7.2 Individual placement/assessment of infection risk

7.2.1 Category implementation and the surrounding environment

7.2.2 Managing individual placement in self-contained residential settings

7.2.3 Individuals returning from day or overnight stay

7.2.4 Providing care at home

7.2.5 Staff cohorting

7.2.6 Discontinuing IPC control measures in community health and care settings for COVID-19 individuals

Table 1: Stepdown requirements for community health and care settings

Risk categories must be established to ensure segregation of individuals determined by their risk of COVID-19. 

Any other known or suspected infections and the need for any Aerosol Generating Procedures (AGPs) must be considered before individual placement within each of the category areas.

Establishing which category an individual is in will determine Personal Protective Equipment (PPE) and decontamination requirements.

Examples of categories are described below.  Your setting may use different names for each of the categories from those described below and you should familiarise yourself with the categories in your setting that align with those described here. 

Any services providing care at home should phone ahead to the individual prior to a visit and ask the triage questions in (examples in section 7.1) to determine what category they will be on.

Within Acute care settings there is an additional low risk pathway which can be found in the Scottish Acute Care COVID-19 Addendum however it is expected that all individuals in community and care at home settings will fall into the Medium or High risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

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

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

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

  1. All other patients/individuals who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
  2. Asymptomatic patients/individuals who refuse testing or for whom testing cannot be undertaken for any reason.
  3. Those who are asymptomatic have been tested and results are still awaited.
  4. Recovered COVID-19 patients/individuals - see footnote 2.

Footnote 1.When deciding patient/individual placement where symptoms are unknown – for e.g. where the patient/individual is unconscious, or patients/individuals who have returned from a country on the quarantine list in the last 10 days, a full clinical and individual assessment of the patient/individual should be carried out prior to placement in a side room on the high or medium category.  This assessment should take account of risk to the patient/individual (immunosuppression, frailty) and clinical care needs (treatment required in specialist unit).

Footnote 2. Further information on Discontinuing IPC control measures in community health and care settings for confirmed COVID-19 patients/individuals can be found in section 7.2.6.

Some individuals who no longer require medical care in hospital will be discharged home or to their long term care facility to fully recover. These people may not have completed their isolation period and can be safely cared for at home if this guidance is followed. The acute should provide information regarding test results and a plan for stepping down IPC measures on discharge.

7.2.1 Category implementation and the surrounding environment

Ideally, community health and care settings should have designated areas for the high risk category and designated areas for the medium risk category. 

Depending on the nature of the services, it may be possible to run clinics at specific times of the day determined by category i.e. Medium risk category in morning session, high risk category in afternoon session. 

As per triage questions above, patients on the high risk category should have their appointment postponed until they have completed their isolation period wherever possible. 

Ensure category areas have signage in place to support and separate entrances to facilities and departments utilised where available.

7.2.2 Managing individual placement in self-contained residential settings

All admissions from the community to a residential facility should be assessed first using the triage questions in section 7.1. This applies to all types of residential facilities and admissions (including for respite).

For individuals who fall into the high risk category, the admission should be delayed until they have completed their self-isolation period wherever possible.

Conduct a local risk assessment if the admission cannot be delayed to ensure it is done safely. See PHS Social Care and Residential Care COVID-19 guidance for further information on admissions to these settings including for respite.

If the admission must go ahead, the patient/individual can start isolation in their own room and must be managed in line with the high risk category.

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

Patients/individuals who are symptomatic of COVID-19 but are still awaiting test results must not be cohorted together.  This is because symptoms may be associated with another respiratory pathogen and cohorting increases the risk of onward transmission to others. These individuals should be isolated in their own single room facility and mixing with others must be avoided wherever possible. 

Additionally, individuals previously considered to be in the shielding category should not be cohorted with other residents/individuals.

Meals should be provided for the individual in the high risk category to eat within their room to avoid them entering any communal spaces.

Ensure that personal toiletries such as towels (unless laundered to a satisfactory standard between individuals) toothbrushes and razors are not shared amongst individuals.

Consider a rota for showering and bathing placing the individuals in the high risk category last.

Only essential staff wearing appropriate PPE should enter the rooms of individuals in the high risk category.  All necessary care should be carried out within the individual’s room.

Any patient/individual in the medium risk category who develop symptoms of COVID-19 should be isolated immediately and tested for COVID-19.  Any patient/individual who goes on to test positive for COVID-19 (whether symptomatic or asymptomatic) should be transferred to the high risk category.

7.2.3 Individuals returning from day or overnight stay

Individuals who have been allowed to leave the community health and care facility for the day or for an overnight stay should be triaged in advance of their immediate return and again on arrival at the facility to determine which category they should be placed on. 

7.2.4 Providing care at home

All efforts should be made to establish which COVID-19 category the individual is in before arrival at an individual’s home.  Establish whether or not the individual has any aerosol generating procedures (AGPs) in progress so that the correct PPE can be donned – see section 7.5.6.

An FRSM should be worn on entering an individual’s home.  On arrival, assess the activities and tasks to be undertaken.  If possible, they should be performed in such a way that 2 metre physical distancing is maintained.  Where 2 metre physical distancing cannot be maintained, PPE should be worn in line with table 2.  Donning and doffing of PPE in the care at home settings is covered in section 7.5.4.

Scottish Government advice on providing care at home is available.

7.2.5 Staff cohorting

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

Providers or employers delivering a service in an individual’s own home should identify individuals at extremely high risk of severe illness, assess their needs and allocate dedicated staff (if possible) to care for them. This should be reviewed regularly to ensure it is up to date. Other staff members should be allocated to consistently care for the needs of those not at extremely high risk of severe illness.

During the pandemic it is important to minimise the visits to those individuals at extremely high risk of severe illness and, if possible, the number of staff undertaking the visits. The person receiving care may make the decision to suspend some of the care or for this to be provided by a carer or guardian. This should be discussed with the relevant authorities and care providers.

Where it is not possible to allocate specific staff to care for individuals who are at extremely high risk of severe illness, it may be possible to schedule visits to these groups of patients before visits to others.

7.2.6 Discontinuing IPC control measures in community health and care settings for COVID-19 individuals

The following applies to individuals in the community health and care settings listed on in this addendum. 

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

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

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

Staff identified as a COVID-19 case or contact should complete a total of 10 days self-isolation in line with Public Health Scotland guidance.

All other individuals should follow stay at home guidance on NHS inform.

For severely immunocompromised individuals or those at extremely high risk of severe illness, negative tests may be required where ongoing care is required as an outpatient in a healthcare setting.  This would be determined by the discharging clinician.

Table 1 - Stepdown requirements for community health and care settings

Group

Number of isolation days required

COVID-19 Clinical requirement for stepdown

Testing required for stepdown

Individuals who have recently been discharged from hospital to either their own home or a community health and care setting 

14 days from symptom onset (or first positive test if symptom onset undetermined)

Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery

Not routinely required.

Individuals who are severely immunocompromised or at high risk of severe illness as determined by Chapter 14a of the Green Book.

14 days from symptom onset (or first positive test if symptom onset undetermined)

Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery

Not routinely required unless returning to healthcare as an outpatient

 

People in prisons

10 days from symptom onset (or first positive test if symptom onset undetermined)

Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.

Not routinely required

Transferring between pathways on stepdown

Residents/individuals should be managed in the high risk category for any outpatient care or care at home until criteria described in this table is met and can then transfer to the medium risk category.