NIPCM

National Infection Prevention and Control Manual

National Infection Prevention and Control Manual

Introduction

Monkeypox

Infection Prevention and Control guidance for the Management of Possible, Probable and Confirmed cases of Monkeypox has been published on 1 June 2022.

Coronavirus (COVID-19)

Relevant Infection Prevention and Control content from within the addendum which has been moved to the main NIPCM is detailed in a transition graphic and transition document

There are 2 appendices available within the NIPCM for acute and community settings which summarise the remaining pandemic measures which exist in addition to the NIPCM and provide links to helpful resources, guidance and policy documents.

Public Health Scotland pandemic guidance is available. 

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 provides IPC guidance to all those involved in care provision and is considered best practice across all health and care settings in Scotland.

The re-launch of the NIPCM by the CNO on 11 July 2022 emphasises the ongoing importance of application of Infection Prevention and Control (IPC) guidance within health and care settings across Scotland. 

Video of Chief Nursing Officer re-launching the NIPCM

It is expected that all NHS Scotland and care home settings apply guidance contained within the NIPCM in order to achieve the aims laid out below.

Disclaimer

When an organisation e.g. when a health and care setting uses products or adopts practices that differ from those stated in this National Infection Prevention and Control Manual, that individual organisation is responsible for ensuring safe systems of work including the completion of a risk assessment approved through local governance procedures.

The national IPC manual aims to:

  • help reduce the risk of Healthcare Associated Infection (HAI)
  • make it easy for care staff to apply effective infection prevention and control precautions
  • reduce variation, promote standardisation and optimise infection prevention and control practices throughout Scotland
  • improve the application of knowledge and skills in infection prevention and control
  • help alignment of practice, education, monitoring, quality improvement and scrutiny

The NIPCM currently contains: 

A helpful animation provides details on the content of the NIPCM.

Responsibilities

Responsibilities for the content of this manual

ARHAI Scotland must ensure

  • that the content of this manual remains evidence based or where evidence is lacking, content is based on consensus of expert opinion.

Stakeholders of the ARHAI Scotland programmes must ensure

  • full participation in the working groups and oversight programmes including full engagement with the consultation process outlined in the Terms of Reference associated with each group

Responsibilities for the adoption and implementation of this manual

Organisations must ensure:

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

Managers of all services must ensure that staff:

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

Staff providing care must ensure that they:

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

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

  • engage with staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of infection prevention and control practices
  • provide expert advice on the application of infection prevention and control in all care settings and provide support to develop individual or organisational risk assessments where deviations from the NIPCM are necessary
  • have epidemiological or surveillance systems capable of distinguishing patient case or cases requiring investigations and control
  • complete documentation when an incident/outbreak or data exceedence is reported (IPCTs should ensure application of the HIIAT where applicable and report incidents and outbreaks using the ORT as outlined by the HIIAT).

 

Last updated: 4 October 2021

 

 

Chapter 1 - Standard Infection Control Precautions (SICPs)

10 must dos to prevent infection every patient, every care setting, every timebadgeStandard 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.

The Hierarchy of Controls detailed in appendix 20 should also be considered in controlling exposures to occupational hazards which include infection risks.

 

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, any equipment or items in the care environment that could have become contaminated and even the environment itself if not cleaned and maintained appropriately.

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 applied continuously by all staff. The application of SICPs during care delivery must take account of;

  • risk to and from the individual for whom care is being provided
  • the task to be undertaken
  • level of interaction
  • the anticipated level of exposure to blood and/or other body

Doing so allows staff to safely apply each of the 10 SICPs by ensuring effective infection prevention and control is maintained.

SICPs implementation monitoring must also be ongoing to demonstrate safe practices and 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.

 

Last updated: 10 May 2022

1.1 Patient Placement/Assessment for infection risk

Badge showing image of patient in bed for patient placement.  Text says assess patients for infection risk and ensure they are cared for in a safe place

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 patient placement decisions in accordance with clinical/care need(s).

Patients who may present a particular cross-infection risk should be isolated on arrival and appropriate clinical samples and screening undertaken as per national protocols to establish the causative pathogen. This includes but is not limited to patients:

  • With symptoms such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms.
  • With a known (laboratory confirmed) or suspected infectious pathogen for which duration of precautions as outlined in Appendix 11 are not yet complete. This includes COVID-19. See also COVID-19 respiratory symptom assessment questions within  Appendix 21 COVID-19 Pandemic controls.
  • Known or suspected to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
  • Who have been a close contact of a person who has been colonised or infected with CPE in the last 12 months.
  • Who have been hospitalised outside Scotland in the last 12 months (including those who received dialysis).

All inpatients admitted to a secondary care facility for an overnight stay must have a COVID-19 test undertaken using a laboratory based PCR test, Rapid Diagnostic Test (including Point of Care Tests) or LFD test on admission.  Results should be documented in patient case records and local arrangements followed for reporting in line with any local and national policy. Repeat testing on day 5 of admission may be undertaken if agreed necessary following a risk assessment by the local NHS Board.  See COVID-19 testing requirements within Appendix 21 COVID-19 Pandemic controls.

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

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

1.2 Hand Hygiene

Image of hand for practise good hand hygieneHand hygiene is considered an important practice in reducing the transmission of infectious agents which cause HAIs.

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

Before performing hand hygiene:

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

Hand washing should be extended to the forearms if there has been exposure of forearms to blood and/or body fluids.

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

To perform hand hygiene:

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

Perform hand hygiene:poster showing who 5 moments for hand hygiene

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

 

Some additional examples of hand hygiene moments include:

  • Before handling medication
  • Before preparing food
  • Before donning (putting on) and after doffing (taking off) PPE
  • After visiting the toilet
  • Between carrying out different care activities on the same patient
  • After cleaning and disinfection procedures
  • After handling waste

Download and print the 5 moments of hand hygiene poster.

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

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

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

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 in the service user’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.

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.

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

For how to:

Skin care:

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

Surgical Hand Antisepsis

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

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

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

  • For surgical scrubbing technique see Appendix 3.
  • For surgical rubbing technique see Appendix 4

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

Information on the WHO World Hand Hygiene Day 2022 with the theme 'Unite for safety - clean your hands' is available.

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

1.3 Respiratory and Cough Hygiene

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

  • Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose. If a disposable tissue is not available use elbow to cover the nose and mouth when coughing or sneezing.
  • Patients showing symptoms of respiratory illness should be encouraged to wear a surgical (TYPE II R FRSM) face mask where it is clinically safe and tolerated by the wearer.
  • Dispose of used tissues and face masks promptly into a waste bin.
  • In the absence of disposable tissues and hand hygiene facilities only, individuals should cough or sneeze into their elbow/sleeve.
  • Wash hands with non-antimicrobial liquid soap and warm water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions.
  • Where there is no running water available or hand hygiene facilities are lacking, staff may use hand wipes followed by ABHR and should wash their hands at the first available opportunity.
  • Keep contaminated hands away from the eyes nose and mouth.

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

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

1.4 Personal Protective Equipment

undefinedBefore undertaking any care task or procedure staff should assess any likely exposure to blood and/or body fluids and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

All PPE should be:

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

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

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

Gloves must:

  • be worn when exposure to blood, body fluids, (including but not limited to secretions and/or excretions), non-intact skin, lesions and/or vesicles, mucous membranes, hazardous drugs and chemicals, e.g. cleaning agents is anticipated/likely;2
  • Gloves are a single-use item and should be changed immediately after each use or upon completion of a task;
  • never be worn inappropriately in situations such as; to go between patients, move around a care area, work at IT workstations;
  • be changed if a perforation or puncture is suspected or identified;
  • be appropriate for use, fit for purpose and well-fitting;
  • not be worn as a substitute to hand hygiene.

Double gloving is only recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and gynaecological operations or when attending major trauma incidents and when caring for a patient with a suspected or known High Consequence Infectious disease.  Double gloving is not necessary at any other time.

For appropriate glove use and selection see Appendix 5.

Further information can be found in the Gloves literature review.

Aprons must be:

  • worn to protect uniform or clothes when contamination is anticipated/likely
  • when in direct care contact with a patient or their immediate environment e.g providing toileting support or changing bed linen;
    and
  • changed between patients and following completion of a procedure or task.

Full body gowns/Fluid repellent coveralls must be:

  • worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in the operating theatre;

  • worn when a disposable apron provides inadequate cover for the procedure/task being performed;

  • changed between patients and immediately after completion of a procedure or task.

The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure. Routine sessional use of gowns/aprons is not permitted.

Sterile surgical gowns must be:

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

Reusable gowns must:

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

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

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

Eye/face protection must:

  • be worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely  and always during Aerosol Generating Procedures.

  • be worn by all scrubbed members of the surgical team for all surgical procedures;

  • not be impeded by accessories such as piercings/false eyelashes;

  • not be touched when worn;

  • cover the full peri-orbital region and wrap around the sides of the face;

  • be removed or changed in accordance with manufacturer’s instructions, if vision is compromised through contamination with blood or body fluids, if the integrity of the equipment is compromised, at the end of a clinical procedure/task and/or prior to leaving the dedicated clinical area.

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

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

Fluid Resistant Type IIR surgical face masks must be:

  • worn by a patient known or suspected to be infected with a micro-organism spread by the droplet or airborne route when leaving their room or when moving between clinical areas including transfers by portering staff and ambulance services.
  • worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated/likely;
    (as part of SICPs a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray.)
  • worn in combination with a full face shield, integrated half face shield or goggles for AGPs on non-infectious patients;

  • worn to protect patients from the operator as a source of infection when performing invasive spinal procedures such as myelography, lumbar puncture and spinal anaesthesia ,inserting a Central Vascular Catheter (CVC), performing intra-articular (joint) injections;

  • worn by all scrubbed members of the theatre surgical team for all surgical procedures;

  • worn by non-scrubbed members of the theatre surgical team if deemed necessary following a risk assessment of exposure to blood and/or body fluids;

  • well fitting and fit for purpose (fully covering the mouth and nose);

  • removed or changed;
    • at the end of a procedure/task;

    • if the integrity of the mask is breached, e.g. from moisture build-up after extended use or from gross contamination with blood or body fluids;
      and
    • in accordance with specific manufacturers’ instructions.

Transparent face masks

Transparent face masks may be used to aide communication with patients in some settings

Transparent face masks must;

Further information can be found in:

During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is not considered an element of SICPs but an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.

Footwear must be:

  • non-slip, impervious, clean and well maintained, and support and cover the entire foot to avoid contamination with blood or other body fluids or potential injury from sharps
  • removed before leaving a care area where dedicated footwear is used e.g. theatre. Employees must clean and decontaminate footwear upon removal and when visibly soiled with blood and/or body fluids following manufacturers recommended instructions for cleaning and disinfection
  • dedicated for use in settings such as theatres and stored in a designated area when not in use
  • Footwear found to be defective should be repaired or replaced before further use.
  • Overshoes/shoe covers should not be used in the general health and care environment.

Further information can be found in the footwear literature review.

Headwear must be:

  • worn in theatre settings/restricted and semi-restricted areas;
  • worn as PPE for procedures where splashing/spraying of body fluids is anticipated, and as source control when performing clean/aseptic procedures where risk of infection is deemed to be high.
  • well fitting and completely cover the hair;
  • changed/disposed of at the end of a single clinical procedure/task; or at the end of a theatre session (for sessional use); immediately if contaminated with blood and/or body fluids;
  • removed before leaving the theatre/clean room.

Further information can be found in the headwear literature review

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

COVID-19 - the correct order for donning, doffing and disposal of PPE for HCWs in a primary care setting from NHS National Services Scotland on Vimeo.

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

 

Sessional use of PPE

Typically, sessional use of any PPE is not permitted within health and care settings at any time as it may be associated with transmission of infection within health and care settings. 

Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.

This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to patients with suspected or confirmed respiratory infection.  A session ends when the healthcare worker leaves the clinical setting or exposure environment.  When using FRSMs and eye/face protection sessionally it is important to note the following;

  • FRSMs/FFP3/Eye/Face protection must be replaced if visibly contaminated, wet, damaged, uncomfortable, when moving between patients with suspected or confirmed respiratory infection and those without.
  • FRSMs must be replaced following procedures where splash/spray is generated
  • HCWs must not touch their FRSM, eye/face protection or FFP3 respirator whilst in situ. If they inadvertently do so, they must perform hand hygiene immediately afterwards

The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.

No other PPE is permitted to be worn sessionally moving between service users or care tasks.  This includes gloves, aprons and gowns.

PPE for Visitors

PPE may be offered to visitors to protect them from acquiring a transmissible infection.  If a visitor declines to wear PPE when it is offered then this should be respected and the visit must not be refused.  PPE use by visitors can not be enforced and there is no expectation that staff monitor PPE use amongst visitors. Below is the PPE which should be worn where it is appropriate to do so and when the visitor chooses to do so.

Visitors do not routinely require PPE unless they are providing direct care to the individual they are visiting.  In line with extended use of face mask guidance, visitors are strongly recommended to continue to wear a face covering when visiting a healthcare setting.  Should they arrive without one, they can be provided with a FRSM. 

The table below provides a guide to PPE for use by visitors if delivering direct care. 

IPC Precaution

Gloves

Apron

Face covering/mask

Eye/Face Protection

Standard Infection Control Precautions (SICPs)

Not required*1

Not required*2

Where splash/spray to nose/mouth is anticipated during direct care

Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance

Not required*3

Transmission Based Precautions (TBPs)

Not required*1

Not required*2

If within 2 metres of service user with suspected or known respiratory infection

Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance

If within 2 metres of service user with suspected or known respiratory infection

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

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

*3 Unless providing direct care and splashing/spraying is anticipated

1.5 Safe Management of Care Equipment

undefined

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

Care equipment is classified as either:

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

Before using any sterile equipment check that:

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

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

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

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

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

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

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

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

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

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

1.6 Safe Management of Care Environment

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

The care environment must be:

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

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

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

When an organisation adopts decontamination processes not recommended in the NIPCM the care organisation is responsible for governance of and completion of local risk assessment(s) to ensure safe systems of work

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

1.7 Safe Management of Linen

undefinedClean linen

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

Linen used during patient transfer

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

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

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

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

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

Local guidance regarding management of linen may be available.  

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

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

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

Scottish Government uniform, dress code and laundering policy is available.

 

1.8 Safe Management of Blood and Body Fluid Spillages

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

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

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

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

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

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

 

 

 

1.9 Safe Disposal of Waste (including sharps)

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

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

Categories of waste:

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

Waste Streams:

  • Black – Trivial risk:
    • Domestic waste or yellow and black stripes (small quantities of hygiene waste).
    • Final disposal to Landfill.
    • Clear/opaque receptacles may also be used for domestic waste at care area level.
  • Orange, Light Blue (laboratory) – Low risk
    • Orange - consists of items which are contaminated or likely to be contaminated with blood and/or body fluids including saliva . Final disposal following heat disinfection is to landfill.
    • Light Blue – laboratory/microbiological waste that must be autoclaved before disposal via the orange stream.
  • Yellow– High risk:
    • Waste which poses ethical, highly infectious or contamination risks.
    • This includes anatomical and human tissue which is recognisable as body parts, medical devices and sharps waste boxes that have red, purple or blue lids.
    • Disposal is by specialist incineration.
  • Red – Special waste
    • Chemical waste.

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

Safe waste disposal at care area level:

Always dispose of waste:

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

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

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

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

Sharps boxes must:

  • have a dedicated handle
  • have a temporary closure mechanism, which must be employed when the box is not in use
  • be labelled with date of assembly, point of origin and date of closure.
  • be disposed of when the manufacturers’ fill line is reached or following 3 months of assembly (whichever is first)

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

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

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

undefinedExposure in relation to blood borne viruses (BBV) is the focus within this section and reflects the existing evidence base.

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

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

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

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

Needles must not be re-sheathed/recapped.4

Always dispose of needles and syringes as 1 unit.

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

An occupational exposure is a percutaneous or mucocutaneous exposure to blood or other body fluids.

Occupational exposure risk can be reduced via application of other SICPs and TBPs outlined within the NIPCM.

 

A significant occupational exposure is a percutaneous or mucocutaneous exposure to blood or other body fluids from a source that is known, or found to be positive for a blood borne virus (BBV).

Examples of significant occupational exposures would be:

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

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

Additionally, employers are obligated to minimise or eliminate workplace risks where it is reasonably practicable. Immunisation against BBV should be available to all qualifying staff, and testing (and post exposure prophylaxis when applicable) offered after significant occupational exposure incidents.

For the management of an occupational exposure incident see Appendix 10

Exposure prone procedures (EEPs) are invasive procedures where there is a risk that injury to the healthcare worker may result in the exposure of the patient’s open tissues to the blood of the worker (bleed-back).

There are some exclusions for HCWs with known BBV infection when undertaking EPPs. The details of these and 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.

Chapter 2 - Transmission Based Precautions (TBPs)

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

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

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

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 any respiratory precautions required.  Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

Contact precautions

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

Droplet precautions

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

Airborne precautions

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

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

 

Last updated 4 October 2021

2.1 Patient Placement/Assessment for Infection Risk

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

Patients who may present a cross-infection risk in any setting includes but is not limited to those:

  • With symptoms of infection such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms. See also COVID-19 respiratory symptom assessment questions within the Appendix 21 COVID-19 Pandemic Controls. Patients who have respiratory symptoms must have a laboratory based PCR undertaken to determine the presence of any respiratory infection however Rapid Diagnostic Testing (including POCT) or LFD may be utilised for COVID-19 to support patient placement decisions.
  • Known (laboratory confirmed) or suspected to have an infectious pathogen for which duration of precautions as outlined in appendix 11 are not yet complete.
  • Known or suspected to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
  • Who have been a close contact of a person who has been colonised or infected with CPE in the last 12 months.
  • Who have been in contact with a confirmed COVID-19 individual and are still within the 10-day self-isolation period.
  • Who have been hospitalised (inpatient) outside Scotland in the last 12 months (including those who received dialysis) .

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.

When single-bed rooms are limited, patients who have conditions that facilitate the transmission of infection to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, invasive devices, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) should be prioritised for placement in a single-bed room. Single-bed room prioritisation should be reviewed daily and 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:

  • Patients who present a cross-infection risk should be isolated in a single room or for patients with a known or suspected pathogen spread by the airborne route, in a specialised negative pressure isolation facility where available.
  • Isolation of infectious patients can be in specialised isolation facilities, single room isolation, cohorting of infectious patients where appropriate, ensuring that they are separated by at least 2 metres with the door closed.
  • Signage should be used on doors/areas to communicate isolation requirements and prevent entry of unnecessary visitors and non-essential staff.
  • Infectious patients should only be transferred to other departments if medically necessary.  If the patient has an infectious agent transmitted by the airborne/droplet route, then if possible/tolerated the patient should wear a surgical face mask during transfer.
  • Receiving department/hospital and transporting staff must be aware of the necessary precautions.

Cohorting in hospital settings

Cohorting of patients should only be considered when single rooms are in short supply and should be undertaken in conjunction with the local IPCT.

Patients who should not be placed in multi bed cohorts;

  • Patients with different infectious pathogens/strains and patients with unknown infectious pathogens (laboratory confirmation still awaited)
  • Patients considered more vulnerable to infection
  • Patients with a known or suspected infectious pathogen spread by the droplet/airborne route who will undergo an AGP
  • Patients who are unlikely to comply with TBPs

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 through planning of staff rotas if there are sufficient levels of staff available to ensure consistency in staff allocation (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). Clinical and molecular tests to show the absence of microorganisms may be considered in the decision to discontinue isolation and can reduce isolation times. 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 on decisions regarding isolation discontinuation.

Primary care/out-patient settings:

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

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

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

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

If an item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

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

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

2.3 Safe Management of the Care Environment

Routine environmental decontamination

Hospital/Care home setting:

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

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

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

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

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

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

Vacated rooms should also be decontaminated following an AGP.

Primary care/Out-patient settings:

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

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

Terminal decontamination

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

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

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

The room should be decontaminated using either:

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

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

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

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

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

When an organisation adopts practices that differ from those recommended/stated in the NIPCM 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.

 

2.4 Personal Protective Equipment (PPE)

2.4.1  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.

During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.

2.4.2  Eye/face protection

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

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

Eye/face protection should be worn

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

2.4.3  Aprons/Gowns

An apron 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 should be used in health and social care settings for protection against contamination with blood and/or body fluids

A fluid repellent gown should be used if excessive splashing or spraying is anticipated.

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.

 

2.4.4  RPE

Filter Face Piece 3 (FFP3) Respirators

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

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.

Please also see Appendix 17 for the extant list of Aerosol Generating Procedures which require the application of airborne precautions.  Appendix 17 also includes details of associated Post AGP Fallow times.

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

  • Fit tested (by a competent fit test operator) on all healthcare staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance.
  • Fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved. The poster below gives further information on compatibility of facial hair and FFP3 respirators and can be used when fit testing and fit checking.
  • Single use (disposable) and 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.
  • Non valved if a sterile procedure is being performed at the same time as an AGP requiring a respirator to be worn. An MHRA safety alert can be viewed. 
  • Compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection. If wearing a valved, non-shrouded FFP3 respirator a full face shield/visor must be worn.
  • Always be put on before entry into the patient room/area and prior to performing an aerosol generating procedure (AGP) and removed in an anteroom/lobby or in a safe area (e.g. outside the isolation/cohort room/area (All other PPE should be removed in the patient care area)
  • Changed after each use. Other indications that a change in respirator is required include: if breathing becomes difficult; if the respirator becomes wet or moist, damaged; or obviously contaminated with body fluids such as respiratory secretions.

Poster on compatibility of facial hair and FFP3 respirators 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.

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.

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

Powered hoods must be:

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

FFP3 respirator or powered respirator hood:

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

Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of 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.

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.

Sessional use of PPE

Typically, sessional use of any PPE is not permitted within health and care settings at any time as it is associated with transmission of infection between service users within health and care settings.

Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.

However, in using FRSMs/eye and face protection/RPE sessionally. This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to respiratory pathogens.  A session ends when the healthcare worker leaves the clinical setting or exposure environment.  it is important to note the following;

  • FRSMs/FFP3/Eye/Face protection must be replaced if visibly contaminated, wet, damaged, uncomfortable, when moving between patients with suspected or confirmed respiratory infection and those without.
  • FRSMs must be replaced following procedures where splash/spray is generated
  • HCWs must not touch their FRSM, eye/face protection or FFP3 respirator whilst in situ. If they inadvertently do so, they must perform hand hygiene immediately afterwards

The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.

No other PPE is permitted to be worn sessionally moving between service users or care tasks.  This includes gloves, aprons and gowns.

2.5 Infection Prevention and Control during care of the deceased

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

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

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

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

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

 

Chapter 3 - Healthcare Infection Incidents, Outbreaks and Data Exceedance

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

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

Built environment incidents/outbreaks

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

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

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

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

 

 

3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance

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

A healthcare infection incident may be:

An exceptional infection episode

  • A single case of an infection that has severe outcomes for an individual patient OR   has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high consequence such as VHF or XDR-TB, botulism, polio, rabies, diphtheria.

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

A healthcare infection exposure incident

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

A healthcare associated infection outbreak

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

or

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

A healthcare infection data exceedance

  • A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.

A healthcare infection near miss incident

  • An incident which had the potential to expose patients to an infectious agent but did not e.g. decontamination failure.

A healthcare infection incident should be suspected if there is:

  • A single case of an infection for which there have previously been no cases in the facility (e.g. infection with a multidrug-resistant organism (MDRO) with unusual resistance patterns or a post-procedure infection with an unusual organism).

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

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

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

Healthcare associated infection (HAI) Surveillance systems should be used to aid incident/outbreak detection using a combination of retrospective detection of cases alongside prospective enhanced surveillance in high risk settings (ICU/PICU/NICU, oncology/haematology). A risk based approach should be applied for other vulnerable groups e.g. cystic fibrosis, oncology and those undergoing renal dialysis.

Local surveillance/reporting systems should be used for recognition and detection of potential healthcare infection incidents /outbreaks within NHS Boards. Systems should make use of ‘triggers’ to allow prompt detection of any variance from normal limits.

The Infection Prevention & Control Team (IPCT)/Health Protection Team (HPT) should utilise surgical site infection (SSI) surveillance systems to identify specific post-surgical healthcare infection incidents/outbreaks (in line with national SSI surveillance program as a minimum).

3.2.1 Assessment

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

  • Undertake an initial assessment, utilising the Healthcare Infection Incident Assessment Tool (HIIAT)Appendix 14, gather epidemiological data and clinical assessment information on the patients condition as per:
  • NHS Boards are required to report all HIIAT assessed Green, Amber and Red reports to ARHAI Scotland through the electronic outbreak reporting tool (ORT).
  • NHS Boards should monitor the ongoing impact of the incident by escalating and de-escalating as appropriate, using the HIIAT assessment tool. The HIIAT assessment should remain Amber or Red whilst there is ongoing risk of exposure, identification of new cases.

3.2.2 Investigation, management and communication

The IPCT/HPT will establish an IMT if required.

  • In the NHS hospital setting the ICD will usually chair the IMT and lead the investigation of healthcare incidents.  Where there are implications for the wider community e.g. TB or measles, or rare events such as CJD or a Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the hospital service, the CPHM may chair the IMT. A draft agenda for the IMT is available.
  • The membership of the IMT will vary depending on the nature of the incident.
  • A healthcare infection incident investigation will usually consist of the following elements; an epidemiological investigation, a microbiological investigation and a specific investigation to identify how cases were exposed to the infectious agent (environmental investigation)
    • As part of the epidemiological investigation, a case definition(s) must be established by the IMT. A case definition should include the following: the people involved (e.g. patients, staff); the symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s) involved); and a limit of time (e.g. between January and March year/date). The case definition(s) should be regularly reviewed and refined (if required) throughout the incident investigation as more information becomes available. A working hypothesis regarding the transmission route and source of the exposure must be formed based on initial investigation findings
    • A microbiological investigation into the nature and characteristics of the implicated hazard /infective agent must be conducted.
    • An environmental investigation must be conducted if the findings of the epidemiological investigation suggest a common exposure to a potential environmental source/ environmental reservoir.
    • An infection prevention and control assessment to review the existing IPC practices must be conducted, so that areas for immediate improvement can be identified.
  • Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
  • Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
  • The IMT should receive and discuss all information gathered and epidemiological outputs e.g. an epidemiological (epi) curve, a timeline and a ward map to:
    • Determine whether additional case finding and control measures may be necessary.
    • Confirm that all incident control measures are being applied effectively and are sufficient.
  • Control measures must be directed at the source of the exposure and/or at affected persons in order to prevent secondary/ further exposure to the agent. Control measures must be initiated within 24 hours of receiving the initial report and should be implemented based on relevant guidance (e.g. pathogen specific) and investigation findings of the nature of the outbreak.
  • A follow-up period may be defined after an infection incident/ outbreak has ended to ensure its termination, including assessment of any ongoing control measures and would be determined by the PAG/IMT.
  • Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
  • Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.

If staff screening is being considered as part of the investigation DL (2020)1 must be followed.

  • HAI deaths, which pose an acute and serious public health risk, must be reported to the Procurator Fiscal, refer to SGHD/CMO(2018)11.
  • The IMT must ensure affected patients, and where appropriate their next of kin, have been informed of any actual or potential harm as a result of the HAI.  Duty of Candour must be considered at each IMT.
  • All significant adverse event reviews involving a category 1 adverse event (events that may have contributed to or resulted in permanent harm, for example unexpected death) should be reported to  
  • If no new cases arise and any remaining cases are considered to no longer pose a risk, the IMT should agree on actions prior to resumption of normal service.

3.2.3 Communications

  • Following the PAG/IMT, the NHS Board is required to communicate all HIIAT Green, Amber and Red assessments with ARHAI Scotland, by completing the electronic Outbreak Reporting Tool (ORT) within 24 hours of HIIAT assessment. Incidents assessed as RED, AMBER and where ARHAI support is required GREEN will be reviewed for onward communication to SGHSCD.
  • Any adverse event related to equipment or medication must be reported as soon as possible (within one working day) to the Incident Reporting and Investigation Centre (IRIC) and the escalation/de-escalation flowchart followed.

Closure of incident/outbreak with lessons learned

  • Once the incident is over and in addition to mandatory electronic reporting, the IMT/NHS Board should decide on the most appropriate format for a report, to communicate incident management/lessons learned (IMT report /SBAR/Hot Debrief Tool). This is not a mandatory requirement but for the purpose of sharing lessons learned across Scotland.

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

3.3 COVID-19 Definition of confirmed and suspected case

COVID-19 case definitions are regularly reviewed and can be found in the Public Health Scotland COVID-19 Guidance for Health Protection Teams.

Confirmed 

A laboratory confirmed detection of SARs-CoV-2 by polymerase chain reaction (PCR) in a clinical specimen OR a positive LFD test for SARS-CoV-2.

Possible COVID-19 Case

Persons with any of the symptoms of a respiratory infection and with a high temperature or not well enough to go to work or carry out normal activities, should be considered a possible case.

Symptoms of COVID-19, flu and common respiratory infections include:

  • continuous cough
  • high temperature, fever or chills
  • loss of, or change in, your normal sense of taste or smell
  • shortness of breath
  • unexplained tiredness, lack of energy
  • muscle aches or pains that are not due to exercise
  • not wanting to eat or not feeling hungry
  • headache that is unusual or longer lasting than usual
  • sore throat, stuffy or runny nose
  • diarrhoea, feeling sick or being sick

A wide variety of additional clinical signs and symptoms have also been associated with COVID-19. Fever may not be reported in all symptomatic people and cases may also be asymptomatic. Healthcare staff should be alert to the possibility of atypical and nonspecific presentations in children, older people with frailty, those with pre-existing conditions and those who are immunocompromised. People with epidemiological links to COVID-19 outbreaks or clusters should also be considered with a high degree of suspicion.

People must be assessed for other infectious or non-infectious causes of symptoms, as appropriate.

3.4 COVID-19 Notification of positive cases

It is essential that NHS Boards have systems in place to ensure that test 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. 

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

3.4.1 Communicating results

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

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

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

3.4.2 Communication with other care facilities and NHS boards

Where a confirmed case or an identified contact has been transferred to another care facility (care home, hospice, mental health facility), the facility must be notified as soon as possible to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented where applicable.  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.

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 where applicable.

3.4.3 Surveillance

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

 

3.5 COVID-19 clusters/incidents definitions

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

3.5.1 Criteria to declare a COVID-19 cluster/incident in an inpatient setting

Two or more patient and/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 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

Where two or more staff cases of suspected or confirmed COVID-19 are identified and where transmission between the staff members is suspected to be associated with workplace exposure/behaviours

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 depending on the contacts and exposures identified.  Where the patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.

3.5.2 Criteria to determine that a COVID-19 cluster/incident in an inpatient setting has ended

No new test-confirmed or suspected cases with illness onset date 10 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 cluster can be closed provided that these criteria are met. 

3.6 COVID-19 Roles and Responsibilities

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

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

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

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

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

3.6.2 Contact tracing responsibilities

The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing.

The COVID-19 Test and Protect service in Scotland ceased on the 1st May 2022 for the general community and as such contact tracing undertaken by public health will focus on outbreaks of COVID-19 associated with closed/high risk settings. 

Contact tracing within acute inpatient settings should continue where an unexpected case of COVID-19 has been identified e.g. any cases that were not confirmed or suspected on admission.

3.6.3 Case definition for the incident

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

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

In determining cases, case definitions in line with section 3.3 should be used.

3.7 COVID-19 Investigations

3.7.1 Epidemiological data/timelines

3.7.2 Identifying missed opportunities to isolate

3.7.3 IPC practice and compliance (including AGPs)

3.7.4 Review of visiting

3.7.5 Testing during an outbreak

3.7.6 Whole Genome Sequencing

3.7.7 Contact tracing

3.7.8 Ventilation considerations

3.7.9 Bed spacing

3.7.10 Review of physical distancing

3.7.11 COVID-19 messaging

 

The extent of the 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 cluster.  Investigations undertaken and subsequent findings should be documented by the IMT.

3.7.1 Epidemiological data/Timelines

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

3.7.2 Identifying missed opportunities to isolate

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

3.7.3 IPC practice and compliance (including AGPs)

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

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

Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within thethe National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 21 COVID-19 pandemic controls.

Ensure that patients are wearing face masks appropriately as per the NIPCM and Scottish Government Extended use of face masks guidance.

3.7.4 Review of visiting

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

3.7.5 Testing during an outbreak

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

A PCR test, Rapid Diagnostic Test (incl POCT) or LFD test may be undertaken to enable early detection of cases however, regardless of test results, a confirmatory follow up laboratory based PCR test must also be undertaken.

3.7.6 Whole Genome Sequencing

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

3.7.7 Contact tracing

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

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

The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors.  IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact. An assessment tool is available to support the process.

Case definitions for contacts

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

Household contact:

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

Non-household contact

Direct contact:

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

Proximity contact:

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

Contact tracing patients

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

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

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

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

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

NB: Patients who have an overnight admission within a hospital setting who have been identified as a contact of a confirmed case of COVID-19 during their hospital inpatient stay must be isolated or cohorted for 10 days from the date of exposure.  See also section 3.9.2 ‘Replacing Transmission Based Precautions with daily testing’.

Contact tracing staff

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

Contact tracing visitors

There is no expectation that contact tracing amongst visitors will be undertaken routinely.

3.7.8 Ventilation considerations

Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation.  It is important to consider best practice on ventilation.  See Appendix 20 - Hierarchy of controls for more information.

The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated. 

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

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

3.7.9 Bed spacing

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

See chapter 4 of the NIPCM for more detail

3.7.10 COVID-19 messaging

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

  • Hand hygiene
  • Appropriate use of face masks and face coverings
  • Awareness of new onset respiratory symptoms and requirement for patients/staff/visitors to report symptoms to staff
  • Good visiting advice including non attendance if visitor has respiratory symptoms
  • Staff testing where applicable

Every opportunity to promote this messaging should be considered.

3.8 COVID-19 Formulate hypothesis

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

3.9 COVID-19 Control Measures

3.9.1 Patient placement

3.9.2 Replacing Transmission based precautions with daily testing

3.9.3 Hand hygiene

3.9.4 Personal Protective Equipment

3.9.5 Safe Management of care Equipment

3.9.6 Safe Management of Care Environment

3.9.7 Waste and Linen

3.9.8 Staff

3.9.9 Management of staff exposed to a case

3.9.10 Closure of the ward/unit

3.9.11  Other control measures which may be considered by the IMT

3.9.12 Conversion of outbreak ward to COVID-19 ward

 

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

3.9.1 Patient placement

  • The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified.
  • Cohort areas may be established where required.
  • Suspected cases (symptomatic) should be isolated on the ward and tested for COVID-19 as soon as possible. Symptomatic patients should not be cohorted together.  The cohorting of symptomatic patients’ risks transmission of other respiratory viruses whilst the causative pathogen remains unknown.
  • Doors to isolation rooms and cohorts should be closed and signage clear.
  • Patient placement is regularly reviewed and documented in patient case notes.
  • Restrict transfers to any other ward or department unless essential including for patients undergoing daily tests to prevent application of TBPs as a contact of a case
  • A local risk assessment should be undertaken by the IMT and take account of whether the ward will remain open or closed.

Any asymptomatic contacts should be isolated or remain cohorted together until the 10 day isolation period has elapsed. It is possible to prevent the need for transmission based precautions for asymptomatic contacts where daily testing is utilised.  See section 3.9.2 for more detail. 

Contacts must be managed in the same manner as a confirmed case.

  • If a contact develops symptoms during the 10 day isolation period, laboratory based PCR testing should be performed as soon as possible. If a contact tests positive for COVID-19 the isolation period should be reset to commence from the day of symptom onset.
  • All efforts should be made to dedicate staff to the management of the cohort and ideally those staff must not then go between the case and contacts and all other unaffected patients on the ward. These staff cohorts should be maintained wherever possible for the duration of the isolation period.

3.9.2 Replacing Transmission based precautions with daily testing

Where these are available, rapid diagnostic tests (including POCTs) or LFDs can be used to prevent the need to apply transmission based precautions for contacts.

For adult contacts who are asymptomatic of respiratory viral symptoms, and for all children and young persons aged 0 to 18 years and 4 months regardless of their vaccination status, a daily Rapid Diagnostic Test (including POCT) or LFD test should be performed for 10 days following the date of exposure.  Application of transmission based precautions (TBPs) are only required should the Rapid Diagnostic Testing (including POCT) or LFD tests positive at any point and a follow up COVID-19 PCR undertaken. Whilst Rapid Diagnostic tests (including POCT) or LFD tests remain negative, application of SICPs is sufficient and there is no need to isolate the contact.

Any patient who has been COVID-19 positive (confirmed by PCR or Rapid Diagnostic Testing (including POCT) or LFD test) in the last 28 days does not need to be considered a contact should there be a subsequent exposure during that 28 period. Daily Rapid Diagnostic Testing (including POCT) or LFD testing of these patients is therefore not required during this time period.

3.9.3 Hand hygiene

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

3.9.4 Personal Protective Equipment

  • Reinforce appropriate PPE use as per NIPCM (general use and AGP) to all staff groups
  • Ensure adequate PPE supplies are available

3.9.5 Safe Management of care Equipment

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

3.9.6 Safe Management of Care Environment

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

3.9.7 Waste and linen

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

3.9.8 Staff

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

3.9.9 Management of staff exposed to a case

  • Staff members who have a positive test must inform their line manager and arrangements should be made for them to stop work immediately and return home, avoiding the use of public transport. Local arrangements for transport of infected patients should be followed.
  • NHS Boards should have arrangements in place to backfill staff who test positive.
  • The staff member who tests positive will need to self-isolate and follow advice laid out in Appendix 21 - COVID-19 Pandemic Controls; Patient facing HCWs Isolation and exemption.

3.9.10 Closure of the ward/unit

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

3.9.11  Other control measures which may be considered by the IMT

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

3.9.12 Conversion of outbreak ward to COVID-19 ward

During the ongoing COVID-19 pandemic when COVID-19 admissions are high and where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a COVID-19 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;

  • It is important that patients are appropriately placed determined by confirmed laboratory testing and all efforts are made to prevent placing COVID-19 patients in the same bed bay as those who have other respiratory viruses.
  • If there are contacts on the ward who remain asymptomatic and do not have a confirmed COVID-19 positive test, these may be moved to other wards for the conversion to take place.  However, these contacts must be placed in single side rooms on transfer and must be managed as a high risk patient until the 10 day isolation period is complete unless daily testing is in place (see section 3.9.2).
  • There must be no patients remaining on the outbreak ward who have not yet tested positive for COVID-19 – all patients on the ward must be confirmed COVID-19 before the conversion takes place.
  • The incident must remain open on the boards reporting dashboard to ensure all contacts are monitored regardless of where they are placed until the ‘ending a cluster’ criteria is met.

In choosing to convert the outbreak ward to a COVID-19 ward, IMTs alongside hospital management must weigh up the risk associated with transferring contacts to other wards and the demand for patient beds to accommodate emergency admissions.

3.10 COVID-19 Communications

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

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

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

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

  • A cluster should be assessed using the Healthcare Infection Incident Assessment Tool (HIIAT) as per Appendix 14 of the NIPCM. 
  • All confirmed clusters/possible outbreaks, must be reported to ARHAI. 
  • All COVID-19 Clusters should be reported through the electronic ORT
  • All board-level data is accessible through the ARHAI Scotland interactive dashboards on the eViz portal
  • The data submitted above is reported through ARHAI to the Scottish Government Healthcare Associated Infection Policy Unit and it is essential that all fields within the tools are completed to enable reporting requirements to be met. 
  • Any media statements prepared by the IMT in response to the incident should be shared with ARHAI.

3.12 COVID-19 Learning from the cluster/incident

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

There is a field within the ORT to capture this information and this should be completed with an evaluation of the effectiveness and efficiency of investigations and control measures.  This will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.

3.13 COVID-19 Cluster Resources

 

 

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

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

Appendix 1 - Assessing staff contacts in Acute Settings

Chapter 4 - Infection Control in the Built Environment and Decontamination

Introduction

Currently, chapter 4 exists as a repository for evidence reviews and tools relating to IPC in the built environment including delivery of appropriate decontamination within health and care settings and risk mitigation for water based pathogens. 

Content going forward will be developed via the ARHAI Scotland Infection Control in the Built Environment and Decontamination (ICBED) programme informed by stakeholder engagement and requirements, learning from NHS Assurance programme and outbreaks and incidents.

This chapter is in the early stages of development and at this current time does not fall into the mandatory requirements for the NIPCM.

Bed spacing

Guidance consistently recognises that bed spacing requirements contribute towards the control of HAIs. All NHS boards and care providers should aim to meet the minimum bed spacing requirements laid out in the guidance below and in keeping with the date of design and construction of the building. This takes account of ergonomics within the clinical environment and not just healthcare associated infection (HAI) risk.  Some other health and care settings may choose to adopt this guidance e.g. hospice settings.

Adult in-patient facilities designed post 2010 should achieve 3.6m (width) x 3.7m (depth) dimensions of SHPN 04-01, HBN 00-03 and SHFN 30.  Width of 3.6m is measured from bed centre to bed centre. Since 2014, HBN 00-03’s Figure 45 states a day treatment bay should achieve 2.45m width/centre-to-centre dimension.

Current NHS Scotland Guidance on bed spacing is listed below:

 

Publications

Work undertaken and published to date has been cited here for ease of reference and use at a clinical level.

Many of these publications were produced prior to development of chapter 4 and were published outwith the existing manual methodology.

Updates to publications will be made where required as part of the ARHAI programme work plans.  

ARHAI Scotland will work with SG directorates responsible for these areas in planning to establish planned implementation.

Decontamination

Probes

Time to clean

Equipment and environment cleaning

Alternative approaches to decontamination

Built environment

Water

Addendum for Infection Prevention and Control within Neonatal Settings (NNU)

The purpose of this addendum is to provide additional guidance to chapters 1,2 and 3 for NNUs

4.1 Placement of neonates/assessment for infection risk

Undertake assessment for infection risk at the point of entry into the unit before placement of the neonate is decided. This assessment is the minimal microbiological testing required and any additional testing would be determined by the clinical presentation of the neonate. The potential for transmission of infection should be continuously reviewed throughout the stay/period and must be documented in the clinical notes.

Neonates who present as a cross infection risk include those who:

  • have been transferred from another unit in Scotland with an ongoing incident/outbreak or
  • were born outside Scotland
  • have previously been positive with a Multidrug Resistant Organism (MDRO), or any alert organism or alert condition as found in Appendix 13.

From mothers who have:

  • been hospitalised outside Scotland in the previous 12 months
  • had no antenatal care
  • been previously positive with a MDRO e.g. Meticillin Resistant Staphylococcus Aureus (MRSA) or Carbapenemase Producing Enterobacterales (CPE)

If a neonate is considered to be a cross infection risk then the clinical judgement of those involved in the management of the baby should assess the placement by prioritising the incubator/cot in a suitable area pending investigation i.e. place in a single room or cohort area/room with a wash hand basin.

Information/advice must be given to parents/carers of all neonates; particularly during outbreaks/incidents

4.2 Healthcare infection, incidents, outbreaks and data exceedance

In addition to the definitions in Chapter 3, in a neonatal unit investigation by IPCT is also required if:

  • a single case of Pseudomonas aeruginosa is identified
  • a single case of infection with an alert organism is identified
  • two or more cases of colonisation with the same organism; linked in time and place are identified

Additionally, the local IPC team should consider the possibility of any onward transmission and potential for an incident/outbreak where there is:

  • A single case of colonisation with an alert organism identified

Assigning a dedicated team to care for infected or 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. Prior to closing or restricting a neonatal unit, communication must be agreed across neonatal services and risk assessed.

Transfers to other units during incidents or outbreaks should be avoided, where possible; however this should take into consideration the clinical needs of neonates, and any practical or logistical issues for parents/carers.

4.3 Personal care of neonates

Due to the vulnerability of some neonates the use of tap water for personal care requires consideration and this is outlined in Guidance for neonatal units (NNUs) (levels 1, 2 & 3), adult and paediatric intensive care units (ICUs) in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. For example, an assessment should be made on the neonate’s condition and whether tap water can be used or if an alternative, such as sterile water, is considered more appropriate.

In addition incubators/cots should not be placed near any water source where spraying or splashing may occur.

Further information for neonatal IPC management of healthcare incidents and outbreaks can be found in the supporting literature review

Infection Prevention and Control Manual for older people and adult care homes

Appendix 22 - Community IPC COVID-19 Pandemic provides details of the measures still to be followed for COVID-19 and should be used alongside existing guidance.

About the Infection Prevention and Control Manual for older people and adult Care Homes

The 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)01-update). The Scottish Government expectation is that it is mandatory for use in all NHS care settings and in all other care homes to support health and social care integration, the content of this manual must be considered best practice.

 

Important words and what they mean

Mandatory means that you must do it.

In order to support care homes successfully adopt and implement the NIPCM, this context specific Care Home Infection Prevention and Control Manual (CH IPCM) has been co-produced with national and local stakeholders. The content of the CH IPCM is completely aligned to the evidence based NIPCM and is intended to be used by all those involved in residential care provision.

The CH IPCM contains chapters on:

  1. Standard Infection Control Precautions (SICPs);
  2. Transmission Based Precautions (TBPs);

There are web links in some sections taking you directly to information contained in the NIPCM.

The CH IPCM is a practice guide for use in care homes, which when used, can help reduce the risk of infections and ensure the safety of those being cared for, staff and visitors in the care home environment. 

It aims to:

  • make it easy for care home staff to apply effective infection prevention and control (IPC) precautions;
  • help reduce the risk of infection;
  • reduce variation and optimise IPC practices throughout care home settings;
  • help align practice, monitoring, quality improvement and scrutiny.

Who should use the CH IPCM?

  • Care home providers
  • Care home staff
  • Health Protection Teams
  • Professionals providing IPC support

It should be adopted for all infection prevention and control practices and procedures.

Is the content based on scientific literature?

The recommendations for practice in the manual are developed from literature reviews of the current scientific literature (for example Medical Journals) that are updated real time and are considered best practice.  Any major changes identified in the scientific literature may lead to a change being made to the content. 

A number of ‘SBAR’s’ are available which are short communication or guidance reports that advise on the situation, background, assessment and recommendations on a specific topic.

Are there any other IPC materials that can be used?

The resources page links to SICPs materials, education and training links and posters and other supporting tools.

How can I find out what the scientific and medical words mean?

You can use the glossary to find out what these words mean. Sometimes we have added the meaning of important words within the chapter or section. 

 

The Care Home Infection Prevention and Control Manual (CH IPCM) was launched on 24 May 2021.

Responsibilities for the CH IPCM

ARHAI Scotland to:

  • ensure that the content of the CH IPCM remains evidence based.

Care Home providers to:

  • ensure that the CH IPCM is adopted and implemented in their care homes in accordance with local governance processes;
  • ensure that systems and resources are in place to facilitate implementation and compliance monitoring of IPC as specified in the manual in all care areas - compliance monitoring includes all staff (permanent, agency and where required external contractors);
  • ensure there is a system in place which promotes incident reporting or potential hazards and focuses on improvement that ensures safe working practices, through regular monitoring and review;
  • ensure there is a nominated lead with responsibility for IPC.

Care Home Managers to:

  • ensure that all staff are aware of, have access to and know where to locate the CH IPCM;
  • ensure that all staff have completed appropriate IPC training relevant to their roles and that this is centrally recorded. Training could include resources developed by your organisation, your local NHS Board or Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC);
  • ensure that all staff have adequate support and resources available to enable them to implement, monitor and take corrective action to ensure compliance with this manual (if this cannot be implemented, a robust risk assessment must be undertaken and approved through local governance procedures);
  • ensure that all staff include IPC as an objective in their Personal Development Plans (or equivalent) and are encouraged to discuss any issues around this with their line manager.

Care Home staff to:

  • ensure that they fully understand and apply the principles of IPC contained in the CH IPCM;
  • maintain competence, skills and knowledge in IPC through completing appropriate training relevant to their role as directed by their line manager. Training can be via resources developed by their organisation, local NHS Board or Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC);
  • communicate IPC practices to be taken by colleagues, those being cared for, relatives and visitors without breaching confidentiality;
  • report to line managers and document any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmission of infection including near misses e.g. sharps or PPE failures;
  • not provide care while at risk of potentially transmitting infectious agents to others e.g. when having a cold/flu or experiencing the symptoms of Norovirus (diarrhoea). If in any doubt they must consult with their line manager;
  • contact HPT/IPCT if there is a suspected or actual HAI incident/outbreak. Outbreak definitions are found on Chapter 3 of the NIPCM.

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

  • engage with and support care home staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of IPC where required;
  • provide expert advice on the application of infection prevention and control in care homes and on individual risk assessments as required;
  • have systems in place capable of distinguishing individual case or cases of infection requiring investigations and;
  • complete documentation when an incident/outbreak or data exceedance is reported.

Chain of infection

In order for infection to occur several things have to happen.  This is often referred to as the Chain of Infection. The six links in the chain are:

  1. The Infectious Agent – or the microorganism which has the ability to cause disease.

  2. The Reservoir or source of infection where the microorganism can live and thrive. This may be a person, an animal, any object in the general environment, food or water.

  3. The Portal of Exit from the reservoir. This describes the way the microorganism leaves the reservoir. For example, in the case of a person with flu, this would include coughing and sneezing. In the case of someone with gastro-enteritis microorganisms would be transmitted in the faeces or vomit.

  4. The Mode of Transmission. This describes how microorganisms are transmitted from one person or place to another. This could be via someone’s hands, on an object, through the air or bodily fluid contact.

  5. The Portal of Entry. This is how the infection enters another individual. This could be landing on a mucous membrane, being breathed in, entering via a wound, or a tube such as a catheter.

  6. The Susceptible Host. This describes the person who is vulnerable to infection.

Infection can be prevented by breaking the Chain of Infection.

The chain of infection diagram illustrates and gives examples of actions that can be taken to break it. The overall aim of Standard Infection Control Precautions (SICPs),  is to break the Chain.

Select image for full size version.

Chain of infection diagram alt text
This diagram shows the 6 different links of the chain of infection.  A diagram showing 6 links of a chain interlinked is in the middle of the diagram with the 6 boxes around it. Here is the description of the 6 boxes. 
Infectious agent: This is the microorganism or bug that can cause harmful infections and make you ill.  Common infections in care homes are respiratory such as cold and flu and stomach bugs like norovirus and clostridiodes difficile (C.diff) 
Reservoir: This is where the germ lives and grows.  This can be on a person for example in their respiratory tract or equipment, environment or on food and water.,
Portal of exit.  Way out: The germ then needs to find a way out of the infected person and then to spread. Ways out can be from sickness and diarrhoea and through the nose and mouth from coughing and sneezing. 
Mode of transmission:  Once the germ is out it can spread from one person to another by hands or on equipment such as a commode, in the air by coughing or contact with blood and body fluids.
Portal of entry. Way in: The germ then needs to find its way into another person.  This can be through the eyes or mouth, hands, open wounds or any tubes that go into the body such as a catheter or feeding tube. 
Susceptible host: This is the person who is at risk of infection as they are unable to fight the infection.  This could be residents, staff or visitors.  Elderly people can have a decreased immune system and catch infections easier. Infections also spread quickly in care homes due to many residents living together.

 

Chapter 1: Standard Infection Control Precautions (SICPs)

The basic IPC measures that should be used in your care home are called Standard Infection Control Precautions (SICPs).

SICPs are used to reduce the risk of transmission of infectious agents from known and unknown sources of infection.

These should be used by all staff, in all care settings, at all times, for all residents whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care home.

SICPs should be part of everyday practice and applied consistently by all staff in the care home including, but not limited to, managers, nurses, care staff, domestics/housekeepers and volunteers.

It is essential that optimal IPC measures are applied continuously as people living in care homes may be elderly or have underlying medical conditions which could make them more at risk from infection which may then be serious and in some cases life threatening. By applying optimum IPC measures you will provide safe and effective care to the people in your care, fellow staff and visitors to your care home.

There are 10 Standard Infection Control Precautions (SICPs)

  1. Resident Placement/Assessment for infection risk
  2. Hand Hygiene
  3. Respiratory and Cough Hygiene
  4. Personal Protective Equipment
  5. Safe Management of Care Equipment
  6. Safe Management of Care Environment
  7. Safe Management of Linen
  8. Safe Management of Blood and Body Fluid Spillage
  9. Safe Disposal of Waste
  10. Occupational Safety: Prevention and Exposure Management (including sharps)

1. Resident placement/assessment for infection risk

 An elderly man sitting in his room with a healthcare worker looking at his notes in a folderIf residents have been admitted from another care setting, for example, external care home or hospital try to pre assess them before they are admitted by speaking to the staff from the other care setting.

Before the resident comes into the care home it is important to risk assess them for infection.

 

Residents who may present a cross-infection risk include those with:

  • diarrhoea
  • vomiting, being sick
  • unexplained rash
  • fever or temperature of 37.8 C or higher
  • respiratory symptoms such as coughing and sneezing
  • known to have been previously positive with a Multi-drug Resistant Organisms (MDRO) e.g. Meticillin Resistant Staphylococcus aureus (MRSA), Carbapenemase Producing Enterobacterales (CPE)

If you suspect or know that a resident has an infection, then details must be confirmed in order for you to put in place the correct IPC measures.

 

Appendix 11 of the National Infection and Prevention Control Manual tells you the precautions you need to put in place for different infections.

Use the NES SIPCEP Breaking the Chain of Infection module to learn about breaking the chain of infection in care homes. 

Read the placement literature review to understand the evidence base for resident placement.

2. Hand Hygiene

The most important thing you can do to prevent the spread of infection in a care home is to keep your hands clean. This is called hand hygiene.

Photo showing hands underneath a tap with running waterHand hygiene is essential to reduce the transmission of infection in care home settings. All staff 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.

 

 

What you need for hand hygiene

  • Liquid soap
  • Running water
  • Alcohol based hand rub (also known as ABHR)
  • Disposable paper towels

When hand hygiene should be performed

before touching a resident;

before clean/aseptic procedures. If ABHR cannot be used, then antimicrobial liquid soap should be used;

after body fluid exposure risk;

after touching a resident;

after touching a resident’s immediate surroundings;

before handling medication;

before preparing/serving food;

after visiting the toilet;

before putting on and after removing PPE;

between carrying out different care activities on the same resident;

after cleaning care equipment;

after disposing of individual’s personal waste;

after handling dirty linen.

It is important that residents are routinely encouraged to perform hand hygiene and given assistance if required.

The four moments for hand hygiene poster can be used in your care home to show staff when hand hygiene should be done and the reasons why.

Select image for full size version.

Before carrying out hand hygiene make sure:

your arms are bare below the elbow;

you take off all your hand and wrist jewellery (a single, plain metal finger ring is allowed but should be taken off (or moved up) during hand hygiene);

bracelets or bangles which are worn for religious reasons, such as the Kara, can be pushed higher up the arm and secured in place;

your finger nails are clean and short;

you cover all cuts or abrasions with a waterproof dressing;

you do not wear artificial nails or nail varnish/products.

Choose the correct product

Liquid soap and water must be used:

Photo showing hands being washed with soap and waterif your hands look dirty; 

If you are caring for a resident who is being sick or having diarrhoea or has diarrhoeal illness such as norovirus or Clostridioides difficile then you must use soap and water for hand hygiene. 

Do not use ABHR as it will not work in these cases.

 

 Make sure you wet your hands before applying liquid soap.

Use paper towels to turn off taps if the taps are not elbow operated mixer taps.

Elbow operated mixer taps are considered to provide the best temperature and flow for optimum hand hygiene and should be considered for any new build, refurbishment or if they need repaired/changed.

When you have washed your hands  dry them thoroughly using paper towel and  dispose of the paper towel in a foot operated waste bin.

 

To make sure you clean your hands properly with soap and water you must follow the steps in the poster How to hand wash step by step images. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.

Select image for full size version

Alcohol based hand rub (ABHR)

Photo of someone using alcohol based hand rubAlcohol based hand rub (ABHR) is a gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to stop or slow down the growth of microorganisms (germs).

If your hands look clean then you can use ABHR for routine care

 

Do not use ABHR if you are caring for a resident who has sickness or diarrhoeal illnesses such as norovirus or Clostridioides difficileYou must use soap and water as ABHR will not work.

 

To make sure you clean your hands properly with ABHR you must follow the steps in the poster ‘How to hand rub step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.

Select image for full size version

Skin care:

Use warm/tepid water to reduce the risk of dermatitis. Avoid using hot water.

After hand washing pat hands dry using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.

Use an emollient hand cream during breaks and when off duty.

Refillable dispensers or communal tubs of hand cream should not be provided or used in the care setting.

Staff with skin problems should seek advice from Occupational Health Department if available or their GP

 

Read the hand hygiene literature reviews to find out more about the evidence base for hand hygiene.

3. Respiratory and cough hygiene

Photo of elderly woman sneezing into a tissueIt is easy for infections to spread within a care home by coughing and sneezing so it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.

 

 

What you need for respiratory and cough hygiene

• Disposable tissues

• Waste bin and waste bags

• Hand hygiene products

If anyone has a cough, cold or other respiratory symptoms then they must:

cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose;

put used tissues into a waste bin immediately after use;

wash their hands with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions;

keep hands away from the eyes nose and mouth.

 

Staff must:

help residents with their respiratory and cough hygiene where required;

make sure that residents are given everything they need for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that it is close enough for them to use;

use hand wipes followed by ABHR if there is no running water available or hand hygiene facilities are out of reach then wash your hands at the first available opportunity.

 

Read the respiratory and cough hygiene literature review to find out the evidence for respiratory and cough hygiene practice.

4. Personal Protective Equipment (PPE)

Health and Safety at Work Act (1974), Control of Substances Hazardous to Health (COSHH) (2002 as amended) regulations and Personal Protective Equipment at Work Regulations 1992 (as amended) legislate that employers must provide PPE which gives you adequate protection against the risks associated with the task being undertaken.

Employees also have a responsibility under these laws which is to make sure that they wear the correct PPE for the task they are doing and wear it correctly.  

PPE products you might need in the care home

  • Gloves
  • Aprons
  • Masks
  • Eye Protection

Deciding which PPE to use:

Before doing any procedure or task you need to:

think about or find out if you could be exposed or come into contact with blood and/or other body fluids (BBF); and

make sure that the PPE worn gives you enough protection against the risks associated with the procedure or task you are doing. 

Examples of potential risks are:  

  • caring for an individual with a known infection
  • inserting or caring for urinary catheters
  • changing wound dressings
  • cleaning tasks using disinfectant products

All PPE should be:

located close to the point of use

stored in a clean and dry area to prevent contamination until needed for use;

within expiry dates;

single-use only items unless specified by the manufacturer;

changed immediately after individual use and/or following completion of a procedure or task;

disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.

Reusable PPE items, for example non-disposable goggles, face shields and visors, must have a decontamination schedule with responsibility assigned.

Gloves must be:

Photo of someone wearing glovesworn when it is likely that you will be exposed to blood and/or other body fluids (BBF);

appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct glove;

changed immediately after each individual and/or following completion of a procedure or task;

changed if damaged or a perforation or puncture is suspected.

Using gloves reduces the risk of contamination but does not remove it all. Gloves should not be used instead of carrying out hand hygiene.

Gloves should never be decontaminated or cleaned with ABHR or by washing with cleaning products.

Choose the correct gloves

Use the glove selection chart to support you to select the correct glove type.

Select image for full size version

Aprons must be worn:

Photo of someone wearing an apron

by care staff when there is a risk of clothing being contaminated with blood or other body fluids;

during direct care, bed-making or when undertaking the decontamination of equipment;

when delivering food and/or supporting residents with nutrition.

 

 

Eye/face protection (including full face visors) must:

Photo of person wearing a mask and visor

be worn if blood and/or body fluid contamination to the eyes/face is expected/likely;

not be touched when worn.

Facial accessories such as piercings or false eyelashes must not be worn when using eye/face protection;

Regular glasses or safety glasses are not considered eye protection.

Fluid Resistant Type IIR surgical face masks must be:

Person wearing surgial face mask

worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/likely;

a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray, however:

    • If you are using droplet precautions, you must always wear a surgical face mask as well as the full face visor (droplet precautions will be discussed further in Chapter 2 Transmission Based Precautions)

well-fitting, fully covering the mouth and nose and fit for purpose, you must follow the manufacturer’s instructions to ensure effective fit/protection.

removed or changed;

    • at the end of a procedure/task;
    • if the mask is damaged or there is a build up from moisture after extended use or from gross contamination with blood or body fluids; and
    • following specific manufacturers’ instructions.

Putting on personal protective equipment (PPE) - donning

Always perform hand hygiene before putting on PPE.

The order for putting on PPE is:

  1. Apron or Gown
  2. Surgical Mask
  3. Eye Protection (where required)
  4. Gloves

Taking off personal protective equipment (PPE) - doffing

The order for taking off PPE is:

  1. Gloves
  2. Apron or Gown
  3. Eye Protection
  4. Surgical Mask

Always carry out hand hygiene immediately after taking off PPE.

All PPE should be removed before leaving the area and disposed of as healthcare waste.

 

A poster showing the order for putting on and removing PPE is available to print.

Select image for full size version

Putting on and taking off PPE step by step

 

 

Read the PPE literature review to find out more about the evidence base for PPE use.

 

5. Safe management of care equipment

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

Important words and what they mean

Routine cleaning is regular cleaning which is carried out on a scheduled basis, not on an unplanned basis and not in response to an outbreak.

Cleaning is the removal of any dirt by use of an appropriate cleaning agent such as detergent.

Decontamination is 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.

Disinfectant is 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.

Detergent is a chemical cleansing agent that can dissolve oils and remove dirt.

For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.

If the resident has a known infection or the equipment is contaminated with blood or body fluids, then a disinfection agent needs to be used.

Do not use household bleach as the required dilution cannot be guaranteed.

Do not use refillable spray container for cleaning products as there is a risk of contamination. 

Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.

What you need for safe management of care equipment

  • Cleaning/disinfectant products:
    • general purpose detergent and water solution/detergent impregnated wipes;

or

    • combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.);

or

    • a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.
  • Paper towels/disposable cloths.

Types of equipment

There are three different types of care equipment that you will use in your care home and it is important that you know how to deal with each type.

You must use and follow manufacturers guidance for all equipment and products you use including those used for cleaning and decontamination.

Before using any sterile equipment, you should check that:

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

1. Single-use - equipment which is used once on a single resident and then discarded.

Single-use equipment must never be reused even on the same resident. The packaging carries the symbol.

The single use symbol shows a number 2 in a circle and is scored out indicating that the item is single use

Needles and syringes are single-use devices. They shoulimage of a syringe with a needled never be used for more than one resident or reused to draw up additional medication.

Never give medications from a single-dose vial or intravenous (IV) bag to multiple residents.

 

2. Single individual use – equipment which can be reused by same resident e.g. nebuliser equipment and decontaminated following use as per manufacturers instructions.

3. Reusable non-invasive equipment (often referred to as ‘communal equipment’) – equipment which can be reused on more than one resident following decontamination between each use e.g. commode, moving and handling equipment or bath hoist.

Cleaning or decontaminating reusable non-invasive equipment

Residents should be given their own reusable (communal) non-invasive equipment if possible.  

Reusable equipment should be checked frequently for cleanliness and signs of integrity. This will include mattresses and pillows which should be clean, have a waterproof covering which is in a good state of repair. 

You should clean or decontaminate reusable equipment:  

between individual use;Photo of a commode

after blood and/or body fluid contamination;

as part of the regular scheduled cleaning process;

before inspection, servicing or repair.

 

Staff must:

follow the local cleaning protocol/schedule which should include responsibility for; frequency of; and method of decontamination required;

use a general purpose detergent and water solution/detergent impregnated wipes;

or

a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.);

or

a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl;

make up cleaning/disinfection solution following manufacturers guidance;

follow the manufacturer’s contact time for the cleaning/disinfection solution;

rinse and dry reusable equipment then store it clean and dry.

 

When an organisation uses cleaning and disinfectant products that differ from those stated in this CH IPCM these products need to meet BS EN standards. 

This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.

Manufacturers instruction and recommended contact times must be adhered to.

BS EN standards and what they mean

  • BS EN 13727 - quantitative test used to evaluate bactericidal activity of disinfectants intended for use in the MEDICAL area (e.g. surface disinfection, surgical and hygienic handrub and handwash). Products must achieve ≥ 5 log reduction (must kill 99.999%) against P. aeruginosa, S. aureus and E. hirae.
  • BS EN 14476 – quantitative test used to evaluate virucidal activity of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against Adenovirus, Norovirus and Poliovirus.
  • BS EN 13624 – quantitative test used to evaluate fungicidal and yeasticidal activities of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against A. brasiliensis, C albicans.
  • BS EN 17126 – quantitative test used to evaluate sporicidal activity of disinfectants in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against bacterial spores. (Used for C. diff). BS EN 13704 has also been used to test products against C. diff.

 

Read the management of care equipment literature review to find out more about why we do things this way for care equipment.

 

The decontamination of non-invasive care equipment poster can help staff decide how to clean equipment.

Select image for full size version

6. Safe management of the care environment

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

Furniture and floorings in a poor state of repair can have micro-organisms (germs) in hidden cracks or crevices.Photo of domestic cleaning floor with a mop

To reduce the spread of infection, the environment must be kept clean and dry and where possible clear from clutter and equipment.
Non-essential items should be stored and displayed in such a way as to aid effective cleaning

Keeping a high standard of environmental cleanliness is important in the care home settings as the residents are often elderly and vulnerable to infections.

The care home environment should be:

visibly clean, free from non-essential items and equipment to help make cleaning effective

well maintained and in a good state of repair

routinely cleaned in accordance with the specified cleaning schedules:

    • A fresh solution of general purpose neutral detergent in warm water is recommended for routine cleaning. This should be changed when dirty or at 15 minutes’ intervals or when changing tasks.
    • Routine disinfection of the environment is not recommended. However, 1,000 parts per million available chlorine (ppm available chlorine (av.cl.) should be used routinely on sanitary fittings.

Staff must:

Report any issues with the environment cleanliness or maintenance to the person in charge to ensure that the care environment is safe.  The person in charge must then act on problems reported to them.

Be aware of the environmental cleaning schedules and clear on their specific responsibilities.

Cleaning schedules should include:

  • responsibility for;
  • frequency of; and
  • method of environmental cleaning.

Managing cleaning services:

Cleaning services should be managed in a systematic way, and staff responsible for cleaning should be appropriately trained to carry out the tasks they are responsible for.

The Care Home Manager is responsible for managing the cleaning service which has a number of essential elements outlined in the cleaning services diagram.

Select the diagram for full size version

Cleaning Services

This diagram 3  shows the cleaning services and is taken from the HFS Care Home Cleaning Specification

An effective service will include all of the elements above.

Care Homes Cleaning Specification

The Care Homes Cleaning Specification provides a guide to planning cleaning services. It has tools to help with the planning and recording of cleaning activities and with the management activities marked with a * in the diagram above. These include:

  • A structure to identify all spaces within a care home and plan appropriate cleaning tasks and frequencies.
  • A set of weekly and monthly cleaning templates to be assigned to each space within a care home. These can be used to develop a schedule and to provide a method for recording all cleaning activity. An example of a cleaning schedule and record is provided:

Table 1: Example cleaning schedule residents room

This is an image of cleaning record A: residents room and ensuite.  The original can be found in the HFS Care Homes cleaning specification.

This is an image of the weekly tasks for cleaning and taken from the HFS Care Homes Cleaning specification

  • Standard operating procedures (SOPs) for all cleaning tasks. Each SOP outlines the correct equipment, safety considerations, method, and outcomes required for each task. The example shows the important steps that must be taken during the cleaning of floors.

Table 2: Example cleaning SOP: Floors

This example cleaning SOP for floors is taken from the HFS Care Homes Cleaning Specification

  • A process for checking the cleanliness of the care environment, to ensure standards are being maintained and to identify areas for improvement.

The tools within the Cleaning Specification should be used by the care home manager in the planning, training of staff, delivery, and checking of standards of the cleaning services they provide.

When an organisation uses cleaning and disinfectant products that differ from those stated in this CH IPCM these products need to meet BS EN standards. 

This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.

Manufacturers instruction and recommended contact times must be adhered to.

BS EN standards and what they mean

  • BS EN 13727 - quantitative test used to evaluate bactericidal activity of disinfectants intended for use in the MEDICAL area (e.g. surface disinfection, surgical and hygienic handrub and handwash). Products must achieve ≥ 5 log reduction (must kill 99.999%) against P. aeruginosa, S. aureus and E. hirae.
  • BS EN 14476 – quantitative test used to evaluate virucidal activity of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against Adenovirus, Norovirus and Poliovirus.
  • BS EN 13624 – quantitative test used to evaluate fungicidal and yeasticidal activities of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against A. brasiliensis, C albicans.
  • BS EN 17126 – quantitative test used to evaluate sporicidal activity of disinfectants in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against bacterial spores. (Used for C. diff). BS EN 13704 has also been used to test products against C. diff.

Decontamination of soft furnishings

Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated with blood or body fluids, it may have to be discarded. 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. Any alternative disinfectant used must meet the relevant BS EN Standards as detailed previously

 

Read the routine cleaning of the care environment literature review to find out more about why we do things this way for the care environment.

7. Safe management of linen

Examples of linen you may have in the care home includes:

  • This photo shows a cupboard filled with rolled up towelsbed linen (bed sheets, duvet, duvet covers, pillowcases);
  • blankets;
  • curtains;
  • hoist slings;
  • towels;
  • resident’s clothing (nightdresses, pyjama tops and bottoms).

There are three categories of linen:

Clean – Linen washed and ready for use

Used – All used linen in the care setting not contaminated by blood or body fluids

Infectious – All linen used by a person known or suspected to be infectious and/or linen that is contaminated with blood or body fluids, e.g. faeces.

Used or infectious linen may also be categorised as heat-labile: usually personal clothing where the clothing may be damaged (shrinking/stretching) by washing at a higher than recommended temperature than the label advises. If such linen needs to be washed at a higher temperature for example if soiled or resident has a known infection they or their relatives need to be advised that the clothing may be damaged.

All clean, used and infectious linen should be handled with care and attention paid to the potential spread of infection.

Clean linen:

Should be stored in a clean, allocated area.

This should be an enclosed cupboard but a trolley could be used as long as it is completely covered with a waterproof covering that is able to withstand cleaning.

Used linen:

Staff must: 

put on disposable gloves and apron prior to handling used linen;

make sure that a laundry trolley or container is available as close as possible to the point of use for immediate linen deposit.

Staff must not:

rinse, shake or sort linen on removal from beds or trolleys;

place used linen on the floor or any other surfaces for example on a locker or table top;

re-handle used linen once bagged;

overfill laundry receptacles or trolleys;

place inappropriate items in the laundry receptacle for example used equipment/needles.

Infectious linen:

Staff must:

wear disposable gloves and apron before handling infectious linen;

put infectious linen directly into a water soluble laundry bag and secure before putting into a clear plastic bag and placing into a laundry receptacle/trolley.

Washing linen

Photo of a washing machine containing clothingMicro-organisms are destroyed by heat and detergent and also by the dilution effect of the water in the washing machine.

wash items using the highest temperature you can and following the washing instructions.

use your normal washing powder or detergent and follow the instructions on the correct amount to use.

tumble-dry (if possible) following the washing instructions.

iron according to washing instructions. If possible, use a hot steam iron.

If visitors wish to take their relatives clothes home to be laundered, place laundry in an appropriate bag and provide them with a washing clothes at home leaflet.

If the residents clothing is very soiled or infectious, staff may recommend that the clothing is washed in the care home’s laundry service if available, otherwise, the item should be disposed of in the appropriate healthcare waste stream following discussion with the resident or their relative(s).

 

Read the safe management of linen literature review to find out more about why we do things this way when dealing with linen.

8. Blood and body fluid spillages

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

Important words and what they mean

A blood borne virus is a virus carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.

Body fluids are fluids produced by the body such as urine, faeces, vomit or diarrhoea. These body fluids may also contain blood.

Blood and body fluid spillages must be decontaminated:

immediately by staff trained to undertake this safely;

using body fluid spill kits/equipment available.

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

Read the management of blood and body fluid spillages literature review to find out more about why we do things this way for blood and body fluid spillages.

Use the poster management of blood and body fluids to help you when you clean up blood and body fluid spillages.

 

Select the image for full size

 

9. Safe disposal of waste (including sharps)

Different types of waste will be produced within care homes. 

Some waste may be disposed of through the domestic waste route but other types of waste needs special handling and disposal for example sharps and waste from people who have or may have an infection.

Waste bags in care settings may be colour coded to denote the various categories of waste.

Local procedures and policies on waste disposal must be followed.

Segregation (separating) of waste

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

Care home waste disposal may differ from categories described and guidance from local contractors may apply.

Safe management of waste

Your care home should make sure that:

waste is correctly segregated according to local regulations;

the correct colour coded bags are being used according to local regulations;

there is a dedicated area for storage of clinical waste that is not accessible to residents or the public;

waste is stored in a safe place whilst awaiting uplift;

there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed.

Staff should:

follow the schedule for emptying domestic waste bins;

always use appropriate personal protective equipment (PPE);

dispose of waste immediately as close as possible to where it was produced;

dispose of clinical waste into the correct UN 3291 approved waste bin or sharps container;

ensure that waste bins are never overfilled. Once the waste bin is three quarters full, tie waste bags up and put into the main waste bin;

use a ‘swan neck’ technique for closure of the bag and label with date and location as per local policy.

    • A ‘swan neck’ is a way of closing bag by tying in a loop and securing with a zip tie or tape to make a handle;

clean waste bins regularly with a general purpose neutral detergent;

remove PPE and perform hand hygiene when you have finished handling waste.

 

Read the safe disposal of waste literature review to find out more about why we do things this way when dealing with waste.

10. Occupational Safety: Prevention and Exposure Management (including sharps)

All care homes should have policies in place to ensure that staff are protected from occupational exposure to micro-organisms (germs), particularly those that may be found in blood and body fluids.

Important words and what they mean

Occupational exposure is exposure of healthcare workers or care staff to blood or body fluids in the course of their work.

A sharp is a device or instrument 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.

Safety device or safer sharp is 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.

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

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

Safe management of sharps in your care homePhoto of a sharps box

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

always dispose of needles and syringes as a single unit immediately at the point of use;

sharps containers need to be assembled and labelled correctly;

use the temporary closure mechanisms in between use;

if a safety device is being used safety mechanisms must be deployed before disposal;

follow manufacturers’ instructions for safe use and disposal;

do not re-sheath used needles or lancets;

do not store sharps containers on the floor;

ensure sharps containers are not accessible to residents or the public;

sharps containers must not be more than three-quarters full.

Significant occupational exposure

A significant occupational exposure is when someone is injured at work from using sharps or exposed to risk from blood or body fluids which may then result in a blood borne virus (BBV) or other infection.

Examples of this would be:

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

If you think or know you have had a significant occupational exposure you must:

report this immediately to the designated person in your care home, this is a legal requirement;

follow the local agreed process for management of an occupational exposure incident and follow the management of occupational injuries flow chart.  

 

Read the management of occupational exposure to Blood Borne Viruses (BBVs) literature review to find out more about why we do things this way for occupational exposure.

The management of occupational exposure incidents flowchart should be used within your care home so you know what to do for an occupational exposure.

Select the image for full size

Transmission based precautions (TBPs)

Sometimes using standard infection control precautions (SICPs) won’t be enough to stop an infection spreading and you will need to use some extra precautions. These extra precautions are called Transmission Based Precautions or TBPs.

When you should use TBPs?

You would use transmission based precautions if a resident has a suspected or known infection or colonisation.  

Important words and what they mean

Colonisation is 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.

How are infections transmitted?

Infections can be transmitted or spread by:

  • direct contact with microorganisms (germs) on hands;
  • indirect contact from contaminated equipment or environment;
  • droplet infection by inhaling infectious droplets e.g. flu or COVID-19;
  • aerosols e.g. chickenpox.

Different transmission routes need different TBPs.

The three routes or ways an infection is transmitted or spread are called contact, droplet and airborne. You need to use different transmission based precautions for each route.

Contact precautions are used to prevent infections that spread through direct contact with the resident or indirectly from the resident’s immediate care environment and care equipment.

Droplet precautions are used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via small droplets from the respiratory tract of one individual directly onto the mucosal surface of another person’s mouth or nose or eyes. Droplets penetrate the respiratory system to above the alveolar level.

Airborne precautions are used to prevent and control infections spread without necessarily having close contact via from the respiratory tract of one individual directly onto the surface of another person’s mouth or nose or eyes. Aerosols penetrate the respiratory system to deep into the lung.

Different infections need different TBPs.

You might have heard of some infections like norovirus, Meticillin-resistant Staphylococcus aureus (MRSA), Clostridioides. difficile (C.diff/CDI) and flu but there are lots of others. 

You can find out more information about the infection the individual has and the precautions you should use in Appendix 11 and/or A-Z of pathogens in the NIPCM.

You can also contact your local Health Protection Team or Infection Prevention and Control Team.

Before using transmission based precautions you need to find out:

What the suspected or known infection/colonisation is?

How is it transmitted?

How severe is the resident’s illness?

What is the care setting and procedures being done?

There are different ways you can find out if a resident has an infection that needs TBPs to be put in place. You can get information about a resident’s infection status from:

  • their GP (doctor);
  • local Health Protection Team;
  • local Infection Prevention and Control Team;
  • laboratory;
  • hospital or care homes staff from where the resident has been discharged or transferred.

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

1. Individual placement/assessment for infection risk

You need to regularly monitor the resident for infection throughout their stay so the correct precautions are in place to minimise the risk of infection being spread to other residents.

Residents may be an infection risk if they have:

  • diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms;
  • been previously positive with a Multi-drug Resistant Organism (MDRO) for example Meticillin-resistant Staphylococcus aureus (MRSA); Carbapenemase Producing Enterobacterales (CPE).

CPE should be considered if the resident meets any of the following criteria within the
12-month period before admission:

  • been an inpatient in a hospital outside of Scotland;
  • received holiday dialysis outside of Scotland;
  • been a close contact of a person who has been colonised or infected with CPE.

CPE guidance for a care home setting is available.  

Staff must:

get advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either your local Health Protection Team or Infection Prevention and Control Team;  

make resident placement decisions based on advice received or sound judgement by experienced staff who are involved in the resident’s management;

let the ambulance service know of the resident’s infectious condition if they need to go to hospital;

not move residents within/between care areas unless essential.

Resident isolation requirements within the care home

Sometimes you will need to isolate a resident in their own room or area because of a known or suspected infection, it is important that: 

Residents remain in their rooms whilst considered infectious and the door should remain closed.

If it is not possible for example the resident has dementia, then there needs to be individual risk assessments and decisions taken documented.

Suitable discrete signage is placed on the door advising others not to enter the room.

Consideration is given to the use of a dedicated team of care staff to care for residents in isolation/cohort rooms areas as an additional IPC measure. This is known as ‘staff cohorting’ and must only be done if there are enough staff available.

You do not stop isolation until you have considered individual risk factors and how this could affect other residents, staff and visitors.

You may need to contact your local health protection team or infection prevention and control team for further advice.

 

Read the patient placement, isolation and cohorting literature review to find out more about why we do things this way for resident placement for TBPs.

2. Safe management of care equipment in an isolation room/area

Cleaning of care equipment is essential to reduce the spread of infection when infection is confirmed/suspected

When dealing with the equipment used in the resident’s isolation room or area you should:

use dedicated reusable care equipment for the individual in isolation e.g. commodes where possible.

clean and decontaminate the care equipment after each use.

cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards

For how to decontaminate non-invasive reusable equipment prior to use on another resident see  SICPs - Safe Management of Care Equipment.

When an organisation uses cleaning and disinfectant products that differ from those stated in this CH IPCM these products need to meet BS EN standards. 

This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.

Manufacturers instruction and recommended contact times must be adhered to.

BS EN standards and what they mean

  • BS EN 13727 - quantitative test used to evaluate bactericidal activity of disinfectants intended for use in the MEDICAL area (e.g. surface disinfection, surgical and hygienic handrub and handwash). Products must achieve ≥ 5 log reduction (must kill 99.999%) against P. aeruginosa, S. aureus and E. hirae.
  • BS EN 14476 – quantitative test used to evaluate virucidal activity of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against Adenovirus, Norovirus and Poliovirus.
  • BS EN 13624 – quantitative test used to evaluate fungicidal and yeasticidal activities of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against A. brasiliensis, C albicans.
  • BS EN 17126 – quantitative test used to evaluate sporicidal activity of disinfectants in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against bacterial spores. (Used for C. diff). BS EN 13704 has also been used to test products against C. diff.

Read the management of care equipment literature review to find out more about why we do things this way for patient care equipment for TBPs.

3. Safe management of the care environment

Isolation room/area cleaning

Staff must:

clean and decontaminate the isolation/cohort rooms/area at least daily or more if advised to do so. If you have been advised to clean more than daily this should be added into the environmental cleaning schedule;

clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily;

make sure you are using the correct product which is:

a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.));

or

a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

follow manufacturers guidance and instructions on how to use the product and what the recommended contact time is for the product to work. This may include rinsing off the disinfection solution to prevent damage to surfaces.

Do not use refillable spray container for cleaning products as there is a risk of contamination. 

Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.

Terminal clean

Important words and what they mean

A terminal clean is cleaning/decontamination of the environment to ensure it is safe for the next resident or when the current resident is no longer considered infectious.

A terminal clean is carried out by:

removing all healthcare waste and other disposable items from the room;

removing bedding, curtains (bagged before removal from the room) and then wash as infectious linen;

cleaning and decontaminating all reusable care equipment in the room (before removal from the room).

The room should then be decontaminated using either:

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

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

When an organisation uses cleaning and disinfectant products that differ from those stated in this IPCM CH these products need to meet BS EN standards. 

This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.

Manufacturers instruction and recommended contact times must be adhered to.

BS EN standards and what they mean

  • BS EN 13727 - quantitative test used to evaluate bactericidal activity of disinfectants intended for use in the MEDICAL area (e.g. surface disinfection, surgical and hygienic handrub and handwash). Products must achieve ≥ 5 log reduction (must kill 99.999%) against P. aeruginosa, S. aureus and E. hirae.
  • BS EN 14476 – quantitative test used to evaluate virucidal activity of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against Adenovirus, Norovirus and Poliovirus.
  • BS EN 13624 – quantitative test used to evaluate fungicidal and yeasticidal activities of disinfectants intended for use in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against A. brasiliensis, C albicans.
  • BS EN 17126 – quantitative test used to evaluate sporicidal activity of disinfectants in the medical area. For surface disinfection, products must achieve ≥ 4 log reduction against bacterial spores. (Used for C. diff). BS EN 13704 has also been used to test products against C. diff.

4. Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)

In addition to PPE used for Standard Infection Control Precautions, appendix 16 of the NIPCM outlines you what type of PPE and RPE you will need to wear for infections spread by different transmission routes.

Important words and what they mean

Respiratory Protective Equipment (RPE) means FFP3 masks and facial protection and must be thought about when a resident is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route and when carrying out aerosol generating procedures (AGPs) on residents with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

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.

Aerosol Generating Procedure (AGP)

The most common AGPs undertaken in the Care Home Setting are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).

The full 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 are:

  • 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*
  • upper ENT airway procedures that involve respiratory suctioning
  • upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs
  • high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

*   only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.

PPE for aerosol generating procedures (AGPs)

If the individual has an infection spread by the airborne route and an AGP is required staff should wear the following PPE:

PPE for aerosol generating procedures

PPE

PPE used

Gloves

Single-use.

Apron or gown

Single-use gown.

Face mask or respirator

FFP3 mask or powered respirator hood.

Eye and face protection

Single-use or reusable.

All FFP3 respirators must be:

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

Rooms should always 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 required; in a side room with 6 ACH this would be approximately one hour. 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 air change rate in these circumstances has been agreed as 1-2 air changes/hour. 

To increase natural ventilation in care home settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

Post AGP fallow time (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 the table below.  It is often difficult to calculate air changes in areas that have natural ventilation only. 

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.  Other 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 a minimum, regardless of air changes per hour (ACH), 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. Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Post AGP fallow times 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)*

*The minimum fallow time (to allow for droplet settling time) is 10 minutes

Contact your local HPT/IPCT if further advice is required.

 

Read the RPE literature review to find out more about why we do things this way for respiratory protective equipment

5. Infection prevention and control during care of the deceased

If a resident dies when in the care home, Standard Infection Control Precautions or Transmission Based Precautions must still be applied. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for the living.

Washing and/or dressing of the deceased - Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased will give you guidance on the precautions that are required and what is permitted for certain types of infections.

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

 

Read the infection prevention and control during care of the deceased literature review to find out more about why we do things this way when dealing with the deceased.

How to contact us

If you have any questions or feedback about the Care Home IPCM then you can contact us by email or telephone.

Email

Telephone: 0141 300 1175

 

 

References

Reference 1

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

Glossary

Abrasion

A graze. A minor wound in which the surface of the skin or a mucous membrane has been worn away by rubbing or scraping.

Acute care setting/Acute hospital

This is a unique, demanding and fast-paced environment designed to accommodate a wide variety of urgent, or emergent patient care needs.

Aerosol Generating Procedures (AGPs)

An 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.

Aerosols

See Airborne particles

Airborne (aerosol) transmission

The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.

Airborne particles (aerosols)

Very small particles (of respirable size) that may contain infectious agents. They can remain in the air for extended periods of time and can be carried over long distances by air currents. Aerosols can be released during aerosol generating procedures (AGPs).

 

Airborne precautions

A group of transmission based precautions to prevent the spread of airborne pathogens

Alcohol based hand rub (ABHR)

A gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to inactivate microorganisms and/or temporarily suppress their growth.

Alert organism

An organism that is identified as being potentially significant for infection prevention and control practices. Examples of alert organisms include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff) and Group A Streptococcus.

 

Alveolar

Refers to the alveoli which are the small air sacs in the lungs. Alveoli are located at the ends of the air passageways in the lungs, and are the site at which gas exchange takes place.

Anteroom

An area with a door from/to the outside corridor and a second door giving access to the patient area (where both doors will never be open at the same time).

Antimicrobial

An agent that kills microorganisms, or prevents them from growing.

Antimicrobials are grouped according to the microorganisms they act against, such as, antibiotics, antivirals, antifungals and antiparasitics.

Antimicrobial hand wipes

Hand wipes that are moistened with an antimicrobial solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth.

Antimicrobial resistance

The ability of a microorganism to resist the action of an antimicrobial drug/agent which previously could treat the infection caused by that microorganism.

Antisepsis

The process of preventing infection by inhibiting the growth and multiplication of infectious agents. This is usually achieved by application of a germicidal preparation known as an antiseptic.

Aseptic Technique

A healthcare procedure designed to minimise the risks of exposing the person being cared for to pathogenic micro-organisms during simple (e.g dressing wounds) and complex care procedures (e.g. surgical procedures).

Asymptomatic

Not showing any symptoms of disease but where an infection may be present.

Augmented Care

In the context of infection prevention and control, most care designated as augmented will be that where medical/nursing procedures render the patients susceptible to invasive disease from environmental and opportunistic pathogens. However, there is no fixed definition of ‘augmented care’.

Autoclave

Machine used for sterilising re-usable equipment using steam sterilisation. Re-usable equipment is exposed to steam at a required temperature, pressure, and time.

Bay

A partly enclosed area within a ward containing one bed (single bay) or multiple beds (multi-bed bay).

Blood Borne Viruses (BBV)

Viruses carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.

Body Fluids

Fluid produced by the body such as urine, faeces, vomit or diarrhoea.

Care setting

Includes but is not limited to general practice, dental and pharmacy (primary care), acute-care hospitals, emergency medical services, urgent-care centres and outpatient clinics (secondary care), specialist treatment centres (tertiary care), long-term care facilities such as nursing homes and skilled nursing facilities (community care), and care provided at home by professional healthcare providers (home care).

Care staff

Any person who cares for patients, including healthcare support workers and nurses.

Central Venous Catheter (CVC)

An intravenous catheter that is inserted directly into a large vein in the neck, chest or groin to give intravenous drugs, fluids and blood and to allow for quick medical tests.

Chlorine

A chemical that is used for disinfecting, fumigating and bleaching.

Cleaning

The removal of any dirt, body fluids (blood, vomit) etc by use of an appropriate cleaning agent such as detergent.

Clinical wash hand basin

A sink designated for hand washing in clinical areas.

Cohort area

A bay/ward in which a group of patients (cohort) with the same infection are placed. Cohorts are created based on clinical diagnosis, microbiological confirmation when available, epidemiology, and mode of transmission of the infectious agent.

Colonisation

The presence of microorganisms on a body surface (such as the skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection.

Conjunctivae

Mucous membranes that cover the front of the eyes and the inside of the eyelids.

Contact precautions

Series of procedures/interventions used in addition to routine practices to prevent transmission of infectious agents that spread by direct or indirect contact

Contact transmission

The spread of infectious agents from one person to another by contact. When spread occurs through skin-to-skin contact, this is called direct contact transmission. When spread occurs via a contaminated object, this is called indirect contact transmission.

Contaminated

The presence of an infectious agent on a body surface; also on or in clothes, bedding, surgical instruments or dressings, or other inanimate articles or substances including water and food.

Cough etiquette/respiratory hygiene

Source control measures intended to contain respiratory secretions in order to limit transmission of respiratory pathogens.

Cross-infection/Cross-transmission

Spread of infection from one person, object or place to another.

Decontamination

The process of removing, or killing pathogens on an item or surface to make it safe for handling, re-use or disposal, by cleaning, disinfection and/or sterilisation.

Detergent

A chemical cleansing agent that can dissolve oils and remove dirt.

Diarrhoea

Passing looser more frequent stools than is normal for the individual.

Direct contact transmission

Spread of infectious agents from one person to another by direct skin-to-skin contact.

Disinfectant

A chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.

Disinfection

The treatment of surfaces/equipment using physical or chemical means, for example using a chemical disinfectant, to reduce the number of infectious agents from an object or surface to a level at which they are not harmful to health.

Doffing

To remove (an item of clothing or an item of PPE).

Domestic waste

Waste produced in the care setting that is similar to waste produced in the home.

Donning

To put on (an item of clothing or an item of PPE).

Droplet

A small drop of moisture, larger than airborne particle, that may contain infectious agents. Droplets can be released when a person talks, coughs or sneezes, and during some medical or patient care procedures such as open suctioning and cough induction by chest physiotherapy. It is thought that droplets can travel around 1 metre (3 feet).

Droplet Nuclei

Droplet nuclei are aerosols formed from the rapid evaporation/desiccation of larger droplet particles when expelled/exhaled from the respiratory tract.

Droplet transmission

The spread of infection from one person to another by droplets containing infectious agents.

Emollient

An agent used to soothe the skin and make it soft and supple. 

Enhanced single room (with en-suite facilities and ventilated lobby)

See Isolation Suite/Room

 

Enhanced single room (with en-suite facilities)

See Isolation Suite/Room

 

En-suite facilities

En-suite facilities should contain a shower, WC and a general wash-hand basin.

 

En-suite single-bed room

A room with space for one patient with en-suite facilities.

Exceptional infection episode

A single case of an infection that has severe outcomes for an individual patient OR has major infection control/public health implications e.g. infectious diseases of high consequence such as extensively drug resistant tuberculosis (XDR-TB).

Excretions

Waste products produced by the body such as urine and faeces (bowel movements).

Exposure

The condition of being exposed to something that may have a harmful effect such as an infectious agent.

Exposure Prone Procedures (EPPs)

Certain medical and patient care procedures where there is a risk that injury to the healthcare worker may result in exposure of the patient’s open tissues to the healthcare worker’s blood e.g the healthcare worker’s gloved hands are in contact with sharp instruments, needle tips or sharp tissues inside a patient’s body.

Face covering

A term that applies collectively to items used to cover the nose and mouth. Also referred to as a face mask.

These should not be confused with items of PPE.

Fallow time

The period of time required for droplets and/or aerosols to settle and be removed from the air following a procedure. It is also known as settle time.

 

FFP3

Respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). FFP stands for filtering facepiece. There are three categories of FFP respirator: FFP1, FFP2 and FFP3. An FFP3 respirator or hood provides the highest level of protection, and is the only category of respirator legislated for use in UK healthcare settings.

Fit Testing

A method of checking that a tight-fitting facepiece respirator fits the wearer and seals adequately to their face. This process helps identify unsuitable facepieces that should not be used.

Fluid resistant surgical mask (FRSM)

See surgical face mask

Fluid-resistant

A term applied to fabrics that resist liquid penetration, often used interchangeably with 'fluid-repellent' when describing the properties of protective clothing or equipment.

GP

General practitioner (your family doctor)

Group 4 Infections

Definition taken from the HSE Approved list of biological agents www.hse.gov.uk/pubns/misc208.pdf

Group 4 infections cause severe human disease and are a serious hazard to employees; they are likely to spread to the community and there is usually no effective prophylaxis or treatment available.

Hand Hygiene

The process of decontaminating your hands using either alcohol based hand rub or liquid soap and water.

Health Protection Team (HPT)

A team of healthcare professionals whose role it is to protect the health of the local population and limit the risk of them becoming exposed to infection and environmental dangers. Every NHS board has a HPT.

Healthcare Associated Infection (HAI)

Infections that occur as a result of medical care, or treatment, in any healthcare setting.

Healthcare associated infection outbreak

Two or more linked cases associated with the same infectious agent, within the same healthcare setting, over a specified time period; or a higher than expected number of cases in a given healthcare area over a specified time period.

Healthcare infection data exceedance

A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.

Healthcare infection exposure incident

An exposure of patients, staff, or the public to a possible infectious agent, as a result of a healthcare system failure or near misses e.g. ventilation, water or a decontamination incident.

Healthcare Waste

Waste produced as a result of healthcare activities for example soiled dressings, sharps.

Hierarchy of controls

This is a systematic process which provides a consistent approach to minimizing or eliminating exposures to hazards in the workplace.

Hospital infection incident assessment tool (HIIAT)

Used by the IPCT or HPT to assess every healthcare infection incident i.e. all outbreaks and incidents including decontamination incidents or near misses in any healthcare setting (that is the NHS, independent contractors providing NHS Services and private providers of healthcare).

Hygiene Waste

Waste that is produced from personal care. In care settings this includes feminine hygiene products, incontinence products and nappies, catheter and stoma bags. Hygiene waste may cause offence due to the presence of recognisable healthcare waste items or body fluids. It is usually assumed that hygiene waste is not hazardous or infectious.

Hypochlorite

A chlorine-based disinfectant such as bleach

Immunisation

To provide immunity to a disease by giving a vaccination.

Immunocompromised patient/individual

Any person whose immune response is reduced or deficient, usually because they have a disease or are undergoing treatment. People who are immunocompromised are more vulnerable to infection.

Impervious

Cannot be penetrated by liquid.

Incident Management Team (IMT)

A multidisciplinary group with responsibility for investigating and managing an incident. 

Indirect contact transmission

The spread of infectious agents from one person to another via a contaminated object.

Infection

Invasion of the body by a harmful organism or infectious agent such as a virus, parasite, bacterium or fungus.

Infection Prevention and Control Team (IPCT)

A multidisciplinary team responsible for preventing, investigating and managing an infection incident or outbreak.

Infectious agent

Any organism, such as a virus, parasite, bacterium or fungus, that is capable of causing an infection or infectious disease.

Infectious Diseases of High Consequence (IDHC)/High Consequence Infectious Disease (HCID)

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. 

Infectious period

The time when an infectious agent may be transmitted directly or indirectly from an infected person to another person. Also known as “period of infectiousness” and “communicability”.

Inpatient

A patient is termed an inpatient when they occupy a staffed bed in a hospital and either remains overnight (whether intended or not), or is expected to remain overnight but is discharged earlier. An inpatient’s admission can be an emergency, an elective or as a transfer.

Invasive device

A device which penetrates the body, either through a body cavity or through the surface of the body. Central Venous Catheters (central line), Peripheral Arterial Lines and Urinary Catheters are examples of invasive devices.

Invasive procedure

A medical/healthcare procedure that penetrates or breaks the skin or enters a body cavity.

Isolation

Physically separating patients to prevent the spread of infection.

Isolation Suite/Room

An isolation room/suite consists of enhanced en-suite single bed rooms:

An en-suite single bed room is defined as: consisting of  a bed; locker/wardrobe; clinical wash-hand basin and en-suite shower, WC and wash-hand basin.  (In new build, space for a social support zone for overnight stay and a clinical support zone is also provided).

  • Enhanced single room (with en-suite facilities), also called isolation room, is the same as an en-suite single-bed room but with a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas. It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors. The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards.
  • Enhanced single room (with en-suite facilities and ventilated lobby), also called isolation suiteis the same as an enhanced single room (with en-suite facilities) but with a lobby having positive pressure ventilation. 
J

No terms

K

No terms

L

No terms

Lateral Flow Device (LFD)

A test carried out using a small medical device that tests whether or not there is a particular substance, gene, etc. in a sample. For example, to identify those who have COVID-19 but are not presenting symptoms. 

 

Long Term Care Facility (LTCF)

Long term care facilities provide a variety of services, both medical and personal care, to people who are unable to live independently.

Mechanical Ventilation

Mechanical ventilation brings fresh air into a building from outside via a controllable method. Basic systems consist of a fan and either collection, (extraction) or distribution (supply) ductwork.

Microorganism (microbe)

Any living thing (organism) that is too small to be seen by the naked eye. Bacteria, viruses and some parasites are microorganisms.

Mode of transmission

The way that microorganisms spread from one person to another. The main modes or routes of transmission are airborne (aerosol) transmission, droplet transmission and contact transmission.

Mucocutaneous exposure

An incident in which the mucous membranes (e.g mouth, nose, eyes) are exposed to blood/other body fluid.

Mucous membranes/mucosa

The surfaces lining the cavities of the body that are exposed to the environment such as the lining of the mouth and nose.

Multi-bed room

A room that contains more than one bed. 

The acceptable maximum number of beds in a multi-bed room is four. Multi-bed rooms require two clinical wash-hand basins and must have en-suite sanitary facilities. Ideally, an assisted shower room (with WC, shower and general wash-hand basin) and a separate semi-ambulant WC (with general wash-hand basin) both en-suite.

 

Needle safety device

Any device designed to reduce the risk of injury from needles. This may include needle-free devices or mechanisms on a needle, such as an automated resheathing device, that cover the needle immediately after use.

Negative pressure room

A room which maintains permanent negative pressure i.e. air flow is from the outside adjacent space (e.g. corridor) into the room and then exhausted to the outside.

The room should be used to accommodate a patient known or suspected to be infected with a microorganism spread by the airborne (aerosol) route whilst the patient is considered infectious.

Nitrile

A synthetic rubber material used to make non-latex gloves.

Non-intact skin

Skin that is broken by cuts, abrasions, dermatitis, chapped skin, eczema etc.

Non-intact skin exposure

An incident in which non-intact skin is exposed to blood or body fluids.

Non-sterile procedure

Care procedure that does not need to be undertaken in conditions that are free from bacteria or other microorganisms.

Nosocomial

An infection occurring in a patient during the process of care in a hospital or other health care facility, which was not present or incubating at the time of admission.

Occupational exposure

Exposure of healthcare workers or care staff to blood or body fluids in the course of their work.

Organism

Any living thing that can grow and reproduce, such as a plant, animal, fungus or bacterium.

Outbreak

When two or more people have the same infection, or more people than expected have the same infection.  The cases will be linked by a place and a time period.

Outpatient

An outpatient is a patient who attends a consultant or other medical/healthcare clinic or has an arranged meeting with a consultant or a senior member of their team out with a clinic session. Outpatient attendances involve treatment or assessment that only take a short time to complete. Outpatient attendances are categorised as new or return (follow-up).

Overcrowding

Within health and care settings, this is the state of being filled past capacity/comfort and therefore being burdened by excessive demands for services.

Pandemic

A disease outbreak that occurs over a wide geographical area (such as multiple countries and/or continents) and typically affects a significant proportion of the population.

Pathogen

Any disease-producing infectious agent.

Patient cohorting

Placing a group of two or more patients (a cohort) with the same infection/strain in the same bay/ward. Cohorts are created based on clinical diagnosis, microbiological confirmation, epidemiology, and mode of transmission.

PCR test

Highly accurate tests used to diagnose certain infectious diseases.

Percutaneous injury

An injury caused by a sharp instrument or object such as a needle or scalpel, cutting or puncturing the skin.

Personal Protective Equipment (PPE)

Equipment a person wears to protect themselves from risks to their health or safety, including exposure to infections e.g. disposable gloves and disposable aprons.

Physical Distancing

Keeping a distance from other people, in order to stop transmission of a disease to another person or other people.

Pre-symptomatic

The time period when someone has the infection but has not yet developed symptoms but does go on to develop symptoms later in the disease.

Primary Care Setting

These provide the first point of contact in the healthcare system and includes general practice, dentistry, community pharmacies etc

Problem Assessment Group (PAG)

A group that is convened by the Infection Prevention and Control Team (IPCT)/Health Protection Team (HPT) to assess a healthcare incident/outbreak/data exceedence and determine if further action is required.

The assessment and outcome may be:

  • HIIAT Green - continue to monitor
  • HIIAT Amber/Red - IMT required
Pyrexia

Fever. Rise in body temperature above the normal level >37.2°.

Quarantine

A period of isolation to prevent spread of a contagious disease.

Recapping/Re-sheathing

To put a needle or other sharp object back into its plastic sheath or cap. Also known as ‘re-sheathing’.

Respiratory droplets

A small droplet >5 μm in diameter, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.

Respiratory Protective Equipment (RPE)

Respirators are devices that cover the nose and mouth and are designed to filter the air breathed in to protect the wearer from inhaling hazardous substances.

They provide respiratory protection from infectious agents transmissible by the airborne (aerosols) route. FPP3 respirators are recommended for use in UK health and care settings when exposure to aerosols is anticipated.

 

 

Safer sharp

A medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury.  Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.

Sanitary fittings

All sinks and furniture in a bathroom, such as a toilet, bath, shower etc.     

Screening

Performing a test or enquiry to identify individuals at risk of a specific disorder or infection to warrant further investigation or direct preventive action.

Secondary care setting

Provided by health professionals who generally are not the first point of contact for a patient. These settings are usually hospitals but can also be community based.

Secretions

Any body fluid that is produced by a cell or gland such as saliva or mucous, for a particular function in the organism or for excretion.

Segregated

Physically separating or isolating from other people.

Sepsis

A life threatening condition that arises when the body’s response to a severe complication of infection e.g. pneumonia (lung infection) injures its own tissues and organs. This can lead to multiple organ failure and death. Early recognition, treatment and management is key to successful patient outcomes.

Sharp

A ‘sharp’ is a device or instrument used in healthcare settings with sharp points or edges, such as needles, lancets and scalpels which have the potential to cause injury through cutting or puncturing the skin.

 

Sharps incident

A type of percutaneous injury caused by a sharp instrument or device which cuts or penetrates the skin. 

Sharps injury

See percutaneous injury.

Significant occupational exposure

A percutaneous, mucocutaneous exposure or non-intact skin (abrasions, cuts, eczema) exposure to blood/other body fluids from a source that is known (or later found to be) positive for a bloodborne virus infection.

Significant sharps incident

An incident which involves a used needle that has exposed, or may have exposed, the employee to blood/body fluids.

Single-bed room

A room with space for one patient and usually contains as a minimum: a bed; locker/wardrobe; clinical wash-hand basin.

Single-bed rooms should also have en-suite sanitary facilities comprising of a shower, WC and a general wash-hand basin.

Source control

This term encompasses all physical measures used to control the transmission of an infectious agent.

Spore

A reproductive cell produced by fungi and some types of bacteria under certain environmental conditions. Spores can survive for long periods of time and are very resistant to heat, drying and chemicals.

Staff cohorting

A dedicated team of healthcare staff who care for a cohort of patients, and do not care for any other patients.

Standard infection control precautions (SICPs)

These are a group of basic infection prevention and control practices that need to be adopted by all staff in health and care settings, irrespective of infectious status of patient.

Sterile

Free from live bacteria or other microorganisms

Sterile procedure

Care procedure that is undertaken in conditions that are free from bacteria or other microorganisms.

Sterilisation

The procedure of making some object free of all germs, live bacteria or other microorganisms (usually by heat or chemical means).

Surgical face mask

A disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious droplets and also to protect patients.  When recommended for infection control purposes a 'surgical face mask' typically denotes a fluid-resistant (Type IIR) surgical mask.

Surgical scrubbing

The process of removing debris and sterilizing hands prior to performing a sterile or surgical procedure.

Surgical site infection

This is an infection which occurs after the surgery at the site of the surgical incision due to introduction and multiplication of pathogens at the surgical site.

Swan-neck

Way of closing bag by twisting the top of the bag (must not be more than 2/3 full), looping the neck back on itself, holding the twist firmly, and placing a seal over the neck of the bag (such as with a tag).

Terminal decontamination

Cleaning/decontamination of the environment following transfer/discharge of a patient, or when they are no longer considered infectious, to ensure the environment is safe for the next patient or for the same patient on return.

Touch surfaces

These are surfaces that are frequently touched by different people throughout the day and are therefore more likely to be contaminated with bacteria or viruses for example doorknobs, tables, phones etc. which can then easily transfer to the user.

Transmission-based precautions (TBPs)

These are additional measures that are used in conjunction with SICPs when caring for patients with a known or suspected infection or colonisation.

U

No terms

Vaccine

A suspension that is administered in order to stimulate the immune response of the body against an infectious agent.

Vascular access devices

Any medical instrument used to access a patient’s veins or arteries such as a Central Venous Catheter or peripheral vascular catheter.

Ventilation

Ventilation is a means of removing and replacing the air in a space. In its simplest form this may be achieved by opening windows and doors.

Viral load

The viral load or viral burden is a numerical expression of the amount of virus present in biological fluids or environmental specimens.

 

Ward

An area forming a division of a care setting (or a suite of rooms) shared by patients who need a similar type of care.

X

No terms

Y

No terms

Z

No terms

Disclaimer: Printed copies of the NIPCM are uncontrolled and only valid at the time of printing. The NIPCM website http://www.nipcm.scot.nhs.uk should be used to ensure you are using the current guidance. This version of the manual was generated at August 07, 2022.