who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic patients/individuals who refuse testing or for whom testing cannot be undertaken for any reason.
3. Those who are asymptomatic have been tested and results are still awaited.
4. Recovered COVID-19 patients/individuals - see footnote 2.

Footnote 1.When deciding patient/individual placement where symptoms are unknown – for e.g. where the patient/individual is unconscious, or patients/individuals who have returned from a country on the quarantine list in the last 10 days, a full clinical and individual assessment of the patient/individual should be carried out prior to placement in a side room on the high or medium category.  This assessment should take account of risk to the patient/individual (immunosuppression, frailty) and clinical care needs (treatment required in specialist unit).

Footnote 2. Further information on Discontinuing IPC control measures in community health and care settings for confirmed COVID-19 patients/individuals can be found in section 7.2.6.

Some individuals who no longer require medical care in hospital will be discharged home or to their long term care facility to fully recover. These people may not have completed their isolation period and can be safely cared for at home if this guidance is followed. The acute should provide information regarding test results and a plan for stepping down IPC measures on discharge.

7.2.1 Category implementation and the surrounding environment

Ideally, community health and care settings should have designated areas for the high risk category and designated areas for the medium risk category. 

Depending on the nature of the services, it may be possible to run clinics at specific times of the day determined by category i.e. Medium risk category in morning session, high risk category in afternoon session. 

As per triage questions above, patients on the high risk category should have their appointment postponed until they have completed their isolation period wherever possible. 

Ensure category areas have signage in place to support and separate entrances to facilities and departments utilised where available.

• Clutter and excess storage items should be removed from all areas to facilitate effective cleaning and minimise the potential for contamination.
  
  
• Soft furnishings which can’t be cleaned appropriately should be avoided where possible such as fabric chairs and carpets.
  
  
• All non-essential items including toys, books and magazines should be removed from receptions, waiting areas, consulting and treatment rooms.

7.2.2 Managing individual placement in self-contained residential settings

All admissions from the community to a residential facility should be assessed first using the triage questions in section 7.1. This applies to all types of residential facilities and admissions (including for respite).

For individuals who fall into the high risk category, the admission should be delayed until they have completed their self-isolation period wherever possible.

Conduct a local risk assessment if the admission cannot be delayed to ensure it is done safely. See PHS Social Care and Residential Care COVID-19 guidance for further information on admissions to these settings including for respite.

If the admission must go ahead, the patient/individual can start isolation in their own room and must be managed in line with the high risk category.

Where all single occupancy rooms are occupied and cohorting is unavoidable, then cohorting could be considered whilst ensuring that:

• Confirmed COVID-19 patients/individuals are placed in multi-occupancy rooms together.
• Suspected COVID-19 patients/ individuals are placed in multi occupancy rooms together.

Patients/individuals who are symptomatic of COVID-19 but are still awaiting test results must not be cohorted together.  This is because symptoms may be associated with another respiratory pathogen and cohorting increases the risk of onward transmission to others. These individuals should be isolated in their own single room facility and mixing with others must be avoided wherever possible. 

Additionally, individuals previously considered to be in the shielding category should not be cohorted with other residents/individuals.

Meals should be provided for the individual in the high risk category to eat within their room to avoid them entering any communal spaces.

Ensure that personal toiletries such as towels (unless laundered to a satisfactory standard between individuals) toothbrushes and razors are not shared amongst individuals.

Consider a rota for showering and bathing placing the individuals in the high risk category last.

Only essential staff wearing appropriate PPE should enter the rooms of individuals in the high risk category.  All necessary care should be carried out within the individual’s room.

Any patient/individual in the medium risk category who develop symptoms of COVID-19 should be isolated immediately and tested for COVID-19.  Any patient/individual who goes on to test positive for COVID-19 (whether symptomatic or asymptomatic) should be transferred to the high risk category.

7.2.3 Individuals returning from day or overnight stay

Individuals who have been allowed to leave the community health and care facility for the day or for an overnight stay should be triaged in advance of their immediate return and again on arrival at the facility to determine which category they should be placed on. 

7.2.4 Providing care at home

All efforts should be made to establish which COVID-19 category the individual is in before arrival at an individual’s home.  Establish whether or not the individual has any aerosol generating procedures (AGPs) in progress so that the correct PPE can be donned – see section 7.5.6.

An FRSM should be worn on entering an individual’s home.  On arrival, assess the activities and tasks to be undertaken.  If possible, they should be performed in such a way that 2 metre physical distancing is maintained.  Where 2 metre physical distancing cannot be maintained, PPE should be worn in line with table 2.  Donning and doffing of PPE in the care at home settings is covered in section 7.5.4.

Scottish Government advice on providing care at home is available.

7.2.5 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for individuals in each of the different categories.  There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between categories wherever possible.  Rotas should be planned in advance wherever possible, to take account of different categories and staff allocation.  For staff groups who need to go between categories, efforts should be made to see individuals in the medium risk category first then the high risk category.  

Providers or employers delivering a service in an individual’s own home should identify individuals at extremely high risk of severe illness, assess their needs and allocate dedicated staff (if possible) to care for them. This should be reviewed regularly to ensure it is up to date. Other staff members should be allocated to consistently care for the needs of those not at extremely high risk of severe illness.

During the pandemic it is important to minimise the visits to those individuals at extremely high risk of severe illness and, if possible, the number of staff undertaking the visits. The person receiving care may make the decision to suspend some of the care or for this to be provided by a carer or guardian. This should be discussed with the relevant authorities and care providers.

Where it is not possible to allocate specific staff to care for individuals who are at extremely high risk of severe illness, it may be possible to schedule visits to these groups of patients before visits to others.

7.2.6 Discontinuing IPC control measures in community health and care settings for COVID-19 individuals

The following applies to individuals in the community health and care settings listed on in this addendum. 

Before IPC control measures are stepped down for COVID-19, it is essential to first consider the ongoing need for transmission based precautions (TBPs) necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or patients with ongoing diarrhoea.

Key notes to be referred to in conjunction with table 1 below;

• Completing the isolation period - – Individuals living in their own home should complete a period of 10 days isolation. Individuals recently discharged from hospital (within the self-isolation period) must complete a total of 14 days isolation.  This is because, in general, those with COVID-19 who are admitted to hospital will have more severe disease than those who remain in the community, especially if they require critical care. In addition, those admitted are more likely to have pre-existing conditions such as severe immunosuppression.

Other household members should complete their 10 day stay at home period (as described in Stay at Home guidance). If this did not start before the individual was admitted to hospital, then it should commence from the day the individual returns to the household, unless the individual has already completed their appropriate period of isolation within hospital.

Staff identified as a COVID-19 case or contact should complete a total of 10 days self-isolation in line with Public Health Scotland guidance.

All other individuals should follow stay at home guidance on NHS inform.

• COVID-19 clinical requirements for stepdown – Clinical improvement with at least some respiratory recovery. Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some individuals, and is not an indication of ongoing infection when other symptoms have resolved.
  
  
• Testing required for stepdown – No testing is required routinely to stepdown IPC precautions in community health and care settings.

For severely immunocompromised individuals or those at extremely high risk of severe illness, negative tests may be required where ongoing care is required as an outpatient in a healthcare setting.  This would be determined by the discharging clinician.

Table 1 - Stepdown requirements for community health and care settings

Group	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Individuals who have recently been discharged from hospital to either their own home or a community health and care setting	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery	Not routinely required.
Individuals who are severely immunocompromised or at high risk of severe illness as determined by Chapter 14a of the Green Book.	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery	Not routinely required unless returning to healthcare as an outpatient
People in prisons	10 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required

Transferring between pathways on stepdown

Residents/individuals should be managed in the high risk category for any outpatient care or care at home until criteria described in this table is met and can then transfer to the medium risk category.

6.3 Hand hygiene

Hand hygiene is considered one of the most important practices in preventing the onward transmission of any infectious agents including COVID-19. 

Hand hygiene should be performed in line with section 1.2 of SICPs bare below the elbow and must be performed:

• before every episode of direct individual/resident care; and
  
  
• after any activity or contact that potentially results in hands becoming contaminated including;
  • removal of personal protective equipment (PPE),
  • equipment decontamination; and
  • waste handling.   

Within this section you will find videos demonstrating how to perform a hand wash and how to perform a hand rub. 

Posters detailing hand washing techniques and alcohol based hand rub (ABHR) technique can be found in the resources section of this addendum. 

Hand washing should be extended to the forearms if there has been exposure of forearms to respiratory secretions.

7.3.1 Hand hygiene in the community

Staff working in the community should carry a supply of Alcohol Based Hand Rub (ABHR) to enable them to perform hand hygiene at the appropriate times. 

Where staff are required to wash their hands (when visibly contaminated) in the individual’s own home they should do so for at least 20 seconds using any hand soap available. 

Staff should carry a supply of disposable paper towels for hand drying rather than using hand towels in the individual’s own home.  Once hands have been thoroughly dried, ABHR should be used.

Staff may also carry antimicrobial hand wipes if they are going to be attending a property where there is no running water.  The use of antimicrobial hand wipes is only permitted where there is no access to running water.  Staff must perform hand hygiene using ABHR immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.

7.4 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19.  The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

The ‘Catch it, Bin it, Kill it’ poster can be downloaded.

7.5 Personal Protective Equipment (PPE)

7.5.1 Extended use of face masks for staff, visitors and outpatients

7.5.2 PPE determined by COVID-19 care category

Table 2: PPE for direct resident care determined by risk category

7.5.3 PPE – Putting on (Donning) and Taking off (Doffing)

7.5.4 Putting on (donning) and taking off (doffing) in an individual’s home

7.5.5 Aerosol Generating procedures (AGPs)

7.5.6 Aerosol Generating Procedures (AGPs) in an individual’s home

7.5.7 PPE for Aerosol Generating Procedures (AGPs)

Table 3: PPE for aerosol-generating procedures, determined by risk category

7.5.8 Post AGP Fallow Times (PAGPFT)

Table 4: Post AGP fallow time calculation

7.5.9 Sessional use of PPE

7.5.10 PPE for delivery of COVID-19 vaccinations

7.5.11 Access to PPE

 

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. 

PPE requirements as per standard infection prevention and control are detailed in section 1.4 SICPs.   

PPE requirements during the COVID-19 pandemic are determined by the care categories and are detailed in table 2.

7.5.1 Extended use of face masks for staff, visitors and outpatients

New and emerging scientific evidence suggests that COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or pre-symptomatic). 

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and residents.  The guidance and FAQs are available Scottish Government guidance and associated FAQs.

For medical grade face masks, a poster detailing the ‘Dos and don’ts’ of wearing a face mask is available.

For non-medical face masks/coverings, a  poster intended to support the wearing of a non-medical face mask/face covering is available.

Where staff are providing ‘live in’ support/care for individuals, the should maintain 2 metres physical distancing when not providing direct care.  When providing direct care, a Type IIR mask should be worn as well as any other PPE required as outlined in section 7.5.2.

7.5.2 PPE determined by COVID-19 care category

The PPE worn for direct care differs depending on the COVID-19 care category and the task being undertaken.  It is important that the need for PPE required for any other known or suspected pathogens is also risk assessed.

Table 2 details the PPE which should be worn when providing care in each of the COVID-19 care risk categories.

Type IIR facemasks should be worn for all direct care regardless of the risk category.  This is a measure which has been implemented alongside physical distancing specifically for the COVID-19 pandemic. FRSMs should be changed if wet, damaged or soiled. 

 

Table 2: PPE for direct individual/patient care determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	If contact with BBF* is anticipated, then single-use.	Worn for all direct care. Single use.
Apron or gown	If direct contact with patient, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated), then Single use.	Always within 2 metres of patient (Gown if splashing spraying anticipated). Single-use.
Face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask
Eye and face protection	If splashing or spraying with BBF, including coughing/sneezing anticipated. Single use or reusable following decontamination.	Always within 2 metres of a patient Single-use, sessional** or reusable following decontamination.

* Blood and body fluids (BFF)

**Sessional use see section 7.5.9

NB: Where a physical partition is insitu e.g. at reception desks/pharmacy counters, Staff need only wear FRSM in line with extended face mask policy described in section 7.5.1.  No other PPE is required.

A flowchart detailing appropriate glove use and selection can be found in Appendix 5 of the NIPCM.

7.5.3 PPE – Putting on (Donning) and Taking off (Doffing)

All staff must be trained in how to put on and remove PPE safely.  A short film showing the correct order for putting on and the safe order for removal of PPE is available.  The video will also describe safe disposal of PPE.  A poster describing the donning and doffing of PPE is available in the NIPCM Appendix 6 and is also described below.

Putting on PPE

Before putting on PPE:

• Check what the required PPE is for the task/visit
  
  
• Select the correct size of PPE
  
  
• Perform hand hygiene

PPE should be put on before entering the room.

• The order for putting on is:

1. 1. apron,
   2. surgical mask
   3. eye protection
   4. gloves 

You may require some of these items or all of them – See Table 2.

• When putting on mask, position the upper straps on the crown of head and the lower strap at the nape of the neck. Mould the metal strap over the bridge of the nose using both hands.

When wearing PPE:

• Keep hands away from face and PPE being worn.
  
  
• Change gloves when torn or heavily contaminated.
  
  
• Limit surfaces touched in the care environment.
  
  
• Always perform hand hygiene after removing gloves.

Removal of PPE

PPE should be removed in an order that minimises the potential for cross-contamination.

Gloves

• Grasp the outside of the glove with the opposite gloved hand; peel off.
• Hold the removed glove in gloved hand.
• Slide the fingers of the un-gloved hand under the remaining glove at the wrist.
• Peel the glove off and discard appropriately.

Gown

• Unfasten or break ties.
• Pull gown away from the neck and shoulders, touching the inside of the gown only.
• Turn the gown inside out, fold or roll into a bundle and discard.

Eye Protection

• To remove, handle by headband or earpieces and discard appropriately.

Fluid Resistant Surgical facemask

• Remove after leaving care area.
• Untie or break bottom ties, followed by top ties or elastic and remove by handling the ties only (as front of mask may be contaminated) and discard as clinical waste.
• For face masks with elastic, stretch both the elastic ear loops wide to remove and lean forward slightly. Discard as clinical waste.

To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.

Perform hand hygiene immediately after removing all PPE.

7.5.4 Putting on (donning) and taking off (doffing) in an individual’s home

PPE should be put on in a safe area either inside the premises, such as a porch or a separate room, or, if there is no available area then the mask can be put on immediately prior to entering the home, and gloves and apron when in the home.

PPE should be removed before leaving the home or care setting and should not be worn out with the home or to the next visit.

If caring for more than one individual in the same house, then only the mask/eye protection can be considered sessional use until completion of the tasks/care.

Hand hygiene must be carried out on immediately after removing PPE.

Disposal of PPE can be found in section 7.10.

7.5.5 Aerosol Generating procedures (AGPs)

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

Below is the full extant list of medical procedures for COVID-19 that have been reported to be aerosol generating and are associated with an increased risk of respiratory transmission:

• tracheal intubation and extubation
• manual ventilation
• tracheotomy or tracheostomy procedures (insertion or removal)
• bronchoscopy
• dental procedures (using high-speed devices, for example, ultrasonic scalers/high-speed drills)
• non-invasive ventilation (NIV): Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• respiratory tract suctioning (see note 1)
• upper ENT airway procedures that involve respiratory suctioning
• upper gastrointestinal endoscopy where open suction of the upper respiratory tract occurs
• high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

Note 1: The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.    It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  The evidence on respiratory tract suctioning is currently being reviewed by the AGP Panel. 

Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres. On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

This recommendation comes from Public Health England and the New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG).  The published evidence view and consensus opinion can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp--2

Certain other procedures/equipment may generate an aerosol from material other than an individual’s secretions but are not considered to represent a significant infection risk and do not require AGP PPE. Procedures in this category include:

• administration of humidified oxygen;
• administration of Entonox or medication via nebulisation.

NERVTAG advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.

An SBAR produced by Health Protection Scotland (HPS) and agreed by NERVTAG specific to AGPS during COVID-19 is available.

The NERVTAG consensus view is that the HPS document accurately presents the evidence base concerning medical procedures and any associated risk of transmission of respiratory infections and whether these procedures could be considered aerosol generating. NERVTAG supports the conclusions within the document and supports the use of the document as a useful basis for the development of UK policy or guidance related to COVID-19 and aerosol generating procedures (AGPs).

7.5.6 Aerosol Generating Procedures (AGPs) in an individual’s home

Wherever possible, staff should avoid visiting patients/individuals in the medium and high categories who require a routine consultation and where AGPs are undertaken in the home.  This is because potentially infectious aerosols will still be circulating in the air (see section 7.5.8).  The most common AGPs undertaken in the community are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).

Consider phone/digital consultations in the first instance to assess whether the individual requires a home visit. If it is safe to postpone the visit, then do so.

Care at home staff will not be able to postpone visits.  In such instances where a home visit cannot be avoided;

• Find out what time the individual is on CPAP/BiPAP and plan to visit at least an hour or more after the CPAP or BiPAP has been switched off.
  
  
• Ask the individual to move to another room in the property and close the door to the room where the CPAP or BiPAP is undertaken.
  
  
• If the visit must take place when the patient is on the CPAP/BiPAP or if the above measures cannot be followed, the member of staff must wear AGP PPE in line with section 7.5.4. It is the responsibility of care providers to ensure that all staff have been fit tested for FFP3 respirators where appropriate.

7.5.7 PPE for Aerosol Generating Procedures (AGPs)

Airborne precautions are required for the medium and high risk categories where AGPs are undertaken and the required PPE is detailed in table 3.

All FFP3 respirators must be:

• Fit tested (by a competent fit test operator) on all healthcare staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance.
  
  
• Fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved.
  
  
• Compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection. If wearing a valved, non-shrouded FFP3 respirator a full face shield/visor must be worn.
  
  
• Changed after each use. Other indications that a change in respirator is required include: if breathing becomes difficult; if the respirator becomes wet or moist, damaged; or obviously contaminated with body fluids such as respiratory secretions.

 

Table 3: PPE for aerosol-generating procedures, determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	Single-use.	Single-use.
Apron or gown	Single-use gown.	Single-use gown.
Face mask or respirator**	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.

**FFP3 masks must be fluid resistant. Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated

7.5.8 Post AGP Fallow Times (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted.  This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate. 

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 4. It is often difficult to calculate air changes in areas that have natural ventilation only. 

All point of care areas require to be well ventilated. Natural ventilation, provides an arbitrary 1-2 air changes per hour. To increase natural ventilation in many community health and social care settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  it is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.

During the PAGPFT staff should not enter this room without FFP3 masks.  Patients, other than the patient on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately.

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 4). Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Table 4: Post AGP fallow time calculation

Duration of AGP (minutes)	1 AC/h	2 AC/h	4 AC/h	6 AC/h	8 AC/h	10 AC/h	12 AC/h	15 AC/h	20 AC/h	25 AC/h
3	230	114	56	37	27	22	18	14	10	8 (10)*
5	260	129	63	41	30	24	20	15	11	8 (10)*
7	279	138	67	44	32	25	20	16	11	9 (10)*
10	299	147	71	46	34	26	21	16	11	9 (10)*
15	321	157	75	48	35	27	22	16	12	9 (10)*

* Note that for duration of 25 air changes per hour the minimum fallow time (to allow for droplet settling time) is 10 minutes.

7.5.9 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between residents and for a period of time where a member of staff was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is not recommended other than when wearing a visor or eye protection in a communal area where the resident is on the high-risk category and when wearing a fluid-resistant surgical face mask (FRSM) across all categories. Sessional use of all other PPE is associated with transmission of infection amongst patients and is considered poor practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) category areas.

The same principles should be observed for staff post toilet and meal breaks, when a new face mask should be put on, once removed the FRSM must never be reused.

Employers are encouraged to plan breaks in such a way that allows 2 metre physical distancing and therefore staff not having to wear a face mask, with natural ventilation where possible.

7.5.10 PPE for delivery of COVID-19 vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct contact and where
  2 metre physical distancing cannot be maintained.  This will protect both the HCWs and resident from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
• perform hand hygiene regularly including before and after each patient/individual contact and as per 4 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
• wear a visor where there is anticipated splashing to the face for e.g. where nasal vaccinations induce sneezing, HCWs may choose to wear a visor to prevent droplet contamination to the face following risk assessment. 

The patient/individual on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance. 

As per SICPs;

• Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
• Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

7.5.11 Access to PPE

NHS staff should continue to obtain PPE through their health board procurement contacts, who will raise their needs via an automated procurement portal to NHS National Service Scotland. This automated internal procurement system has been specifically developed to deal with increased demand, give real time visibility to Health Boards for ordered stock, as well as enabling quick turnaround for delivery.

All services who are registered with the Care Inspectorate that are providing health and/or care support and have an urgent need for PPE after having fully explored local supply routes/discussions with NHS Board colleagues, can contact a triage centre run by NHS National Services for Scotland (NHS NSS).

Please note that in the first instance, this helpline is to be used only in cases where there is an urgent supply shortage after “business as usual” routes have been exhausted.

The following contact details will direct social care providers to the NHS NSS triage centre for social care PPE:

Email: support@socialcare-nhs.info

Phone: 0300 303 3020.

The helpline will be open (8am - 8pm) 7 days a week.

7.6 Safe management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents. Consequently it is easy to transfer infectious agents from communal care equipment during care delivery. 

All care equipment should be decontaminated as per Table 5.

Re-useable care equipment used in the community setting such as stethoscopes, syringe drivers and pumps must be decontaminated prior to removal from an individual’s home.  Where this is not possible, they should be bagged and transported back to base for decontamination.

Table 5: Equipment cleaning determined by risk category

Risk category	Product
Medium-risk category (Amber)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.
High-risk category (Red)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

7.7 Safe Management of the Care Environment

During this ongoing pandemic, cleaning frequency of the environment should be increased across all categories. A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean.  Where a room has not been occupied by any staff or residents since the first daily clean was undertaken, a second daily clean is not required.

It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean
• free from non-essential items and equipment to facilitate effective cleaning
• well maintained and in a good state of repair

Ideally rooms which are carpeted should be avoided when carrying out consultations in healthcare facilities

Environmental cleaning in the Medium and High Risk COVID-19 categories should be undertaken using either a combined detergent/disinfectant solution at a dilution of 1000 ppm available chlorine or a general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm.

Cleaning across the categories is summarised in table 6.

Table 6: Environmental cleaning determined by category

	Medium risk category (Amber)	High risk category (Red)
First daily clean	Full clean	Full clean
Second daily clean	High Risk Touch Surfaces*	High Risk Touch Surfaces
Product	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If an item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If an item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

*High risk touch surfaces as a minimum should include door handles/push pads, taps, light switches, lift buttons.  Resident areas should include the bedroom and treatment areas and staff rest areas.

Any areas contaminated with blood and body fluids across any of the three categories require to be cleaned as per Appendix 9 of the National Infection Prevention and Control Manual.

7.7.1 Cleaning practice points

NHS healthcare facilities will be cleaned by NHS domestic services who will adhere to the National Cleaning Specification Standards. For all other health and care facilities (excluding patient/individuals own home) the following good practice points apply:

• Use disposable cloths/paper roll/disposable mop heads, to clean and disinfect all hard surfaces/floor/chairs/door handles/reusable non-invasive care equipment/sanitary fittings in the room.
  
  
• Clean, dry and store re-usable parts of cleaning equipment, such as mop handles.
  
  
• For carpeted floors/items that cannot withstand chlorine-releasing agents, consult the manufacturer’s instructions for a suitable alternative to use following, or combined with, detergent cleaning.
  
  
• Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated, you may have to discard it. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.
  
  
• If an item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

When an organisation adopts practices that differ from those recommended/stated in this national guidance with regards to cleaning agents, the individual organisation is fully responsible for ensuring safe systems of work, including the completion of local risk assessment(s) approved and documented through local governance procedures.

7.8 Safe Management of Linen

All linen should be handled as per section 1.7 of SICPs – Safe Management of Linen.

Linen used on patients/individuals who are known to be COVID positive, or suspected should be treated as infectious. Following local risk assessment/ and there is no confirmed outbreak in the setting laundry can be processed as normal.

Provided curtains around examination bays have no visible contamination and are kept tied back when not in use, they may remain insitu however regular curtain change regimes should be in place and when changed, curtains should be treated as infectious linen.

Where care providers are supporting individuals with laundering in the community, If the individual does not have a washing machine, the laundry items should be bagged, held for 72 hours before being taken to a public launderette.

Care at home staff who manage linen in the individual’s own home should wash linen as normal unless the individual is on the high risk category.  In this instance, any linen belonging to the individual should be washed separately from others living in the same household.

Community Health and Care Settings with their own in-house laundries may also refer to National guidance for safe management of linen in NHSScotland for more information.

See section 7.13 for staff uniforms.

7.9 Safe Management of Blood and Body Fluid Spillages

All blood and body fluid spillages across the three pathways should be managed as per section 1.8 of SICPs – Safe management of Blood and Body Fluid Spillages and Appendix 9 of the National Infection Prevention and Control Manual.

Waste generated during the management of blood and body fluid spillages should be disposed of as per section 7.10.

7.10 Safe Disposal of waste (including sharps)

Waste should be handled in accordance with Section 1.9 of SICPs.

Waste generated from patients/individuals who are known to be COVID positive, or suspected or where there is a confirmed outbreak, should be disposed of as clinical waste where clinical waste contracts are in place.

NB: Type IIR facemasks worn as part of the extended use of facemasks policy should be disposed of as clinical waste.

If the community health and care setting does not have a clinical waste contract, or for care at home, ensure all waste items that have been in contact with the patient/ individual (e.g. used tissues and disposable cleaning cloths) are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.

7.11 Occupational Safety

Section 1.10 of SICPs remains applicable to COVID-19 individuals.

Occupational risk assessment guidance specific to COVID-19 is available.

PPE is provided for occupational safety and should be worn as per Tables 1 and table 2.

7.11.1 Vehicle sharing for all staff

Wherever possible, car sharing should be avoided with anyone outside of your household or your support bubble.  This is because the close proximity of individuals sharing the small space within the vehicle increases the risk of transmission of COVID-19.  All options for travelling separately should be explored and considered such as;

• Staff travelling separately in their own cars
• Geographical distribution of visits – can these be carried out on foot or by bike?
• Use of public transport where social distancing can be achieved via use of larger capacity vehicles

However, it is recognised that there are occasions where car sharing is unavoidable such as:

• Staff who carry out community visits;
• Staff who are commuting with residents as part of supported care;
• Staff who are commuting with students as part of supported learning/mentorship;
• Staff living in areas where public transport is limited and car sharing is the only means of commuting to and from the workplace;

Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;

• Staff (and students) must not travel to work/car share if they have symptoms compatible with a diagnosis of COVID-19.
  
  
• Ideally, no more than 2 people should travel in a vehicle at any one time
  
  
• Use the biggest car available for car sharing purposes
  
  
• Car sharing should be arranged in such a way that staff share the car journey with the same person each time to minimise the opportunity for exposure. Rotas should be planned in advance to take account of the same staff commuting together/car sharing as far as possible.
  
  
• The car must be cleaned regularly (at least daily) and particular attention should be paid to high risk touch points such as door handles, electronic buttons and seat belts. General purpose detergent is sufficient unless a symptomatic or confirmed case of COVID-19 has been in the vehicle in which case a disinfectant should be used.
  
  
• Occupants should sit as far apart as possible, ideally the passenger should sit diagonally opposite the driver.
  
  
• Windows in the car must be opened as far as possible taking account of weather conditions to maximise the ventilation in the space.
  
  
• Occupants in the car, including the driver, should wear a fluid resistant surgical mask (FRSM) provided it does not compromise driver safety in any way.
  
  
• Occupants should perform hand hygiene using an alcohol based hand rub (ABHR) before entering the vehicle and again on leaving the vehicle. If hands are visibly soiled, use ABHR on leaving the vehicle and wash hands at the first available opportunity.
  
  
• Occupants should avoid eating in the vehicle.
  
  
• Passengers in the vehicle should minimise any surfaces touched – it is not necessary for vehicle occupants to wear aprons or gloves.
  
  
• Keep the volume of any music/radio being played to a minimum to prevent the need to raise voices in the car

Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.

7.12 Hierarchy of Controls

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below is a graphic specifying the general principles of prevention legislated in the Management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1. It details the most to the least effective hierarchy of controls and can be used to help implement effective controls in preventing the spread of COVID-19 within healthcare settings.  NHS boards and NHS staff should employ the most effective method of control first.  Where that is not possible, all others must be considered.  PPE is the last in the hierarchy of controls.

Hierarchy of Risk Controls graphic //commons.wikimedia.org/index.curid=90190143 (original version: NIOSH Vector version: Michael Pittman)

Application of the hierarchy of control in health and social care settings is as follows;

1. Elimination
   • Patients must not attend for an appointment if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff who can work from home should be supported to do so
   • Consideration should be given to non clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible
2. Substitute
   • Patient consultations over phone as far as possible rather than in person
3. Engineering controls
• Installations of partitions at appropriate places (e.g reception desks)
• 2 metre physical distancing on the premises (see section 7.15) 
• Efforts made to reduce number of people on premises at any one time
• reduce waiting time for individuals in clinic and radiology departments
• improve ventilation by opening windows on the premises 
• Optimal bed spacing and chair spacing (see section 7.15.1) 
  
  
4. Administrative Controls (more detail in section 7.15.1) 
• Working from behind or at the side of the individual (no face to face close contact)
• development of pathways/one way systems on the premises
• use of various COVID-19 related signage
• provision of additional hand hygiene stations
• increased cleaning. 
5. PPE
• Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask
• PPE when a risk assessment indicates this (see PPE section of this addendum).

7.13 Staff Uniforms

It is safe to launder uniforms at home. If the uniform is changed before leaving work, then transport this home in a disposable plastic bag. If wearing a uniform to and from work, then change as soon as possible when returning home.

Uniforms should be laundered daily, and:

• separately from other household linen;
• in a load not more than half the machine capacity;
• at the maximum temperature the fabric can tolerate, then ironed or tumble dried.

Scottish Government uniform, dress code and laundering policy is available.

7.13 Caring for someone who has died

The IPC measures described in this document continue to apply whilst the individual who has died remains in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living individuals.

Where the deceased was known or suspected to have been infected with COVID-19, there is no requirement for a body bag, and viewing, hygienic preparations, post-mortem and embalming are all permitted. Body bags may be used for other practical reasons such as maintaining dignity or preventing leakage of body fluids.

For further information, please see the following guidance produced by Scottish Government Coronavirus (COVID-19): guidance for funeral directors on managing infection risks.

 

7.15 Physical distancing

All staff working within NHSScotland healthcare facilities, including non-clinical areas, must maintain 2 metres physical distancing wherever possible.  This does not apply to the provision of direct care where appropriate PPE should be worn in line with section 7.5. 

Outbreaks amongst staff have been associated with a lack of physical distancing in recreational areas during staff breaks and when car sharing.  There are many areas within healthcare facilities where maintaining 2 metres physical distancing is a challenge due to the nature of the work undertaken.  Where 2 metres physical distancing cannot be maintained, staff must ensure they are wearing face masks/coverings in line with the extended use of facemasks guidance. See section 7.5.1.

Staff must adhere to physical distancing as much as possible and should;

• stagger tea breaks to reduce the number of staff in recreational areas at any one time.
  
  
• maintain 2 metre physical distancing when removing FRSMs to eat and drink.
  
  
• not care share with colleagues when commuting to and from work unless absolutely necessary. Where this is absolutely necessary, staff should sit as far apart as possible, wear a face covering or FRSM and keep windows open in the car to improve ventilation. 

7.15.1 Engineering & Administration control measures in healthcare settings

Boards and departments should apply administrative controls to establish separation of patient pathways and minimise contact between the pathways. 

Due to the wide variance in the lay out, structure and fabric of NHS facilities across Scotland it is not possible to be descriptive in exactly how these should be applied and full assessment should be undertaken locally. 

The following bullet points provide guidance which boards and departments may use when considering how best to develop pathways and promote 2 metre physical distancing.

• Signage on entry to buildings, wards and departments advising of the necessary precautions to take (face coverings, hand hygiene, physical distancing) including advice for visitors not to enter the premises if symptomatic of COVID-19.
  
  
• Ensure signage is clearly displayed to clearly identify pathways. Floor markings may also be used.  Physical barriers may be used where appropriate to prevent cross over of pathways.
  
  
• Ensure there are adequate hand hygiene facilities (wash hand basins or alcohol based hand rub stations) available including the use of posters promoting hand hygiene and detailing the effective method for doing so.
  
  
• Where required, facilitate the use of screens to reduce exposure risk, for example at admission desks or help desks.

Screens may be used in clinical care areas to help segregate patients however installation of these must not hinder the ability of staff to observe their patients and must be assessed by fire officers and health and safety teams first to ensure all other regulations remain compliant.

There is limited evidence supporting the use of partitions for face-to-face interactions or between bed spaces, but it appears logical that a physical barrier can reduce contact between individuals and reduce the spread of infected particles from an infective source.

• • Full bed length, floor to ceiling partitions are likely to be the most efficacious in preventing transmission of COVID-19. Partitions for face-to-face interactions, as a minimum, should cover both individuals breathing zone which encompasses a radius of 30cm from the middle of the face.
    
    
• Consider remote consultations where possible rather than face to face.
  
  
• Ensure areas are well ventilated where possible – open windows if temperature/weather conditions allow

7.16 Visiting in residential facilities

All visitors must be informed on arrival of IPC measures and adhere to these at all times.  Visitors should wear face coverings in line with current Scottish Government guidance (see section 7.5.1) and must not attend with COVID-19 symptoms or before a period of self-isolation has ended, whether identified as a case of COVID-19 or as a contact.

Visiting may be suspended if an area moves to Level 4, or on the advice of the local HPT. Consider alternative measures of communication including telephone or video call where visiting is not possible.

Visitors must;

• Not visit if they have suspected or confirmed COVID-19 or if they have been advised to self-isolate for any reason
  
  
• Wear a face covering on entering the facility
  
  
• Be provided with appropriate PPE (see table 7)
  
  
• Perform hand hygiene at the appropriate times;     
• On entry to the facility
• Prior to putting on PPE
• After removing PPE
  
  
• Observe physical distancing.
  
  
• Not move around the facility and should stay in the areas advised by staff.
  
  
• Not visit other individuals in the facility.
  
  
• Not touch their face or face covering/mask once in place.
  
  
• Avoid sharing mobile phone devices with the individual unnecessarily – if mobile devices are shared to enable communications with other friends and family members, the phone should be cleaned between uses using manufacturer’s instructions

 

Table 7: PPE for Visitors

PPE used	Medium-risk category	High-risk category
Gloves	Not required1	Not required1
Apron or gown	Not required2	If within 2 metres of resident
Face mask	Face covering or provide with FRSM if visitor arrives without a face covering.	FRSM
Eye and face protection	Not required3	If within 2 metres of resident

¹ unless providing direct care to the patient which may expose the visitor to blood and/or body fluids i.e toileting.

² unless providing care to the patient resulting in direct contact with the patient, their environment or blood and/or body fluid exposure i.e toileting, bed bath.

³ Unless providing direct care to the patient and splashing/spraying is anticipated.

 

 

7.16 Resources

This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.

• PPE poster – medium-risk pathway
• PPE poster – high-risk pathway
• COVID-19 Safe practice in acute healthcare settings poster
• COVID-19 Wearing a facemask poster (staff)
• Wearing a non-medical face mask or face covering
• Poster suggested ways of wearing a face mask
• Key messages in the workplace poster
• 4 moments for hand hygiene poster – residential and care home settings
• How to wash hands – Appendix 1 - NIPCM
• How to use alcohol based hand rub – Appendix 2 - NIPCM
• PHS Primary Care COVID-19 guidance
• PHS Social Care and Residential Care settings COVID-19 guidance
• COVID-19 Social, Community and Residential Care Outbreak Checklist

 

7.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Review of the National and International Guidance on Infection Prevention and Control Measures for Personal Protective Equipment (PPE) and Aerosol Generating Procedures (AGPS) for COVID-19
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• Provision of gloves for COVID-19 in health and care settings
• Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

7.18 COVID-19 Education resources

This section contains a number of educational resources to support the COVID-19 response in partnership with a range of stakeholders

• TURAS - COVID-19 vaccination programme
• Correct use of Alcohol Based Hand Rub
• Correct Hand Hygiene Technique using soap and water
• Correct order for putting on, the safe order for removal, and the disposal of PPE
• Obtaining a sample swab test in care homes
• Protecting yourself and your work environment

 

 

The purpose of this addendum is to provide additional guidance to chapters 1,2 and 3 for NNUs

4.1 Placement of neonates/assessment for infection risk

Undertake assessment for infection risk at the point of entry into the unit before placement of the neonate is decided. This assessment is the minimal microbiological testing required and any additional testing would be determined by the clinical presentation of the neonate. The potential for transmission of infection should be continuously reviewed throughout the stay/period and must be documented in the clinical notes.

Neonates who present as a cross infection risk include those who:

• have been transferred from another unit in Scotland with an ongoing incident/outbreak or
• were born outside Scotland
• have previously been positive with a Multidrug Resistant Organism (MDRO)

From mothers who have:

• been hospitalised outside Scotland in the previous 12 months
• had no antenatal care
• been previously positive with a MDRO e.g. Multidrug Resistant Staphylococcus Aureaus (MRSA) or Carbapenemase Producing Enterobacteriaceae (CPE)

If a neonate is considered to be a cross infection risk then the clinical judgement of those involved in the management of the baby should assess the placement by prioritising the incubator/cot in a suitable area pending investigation i.e. place in a single room or cohort area/room with a wash hand basin.

Information/advice must be given to parents/carers of all neonates; particularly during outbreaks/incidents

4.2 Healthcare infection, incidents, outbreaks and data exceedence

In addition to the definitions in Chapter 3, in a neonatal unit investigation by IPCT is also required if:

• a single case of infection with an alert organism is identified
• two or more cases of colonisation with the same organism; linked in time and place are identified

Assigning staff to nurse only infected/colonised neonates may also be required. During outbreaks or incidents the ratio of staff to neonates may need to increase and it may be necessary to restrict admissions to the area.

4.3 Personal care of neonates

Due to the vulnerability of some neonates the use of tap water for personal care requires consideration and this is outlined in Guidance for neonatal units (NNUs) (levels 1, 2 & 3), adult and paediatric intensive care units (ICUs) in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. For example, an assessment should be made on the neonate’s condition and whether tap water can be used or if an alternative, such as sterile water, is considered more appropriate.

In addition incubators/cots should not be placed near any water source where spraying or splashing may occur.

Reference 1

The use of the word 'Persons' can be used instead of ‘Patient’ when using this document in non-healthcare settings.

Abrasion

A graze. A minor wound in which the surface of the skin or a mucous membrane has been worn away by rubbing or scraping.

Aerosol Generating Procedures (AGPs)

Certain medical and patient care activities that can result in the release of airborne particles (aerosols). AGPs can create a risk of airborne transmission of infections that are usually only spread by droplet transmission.

See Appendix 11, footnote 3 for further information

Aerosols

See Airborne particles

Airborne (aerosol) transmission

The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.

Airborne particles (aerosols)

Very small particles that may contain infectious agents. They can remain in the air for long periods of time and can be carried over long distances by air currents. Aerosols can be released during aerosol generating procedures (AGPs).

 

Alcohol based hand rub (ABHR)

A gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to inactivate microorganisms and/or temporarily suppress their growth.

Alert organism

An organism that is identified as being potentially significant for infection prevention and control practices. Examples of alert organisms include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff) and Group A Streptococcus.

 

Alveolar

Refers to the alveoli which are the small air sacs in the lungs. Alveoli are located at the ends of the air passageways in the lungs, and are the site at which gas exchange takes place.

Anteroom

An area with a door from/to the outside corridor and a second door giving access to the patient area (where both doors will never be open at the same time).

Antimicrobial

An agent that kills microorganisms, or prevents them from growing. Antibiotics and disinfectants are antimicrobial agents.

Antimicrobial hand wipes

Hand wipes that are moistened with an antimicrobial solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth.

Aseptic Technique

A healthcare procedure designed to minimise the risks of exposing the person being cared for to pathogenic micro-organisms during simple (e.g dressing wounds) and complex care procedures (e.g. surgical procedures).

Asymptomatic

Not showing any symptoms of disease but where an infection may be present.

Autoclave

Machine used for sterilising re-usable equipment using superheated steam under pressure.

Bay

A partly enclosed area within a ward containing one bed (single bay) or multiple beds (multi-bed bay).

Blood Borne Viruses (BBV)

Viruses carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.

Body Fluids

Fluid produced by the body such as urine, faeces, vomit or diarrhoea.

Carbapenemase Producing Enterobacteriaceae (CPE)

A group of bacteria that have become extremely resistant to antibiotics including those called carbapenems.

Care setting

Includes but is not limited to general practice, dental and pharmacy (primary care), acute-care hospitals, emergency medical services, urgent-care centres and outpatient clinics (secondary care), specialist treatment centres (tertiary care), long-term care facilities such as nursing homes and skilled nursing facilities (community care), and care provided at home by professional healthcare providers (home care).

Care staff

Any person who cares for patients, including healthcare support workers and nurses.

Central Decontamination Unit (CDU)

A large, centralised facility for the decontamination and re-processing of re-usable medical equipment e.g. surgical instruments.

Central Vascular Catheter (CVC)

An intravenous catheter that is inserted directly into a large vein in the neck, chest or groin to allow intravenous drugs and fluids to be given and to allow blood monitoring.

Chlorine

A chemical that is used for disinfecting, fumigating and bleaching.

Cleaning

The removal of any dirt, body fluids (blood, vomit) etc by use of an appropriate cleaning agent such as detergent.

Clinical wash hand basin

A sink designated for hand washing in clinical areas.

Clostridioides difficile (C.diff)

An infectious agent (bacterium) that can cause mild to severe diarrhoea which in some cases can lead to gastro-intestinal complications and death.

Cohort area

An area (room, bay, ward) in which two or more patients (a cohort) with the same confirmed infection are placed. A cohort area should be physically separate from other patients.

Colonisation

The presence of bacteria on a body surface (such as the skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection.

Conjunctivae

Mucous membranes that cover the front of the eyes and the inside of the eyelids.

Contact transmission

The spread of infectious agents from one person to another by contact. When spread occurs through skin-to-skin contact, this is called direct contact transmission. When spread occurs via a contaminated object, this is called indirect contact transmission.

Contaminated

The presence of an infectious agent on a body surface; also on or in clothes, bedding, surgical instruments or dressings, or other inanimate articles or substances including water and food.

Cross-infection/Cross-transmission

Spread of infection from one person to another.

Decontamination

Removing, or killing pathogens on an item or surface to make it safe for handling, re-use or disposal, by cleaning, disinfection and/or sterilisation.

Detergent

A chemical cleansing agent that can dissolve oils and remove dirt.

Diarrhoea

3 or more loose or liquid bowel movements in 24 hours or more often than is normal for the individual.

Direct contact transmission

Spread of infectious agents from one person to another by direct skin-to-skin contact.

Disinfectant

A chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.

Disinfection

A process, for example using a chemical disinfectant, to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to your health.

Domestic waste

Waste produced in the care setting that is similar to waste produced in the home.

Droplet

A small drop of moisture, larger than airborne particle, that may contain infectious agents. Droplets can be released when a person talks, coughs or sneezes, and during some medical or patient care procedures such as open suctioning and cough induction by chest physiotherapy. It is thought that droplets can travel around 1 metre (3 feet).

Droplet transmission

The spread of infection from one person to another by droplets containing infectious agents.

Emollient

An agent used to soothe the skin and make it soft and supple. 

Enhanced single room (with en-suite facilities and ventilated lobby)

This is a single room with space for one patient and contains a bed; locker/wardrobe; clinical wash-hand basin, en-suite shower, WC and wash-hand basin and has a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas and a lobby with positive pressure ventilation. 

It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors. 

The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards. 

Enhanced single room (with en-suite facilities)

This is a single room with space for one patient and contains a bed; locker/wardrobe; clinical wash-hand basin, en-suite shower, WC and wash-hand basin and has a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas. 

It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors. 

The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards. 

 

En-suite

A room containing a sink and toilet and sometimes a shower/wetroom or bath.

En-suite single-bed room

A room with space for one patient and containing a bed; locker/wardrobe, clinical wash-hand basin, en-suite shower, WC and wash-hand basin.

Exceptional infection episode

A single case of an infection that has severe outcomes for an individual patient OR has major infection control/public health implications e.g. infectious diseases of high consequence such as extensively drug resistant tuberculosis (XDR-TB).

Excretions

Waste products produced by the body such as urine and faeces (bowel movements).

Exposure

The condition of being exposed to something that may have a harmful effect such as an infectious agent.

Exposure Prone Procedures (EPPs)

Certain medical and patient care procedures where there is a risk that injury to the healthcare worker may result in exposure of the patient’s open tissues to the healthcare worker’s blood e.g the healthcare worker’s gloved hands are in contact with sharp instruments, needle tips or sharp tissues inside a patient’s body.

FFP3

Respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). FFP stands for filtering facepiece. There are three categories of FFP respirator: FFP1, FFP2 and FFP3. An FFP3 respirator or hood provides the highest level of protection, and is the only category of respirator legislated for use in UK healthcare settings.

Fit Testing

A method of checking that a tight-fitting facepiece respirator fits the wearer and seals adequately to their face. This process helps identify unsuitable facepieces that should not be used.

Fluid-resistant

A term applied to fabrics that resist liquid penetration, often used interchangeably with 'fluid-repellent' when describing the properties of protective clothing or equipment.

GP

General practitioner (your family doctor)

Group 4 Infections

Definition taken from the HSE Approved list of biological agents www.hse.gov.uk/pubns/misc208.pdf

Group 4 infections cause severe human disease and is a serious hazard to employees; it is likely to spread to the community and there is usually no effective prophylaxis or treatment available.

 

 

Hand Hygiene

The process of decontaminating your hands using either alcohol based hand rub or liquid soap and water.

Hand wash station

A wash hand basin with mixer tap, paper towels and non-antimicrobial liquid soap in a single use container designed for hand washing use only.

Health Protection Team (HPT)

A team of healthcare professionals whose role it is to protect the health of the local population and limit the risk of them becoming exposed to infection and environmental dangers. Every NHS board has a HPT.

Healthcare Associated Infection (HAI)

Infections that occur as a result of medical care, or treatment, in any healthcare setting.

Healthcare associated infection outbreak

Two or more linked cases associated with the same infectious agent, within the same healthcare setting, over a specified time period; or a higher than expected number of cases in a given healthcare area over a specified time period.

Healthcare infection data exceedance

A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.

Healthcare infection exposure incident

An exposure of patients, staff, or the public to a possible infectious agent, as a result of a healthcare system failure or near misses e.g. ventilation, water or a decontamination incident.

Healthcare Waste

Waste produced as a result of healthcare activities for example soiled dressings, sharps.

Hospital infection incident assessment tool (HIIAT)

Used by the IPCT or HPT to assess every healthcare infection incident i.e. all outbreaks and incidents including decontamination incidents or near misses in any healthcare setting (that is the NHS, independent contractors providing NHS Services and private providers of healthcare).

Hygiene Waste

Waste that is produced from personal care. In care settings this includes feminine hygiene products, incontinence products and nappies, catheter and stoma bags. Hygiene waste may cause offence due to the presence of recognisable healthcare waste items or body fluids. It is usually assumed that hygiene waste is not hazardous or infectious.

Hypochlorite

A chlorine-based disinfectant such as bleach

Immunisation

To provide immunity to a disease by giving a vaccination.

Immunocompromised patient/individual

Any person whose immune response is reduced or deficient, usually because they have a disease or are undergoing treatment. People who are immunocompromised are more vulnerable to infection.

Impervious

Cannot be penetrated by liquid.

Incident Management Team (IMT)

A multidisciplinary group with responsibility for investigating and managing an incident. 

Indirect contact transmission

The spread of infectious agents from one person to another via a contaminated object.

Infection

Invasion of the body by a harmful organism or infectious agent such as a virus, parasite, bacterium or fungus.

Infection Prevention and Control Team (IPCT)

A multidisciplinary team responsible for preventing, investigating and managing an infection incident or outbreak.

Infectious agent

Any organism, such as a virus, parasite, bacterium or fungus, that is capable of invading body tissues, multiplying, and causing disease.

Infectious Diseases of High Consequence (IDHC)

An Infectious Disease of high consequence (IDHC) typically causes severe symptoms requiring a high level of care and a high case-fatality rate, there may not be effective prophylaxis or treatment.  IDHC are transmissible from human to human (contagious) and capable of causing large-scale epidemics or pandemics. 

Invasive device

A device which penetrates the body, either through a body cavity or through the surface of the body. Central Venous Catheters (central line), Peripheral Arterial Lines and Urinary Catheters are examples of invasive devices.

Invasive procedure

A medical/healthcare procedure that penetrates or breaks the skin or enters a body cavity.

Isolation

Physically separating patients to prevent the spread of infection.

Isolation Suite/Room

An isolation room/suite consists of enhanced en-suite single bed rooms:

An en-suite single bed room is defined as: consisting of  a bed; locker/wardrobe; clinical wash-hand basin and en-suite shower,wc and wash-hand basin.  (In new build, space for a social support zone for overnight stay and a clinical support zone is also provided).

• Enhanced single room (with ensuite facilities) is the same as an en-suite single-bed room but with a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas.It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors. The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards.<br>

• Enhanced single room (with en-suite facilities and ventilated lobby) is the same as an enhanced single room (with ensuite facilities) but with a lobby having positive pressure ventilation. 

J

No terms

K

No terms

L

No terms

Microorganism (microbe)

Any living thing (organism) that is too small to be seen by the naked eye. Bacteria, viruses and some parasites are microorganisms.

Mode of transmission

The way that microorganisms spread from one person to another. The main modes or routes of transmission are airborne (aerosol) transmission, droplet transmission and contact transmission.

MRSA

Meticillin Resistant Staphylococcus aureus are strains of infectious agent (bacterium) Staphylococcus aureus that are resistant to the antibiotic meticillin.

Mucocutaneous exposure

An incident in which the mucous membranes (e.g mouth, nose, eyes) are exposed to blood/other body fluid

Mucous membranes/mucosa

The surfaces lining the cavities of the body that are exposed to the environment such as the lining of the mouth and nose.

Multi-bed room

A room that contains more than one bed.  It is best practice for these to have both en-suite toilet with shower, clinical wash-hand basin and doors to the main ward area.

Needle safety device

Any device designed to reduce the risk of injury from needles. This may include needle-free devices or mechanisms on a needle, such as an automated resheathing device, that cover the needle immediately after use.

Negative pressure room

A room which maintains permanent negative pressure i.e air flow is from the outside adjacent space (e.g corridor) into the room and then exhausted to the outside.

Nitrile

A synthetic rubber material used to make non-latex gloves.

Non-intact skin

Skin that is broken by cuts, abrasions, dermatitis, chapped skin, eczema etc.

Non-intact skin exposure

An incident in which non-intact skin is exposed to blood or body fluids.

Non-sterile procedure

Care procedure that does not need to be undertaken in conditions that are free from bacteria or other microorganisms.

Occupational exposure

Exposure of healthcare workers or care staff to blood or body fluids in the course of their work.

Organism

Any living thing that can grow and reproduce, such as a plant, animal, fungus or bacterium.

Outbreak

When two or more people have the same infection, or more people than expected have the same infection.  The cases will be linked by a place and a time period.

Pathogen

Any disease-producing infectious agent.

Patient cohorting

Placing a group of two or more patients (a cohort) with the same suspected or confirmed infection in the same room or area.

Percutaneous injury

An injury caused by a sharp instrument or object such as a needle or scalpel, cutting or puncturing the skin.

Personal Protective Equipment (PPE)

Equipment a person wears to protect themselves from risks to their health or safety, including exposure to infections e.g. disposable gloves and disposable aprons.

Problem Assessment Group (PAG)

A group that is convened by the Infection Prevention and Control Team (IPCT)/Health Protection Team (HPT) to assess a healthcare incident/outbreak/data exceedence and determine if further action

The assessment and outcome may be:

• HIIAT Green - continue to monitor
• HIIAT Amber/Red - IMT required

Pyrexia

Fever. Rise in body temperature above the normal level >37.2°.

Q

No terms

Recapping/Re-sheathing

To put a needle or other sharp object back into its plastic sheath or cap. Also known as ‘re-sheathing’.

Respiratory droplets

A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.

Respiratory Protective Equipment (RPE)

There are two main types of RPE: respirators and breathing apparatus.

• Respirators are devices worn over the nose and mouth or head and are designed to filter the air breathed in to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). The most commonly used item of RPE in healthcare settings is an FFP3 respirator.

• Breathing apparatus provides a supply of breathing quality air from an external source such as a cylinder or an air compressor.

Safer sharp

A medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury.  Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.

Sanitary fittings

All sinks and furniture in a bathroom, such as a toilet, bath, shower etc.     

Secretions

Any body fluid that is produced by a cell or gland such as saliva or mucous.

Segregated

Physically separating or isolating from other people.

Sepsis

A life threatening condition that arises when the body’s response to a severe complication of infection e.g. pneumonia (lung infection) injures its own tissues and organs. This can lead to multiple organ failure and death. Early recognition, treatment and management is key to successful patient outcomes.

Sharp

A ‘sharp’ is a device or instrument  used in healthcare settings such as needles, lancets and scalpels which are necessary for the exercise of specific healthcare activities and are able to cut, prick and/or have the potential to cause injury.

 

Sharps incident

A type of percutaneous injury caused by a sharp instrument or device which cuts or penetrates the skin. 

Sharps injury

See percutaneous injury.

Significant occupational exposure

A percutaneous, mucocutaneous exposure or non-intact skin (abrasions, cuts, eczema) exposure to blood/other body fluids from a source that is known (or later found to be) positive for a bloodborne virus infection.

Significant sharps incident

An incident which involves a used needle that has exposed, or may have exposed, the employee to blood/body fluids.

Single-bed room

A room with space for one patient and usually contains as a minimum: a bed; locker/wardrobe; clinical wash-hand basin.

Spore

A reproductive cell produced by fungi and some types of bacteria under certain environmental conditions. Spores can survive for long periods of time and are very resistant to heat, drying and chemicals.

Staff cohorting

A dedicated team of healthcare staff who care for a cohort of patients, and do not care for any other patients.

Sterile

Free from live bacteria or other microorganisms

Sterile procedure

Care procedure that is undertaken in conditions that are free from bacteria or other microorganisms.

Sterilisation

The procedure of making some object free of all germs, live bacteria or other microorganisms (usually by heat or chemical means).

Surgical face mask

A disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious droplets and also to protect patients.  When recommended for infection control purposes a 'surgical face mask' typically denotes a fluid-resistant (Type IIR) surgical mask.

Swan-neck

Way of closing bag by tying in a loop and securing with a zip tie to make a handle.

Terminal decontamination

Cleaning/decontamination of the environment following transfer/discharge of a patient, or when they are no longer considered infectious, to ensure the environment is safe for the next patient or for the same patient on return.

U

No terms

Variable pressure room

Room where it is possible to change the pressure from positive to negative or vice-versa by switch.

Vascular access devices

Any medical instrument used to access a patient’s veins or arteries such as a Central Venous Catheter or peripheral vascular catheter.

Ward

An area forming a division of a care setting (or a suite of rooms) shared by patients who need a similar type of care.

X

No terms

Y

No terms

Z

No terms