National Infection Prevention and Control Manual
For pathogen specific information go to the A-Z of pathogens.
The NHSScotland National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO (2012)1 Update).
The NIPCM was endorsed on 3 April 2017 by the Chief Medical Officer (CMO), Chief Pharmaceutical Officer (CPO), Chief Dental Officer (CDO) and Chief Executive Officer of Scottish Care.
The NIPCM provides guidance to all those involved in care provision and should be adopted for infection prevention and control practices and procedures. The national manual is mandatory for NHSScotland. In all other care settings to support with health and social care integration the content of this manual is considered best practice.
The manual aims to:
The NIPCM currently contains guidance on Standard Infection Control Precautions (SICPs), Chapter 1 and Transmission Based Precautions (TBPs), Chapter 2 and Healthcare Infection incidents, outbreaks and data exceedance - Chapter 3. It is planned to further develop the content of the manual.
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.
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:
For assessment of infection risk see Section 2: Transmission Based Precautions.
Further information can be found in the patient placement literature review.
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:
*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.
Some additional examples of hand hygiene moments include:
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:
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:
Skin care:
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.
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:
(The video above demonstrating Surgical Scrubbing using ABHR was produced by Golden Jubilee National Hospital)
Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of respiratory illness (pathogens):
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.
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:
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:
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:
Full body gowns/Fluid repellent coveralls must be:
The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure.
Sterile surgical gowns must be:
Reusable gowns must:
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:
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:
Further information can be found in:
Footwear must be:
Further information can be found in the footwear literature review.
Headwear must be:
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.
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:
Before using any sterile equipment check that:
Decontamination of reusable non-invasive care equipment must be undertaken:
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.
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:
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.
Clean linen
Linen used during patient transfer
For all used linen (previously known as soiled linen):
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:
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.
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.
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:
Waste Streams:
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:
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:
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.
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:
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:
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:
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.
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.
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.
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.
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:
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:
Care home settings:
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:
Further information can be found in the patient placement literature review.
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.
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:
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.
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:
The room should be decontaminated using either:
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.
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
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:
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:
FFP3 respirator or powered respirator hood:
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.
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)
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
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
See literature review for Infectious Diseases of High Consequence (IDHC)
A healthcare associated infection outbreak
or
A healthcare infection exposure incident
A healthcare infection data exceedance
Further information can be found in the literature review Healthcare infection incidents and outbreaks in Scotland.
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:
3.2.2 Investigation
The IPCT/HPT will establish an IMT if required.
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.
COVID-19 case definitions are regularly reviewed and can be found in the guidance for secondary care and are defined as:
A laboratory confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.
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;
recent onset new continuous cough
or
fever
or
loss of/change in sense of taste or smell (anosmia)
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
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.
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.
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.
Active surveillance should be undertaken by IPCTs to allow outbreaks to be detected at the earliest possible opportunity.
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.
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.
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 .
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.
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.
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:
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.
A case definition for the purpose of the incident must be agreed by the IMT and should include the following:
Suggested case definitions for COVID-19 as follows;
3.7.1 Epidemiological data/timelines
3.7.2 Identifying missed opportunities to isolate
3.7.3 IPC practice and compliance (including AGPs)
3.7.5 Testing during an outbreak
3.7.8 Ventilation considerations
3.7.10 Review of physical distancing
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.
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.
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.
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.
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.
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.
Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions.
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.
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:
Non-household contact
Direct contact:
Proximity contact:
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:
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.
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.
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.
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;
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.
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.
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;
Every opportunity to promote this messaging should be considered.
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.
3.9.3 Personal Protective Equipment
3.9.4 Safe Management of care Equipment
3.9.5 Safe Management of Care Environment
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:
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.
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;
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.
Reporting should be led by the IPCT. Reporting of COVID-19 should occur on recognition of a COVID-19 cluster
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.
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.
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.
Whilst guidance contained within this addendum is specific to COVID-19, clinicians must consider the possibility of infection associated with other respiratory pathogens spread by the droplet or airborne route. Therefore Transmission Based Precautions (TBPs) should not be automatically discontinued where COVID-19 has been excluded. See Appendix 13 -NHSScotland alert organism/condition list.
Any patient who has a coinfection with COVID-19 must not be cohorted with other COVID-19 patients.
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
5.1.1 Definition of a confirmed case
5.1.2 Definition of a suspected case
A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.
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:
or
or
Definition for individuals requiring hospital admission:
or
or
or
Patients must be assessed for bacterial sepsis or other causes of symptoms as appropriate.
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:
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.
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.
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.
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 .
If yes, provide advice on who to contact (GP/NHS111) or, if admission required, follow high-risk pathway and isolate for 14 days.
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.
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 27th November detailing the staged roll out of the admission testing expansion plan to include;
A table containing a summary of testing requirements in NHSScotland is available. When using this table the following applies;
5.3.4 Moving patients between pathways
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.
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.
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.
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.
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.
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.
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
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’.
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.
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 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;
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.
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).
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.
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).
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;
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.
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.
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. |
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. |
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:
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.
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.
5.6.1 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)
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.
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.
In Scotland, staff are provided with Type IIR masks for use as part of the extended wearing of facemasks.
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.
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.
PPE used |
Low-risk pathway |
Medium-risk pathway |
High-risk pathway |
---|---|---|---|
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. |
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:
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.
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).
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.
PPE used |
Low-risk pathway |
Medium-risk pathway |
High-risk pathway |
---|---|---|---|
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.
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.
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.
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.
Healthcare workers (HCWs) delivering vaccinations must;
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.
A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.
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.
Pathway |
Product |
---|---|
Low-risk pathway |
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 |
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 |
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. |
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:
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.
|
Low risk pathway |
Medium risk pathway |
High risk pathway |
---|---|---|---|
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.
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
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.
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.
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;
However, it is recognised that there are occasions where car sharing is unavoidable such as;
Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;
Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.
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;
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:
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.
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.
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;
PPE used |
Low-risk pathway |
Medium-risk pathway |
High-risk pathway |
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;
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.
This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.
PPE
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:
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.
This section contains links to current national and international policy, guidance and resources on COVID-19 from key organisations.
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.
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.
Whilst guidance contained within this addendum is specific to COVID-19, clinicians must consider the possibility of infection associated with other respiratory pathogens spread by the droplet or airborne route. Therefore Transmission Based Precautions (TBPs) should not be automatically discontinued where COVID-19 has been excluded.
Any resident who has a coinfection with COVID-19 must not be cohorted with other COVID-19 patients.
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.
A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.
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:
or
or
Definition for residents who may require hospital admission:
or
or
or
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:
If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.
If yes, follow the high-risk category.
If yes, follow the high-risk category.
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.
If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.
If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.
6.2.2 Requirements for risk categories
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.
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.
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.
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.
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:
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;
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 |
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 |
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.
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.
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:
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.
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:
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.
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.
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.
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.
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
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
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:
PPE should be put on before entering the room.
When wearing PPE:
Removal of PPE
PPE should be removed in an order that minimises the potential for cross-contamination.
Gloves
Gown
Eye Protection (if worn)
Fluid Resistant Surgical facemask
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.
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:
*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:
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.
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
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.
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.
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.
Healthcare workers (HCWs) delivering vaccinations must;
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.
As per SICPs;
A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.
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.
Risk category |
Product |
---|---|
Medium-risk category |
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 |
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. |
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:
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.
|
Medium risk category |
High risk category |
---|---|---|
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.
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.
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.
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.
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.
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;
However, it is recognised that there are occasions where car sharing is unavoidable such as:
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;
Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.
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.
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;
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.
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.
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;
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:
This section contains links to current national and international policy, guidance and resources on COVID-19 from key organisations.
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.
Whilst guidance contained within this addendum is specific to COVID-19, clinicians must consider the possibility of infection associated with other respiratory pathogens spread by the droplet or airborne route and therefore Transmission Based Precautions (TBPs) should not be automatically discontinued where COVID-19 has been excluded.
This guidance if for use within the following settings;
Within this document, service users are referred to as patients and/or individuals depending on the facility/setting in which care is provided.
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
7.1.1 Definition of a confirmed case
7.1.2 Definition of a suspected case
A laboratory-confirmed (detection of SARs-CoV-2 RNA in a clinical specimen) case of COVID-19.
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:
or
or
Definition for individual who may require hospital admission:
or
or
or
Individuals must be assessed for bacterial sepsis of other causes of symptoms as appropriate
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.
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:
If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.
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.
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).
If yes, wait until self-isolation period is complete before admission or if urgent care is required, follow the high-risk category.
If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.
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.
7.2.1 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
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.
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.
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.
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.
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:
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.
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.
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.
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.
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;
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.
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.
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.
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:
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.
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.
7.5.1 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
7.5.10 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 categories and are detailed in table 2.
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.
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.
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.
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:
PPE should be put on before entering the room.
You may require some of these items or all of them – See Table 2.
When wearing PPE:
Removal of PPE
PPE should be removed in an order that minimises the potential for cross-contamination.
Gloves
Gown
Eye Protection
Fluid Resistant Surgical facemask
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.
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.
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:
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:
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).
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;
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:
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
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.
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.
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.
Healthcare workers (HCWs) delivering vaccinations must;
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.
As per SICPs;
A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.
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.
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.
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 |
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. |
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:
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.
|
Medium risk category |
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.
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:
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.
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.
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.
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.
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.
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;
However, it is recognised that there are occasions where car sharing is unavoidable such as:
Where car sharing cannot be avoided, individuals should adhere with the guidance below to reduce any risk of cross transmission;
Adherence with the above measures will be considered should any staff be contacted as part of a COVID-19 contact tracing investigation.
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;
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:
Scottish Government uniform, dress code and laundering policy is available.
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.
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;
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.
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.
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;
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.
This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.
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:
This section contains a number of educational resources to support the COVID-19 response in partnership with a range of stakeholders
The purpose of this addendum is to provide additional guidance to chapters 1,2 and 3 for NNUs
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:
From mothers who have:
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
In addition to the definitions in Chapter 3, in a neonatal unit investigation by IPCT is also required if:
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.
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.
The use of the word 'Persons' can be used instead of ‘Patient’ when using this document in non-healthcare settings.
A graze. A minor wound in which the surface of the skin or a mucous membrane has been worn away by rubbing or scraping.
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
The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.
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).
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.
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.
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.
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).
An agent that kills microorganisms, or prevents them from growing. Antibiotics and disinfectants are antimicrobial agents.
Hand wipes that are moistened with an antimicrobial solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth.
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).
Not showing any symptoms of disease but where an infection may be present.
Machine used for sterilising re-usable equipment using superheated steam under pressure.
A partly enclosed area within a ward containing one bed (single bay) or multiple beds (multi-bed bay).
Viruses carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.
Fluid produced by the body such as urine, faeces, vomit or diarrhoea.
A group of bacteria that have become extremely resistant to antibiotics including those called carbapenems.
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).
Any person who cares for patients, including healthcare support workers and nurses.
A large, centralised facility for the decontamination and re-processing of re-usable medical equipment e.g. surgical instruments.
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.
A chemical that is used for disinfecting, fumigating and bleaching.
The removal of any dirt, body fluids (blood, vomit) etc by use of an appropriate cleaning agent such as detergent.
A sink designated for hand washing in clinical areas.
An infectious agent (bacterium) that can cause mild to severe diarrhoea which in some cases can lead to gastro-intestinal complications and death.
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.
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.
Mucous membranes that cover the front of the eyes and the inside of the eyelids.
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.
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.
Spread of infection from one person to another.
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.
A chemical cleansing agent that can dissolve oils and remove dirt.
3 or more loose or liquid bowel movements in 24 hours or more often than is normal for the individual.
Spread of infectious agents from one person to another by direct skin-to-skin contact.
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.
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.
Waste produced in the care setting that is similar to waste produced in the home.
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).
The spread of infection from one person to another by droplets containing infectious agents.
An agent used to soothe the skin and make it soft and supple.
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.
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.
A room containing a sink and toilet and sometimes a shower/wetroom or bath.
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.
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).
Waste products produced by the body such as urine and faeces (bowel movements).
The condition of being exposed to something that may have a harmful effect such as an infectious agent.
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.
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.
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.
A term applied to fabrics that resist liquid penetration, often used interchangeably with 'fluid-repellent' when describing the properties of protective clothing or equipment.
General practitioner (your family doctor)
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.
The process of decontaminating your hands using either alcohol based hand rub or liquid soap and water.
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.
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.
Infections that occur as a result of medical care, or treatment, in any healthcare setting.
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.
A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.
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.
Waste produced as a result of healthcare activities for example soiled dressings, sharps.
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).
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.
A chlorine-based disinfectant such as bleach
To provide immunity to a disease by giving a vaccination.
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.
Cannot be penetrated by liquid.
A multidisciplinary group with responsibility for investigating and managing an incident.
The spread of infectious agents from one person to another via a contaminated object.
Invasion of the body by a harmful organism or infectious agent such as a virus, parasite, bacterium or fungus.
A multidisciplinary team responsible for preventing, investigating and managing an infection incident or outbreak.
Any organism, such as a virus, parasite, bacterium or fungus, that is capable of invading body tissues, multiplying, and causing disease.
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.
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.
A medical/healthcare procedure that penetrates or breaks the skin or enters a body cavity.
Physically separating patients to prevent the spread of infection.
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).
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Any living thing (organism) that is too small to be seen by the naked eye. Bacteria, viruses and some parasites are microorganisms.
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.
Meticillin Resistant Staphylococcus aureus are strains of infectious agent (bacterium) Staphylococcus aureus that are resistant to the antibiotic meticillin.
An incident in which the mucous membranes (e.g mouth, nose, eyes) are exposed to blood/other body fluid
The surfaces lining the cavities of the body that are exposed to the environment such as the lining of the mouth and nose.
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.
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.
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.
A synthetic rubber material used to make non-latex gloves.
Skin that is broken by cuts, abrasions, dermatitis, chapped skin, eczema etc.
An incident in which non-intact skin is exposed to blood or body fluids.
Care procedure that does not need to be undertaken in conditions that are free from bacteria or other microorganisms.
Exposure of healthcare workers or care staff to blood or body fluids in the course of their work.
Any living thing that can grow and reproduce, such as a plant, animal, fungus or bacterium.
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.
Any disease-producing infectious agent.
Placing a group of two or more patients (a cohort) with the same suspected or confirmed infection in the same room or area.
An injury caused by a sharp instrument or object such as a needle or scalpel, cutting or puncturing the skin.
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.
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:
Fever. Rise in body temperature above the normal level >37.2°.
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To put a needle or other sharp object back into its plastic sheath or cap. Also known as ‘re-sheathing’.
A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.
There are two main types of RPE: respirators and breathing apparatus.
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.
All sinks and furniture in a bathroom, such as a toilet, bath, shower etc.
Any body fluid that is produced by a cell or gland such as saliva or mucous.
Physically separating or isolating from other people.
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.
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.
A type of percutaneous injury caused by a sharp instrument or device which cuts or penetrates the skin.
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.
An incident which involves a used needle that has exposed, or may have exposed, the employee to blood/body fluids.
A room with space for one patient and usually contains as a minimum: a bed; locker/wardrobe; clinical wash-hand basin.
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.
A dedicated team of healthcare staff who care for a cohort of patients, and do not care for any other patients.
Free from live bacteria or other microorganisms
Care procedure that is undertaken in conditions that are free from bacteria or other microorganisms.
The procedure of making some object free of all germs, live bacteria or other microorganisms (usually by heat or chemical means).
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.
Way of closing bag by tying in a loop and securing with a zip tie to make a handle.
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.
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Room where it is possible to change the pressure from positive to negative or vice-versa by switch.
Any medical instrument used to access a patient’s veins or arteries such as a Central Venous Catheter or peripheral vascular catheter.
An area forming a division of a care setting (or a suite of rooms) shared by patients who need a similar type of care.
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