NIPCM

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

 

 

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

The Hierarchy of Controls 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

 

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. This includes COVID-19 (see COVID-19 respiratory symptom assessment questions and testing requirements within Appendix 19 - COVID-19 Pandemic controls)
• With a known (laboratory confirmed) or suspected infectious pathogen for which appropriate duration of precautions as outlined in A-Z pathogens 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 hospitalised outside Scotland in the last 12 months (including those who received dialysis).

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

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

1.2 Hand Hygiene

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

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* including any embedded jewellery (a single, plain metal finger ring or ring dosimeter (radiation ring) is permitted but should be removed (or manipulated) 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 fingernails 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.

Application of sufficient volume of ABHR to cover all surfaces of the hands is important to ensure effective hand hygiene. Manufacturer’s instruction should be followed for the volume of ABHR required to provide adequate coverage for the hands. In the absence of manufacturers instructions, volumes of approximately 3ml are recommended to ensure full coverage.

Perform hand hygiene:

The World Health Organization’s ‘5 moments for hand hygiene’ should be used to highlight the key indications 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
5. after touching a patient’s immediate surroundings

Some additional examples of hand hygiene moments include but are not limited to: 

• 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
• hands are potentially contaminated with blood, other body fluids or excretions
• caring for patients with vomiting or diarrhoeal illnesses;
• caring for a patient with a suspected or known gastro-intestinal infection, for example Norovirus or a spore forming organism such as Clostridioides difficile

Hands should be washed with warm/tepid water to mitigate the risk of dermatitis associated with repeated exposures to hot water and to maximise hand washing compliance. Compliance may be compromised where water is too hot or too cold. Hands should be dried thoroughly following hand washing using a soft, absorbent, disposable paper towel from a dispenser which is located close to the sink but beyond the risk of splash contamination.

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

Staff working in the community should carry a supply of ABHRs 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:

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

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.

NSS support WHO World Hand Hygiene Day 2023 'Accelerate action together'.

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

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

1.3 Respiratory and Cough Hygiene

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

• Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose. 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

Before 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. (Scottish National Blood Transfusion Service (SNBTS) adopt practices that differ from those stated in the National Infection Prevention and Control Manual);
• Gloves are a single-use item and should be donned immediately prior to exposure risk 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 prolonged 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;

• meet the specification standards of the Transparent face mask technical specification (Department of Health and Social Care - November 2021);and 
• have been approved by the UK Transparent Mask review group for use within health and social care settings 
• only be worn in areas where Fluid Resistant Type IIR surgical face masks are used as personal protective equipment.

Further information can be found in:

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

Footwear must be:

• 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.

 

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 cannot 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.  

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	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	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

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

Care equipment is classified as either:

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

Before using any sterile equipment check that:

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

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

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

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

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

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

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

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

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

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

1.6 Safe Management of Care Environment

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

The care environment must be:

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

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

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

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

Clean linen

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

Linen used during patient transfer

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

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

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

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

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

Local guidance regarding management of linen may be available.  

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

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

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

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

 

1.8 Safe Management of Blood and Body Fluid Spillages

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

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

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

If superabsorbent polymer gel granules for containment of bodily waste are used these should be used in line with national guidance. In Scotland refer to Safety Action Notice - SAN(SC)19/03 | National Services Scotland (nhs.scot)

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

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

 

 

 

1.9 Safe Disposal of Waste (including sharps)

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

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

Categories of waste:

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

Waste Streams:

• Black – Trivial risk:
  • Domestic waste or yellow and black stripes (small quantities of hygiene waste).
  • Final disposal to Landfill.
  • Clear/opaque receptacles may also be used for domestic waste at care area level.
• Orange, Light Blue (laboratory) – Low risk
  • Orange - consists of items which are contaminated or likely to be contaminated with blood and/or body fluids 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)

Exposure 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.

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 such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms. This includes COVID-19 (see also COVID-19 respiratory symptom assessment questions within the Appendix 19 COVID-19 Pandemic Controls).
• With a known (laboratory confirmed) or suspected infectious pathogen for which appropriate duration of precautions as outlined in A-Z of pathogens 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 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.

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   Gloves

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 donned immediately prior to exposure risk 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.

2.4.5  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.

Where staff have concerns, they may choose to wear an FFP3 respirator rather than a fluid-resistant surgical mask (FRSM) when providing patient care, provided they are fit tested. This is a personal PPE risk assessment.

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.

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.

It is important that information on the infection status of the deceased is sought and communicated at each stage of handling. Appropriate risk assessment must be carried out before performing activities that may increase the risk of transmission of infectious agents from deceased individuals (see literature review for further information on these activities).

Washing and/or dressing should not be carried out when the deceased is known or suspected to have been infected by any of the following key infectious agents: Hazard Group 4 organisms, anthrax, and rabies. For other HCIDs a local risk assessment should be undertaken to inform any decision making on washing and/or dressing of the deceased.

Viewing of the deceased should be avoided when the deceased is known or suspected to have been infected by Hazard Group 4 organisms, specifically those causing VHFs (including Ebola, Lassa etc.) and anthrax. For other HCIDs a local risk assessment should be undertaken to inform any decision making on viewing of the deceased.

See Appendix 12 Application of infection control precautions in the deceased.

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

Deceased individuals known or suspected to have a Hazard 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 1000 ppm 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 Hazard Group 4 infectious agents.  See Appendix 12 Application of infection control precautions 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. 

Post-mortem examination of deceased individuals known or suspected to have been infected by transmissible spongiform encephalopathies (TSE) causing agents should be carried out in such a way as to minimise contamination of the working environment. See Literature review for further information.

 

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 

Built environment incidents/outbreaks

ARHAI Scotland 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. 

Two Aide-Memoires currently 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 patient's condition as per:
  • Section 1.1
  • Section 2.1
• 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.
  • Review of patient cases should consider any potential missed opportunities to isolate a patient, a delay in which may have resulted in onward transmission. Any learning should be widely communicated to all clinical staff in the board.
  • 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 also be reported.
• 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 Scottish Government Healthcare Associated Infection Policy Unit.

• 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 declared over, and in addition to reporting via the electronic outbreak reporting tool (ORT), the IMT / NHS Board should decide on the most appropriate format for a report. This is to communicate any lessons learned using the Hot Debrief Tool. Completion of this and submission to ARHAI Scotland is not mandatory, but for the purposes 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 Case definitions

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

Please note: People must also 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 (including other care facilities and NHS Boards)

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

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 stay at home advice.

Where a confirmed COVID-19 positive patient has been discharged or transferred to another care facility or NHS Board (e.g., care home, hospice, mental health facility), the patient and/or the receiving area must be notified at the earliest opportunity 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. 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.

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.

3.4.2 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.

Note: the current COVID-19 cluster reporting system is currently under review due to changes in asymptomatic testing policy announced on 14 September 2022.

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 further investigation undertaken 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 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 Occupational Health Services (OHS) within their board when responding to COVID-19 clusters/incidents. 

3.6.1 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 1 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 be based on local outbreak management and on the advice of the local Infection Control Doctor as per the Hospital Testing table.

3.7 COVID-19 Investigations

3.7.1 IPC practice and compliance (including AGPs)

3.7.2 Review of visiting

3.7.3 Testing during an outbreak

3.7.4 Whole Genome Sequencing

3.7.5 Contact tracing

3.7.6 Ventilation considerations

3.7.7 Bed spacing

3.7.8 COVID-19 messaging

 

 

3.7.1 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 appropriate 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 the National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 19 COVID-19 pandemic controls.

3.7.2 Review of visiting

When investigating a COVID-19 cluster, ascertain from ward staff if there have been any visitors known to have respiratory symptoms.  Consider what, if any, measures need to be introduced to mitigate any risks identified.

Further hospital visiting guidance can be found here: Coronavirus (COVID-19): hospital visiting

3.7.3 Testing during an outbreak

Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.

Any patient who develops symptoms should be tested immediately using laboratory based PCR. Rapid Diagnostic Test (PCR or non-PCR based) or LFD may be used in addition to laboratory based PCR test to support rapid patient placement decisions whilst PCR results are awaited. If LFD (or other non-PCR based test) is positive at any point, a follow up PCR test is required and TBPs must commence. Further detail of current testing requirements is provided in the Hospital Testing table.

All staff who are symptomatic of COVID-19 must be tested and excluded from work and follow advice outlined in Annex B of the Directorate Letter of 14^th September 2022 (DL 2022 (32)).

3.7.4 Whole Genome Sequencing

Public Health Scotland offer a whole genome sequencing service to support outbreak investigations and address important clinical and epidemiological questions.

3.7.5 Contact tracing

Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.

In the event of a decision to undertake contact tracing, 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. 

Assessing patient contacts

Typically, any patients in the same bed bay as a confirmed case should be considered a contact.  For larger open bedded areas such as ITUs or nightingale wards. IMTs should agree which patients should be classed as contacts, 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. Local risk assessment should be undertaken taking into consideration the Hierarchy of Controls. 

Any asymptomatic contacts identified as part of local outbreak management should be observed for symptom onset. Symptom vigilance is essential for all patients, irrespective of whether a contact.

Depending on 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 and patients 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.

Staff contact tracing in an outbreak situation should be based on local outbreak management and on the advice of the local Infection Control Doctor.

Contact tracing visitors

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

3.7.6 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 18 - 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, Air Handling Units, ductwork etc clean and free from dust/debris?
• Is cleaning schedule for the above up to date?
• Does the ventilation system meet current specification?

3.7.7 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 are adequate.

See Chapter 4 of the NIPCM for more detail

3.7.8 COVID-19 messaging

The 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 Control Measures

3.8.1 Patient placement

3.8.2 Hand hygiene

3.8.3 Personal Protective Equipment

3.8.4 Safe Management of care Equipment

3.8.5 Safe Management of Care Environment

3.8.6 Waste and Linen

3.8.7 Staff

3.8.8 Management of staff exposed to a case

3.8.9 Closure of the ward/unit

3.8.10  Other control measures which may be considered by the IMT

3.8.11 Conversion of outbreak ward to COVID-19 ward

 

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

3.8.1 Patient placement

• The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified through outbreak assessment.
• 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.
• 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 identified as part of local outbreak management should be observed for symptom onset. Symptom vigilance is essential for all patients, irrespective of whether a contact.
• If a contact or any other patients develops symptoms, they should be isolated and laboratory based PCR testing should be performed as soon as possible.
• 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.

3.8.2 Hand hygiene

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

3.8.3 Personal Protective Equipment

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

3.8.4 Safe Management of Care Equipment

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

3.8.5 Safe Management of Care Environment

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

3.8.6 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.

3.8.7 Staff

• Ward staff should be 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 and arrangements made for staff to leave the ward if symptoms develop during a shift.

3.8.8 Management of staff exposed to a confirmed case of COVID-19

• Staff should remain symptom vigilant. Symptomatic staff members should not attend work, inform their line manager and follow advice outlined in Annex B of the Directorate Letter of 14 September 2022 (DL 2022 (32)).

3.8.9 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.

3.8.10  Other control measures which may be considered by the IMT

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

3.8.11 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. 

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.

 

3.9 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 Scotland in line with section 3.10.
• 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.

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

Note: the current COVID-19 cluster reporting system is currently under review due to changes in asymptomatic testing policy announced on 14 September 2022.

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 Scotland. 
• 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 Scotland 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.

3.11 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 Scotland 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.

3.12 COVID-19 Cluster Resources

• COVID-19 Outbreak checklist v3 (February 2022) (Currently under review)
• Outbreak data collection tool
• IMT generic COVID-19 Agenda
• IMT generic COVID-19 Agenda Aide-memoire

 

 

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. 

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:

• Core guidance - General design for healthcare buildings (HBN 00-01)
• Core guidance - Clinical and clinical support spaces (HBN 00-03)
• Critical care units (HBN 04-02)
• HAI-SCRIBE Manual information for project teams (SHFN 30 Part A)
• HAI-SCRIBE Implementation strategy and assessment process (SHFN 30 Part B)
• HAI-SCRIBE question sets and checklists (SHFN 30 Part C)
• Adult in-patient facilities (SHPN 04-01)
• In-patient accommodation - supp 1 - Isolation facilities in acute settings (SHPN 4 sup 1)

 

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

• NHS Scotland Guidance for decontamination of ultrasound probes
• NHSScotland Risk Based Recommendations for the Decontamination of Semi-Invasive Ultrasound Probes: Risk of infection following semi-invasive ultrasound procedures in Scotland, 2010 to 2016

Time to clean

• NSS time to clean report
• Report on National Time to clean a bedspace

Equipment and environment cleaning

• Roles & Responsibilities for Reusable Patient Care Equipment and Environmental Decontamination
• Summary Report from Pilot of Patient Equipment and Environment Compliance Monitoring Tool
• NHSScotland Guidance for Decontamination and testing of Cardiac Heater Cooler Units (HCUs). v1.0 | National Services Scotland

Alternative approaches to decontamination

• UK and International Review of Alternative Approaches to Environmental and Equipment decontamination

• Literature Review and Practice Recommendations: Existing and emerging technologies used for decontamination of the healthcare environment
  • Antimicrobial Copper Surfaces
  • Antimicrobial Copper and Silver Solutions
  • ATP Bioluminescence and Fluorescent Markers
  • Chlorine Dioxide
  • Electrolysed Water
  • HINS Light
  • Hydrogen Peroxide
  • Microfibre
  • Ozone
  • Steam
  • UV light (v2.0, November 2022)
  • Wipes (v2.0, December 2022)

Built environment

Water

• NHSScotland Guidance for the interpretation and clinical management of endoscopy rinse water
• Literature Review and Recommendations: Management of Dental Unit Waterlines

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. 

Neonatal resources

Quality improvement tools provide short practice points which when followed correctly can help reduce HAIs and improve patient safety.

These quality improvement tools are based on scientific literature reviews and practice recommendations from ARHAI Scotland. 

Materials including posters are available for the following procedures/situations:

• CVC insertion and maintenance quality improvement tools for neonates 
• CVC insertion and maintenance poster for neonates 

When an organisation uses products or adopts practices that differ from those stated in this Care Home Infection Prevention and Control Manual, that individual organisation is responsible for ensuring safe systems of work including the completion of risk assessments approved through local governance procedures.

 

Use of this manual online is advised as printed versions are uncontrolled.Appendix 19 provides details of the remaining IPC measures advised for COVID-19 that should be applied alongside this manual.The ARHAI Scotland Transmission Based Precautions (TBPs) literature review is currently ongoing and so the information may be subject to change.

Last updated: 24 May 2023

What is the Care Home Infection Prevention and Control Manual (CH IPCM)?

The Care Home Infection Prevention and Control Manual (CH IPCM), referred to as ‘the manual’ throughout, was first published in 2021. It is evidence-based and is intended to be used by all those involved in care home provision in Scotland.

The manual is context specific and has been co-produced with national and local stakeholders. The content of the manual is completely aligned to the evidence based National Infection Prevention and Control Manual (NIPCM) which was first published in 2012, by the Chief Nursing Officer (CNO (2012)1).

The manual currently contains

• Chapter 1 – Standard Infection Control Precautions (SICPs)
• Chapter 2 – Transmission Based Precautions (TBPs)

The manual is a practice guide for use in care homes. When used, it can help reduce the risk of infections and ensure the safety of residents, as well as staff and visitors in the care home environment. It is the Scottish Government expectation that care home settings apply guidance contained within this manual to achieve the aims.

The manual aims to:

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

The manual should be adopted for all IPC practices and procedures within care home settings.

Is the manual based on scientific literature?

The recommendations for practice made in the manual are fully aligned to the NIPCM and are based on real-time reviews of the current scientific literature (for example Medical Journals) and best practice. Any major changes identified in the scientific literature may lead to a change being made to the content, and so, it is recommended that the online version is always accessed and used locally.

What's in the appendices?

The appendices can be used as practical implementation of the manual and contain graphical representations (for example diagrams and charts) that can be used along with the contents of the manual.

Many of the appendices can be printed off as posters for local use throughout the care home.

Are there any other IPC materials that can be used?

There are links throughout the manual to additional resources and the resources page links to IPC campaign materials, education, training links and posters.

In addition you may find it useful to read the literature reviews and SBARs for the manual.

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

A glossary section has been provided.

Does the manual content work on mobile devices?

Yes, all content including appendices work on mobile devices for example laptops and smartphones.

 

Responsibilities for the CH IPCM

Responsibilities for content of the manual 

ARHAI Scotland to 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 ARHAI Scotland programme working groups to ensure:

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

Responsibilities for the adoption and implementation of this manual

The manual should be used by:

• care home organisations
• care home staff including permanent, agency and where required external contractors
• health protection teams
• infection prevention and control teams
• professionals providing support
• individuals visiting the care home

Care home providers to ensure:

• the adoption and implementation of this manual in accordance with existing local governance processes
• that systems and resources are in place to facilitate implementation and compliance monitoring of IPC 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 IPC working practices including near misses
• there is a nominated lead with responsibility for IPC within the care home

Care home managers to ensure that all staff:

• are aware of and have access to this manual
• have completed appropriate IPC training relevant to their roles and that this is centrally recorded. Training may include resources developed by your organisation, your local NHS board, Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC)
• have adequate support and resources available to enable them to implement, monitor and take corrective action to ensure full compliance with this manual
• implement a robust risk assessment including detailing any deviations from the manual and the local mitigation measures that were undertaken and post-approval  documented via local governance procedures
• with health concerns (including pregnancy) or those who have had an occupational exposure relating to IPC are timeously referred to the relevant agency, for example general practitioner (GP or doctor), occupational health or if required accident and emergency
• have undergone the required health checks or clearance (including those undertaking exposure prone procedures (EPPs))
• include IPC as an objective in their personal development plans (or equivalent)

Care home staff providing care to:

• understand, adopt and implement the principles of IPC as set out in this manual
• maintain IPC competence, skills, and knowledge through completing appropriate training relevant to their role as directed by their line manager. IPC training, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC)
• communicate the IPC practices to be taken to appropriate colleagues, residents, 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 gaps in IPC knowledge, resources, equipment and facilities or incidents that may result in transmission of infection including near misses for example sharps or PPE failures
• do not provide care while at risk of potentially transmitting infectious agents to others - if in any doubt they should consult with their line manager, occupational health department, local infection prevention and control team (IPCT) or local health protection team (HPT)
• contact the local HPT/IPCT if there is a suspected or actual HAI incident/outbreak

Local infection prevention and control teams (IPCTs) and health protection teams (HPTs) to: 

• engage with care home staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of IPC practice
• provide expert advice on the application of IPC and provide support when requested to develop individual or organisational risk assessments where deviations from the manual are necessary
• have epidemiological or surveillance systems capable of distinguishing resident case or cases requiring investigations and control
• provide local support and advice (when necessary and/or requested) 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. infectious agent or the microorganism which can cause disease
   
   
2. 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. 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 gastroenteritis microorganisms would be transmitted in the faeces or vomit
   
   
4. 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. 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. 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 of infection.

Select image for full size version.

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

 

 

Reducing risk

The hierarchy of controls (HoC) is a system used to help prevent the transmission of infection. It details the most to least effective controls.  You will note that PPE is the last level of control in the hierarchy, used when all other controls have not reduced the risks sufficiently. To be effective, PPE must be used correctly which means putting it on and removing it correctly and safely.

See the Health and Safety Executive’s (HSE) toolkit on management of risk when planning work: the right priorities for additional information.

 

The HoC principles can be broadly interpreted for care home settings and include:

• reducing hazards in the care home
• changing practice in the care home
• making the care home as safe as possible
• changing how we organise and work in the care home
• use of PPE

Examples of HoC principles

Here are some examples of how to apply the HoC principles in care home settings. These examples do not cover every situation where you might need to use HoC principles.

Reducing hazards in the care home

Measures such as vaccination, testing and isolation help to reduce the risk of infection. Not coming to work when ill, isolating while infectious and recognising and reporting infections promptly, all help to prevent infections spreading.

Changing practice in the care home

When faced with a particular risk, such as an outbreak, we may need to change what we do. This might include reducing communal activities, considering limiting visiting for a short period of time, or cleaning the care home environment more frequently. The local IPCT and/or HPT should always be contacted for advice and support in outbreak situations.

Making the care home as safe as possible

It is very unlikely that we will be able to change where we work but the care home setting should be made as safe as possible. You can reduce opportunities for pathogens to survive in the care home, ensuring fixtures and fittings are in good repair and can be easily cleaned and following water safety guidelines. Ventilation is also an effective measure to reduce the risk of some respiratory infections, by diluting and dispersing the pathogens which cause them. Consider opening windows and vents more than usual, even opening a small amount can be beneficial. Opening windows and doors may present security and safety issues and so a local risk assessment should always be undertaken.

Changing how we organise and work in the care home

Changing the way, we organise and work in the care home can also help reduce risk. This might include reducing the number of people in a space at any one time and minimising the movement of staff between different settings as well as using administrative controls. Administrative controls include local risk assessments, staff training, IPC audits, and providing clear signage and instructions throughout the care home.

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 residents, staff and visitors in the care home.

SICPs should be part of everyday practice and applied consistently by everyone in the care home. 

It is essential that optimal IPC measures are applied continuously as residents living in care homes are more vulnerable, therefore increasing their risk of acquiring infections which may then be serious and potentially life threatening. By applying optimum IPC precautions you will provide a safe environment and effective care. 

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

Before a resident is admitted to the care home it is important to risk assess for infection as part of resident’s care plan, an IPC admission assessment should be undertaken by staff.

If you suspect or are aware that a resident has an infection, then details should be confirmed for the correct IPC precautions to be put in place for the safety of the resident and others.

Obtaining infection details may include appropriate clinical samples and/or screening to establish the causative organism which may be on advice from your local GP, IPCT or HPT.

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), for example Meticillin Resistant Staphylococcus aureus (MRSA), Carbapenemase Producing Enterobacterales (CPE)

A part of the admission process, a respiratory symptom assessment should be undertaken to help inform staff of the resident’s respiratory status and potential associated risk. 

Note: If a resident requires isolation because of infection or in an outbreak situation, this should be individually risk assessed to ensure the safety and health and wellbeing needs of the resident. Isolation periods must be monitored on daily basis and be for the minimum period specified.

 

Appendix 11 of the NIPCM gives you further information on the precautions required for different infections. 

 

 

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.

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

 

 

Before performing hand hygiene:

• expose forearms (known as bare below the elbows)
• remove all hand/wrist jewellery including any embedded jewellery (a single, plain metal finger ring or ring dosimeter (radiation ring) is permitted but should be removed (or manipulated) 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 fingernails are clean, short and that artificial nails or nail products are not worn
• 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

To perform hand hygiene:

• alcohol based hand rubs (ABHRs) should be available for staff as near to point of resident care as possible. Where this is not practical, personal ABHR dispensers should be used
• application of sufficient volume of ABHR to cover all surfaces of the hands is important to ensure effective hand hygiene
• manufacturer’s instructions should be followed for the volume of ABHR required to provide adequate coverage for the hands. In the absence of manufacturer’s instructions, volumes of approximately 3ml are recommended to ensure full coverage
• wall mounted or personal ABHR dispensers (cartridges/bottles) should not be refilled and should be replaced when empty or if outwith manufacturer expiry date 

 

The World Health Organization’s ‘4 moments for hand hygiene’ should be used to highlight the key indications for hand hygiene:

1. before touching a resident
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 resident

 

Some additional examples of hand hygiene moments include, but are not limited to:

• after touching a resident’s immediate surroundings
• before handling medication
• before preparing food
• before donning (putting on) and after doffing (taking off) PPE
• after visiting the toilet
• before putting on and after removing PPE
• between carrying out different care activities on the same resident
• after cleaning and disinfection procedures
• after handling used linen
• after handling waste

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.

 

 

 

 

 

Hands should be washed with liquid soap and water if/when:

• they are visibly soiled or dirty
• they are potentially contaminated with blood, other body fluids or excretions
• caring for a resident with vomiting or diarrhoeal illness
• caring for a resident with a suspected or known gastro-intestinal infection such as norovirus or a spore forming organism such as  Clostridioides difficile 

 

Note:

Hands should be washed with warm/tepid water to mitigate the risk of dermatitis associated with repeated exposures to hot water and to maximise hand washing compliance. Compliance may be compromised where water is too hot or too cold.

Hands should be dried thoroughly following hand washing using a soft, absorbent, disposable paper towel from a dispenser which is located close to the sink but beyond the risk of splash contamination.

The use of antimicrobial hand wipes is only permitted where there is no access to running water. Staff should perform hand hygiene using ABHR immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.

In all other circumstances use ABHRs for routine hand hygiene. 

 

Skin care

• ABHRs should contain emollients in their formulation.
• Pat hands dry after hand washing using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.
• Use an emollient hand cream during breaks and when off duty.
• Staff with skin problems should seek advice from the local occupational health department if available or their GP.

Do not use refillable containers or communal tubs of hand cream in the care home setting.

 

 

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

 

To make sure you clean your hands properly with soap and water you should 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

 

 

To make sure you clean your hands properly with ABHR you should 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

 

3. Respiratory and cough hygiene

Infections can spread by coughing and sneezing, therefore it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.

Any resident displaying symptoms of respiratory illness should be encouraged to wear a surgical (for instance TYPE IIR FRSM) face mask where it is clinically safe and can be tolerated by the wearer, especially in communal areas.

 

What you need for respiratory and cough hygiene• disposable tissues• waste bin and waste bags• hand hygiene products

If a resident has a cough, cold or other respiratory symptoms then they should be supported and encouraged to:

• cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and/or blowing the nose.  If a disposable tissue is not available encourage the use of elbow/sleeve to cover the nose and mouth when coughing or sneezing
• put used tissues and face masks 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 contaminated hands away from the eyes nose and mouth

 

Staff should:

• promote respiratory and cough hygiene and help residents who need assistance
• ensure that residents are provided with the necessary products for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that products are in close vicinity for the resident to access 
• use hand wipes followed by ABHR if there is no running water available or if hand hygiene facilities are out of reach then wash 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)

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 staff should risk 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 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, this means healthcare waste or domestic waste

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

Read further information on best practice for PPE in Appendix 16.

 

Donning (putting on) personal protective equipment (PPE) 

The order for putting on PPE is:

1. apron or gown
2. surgical mask
3. eye protection (where required)
4. gloves

Doffing (taking off) personal protective equipment (PPE) 

It is important that PPE is removed in the correct order.

The order for taking off PPE is:

1. gloves
2. apron or gown
3. eye protection (if worn)
4. surgical mask

Note:

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 video demonstrating the order for donning and doffing PPE is available. Note: This video was produced as part of COVID-19 education materials but is not specific to COVID-19.

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.

 

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

 

Select image for full size version

Gloves

Gloves should be:

• worn when it is likely or anticipated that you will be exposed to blood,  body fluids (including but not limited to secretions and/or excretions), non-intact skin, mucous membranes, lesions and/or vesicles, hazardous drugs, and chemicals for example cleaning agents
• single-use and should be donned (put on) immediately prior to exposure risk and should be doffed (taken off) immediately after each use or upon completion of a task
• appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct gloves
• changed if damaged or a perforation or puncture is suspected

 

Note:

Using gloves reduces the risk of contamination but does not remove all risk.

Gloves should not be used instead of carrying out hand hygiene.

Gloves should not be worn inappropriately in situations such as to go between residents, move around a care area or whilst at workstations (on the telephone /computer).

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

 

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

Select image for full size version

Aprons and gowns

Aprons should be:

• worn by care staff when there is a risk of clothing being contaminated with blood or other body fluids
• worn during direct care, for example oral hygiene, bed-making or when undertaking the decontamination of equipment
• changed between residents and following completion of a procedure or task

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

Eye/face protection

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

• be worn if blood and/or body fluid contamination to the eyes/face is expected/likely and always during aerosol generating procedures (AGPs)

Note:

Eye/face protection (including visors) should not be touched when worn.

Facial accessories such as piercings or false eyelashes should 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 (FRSM)

Fluid Resistant Type IIR surgical face masks should be:

• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/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)
• well-fitting, fully covering the mouth and nose and fit for purpose. Manufacturer’s instructions should be followed 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 prolonged use or from gross contamination with blood or body fluids 
  • following specific manufacturers’ instructions

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

Transparent face masks

Transparent face masks may be used to aid communication with residents where required.

Transparent face masks should:

• meet the specification standards of the Transparent face mask technical specification (Department of Health and Social Care - November 2021)
• have been approved for use within health and social care settings
• only be worn in areas where Fluid Resistant Type IIR surgical face masks are used as personal protective equipment

 

Read the aerosol generating procedures literature review and surgical face masks literature review for further information regarding the evidence base.

 

 

See appendix 11 for further information.

 

PPE for visitors 

At times, 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 visitor should not be refused entry to the care home. PPE use by visitors cannot 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 residents they are visiting. 

Table 1 is a guide to PPE for use by visitors if delivering direct care.

Table 1: PPE for use by visitors

IPC Precaution	Gloves	Apron/Gown	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	Not required*3
Transmission Based Precautions (TBPs)	Not required*1	Not required*2	If within 2 metres of resident with suspected or known respiratory infection	If within 2 metres of resident with suspected or known respiratory infection

*1 Unless providing direct care which may expose the visitor to blood and/or body fluids, for instance toileting.

*2 Unless providing care resulting in direct contact with the resident, their environment or blood and/or body fluid exposure, for instance toileting, bed bath.

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

 

Read the PPE literature reviews to find out more information 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 meanRoutine cleaning is regular cleaning which is carried out on a scheduled basis, not on an unplanned basis and not in response to an outbreak. For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.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.

 

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.

Note:

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

Do not refill spray containers for cleaning products as there is a risk of contamination. 

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 should 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.

Note:

Needles and syringes are single-use devices. They should 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 for example a sling 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 for example 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 where 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. 

Pillows used on resident’s beds may not require a waterproof cover if they are single resident use and are subject to regular checks/laundering. Resident pillows may require labelling where appropriate.

Reusable equipment should be cleaned or decontaminated:  

• between individual use
• after blood and/or body fluid contamination
• as part of the regular scheduled cleaning schedules/process
• before inspection, servicing or repair

Staff should:

• 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

 

Note: When an organisation use products or adopts practices that differ from those stated in this manual, that individual organisation is responsible for ensuring safe systems of work including the completion of risk assessments approved through local governance procedures.

 

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 microorganisms (germs) for example door handles, toilets, waste bins, surfaces.

Furniture and floorings in a poor state of repair can have microorganisms (germs) in hidden cracks or crevices.

To reduce the spread of infection, the environment should 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 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 should:

• 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 should then act on problems reported to them
• be aware of the environmental cleaning schedules and clear on their specific responsibilities

Cleaning schedules should include:

• staff responsibilities 
• cleaning frequencies
• cleaning methods

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 Care Homes Cleaning Specification for full size version of cleaning services diagram.

Select the diagram for full size version

Cleaning Services

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

Table 2 provides an example of a cleaning schedule and record. These tools are examples and designed to support local practice, however care homes can use their own tools if preferred. If a local tool is used, it should reflect the standards set out in the Care Homes Cleaning Specification.

Table 2: Example cleaning schedule residents room

• Standard operating procedures (SOPs) for all cleaning tasks. Each SOP outlines the correct equipment, safety considerations, method, and outcomes required for each task. Table 3 shows the important steps that must be taken during the cleaning of floors.

Table 3: Example cleaning SOP: Floors

• 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.

Manufacturer’s instructions and recommended contact times should be adhered to.

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. 

 

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

 

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:

• bed linen (bed sheets, duvet, duvet covers, pillowcases)
• blankets
• curtains
• hoist slings
• towels
• resident clothing 

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 for example 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 and therefore, cannot be subject to thermal disinfection. 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. Appropriate temperatures for processing all used and infectious linen should be adhered to achieve thermal disinfection.

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 should: 

• 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 should 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 tabletop
• 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 should:

• 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

If using external laundry services both used and infectious linen bags/receptacles should follow local procedure and arrangements. Store all used/infectious linen in a designated, safe, lockable area whilst awaiting uplift. 

All linen that is deemed unfit for re-use, for example torn or heavily contaminated, should be categorised at the point of use and disposed of in the appropriate local healthcare waste stream.

Washing residents personal linen

Appendix 1 National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution contains information that is particularly relevant and may be useful for residential care settings where domestic-type (household) washing machines may be in place for laundering resident’s personal items and clothing.

Domestic-type washing machines are not typically programmed with the temperature settings required for thermal disinfection, therefore domestic-type machines may only be used for laundering personal items of clothing belonging to residents, such as those that are heat-labile.

Other types of used linen such as sheets should be reprocessed using a machine that is capable of a validated temperature disinfection stage.

If using a domestic type washing machine to launder resident’s personal items:

• 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.

It is considered best practise to launder a resident’s personal items separately, that means not to mix items from multiple persons within a single load.

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 meanA 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 should be colour coded to denote the various categories of waste.

Local procedures and policies on waste disposal should be followed.

Segregation (separating) of waste

• Healthcare (including clinical) waste is produced as a direct result of healthcare activities for example 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 for example 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

Care home managers and staff should ensure:

• all waste is correctly segregated according to local regulations
• 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 designated, safe, lockable area whilst awaiting uplift. Uplift schedules should be acceptable to the care area and there should be no build-up of waste receptacles
• there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed

All staff should:

• follow local schedules 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 microorganisms (germs), particularly those that may be found in blood and body fluids.

 

 

 

 

 

 

Important words and what they meanOccupational exposure is exposure of 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 the care home

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

Sharps safety

• Always dispose of needles and syringes as a single unit immediately at the point of use.
• Always assemble and label sharps containers correctly as per manufacturers instructions.
• Always use the temporary closure mechanisms on sharps containers in between use.
• Always follow manufacturers’ instructions for safe use and disposal.

 

• Never re-sheath used needles or lancets.
• Never store sharps containers on the floor.
• Never allow access of sharps containers to residents or the public.
• Never fill sharps containers 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
• exposure of broken skin for example abrasions, cuts, eczema
• 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 should:

• 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)

In certain circumstances 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.

Clinical judgement and decisions should be made by staff to determine the necessary IPC precautions required (the local IPCT and/or the HPT should be contacted for advice and support where required).

Clinical judgement and decisions should 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

When TBPs should be used

TBPs should be used if a resident has a suspected or known infection or colonisation.  

Important words and what they meanColonisation is 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.

Infection transmission routes

Infections can be transmitted or spread by:

• contact with microorganisms (germs) on hands or from contaminated equipment or environment
• droplet infection by inhaling infectious droplets, for example flu or COVID-19
• aerosol infection which are inhaled or directly contaminate a mucosal surface or conjunctivae (eyes, nose, and mouth)

Different transmission routes need different TBPs

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 resident 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 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. This is the most common route of cross-infection transmission.

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 IPCT or HPT for further advice if required. 

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 required procedures?

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 
• 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

Local processes should be followed when obtaining this information.

 

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

 

 

1. Resident placement/assessment for infection risk

All residents require to be regularly monitored for infection throughout their stay for the correct IPC precautions to be put in place to minimise the risk of infection being spread. 

Residents may be an infection risk if they have:

• diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms
• a known (laboratory confirmed) or suspected infectious pathogen for which appropriate duration of precautions as outlined in A-Z of pathogens  are not yet complete
• 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.

See the CPE toolkit for non-acute settings for further information and requirements. 

 

Staff should do the following if any resident displays signs and/or symptoms of infection:

• obtain advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either the local HPT or IPCT
• make resident placement decisions based on advice received or sound judgement by clinical staff who are involved in the resident’s management
• advise the ambulance service of the resident’s infectious condition if transport to hospital is required

Residents should not be moved within the care home if they have signs and symptoms of infection unless essential.

Resident isolation requirements within the care home

Residents may require to be isolated in their own room because of a known or suspected infection. During this time it is important that: 

• residents remain in their rooms whilst considered infectious and the door should remain closed. If it is not possible for safety reasons, for example the resident has dementia, an individual risk assessment should be done and any decisions or actions should be documented. The local HPT or IPCT should be contacted for advice
• suitable discrete signage is placed on the door advising others not to enter the room
• there should be as much consistency in staff allocation as possible to care for residents in isolation room areas as an additional IPC measure. This is known as ‘staff cohorting’
• resident isolation requirements should remain under continuous review considering individual risk factors and the impact on the resident. The local HPT or IPCT should be contacted for advice in these circumstances

Note: If a resident requires isolation because of infection or in an outbreak situation, this should be individually risk assessed to ensure the safety and health and wellbeing needs of the resident. Isolation periods must be monitored on daily basis and be for the minimum period specified.

 

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

Cleaning and decontamination 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 staff should:

• use single use or dedicated reusable care equipment, for example commodes, for the resident in isolation where possible
• clean and decontaminate all care equipment after each use as per Appendix 7

 

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 cleaning

Staff should:

• clean and decontaminate the isolation room at least daily or more frequently if advised to do so. If you have been advised to clean more than daily this should be documented in the environmental cleaning schedule
• clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily
• use correct cleaning products which are 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.

• 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 refill spray containers for cleaning products as there is a risk of contamination. 

Terminal clean

A terminal clean is carried out when the resident is no longer considered infectious and/or when the environment is cleaned/decontaminated to ensure it is safe for a new resident.

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 (prior to 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 should be cleaned from the highest to lowest point and from the least to most contaminated point.

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

 

Appendix 7 is a poster flowchart for decontamination of reusable non-invasive care equipment that you may wish to print off and place in the care home.

 

Note: When an organisation use products or adopts practices that differ from those stated in this manual, that individual organisation is responsible for ensuring safe systems of work including the completion of risk assessments approved through local governance procedures.

 

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 what type of PPE and RPE you will need to wear for infections spread by different transmission routes.

Gloves

Gloves are a single-use item and should be donned immediately prior to exposure risk and should be doffed immediately after each use or upon completion of a task.

Gloves should:

• 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 for example cleaning agents, is anticipated/likely
• never be worn inappropriately in situations such as to go between residents, 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
• never be decontaminated with ABHR

 

For appropriate glove use and selection see the flowchart poster which may be printed off and placed in the care home.

 

Further information can be found in the Gloves literature review.

 

Aprons/gowns

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

Plastic aprons should be used in care home 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 residents known or suspected to be infected with a respiratory infectious agent.

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

 

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 residents 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 residents infected with an airborne transmitted infectious agent.

Eye/face protection should be worn:

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

Read Appendix 11 for details of the type of precautions, optimal resident placement, isolation requirements and any respiratory precautions required.

 

Surgical masks

A Type IIR fluid resistant surgical mask (FRSM) should be worn when caring for a resident with a suspected/confirmed infectious agent spread by the droplet route.

FRSMs should be worn (where tolerated) by residents with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control and should meet type II or IIR standards.

Read Appendix 11 for details of the type of precautions, optimal resident placement, isolation requirements and any respiratory precautions required.

 

Respiratory Protective Equipment (RPE)

PPE should still be used in accordance with SICPs when using respiratory protective equipment (RPE). See Chapter 1.4 for PPE use for SICPs. 

The use of FFP3s is governed by health and safety regulations and they must be fit tested to the user to ensure the required protection is provided.

The Health and Safety Executive (HSE) provides information regarding fitting and fit checking of RPE.

Respiratory Protective Equipment (RPE), for instance FFP3 and facial protection, should be considered when:

• a resident is admitted or develops a known/suspected infectious agent/disease spread wholly by the airborne route
• carrying out AGPs on residents with known/suspected infectious agent spread wholly or partly by the airborne or droplet route

FFP3 respirators

It is an HSE requirement that staff who need to wear an FFP3 respirator must be fit tested.

FFP3 respirators should not be worn by staff who are not trained in their use or who have not been fit tested.

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
• single-use (disposable) and fluid resistant
• 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
• put on before entry into the resident’s room and removed in a safe area once outside the resident’s room
• changed after each use

Signs that a change in respirator is required include:

• breathing becomes difficult
• the respirator is wet or moist
• the respirator is damaged
• the respirator is obviously contaminated with body fluids such as respiratory secretions

 

A poster containing information 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 from the Health and Safety Executive

 

Aerosol Generating Procedure (AGP)

An AGP is a medical procedure that can result in the release of airborne particles from the respiratory tract and is associated with an increased risk of transmission 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.

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) or tracheostomy procedures (insertion or removal) and open suctioning beyond the oro-pharynx. 

The full list of medical procedures that have reported to be aerosol generating and are associated with an increased risk of respiratory transmission can be found in appendix 17.

A poster is also available on PPE when undertaking AGPs within health and social care settings.

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 mechanical ventilation 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, meaning no mechanical ventilation.  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. 

Rooms should always be decontaminated following the completion of an AGP. Regardless of the number of air changes, a period of 10 minutes should pass to allow larger droplets to settle before the room can be cleaned. Staff are required to wear the appropriate PPE until the fallow time has been met.

For further information on fallow times refer to Table 1 in  Appendix 17.

 

 

Further information can be found in the literature reviews aerosol generating procedures, Respiratory Protective Equipment (RPE), Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) 

 

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 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 appendix 17. 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, should 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 should pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff should 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.

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 SICPs and TBPs should 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.

It is important that information on the infection status of the deceased is sought and communicated at each stage of handling and risk assessments performed.

Viewing, washing and/or dressing of the deceased see Appendix 12 - Application of infection prevention precautions in the deceased for guidance on the precautions required and what is permitted for certain types of infections.

Staff should advise relatives of the appropriate precautions to be taken when viewing and/or having physical contact with the deceased, including 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

 

 

Reference 1

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

Abrasion

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

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.

Adverse event

An event that could have caused or did result in harm to people or groups of people.

 

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.

British Standards (BS), European Standards (EN) and International Standards (ISO)

National standards specify the requirements for application in the particular country.

• BS denotes Britain's National Standards which are controlled by the British Standards Institute (BSI)
• EN denotes a Standard which is adopted by the European community and is controlled by the European Committee for Standardisation (CEN). Once a European Standard has been agreed it supersedes any existing national standard and becomes the new national standard. In Britain these Standards are then prefixed with BS EN
• ISO denotes a worldwide standard issued by the International Organisation for Standardisation. Once an International Standard has been adopted as a European Standard it supersedes the existing European standard. In Britain these Standards are then prefixed with BS EN ISO

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.

Fomites

An inanimate substance or object that can transfer a pathogen to a host.

Germicide

An agent capable of destroying microorganisms, particularly organisms that are pathogenic.

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.

High Consequence Infectious Disease (HCID)

A High Consequence Infectious Disease (HCID) is defined according to the following criteria:

• causes acute infectious disease
• typically has a high case-fatality rate
• may not have effective prophylaxis or treatment
• difficult to recognise and detect quickly
• ability to spread in the community and within healthcare settings
• requires an enhanced individual, population, and system response for safe, efficient, and effective management

Previously referred to as an Infectious Diseases of High Consequence (IDHC).

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. 

Incident/outbreak

An incident/outbreak may be:

• An exceptional infection episode, defined as a single case of an infection that has severe outcomes for an individual patient OR has major infection control/public health implications
• A healthcare infection exposure incident, defined as an exposure of patients, staff or the public to a possible infectious agent
• A healthcare associated infection outbreak, defined as two or more linked cases associated with the same infectious agent, within the same healthcare setting, over a specified time period; or a higher-than-expected number of cases in a given healthcare area over a specified time period
• A healthcare infection data exceedance, defined as 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, which had the potential to expose patients to an infectious agent but did not e.g., decontamination failure

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 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 suite,  is the same as an enhanced single room (with en-suite facilities) but with a lobby having positive pressure ventilation. 

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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) or non-intact skin have been contaminated with blood or other bodily fluids.

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.

Novel

Scientifically, novel is used to refer to things of recent origin or introduction, such as a novel pathogen.

Occupational exposure

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

Organism

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

Outbreak

See incidents/outbreaks 

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 needle/sharp, human scratch or bite 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

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No pathogens

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.

Ultraviolet germicidal irradiation (UVGI)

The use of ultraviolet (UV) radiation to kill or inactivate microorganisms.

Vaccination

Treatment with a vaccine to produce immunity against a disease.

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.

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