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National Infection Prevention and Control Manual

National Infection Prevention and Control Manual

Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings

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

The purpose of this addendum is to provide COVID-19 specific IPC guidance for NHS Scotland 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.

Important

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.

Version control

26 October 2020
Version 1.0
First publication.

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

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

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

5.1 COVID-19 case definitions and triage

5.1.1 Definition of a confirmed case

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

5.1.2 Definition of a suspected case

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

Community definition:

  • Recent onset new continuous cough

or

  • fever

or

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

Definition for individuals requiring hospital admission:

  • clinical or radiological evidence of pneumonia

or

  • Acute Respiratory Distress Syndrome

or

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

or

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

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

5.1.3 Triaging patients

Triaging of patients within all healthcare facilities must be undertaken to enable early recognition of COVID-19 cases.  Wherever possible, triage questions should be undertaken prior to arrival at the healthcare facility.  For emergency admissions, triage questions should be completed immediately on arrival where it is safe to do so without delaying any necessary immediate life-saving interventions. 

The following are examples of triage questions:

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

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

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

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

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

If yes, 14 days of self-isolation will apply.  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).

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

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

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

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

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

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

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

5.2 Patient placement/assessment of risk

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

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

High-risk COVID-19 pathway

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

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

Low-risk COVID-19 pathway

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

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

Medium-risk COVID-19 pathway

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

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

5.2.1 Critical care units

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

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

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

Where AGPs on any medium and high risk patient is required on the main unit, this presents a risk to the surrounding patients and staff and unit-wide airborne precautions would be required.

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

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

5.2.2 Split pathways

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

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

5.2.3 Staff cohorting

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

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

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

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

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

5.2.4 Moving patients between pathways

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

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

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

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

Patients who have been on the high risk pathway having had confirmed COVID-19, may be moved to the Medium risk pathway after they meet the definition for a ‘recovered patient’ – see footnote 2

5.2.5 Transferring patients between wards, departments or hospitals during infectious period

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

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

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

Communication with the receiving department/NHS Board is vital to ensure appropriate IPC measures are continued during and after transfer.  Communications must include;

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

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

5.2.6 Single side room prioritisation

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

5.2.7 Stepdown of Infection Prevention & Control measures for confirmed COVID-19

Use the guidance for stepdown of infection prevention and control precautions and criteria for discharging patients from hospital to residential settings.

5.2.8 Local and National prevalence data

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

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

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

Footnote 1

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

Footnote 2

Recovered patients can generally be defined as those who have completed 14 days isolation whilst an inpatient starting from the date of symptom onset (or from positive test date if asymptomatic) and have had absence of fever for 48 hours (without use of antipyretics).  However, individual risk assessment is required to take account of those who are severely immunocompromised and those at extremely high risk of illness.  These patient groups are at increased risk of prolonged viral shedding.

5.3 Hand hygiene

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

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

5.4 Respiratory and cough hygiene

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

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

5.5 Personal Protective Equipment (PPE)

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

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

PPE requirements during the COVID-19 pandemic are determined by the care pathways and are detailed in 5.5.3.

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

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

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

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

5.5.2 Face masks for inpatients

A surgical facemask should be worn by all inpatients in the high-risk pathway where it can be tolerated and does not compromise their clinical care for example when receiving oxygen therapy. 

All inpatients on the medium pathway must wear a surgical facemask where tolerated. The purpose of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination.  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.

Patients on the low-risk pathway do not need to wear surgical facemasks.

More information on physical distancing in inpatient settings can be found in section 5.12.

5.5.3 PPE determined by COVID-19 care pathway

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

Table 1 below 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 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’

 

Table 1: PPE for direct patient care determined by pathway

PPE used

Low-risk pathway
(green)

Medium-risk pathway
(amber)

High-risk pathway
(red)

Gloves

If contact with blood and body fluid (BBF) anticipated, then single-use.

If contact with BBF is anticipated, then single-use.

Worn for all direct patient care. Single use.

 

Apron or gown

If direct contact with patient, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated), then single use

If direct contact with patient, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated), then Single use.

Always within 2 metres of a 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

Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask

Eye and face protection

If splashing or spraying with BBF anticipated.  Single-use or reusable.

If splashing or spraying with BBF anticipated Single-use or reusable.

Always within 2 metres of a patient

Single-use, sessional or reusable following decontamination.

5.5.4 Aerosol Generating procedures (AGPs)

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

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

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

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

Other procedures

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

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

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

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

5.5.5 PPE for Aerosol Generating Procedures (AGPs)

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

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

Airborne precautions are required for the medium and high-risk pathways where AGPs are undertaken and the required PPE is detailed in table 2 below.

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

Table 2: PPE for aerosol-generating procedures, determined by pathway

PPE used

Low-risk pathway
(green)1

Medium-risk pathway
(amber)

High-risk pathway
(red)

Gloves

 Single-use.

 Single-use.

 Single-use.

Apron or gown

Single-use apron. Gown if If splashing or spraying anticipated.

Single-use gown.

Single-use gown.

Face mask or respirator

Type IIR.2

FFP3 mask or powered respirator hood.2

FFP3 mask or powered respirator hood.

Eye and face protection

Single-use or reusable.

Single-use or reusable.

Single-use or reusable.

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

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

5.5.6 Post AGP Fallow Times (PAGPFT)

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

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

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

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

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

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

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

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

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

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

5.5.7 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between 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.

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.

Critical care units may use some sessional PPE when unit-wide airborne precautions have been applied.  See critical care frequently asked questions for more information.

5.6 Safe management of Care Equipment

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

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

All care equipment should be decontaminated as per Table 4.

Table 4: Equipment cleaning determined by pathway

Pathway

Product

Low-risk pathway
(green)

General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids or it has been used on a patient with a known or suspected infectious pathogen.

Medium-risk pathway
(amber)

Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

High-risk pathway
(red)

Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

5.7 Safe Management of the Care Environment

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

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

The care environment must be:

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

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

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

Cleaning across the pathways is summarised in table 5. It is recognised that NHS boards will have local protocols in place to determine the staff groups who have responsibility for cleaning different items and areas. 

Table 5: Environmental cleaning determined by pathway

 

Low risk pathway
(green)

Medium risk pathway
(amber)

High risk pathway
(red)

First daily clean

Full clean

Full clean

Full clean

Second daily clean

High Risk Touch Surfaces* within clinical inpatient areas

High Risk Touch Surfaces within clinical inpatient areas

High Risk Touch Surfaces within clinical inpatient areas

Product

General-purpose detergent.

Note that cleaning in the low-risk pathway should be carried out with chlorine-based detergent for patient rooms where the patient is known to have any other known or suspected infectious agent.

Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

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

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

5.8 Safe Management of Linen

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

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

5.9 Safe Management of Blood and Body Fluid Spillages

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

5.10 Safe Disposal of waste (including sharps)

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

Care home and community settings

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

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

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

 

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

 

5.11 Occupational Safety

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

5.11.1 Car sharing for Healthcare professionals including trainees/students

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

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

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

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

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

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

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

5.12 Physical distancing

All staff working with NHS Scotland healthcare facilities must maintain 2 metres physical distancing wherever possible.  This does not apply to the provision of direct patient care where appropriate PPE should be worn in line with section 5.5

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 in line with the extended use of facemasks 5.5.1.

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

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

5.12.1 Inpatient bed spacing and OPD chair spacing

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

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

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

5.12.2 Engineering and Administration control measures in healthcare settings

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

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

5.13 Visiting

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

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

 

Table 6: PPE for Visitors

PPE used

Low-risk pathway
(green)

Medium-risk pathway
(amber)

High-risk pathway
(red)

Unit wide AGP Zone

 

Gloves

Not required1

Not required1

 

Not required1

Not required1

Apron or gown

Not required2

Not required2

If within 2 metres of patient

Apron Required

Face mask

Face covering or provide with FRSM if visitor arrives without a face covering

Face covering or provide with FRSM if visitor arrives without a face covering

FRSM

FRSM4

Eye and face protection

Not required3

Not required3

If within 2 metres of patient

Not required3

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

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

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

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

 

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

 

 

5.15 COVID-19 Education resources

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

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

 

 

5.17 COVID-19 Compendium

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

 

References