National Infection Prevention and Control Manual
Infection Prevention and Control guidance for the Management of Possible, Probable and Confirmed cases of Monkeypox has been published on 1 June 2022.
ARHAI Scotland have begun the process of transitioning away from COVID-19 specific guidance back to the NIPCM on 10 May 2022. The Winter Respiratory Infection IPC addendum will only remain live until Monday 11 July.
Relevant Infection Prevention and Control content from within the addendum which has been moved to the main NIPCM is detailed in a transition graphic and transition document.
Public Health Scotland pandemic guidance is available.
For pathogen specific information go to the A-Z of pathogens.
The NHSScotland National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO (2012)1 Update).
The NIPCM was endorsed on 3 April 2017 by the Chief Medical Officer (CMO), Chief Pharmaceutical Officer (CPO), Chief Dental Officer (CDO) and Chief Executive Officer of Scottish Care.
The NIPCM provides guidance to all those involved in care provision and should be adopted for infection prevention and control practices and procedures. The national manual is mandatory for NHSScotland, in all other care settings to support with health and social care integration the content of this manual is considered best practice. The Infection Prevention and Control Manual for Older People and Adult Care homes is mandatory within the care home setting.
The manual aims to:
The NIPCM currently contains:
Work is underway to update and improve the NIPCM to further include;
Disclaimer
When an organisation e.g. when a health and care setting uses products or adopts practices that differ from those stated in this National Infection Prevention and Control Manual, that individual organisation is responsible for ensuring safe systems of work including the completion of a risk assessment approved through local governance procedures.
Last updated: 10 May 2022
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 detailed in appendix 20 should also be considered in controlling exposures to occupational hazards which include infection risks.
SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection.
Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes, any equipment or items in the care environment that could have become contaminated and even the environment itself if not cleaned and maintained appropriately.
The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction and/or the anticipated level of exposure to blood and/or other body fluids.
To be effective in protecting against infection risks, SICPs must be applied continuously by all staff. The application of SICPs during care delivery must take account of;
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
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:
All inpatients admitted to a secondary care facility for an overnight stay must have a COVID-19 test undertaken using a laboratory based PCR test, Rapid Diagnostic Test (including Point of Care Tests) or LFD test on admission. Results should be documented in patient case records and local arrangements followed for reporting in line with any local and national policy. Repeat testing on day 5 of admission may be undertaken if agreed necessary following a risk assessment by the local NHS Board. See COVID-19 testing requirements within Appendix 21 COVID-19 Pandemic controls.
For assessment of infection risk see Section 2: Transmission Based Precautions.
Further information can be found in the patient placement literature review.
Hand hygiene is considered an important practice in reducing the transmission of infectious agents which cause HAIs.
Hand washing sinks must only be used for hand hygiene and must not be used for the disposal of other liquids. (See Appendix 3 of Pseudomonas Guidance)
Before performing hand hygiene:
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.
Some additional examples of hand hygiene moments include:
Download and print the 5 moments of hand hygiene poster.
Wash hands with non-antimicrobial liquid soap and water if:
In all other circumstances use ABHRs for routine hand hygiene during care.
Staff working in the community should carry a supply of Alcohol Based Hand Rub (ABHR) to enable them to perform hand hygiene at the appropriate times.
Where staff are required to wash their hands in the service user’s own home they should do so for at least 20 seconds using any hand soap available.
Staff should carry a supply of disposable paper towels for hand drying rather than using hand towels in the individual’s own home. Once hands have been thoroughly dried, ABHR should be used.
The use of antimicrobial hand wipes is only permitted where there is no access to running water. Staff must perform hand hygiene using ABHR immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.
(The video above demonstrating Hand Washing and Drying Technique was produced by NHS Ayrshire and Arran)
For how to:
Skin care:
Surgical Hand Antisepsis
Surgical scrubbing/rubbing: (applies to persons undertaking surgical and some invasive procedures)
Perform surgical scrubbing/rubbing before donning sterile theatre garments or at other times e.g. prior to insertion of central vascular access devices.
Hand Hygiene posters/leaflets can be found at Wash Your Hands of Them Resources.
Information on the WHO World Hand Hygiene Day 2022 with the theme 'Unite for safety - clean your hands' is available.
Further information can be found in the Hand Hygiene literature reviews:
Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of respiratory illness (pathogens):
Staff should promote respiratory and cough hygiene helping those (e.g. elderly, children) who need assistance with this e.g. providing patients with tissues, plastic bags for used tissues and hand hygiene facilities as necessary.
Further information can be found in the cough etiquette/respiratory hygiene literature review.
Before undertaking any 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:
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:
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:
Full body gowns/Fluid repellent coveralls must be:
The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure. Routine sessional use of gowns/aprons is not permitted.
Sterile surgical gowns must be:
Reusable gowns must:
If hand hygiene with soap and water is required, this should not be performed whilst wearing an apron/gown in line with a risk of apron/gown contamination; hand hygiene using ABHR is acceptable.
Further information can be found in the Aprons/Gowns literature review.
Eye/face protection must:
Regular corrective spectacles and safety spectacles are not considered eye protection.
Further information can be found in the eye/face protection literature review.
Fluid Resistant Type IIR surgical face masks must be:
Transparent face masks may be used to aide communication with patients in some settings
Transparent face masks must;
Further information can be found in:
During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is not considered an element of SICPs but an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.
Footwear must be:
Further information can be found in the footwear literature review.
Headwear must be:
Further information can be found in the headwear literature review
For the recommended method of putting on and removing PPE see video below and Appendix 6.
COVID-19 - the correct order for donning, doffing and disposal of PPE for HCWs in a primary care setting from NHS National Services Scotland on Vimeo.
2Scottish National Blood Transfusion Service (SNBTS) adopt practices that differ from those stated in the National Infection Prevention and Control Manual.
Sessional use of PPE
Typically, sessional use of any PPE is not permitted within health and care settings at any time as it may be associated with transmission of infection within health and care settings.
Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.
This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to patients with suspected or confirmed respiratory infection. A session ends when the healthcare worker leaves the clinical setting or exposure environment. When using FRSMs and eye/face protection sessionally it is important to note the following;
The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.
No other PPE is permitted to be worn sessionally moving between service users or care tasks. This includes gloves, aprons and gowns.
PPE for Visitors
PPE may be offered to visitors to protect them from acquiring a transmissible infection. If a visitor declines to wear PPE when it is offered then this should be respected and the visit must not be refused. PPE use by visitors can not be enforced and there is no expectation that staff monitor PPE use amongst visitors. Below is the PPE which should be worn where it is appropriate to do so and when the visitor chooses to do so.
Visitors do not routinely require PPE unless they are providing direct care to the individual they are visiting. In line with extended use of face mask guidance, visitors are strongly recommended to continue to wear a face covering when visiting a healthcare setting. Should they arrive without one, they can be provided with a FRSM.
The table below provides a guide to PPE for use by visitors if delivering direct care.
IPC Precaution |
Gloves |
Apron |
Face covering/mask |
Eye/Face Protection |
---|---|---|---|---|
Standard Infection Control Precautions (SICPs) |
Not required*1 |
Not required*2 |
Where splash/spray to nose/mouth is anticipated during direct care Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
Not required*3 |
Transmission Based Precautions (TBPs) |
Not required*1 |
Not required*2 |
If within 2 metres of service user with suspected or known respiratory infection Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
If within 2 metres of service user with suspected or known respiratory infection |
*1 unless providing direct care which may expose the visitor to blood and/or body fluids i.e. toileting.
*2 unless providing care resulting in direct contact with the service user, their environment or blood and/or body fluid exposure i.e. toileting, bed bath.
*3 Unless providing direct care and splashing/spraying is anticipated
Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents. Consequently it is easy to transfer infectious agents from communal care equipment during care delivery.
Care equipment is classified as either:
Before using any sterile equipment check that:
Decontamination of reusable non-invasive care equipment must be undertaken:
Adhere to manufacturers’ guidance for use and decontamination of all care equipment.
All reusable non-invasive care equipment must be rinsed and dried following decontamination then stored clean and dry.
Decontamination protocols should include responsibility for; frequency of; and method of environmental decontamination.
An equipment decontamination status certificate will be required if any item of equipment is being sent to a third party e.g for inspection, servicing or repair.
Guidance may be required prior to procuring, trialling or lending any reusable non-invasive equipment.
Further information can be found in the management of care equipment literature review.
For how to decontaminate reusable non-invasive care equipment see Appendix 7.
It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.
The care environment must be:
Staff groups should be aware of their environmental cleaning schedules and clear on their specific responsibilities.
Cleaning protocols should include responsibility for; frequency of; and method of environmental decontamination.
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.
Clean linen
Linen used during patient transfer
For all used linen (previously known as soiled linen):
For all infectious linen (this mainly applies to healthcare linen) i.e. linen that has been used by a patient who is known or suspected to be infectious and/or linen that is contaminated with blood and/or other body fluids e.g. faeces:
Local guidance regarding management of linen may be available.
All linen that is deemed unfit for re-use e.g torn or heavily contaminated, should be categorised at the point of use and returned to the laundry for disposal.
Further information can be found in the safe management of linen literature review and National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution.
Further information about linen bagging and tagging can be found in Appendix 8.
Scottish Government uniform, dress code and laundering policy is available.
Spillages of blood and other body fluids may transmit blood borne viruses.
Spillages must be decontaminated immediately by staff trained to undertake this safely.
Responsibilities for the decontamination of blood and body fluid spillages should be clear within each area/care setting.
If superabsorbent polymer gel granules for containment of bodily waste are used these should be used in line with national guidance. In Scotland refer to http://www.hfs.scot.nhs.uk/publications/1575969155-SAN(SC)1903.pdf. In England refer to https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102937.
For management of blood and body fluid spillages see Appendix 9.
Further information can be found in the management of blood and body fluid in health and social care settings literature review.
Scottish Health Technical Note (SHTN) 3: NHSScotland Waste Management Guidance contains the regulatory waste management guidance for NHSScotland including waste classification, segregation, storage, packaging, transport, treatment and disposal.
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to the safe disposal of sharps.
Categories of waste:
Waste Streams:
For care/residential homes waste disposal may differ from the categories described above and guidance from local contractors will apply. Refer to SEPA guidance.
Safe waste disposal at care area level:
Always dispose of waste:
Liquid waste e.g. blood must be rendered safe by adding a self-setting gel or compound before placing in an orange lidded leak-proof bin.
Waste bags must be no more than 3/4 full or more than 4 kgs in weight; and use a ratchet tag/or tape (for healthcare waste bags only) using a ‘swan neck’ to close with the point of origin and date of closure clearly marked on the tape/tag.
Store all waste in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of waste receptacles.
Sharps boxes must:
Local guidance regarding management of waste at care level may be available.
Further information can be found in the safe disposal of waste literature review.
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:
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:
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:
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.
Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of cross-infection transmission.
Used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.
Used to prevent and control infections spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.
Further information on Transmission Based Precautions can be found in the definitions of Transmission Based Precautions literature reviews.
Last updated 4 October 2021
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:
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:
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;
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:
Further information can be found in the patient placement literature review.
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.
Routine environmental decontamination
Hospital/Care home setting:
Patient isolation/cohort rooms/area must be decontaminated at least daily, this may be increased on the advice of IPCTs/HPTs. These areas must be decontaminated using either:
Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .
Increased frequency of decontamination/cleaning schedules should be incorporated into the environmental decontamination schedules for areas where there may be higher environmental contamination rates e.g.
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:
The room should be decontaminated using either:
The room must be cleaned from the highest to lowest point and from the least to most contaminated point.
Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .
Unless instructed otherwise by the IPCT there is no requirement for a terminal clean of an outpatient area or theatre recovery.
Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.
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.
A type IIR fluid resistant surgical mask should be worn when caring for a patient with a suspected/confirmed infectious agent spread by the droplet route.
Surgical masks worn by patients with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control, should meet type II or IIR standards.
During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.
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
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.
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:
Please also see Appendix 17 for the extant list of Aerosol Generating Procedures which require the application of airborne precautions. Appendix 17 also includes details of associated Post AGP Fallow times.
All tight fitting RPE i.e FFP3 respirators must be:
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.
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:
FFP3 respirator or powered respirator hood:
Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators for decontamination. This literature review will be updated to incorporate recommendations from this group when available. In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.
Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) literature review.
Frameworks to support the assessing and recording of staff competency in PPE for HCID are available in the resources section of the NIPCM.
Sessional use of PPE
Typically, sessional use of any PPE is not permitted within health and care settings at any time as it is associated with transmission of infection between service users within health and care settings.
Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.
However, in using FRSMs/eye and face protection/RPE sessionally. This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to respiratory pathogens. A session ends when the healthcare worker leaves the clinical setting or exposure environment. it is important to note the following;
The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.
No other PPE is permitted to be worn sessionally moving between service users or care tasks. This includes gloves, aprons and gowns.
The principles of SICPs and TBPs continue to apply whilst deceased individuals remain in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living patients.
Washing and/or dressing of the deceased should be avoided if the deceased is known or suspected to have an invasive streptococcal infection, viral haemorrhagic fevers or other Group 4 infectious agents. See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased.
Staff should advise relatives of the precautions following viewing and/or physical contact with the deceased and also when this should be avoided.
Deceased individuals known or suspected to have a Group 4 infectious agent should be placed in a sealed double plastic body bag with absorbent material placed between each bag. The surface of the outer bag should then be disinfected with 1000ppm av.cl before being placed in a robust sealed coffin.
Post mortem examination should not be performed on a deceased individual known or suspected to have Group 4 infectious agents. See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased”. Blood sampling can be undertaken in the mortuary by a competent person to confirm or exclude this diagnosis. Refer to Section 2.4 for suitable PPE.
The purpose of this chapter is to support the early recognition of potential infection incidents and to guide IPCT/HPTs in the incident management process within care settings; (that is, NHSScotland, independent contractors providing NHS services and private providers of care).
This guidance is aligned to the Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams (2017)
HPS are currently working towards delivery of comprehensive evidence-based guidance which will form Chapter 4 of the National Infection Prevention and Control Manual (NIPCM) on the built environment and decontamination.
In the interim two Aide-Memoires have been produced to provide best practice recommendations to be implemented in the event of a healthcare water-associated or healthcare ventilation-associated infection incident/outbreak. These will ensure clinical staff, estates and facilities staff, and Infection Prevention and Control Teams (IPCT) have an understanding of the preventative measures required and the appropriate actions that should be taken.
Prevention and management of healthcare water-associated infection incidents/outbreaks
Prevention and management of healthcare ventilation-associated infection incidents/outbreaks
The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover both incidents and outbreaks
A healthcare infection incident may be:
An exceptional infection episode
See literature review for Infectious Diseases of High Consequence (IDHC)
A healthcare infection exposure incident
A healthcare associated infection outbreak
or
A healthcare infection data exceedance
A healthcare infection near miss incident
A healthcare infection incident should be suspected if there is:
Further information can be found in the literature review Healthcare infection incidents and outbreaks in Scotland.
An early and effective response to an actual or potential healthcare incident, outbreak or data exceedance is crucial. The local Board IPCT and HPT should be aware of and refer to the national minimum list of alert organisms/conditions. See Appendix 13.
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).
Following detection/recognition of an incident/outbreak a member of IPCT or HPT will:
The IPCT/HPT will establish an IMT if required.
If staff screening is being considered as part of the investigation DL (2020)1 must be followed.
Closure of incident/outbreak with lessons learned
The IMT Chair, in discussion with the IMT, should determine whether further reporting on the incident and the incident management is required i.e. SBAR Report and full IMT report template are available in the resources section of the NIPCM website.
COVID-19 case definitions are regularly reviewed and can be found in the Public Health Scotland COVID-19 Guidance for Health Protection Teams.
A laboratory confirmed detection of SARs-CoV-2 by polymerase chain reaction (PCR) in a clinical specimen OR a positive LFD test for SARS-CoV-2.
Persons with any of the symptoms of a respiratory infection and with a high temperature or not well enough to go to work or carry out normal activities, should be considered a possible case.
Symptoms of COVID-19, flu and common respiratory infections include:
A wide variety of additional clinical signs and symptoms have also been associated with COVID-19. Fever may not be reported in all symptomatic people and cases may also be asymptomatic. Healthcare staff should be alert to the possibility of atypical and nonspecific presentations in children, older people with frailty, those with pre-existing conditions and those who are immunocompromised. People with epidemiological links to COVID-19 outbreaks or clusters should also be considered with a high degree of suspicion.
People must be assessed for other infectious or non-infectious causes of symptoms, as appropriate.
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.
On confirmation of a positive COVID-19 patient isolate, the ward staff should be informed by the reporting laboratory or IPCT if the patient is still an inpatient. There must be agreed processes in place for communicating results and IPC advice out of hours when IPCTs are not available.
IPCTs should agree local notification process for any patients who have been discharged home since the COVID-19 test was undertaken to ensure that the patient is contacted at home and provided with the appropriate self-isolation advice.
There should be processes in place to ensure that IPCTs and OHS share intelligence which may indicate an outbreak is occurring in a specific ward/department.
Where a confirmed case or an identified contact has been transferred to another care facility (care home, hospice, mental health facility), the facility must be notified as soon as possible to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented where applicable. There should be a local agreement in place to determine whether clinical teams or IPCTs will notify the facility and HPTs where required. Local agreements should include reporting arrangements out of hours.
If a confirmed case or an identified contact has been transferred to another NHS board,
the receiving NHS board must be notified by the IPCT or clinical team and alert them to the positive COVID-19 status or exposure to ensure the appropriate control measures are implemented.
Similarly, if a confirmed case has transferred from another board within 48 hours of symptom onset or positive test, the IPCT must inform the NHS board from which the patient transferred to allow risk assessment to be undertaken and contacts to be identified where applicable.
Active surveillance should be undertaken by IPCTs to allow clusters/incidents to be detected at the earliest possible opportunity.
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.
Two or more patient and/or staff cases of COVID-19 within a specific setting where nosocomial infection and ongoing transmission is suspected. For the purposes of this reporting, a high degree of suspicion should be applied and should be completed for any ward where there are unexpected cases of suspected or confirmed COVID-19. e.g. any cases that were not confirmed or suspected on admission. No time limit should be applied to determining whether a case is nosocomial e.g. 48 hours.
or
Where two or more staff cases of suspected or confirmed COVID-19 are identified and where transmission between the staff members is suspected to be associated with workplace exposure/behaviours
Note: If there is a single suspected or confirmed case in a patient who was not suspected as having COVID-19 on admission, this should initiate further investigation and risk assessment This single case may constitute a possible cluster depending on the contacts and exposures identified. Where the patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.
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. Further information on duration of transmission based precautions for COVID-19.
NHS Boards should have a COVID-19 outbreak response plan which details the roles and responsibilities of Infection Prevention and Control Teams (IPCTs) ,Health Protection Teams (HPTs) and the occupational health services (OHS) within their board when responding to COVID-19 outbreaks.
In a healthcare setting, the CPH(M) or the Infection Prevention and Control Doctor (IPCD) will chair the IMT depending on the circumstances and this should be agreed in advance and documented in the COVID-19 outbreak response plan. The ICD will usually chair the IMT, lead the investigation and management of incidents limited to the healthcare site, where no external agencies are involved and where there are no implications for the wider community. The CPH(M) would normally chair the IMT where there are implications for the wider community.
More information on IMTs and PAGS can be found in the Management of Public Health incidents: guidance on the roles and responsibilities of NHS led Incident Management Teams
An IMT generic COVID-19 agenda and a supporting agenda aide memoire for use by the chair or wider IMT members to support consistency in discussion points during COVID-19 IMTs across NHS Scotland are available.
The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing.
The COVID-19 Test and Protect service in Scotland ceased on the 1st May 2022 for the general community and as such contact tracing undertaken by public health will focus on outbreaks of COVID-19 associated with closed/high risk settings.
Contact tracing within acute inpatient settings should continue where an unexpected case of COVID-19 has been identified e.g. any cases that were not confirmed or suspected on admission.
A case definition for the purpose of the incident must be agreed by the IMT and should include the following:
In determining cases, case definitions in line with section 3.3 should be used.
3.7.1 Epidemiological data/timelines
3.7.2 Identifying missed opportunities to isolate
3.7.3 IPC practice and compliance (including AGPs)
3.7.5 Testing during an outbreak
3.7.8 Ventilation considerations
3.7.10 Review of physical distancing
The extent of the investigations should be decided by the IMT with an emphasis on active case finding and identifying any factors which have contributed towards the development of the cluster. Investigations undertaken and subsequent findings should be documented by the IMT.
A basic epidemiological investigation characterising the cluster in time, place and person should be undertaken. This process will help identify potential sources and mode of transmission.
Review of patient cases should consider any potential missed opportunities to isolate a patient, a delay in which may have resulted in onward transmission. In particular, consider any missed atypical presentation of COVID-19. Any learning should be widely communicated to all clinical staff in the board.
Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission. Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed.
Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the correct fallow times are being observed prior to other patients using the room in which the AGP was undertaken. The IMT may choose to repeat audits as part of the investigation.
Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within thethe National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 21 COVID-19 pandemic controls.
Ensure that patients are wearing face masks appropriately as per the NIPCM and Scottish Government Extended use of face masks guidance.
When investigating a COVID-19 cluster, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic or declining to wear face coverings. Consider what, if any, measures need to be introduced to mitigate any risks identified.
Proactive case finding should be supported through selected testing of any suspected symptomatic cases and when indicated, asymptomatic testing as determined by the IMT. The highest level of benefit in terms of reducing transmission will be from identifying those most likely to have been infected. The highest level of benefit in terms of reducing harm will be from detecting asymptomatic positive cases who may transmit the infection.
A PCR test, Rapid Diagnostic Test (incl POCT) or LFD test may be undertaken to enable early detection of cases however, regardless of test results, a confirmatory follow up laboratory based PCR test must also be undertaken.
Public Health Scotland now offer a sequencing service to expedite outbreak investigations and address important clinical and epidemiological questions.
This is a 2 step process involving identification of contacts and then risk assessing which contacts will require self-isolation.
Anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact.
The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors. IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact. An assessment tool is available to support the process.
A contact is defined as a person who, in the period 48 hours prior to and 10 days after the confirmed case’s symptom onset, or date a positive test was taken if asymptomatic and had at least one of the exposures listed below.
Household contact:
Non-household contact
Direct contact:
Proximity contact:
Typically, any patients in the same bed bay as a confirmed case should be considered household contacts. For larger open bedded areas such as ITUs or nightingale wards. IMTs may choose to use proximity contact definition however, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures such as:
Depending on the findings of the considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.
For cases who have been in a single side room for the exposure period, only staff, patients and visitors who have entered the room of the confirmed case should be considered potential contacts. If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.
IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g radiology, other wards and consider any potential contacts in these areas.
NB: Patients who have an overnight admission within a hospital setting who have been identified as a contact of a confirmed case of COVID-19 during their hospital inpatient stay must be isolated or cohorted for 10 days from the date of exposure. See also section 3.9.2 ‘Replacing Transmission Based Precautions with daily testing’.
The flow chart in appendix 1 should be used to assess staff contacts in the healthcare setting and assumes that staff who have worn PPE have had training in its use and that the PPE worn at the time of contact met technical and quality standards.
There is no expectation that contact tracing amongst visitors will be undertaken routinely.
Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation. It is important to consider best practice on ventilation. See Appendix 20 - Hierarchy of controls for more information.
The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated.
The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;
Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing are adequate.
See chapter 4 of the NIPCM for more detail
IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate. COVID-19 messaging should be in place to promote;
Every opportunity to promote this messaging should be considered.
A hypothesis or hypotheses should be generated at the first IMT. The hypothesis should address the potential source and mode of transmission. The hypothesis should be re-visited at every IMT and consideration given as to whether it remains to be the most probable cause of the outbreak.
3.9.2 Replacing Transmission based precautions with daily testing
3.9.4 Personal Protective Equipment
3.9.5 Safe Management of care Equipment
3.9.6 Safe Management of Care Environment
3.9.9 Management of staff exposed to a case
3.9.10 Closure of the ward/unit
3.9.11 Other control measures which may be considered by the IMT
3.9.12 Conversion of outbreak ward to COVID-19 ward
Control measures should be implemented immediately to prevent onward transmission of COVID-19. These must include:
Any asymptomatic contacts should be isolated or remain cohorted together until the 10 day isolation period has elapsed. It is possible to prevent the need for transmission based precautions for asymptomatic contacts where daily testing is utilised. See section 3.9.2 for more detail.
Contacts must be managed in the same manner as a confirmed case.
Where these are available, rapid diagnostic tests (including POCTs) or LFDs can be used to prevent the need to apply transmission based precautions for contacts.
For adult contacts who are asymptomatic of respiratory viral symptoms, and for all children and young persons aged 0 to 18 years and 4 months regardless of their vaccination status, a daily Rapid Diagnostic Test (including POCT) or LFD test should be performed for 10 days following the date of exposure. Application of transmission based precautions (TBPs) are only required should the Rapid Diagnostic Testing (including POCT) or LFD tests positive at any point and a follow up COVID-19 PCR undertaken. Whilst Rapid Diagnostic tests (including POCT) or LFD tests remain negative, application of SICPs is sufficient and there is no need to isolate the contact.
Any patient who has been COVID-19 positive (confirmed by PCR or Rapid Diagnostic Testing (including POCT) or LFD test) in the last 28 days does not need to be considered a contact should there be a subsequent exposure during that 28 period. Daily Rapid Diagnostic Testing (including POCT) or LFD testing of these patients is therefore not required during this time period.
During the ongoing COVID-19 pandemic when COVID-19 admissions are high and where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a COVID-19 ward to allow confirmed COVID-19 cases to be transferred/admitted to the area and utilise bed capacity within the ward. This is an operational decision which must be carefully considered, documented and undertaken as a last resort. The following must apply;
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.
Reporting should be led by the IPCT. Reporting of COVID-19 should occur on recognition of a COVID-19 cluster
As the COVID-19 pandemic continues, it is essential that NHS Boards record and disseminate learning from clusters internally and with ARHAI for sharing nationally.
There is a field within the ORT to capture this information and this should be completed with an evaluation of the effectiveness and efficiency of investigations and control measures. This will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.
This appendix should be used by Health Protection Teams (HPTs), Occupational Health Services (OHS) and Infection Preventon and Control Teams (IPCTs) aiming to apply some consistency in approach to assessment of staff contacts within healthcare and state health and care settings.
Currently, chapter 4 exists as a repository for evidence reviews and tools relating to IPC in the built environment including delivery of appropriate decontamination within health and care settings and risk mitigation for water based pathogens.
Content going forward will be developed via the ARHAI Scotland Infection Control in the Built Environment and Decontamination (ICBED) programme informed by stakeholder engagement and requirements, learning from NHS Assurance programme and outbreaks and incidents.
This chapter is in the early stages of development and at this current time does not fall into the mandatory requirements for the NIPCM.
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:
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.
v.1.0 - 29 November 2021
Guidance launched
v1.1 -13 December 2021
Update to ‘Determining the IPC precautions required for AGPs’
v1.2 - 17 January 2022
Addition of advice for regular testing in critical care units where AGPs are regularly performed on the non respiratory pathway
Reduction of COVID-19 duration of precautions from 14 days to 10 days.
v1.3 - 20 January 2022
Update to Non COVID-19 discharges (non respiratory pathway) from hospitals to care homes
Addition of sections for primary care and care homes to reinforce and support assessment using the hierarchy of controls.
v1.4 - 3 February 2022
Additional information for visitors entering AGP zones.
v1.5 - 23 February 2022
Risk assessment for management of patient placement in long term residential community settings (section 5.8 and section 5.12.2)
Update to hospital testing table
v1.6 - 1 April 2022
The following updates reflect changes to healthcare COVID-19 pandemic controls as outlined in DL (2022) 07 as follows;
Changes to patient testing requirements including Hospital Testing Table
Inclusion of the wider use of Rapid Diagnostic Testing (including POCT) or LFD testing
Changes to management of contacts including inclusion of 28 day contact exemption
Changes to respiratory screening questions
Changes to testing requirement pre AGP on the non respiratory pathway
Withdrawal of car sharing guidance
Removal of physical distancing guidance
Please note: the above changes within version 1.6 are not applicable in care homes, prisons and social community and residential care settings at the time of version update; Extant guidance remains in place for these settings.
v1.7 - 7 April 2022
Update to include definition of fully vaccinated
Addition to physical distancing noting that services may choose to retain physical distancing where they deem it necessary
v1.8 - 27 April 2022
Addition of testing responsibilities at an organisational level and clarity of testing language
Change to isolation advice for service users with COVID-19
Removal of vaccination as part of contact management.
This guidance has been developed in collaboration and consultation with representatives from health and care NHS Boards and Organisations across Scotland and approved by the CNO Nosocomial Review Group (CNRG). This process deviates from the National Infection Prevention & Control Manual (NIPCM) normal governance process for guidance production and sign off due to the urgent nature for respiratory pathway Infection Prevention & Control (IPC) guidance during the COVID-19 pandemic and the next winter season. This guidance will be incorporated into the NPGO programme for routine annual update as the Pandemic response allows a return to normal governance procedures.
When an organisation adopts practices that differ from those recommended/stated in this national guidance, that individual organisation is responsible for ensuring safe systems of work, including the completion of a risk assessment(s) approved through local governance procedures.
This guidance has been developed during the ongoing COVID-19 pandemic recognising the likelihood of a surge in other respiratory viruses in addition to COVID-19 over the winter season of 2021/22 and supersedes the 3 COVID-19 addenda (Acute, Care home and Community health and care settings) first published in October 2020. This guidance is aligned with the UK Infection Prevention and Control for Seasonal Respiratory Infections in Health and Care settings including SARS-CoV-2 for Autumn Winter 2021/2022. High consequence infection diseases (HCIDs) transmitted by the airborne route such as emerging pandemic influenza or other novel respiratory viruses are out of scope for this guidance.
Key changes as we move from the COVID-19 addenda to Winter (21/22), Respiratory Infections in Health and Care Settings Infection Prevention and Control (IPC) Addendum are;
A summary of changes compared with the previous COVID-19 addenda is available. It should be noted that the principles of applying TBPs for service users presenting with a suspected/confirmed respiratory virus apply at all times throughout the year however the purpose of this guidance is to support health and care settings when cases of respiratory viruses/infections increase impacting on flow and service delivery.
NHS Scotland boards are preparing for an increase in service demand as a result of respiratory virus this winter season (21/22) and this guidance should be implemented to minimise risk and harm to staff, service users and visitors during this period of increased admissions and whilst the COVID-19 pandemic continues. It is intended that this guidance will be reviewed regularly and adapted for use routinely on an annual basis.
IPC measures required for COVID-19 are incorporated within this guidance and IPC principles are applied consistently across all respiratory pathogens wherever possible. Some pandemic measures specific to COVID-19 remain at this time and these will be highlighted within this guidance.
Although many of the COVID-19 pandemic measures within the general community are relaxing, there remains a very real risk within healthcare settings of COVID-19 transmission and transmission of other respiratory pathogens e.g Influenza, Respiratory Syncytial Virus (RSV), Rhinovirus. This is due to compounding factors such as vulnerability of the service users, the communal nature of many of the care facilities and within primary and secondary care settings, the very nature of the service provided in treating respiratory infections which facilitates the presence of high numbers of symptomatic individuals in the setting.
The term ‘service users’ will be used in generic sections to describe patients, residents and individuals.
This guidance is intended for use by all those involved in health and care provision and applies to the following settings;
This guidance is generic amd applies across all the settings described above however, where specific sector guidance exists it will be highlighted as follows;
Guidance specific to Secondary care settings or particular services within secondary care will be highlighted in blue.
Guidance specific to Primary care and Community Health and Social Care settings or particular services within primary care or health and social care (excluding care homes) will be highlighted in green.
Guidance specific to Care home settings or particular services within the care home settings will be highlighted in pink.
Guidance specific to Dental settings or particular services within dental settings will be highlighted in lilac. (Dental services operating in secondary care settings may also choose to refer to guidance specific to secondary care)
All health and care settings must make efforts to prepare and plan for an increase in cases of respiratory viruses and as such the management of respiratory viruses in advance of the respiratory season. IPC should form part of winter planning for NHS boards and other care providers. The impact of the respiratory season on individual settings will vary depending on;
Health and care settings and in some cases, individual departments e.g. emergency departments, critical care units are encouraged to develop a respiratory plan applicable for their area. Examples of considerations within the respiratory plan may include;
The choice of COVID-19 tests being deployed in boards requires strategic/executive decision making in consultation with board Microbiologists / Virologists and with consideration of wider service impacts. The option to use Rapid Diagnostic Tests (including POCT) or LFD as a means to alleviate systems pressure may be considered by boards.
Various Rapid Diagnostic Tests (including POCT) or LFD kits have been approved for use within acute and community hospital settings to date and NHS Boards should seek to understand which Rapid Diagnostic Tests (including POCT) or LFD tests are available for use in their areas. Some tests have greater validity and these should be considered for use wherever possible and where the risk of COVID-19 transmission and resulting severe disease is greatest e.g. admissions to high risk departments such as haemato-oncology.
5.3.1 Ventilation in health and care settings
5.3.2 Mechanically ventilated areas
5.3.3 Naturally ventilated areas (no mechanical ventilation)
5.3.5 Bed and treatment chair spacing
Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting users of the health and care facilities. Figure 1 is a graphic specifying the general principles of prevention legislated in the Management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1. It details the most to the least effective hierarchy of controls and can be used to help implement effective controls in preventing the spread of respiratory viruses within health and care settings. The hierarchy of controls will help protect all users of the health and care facility and not just staff. NHS Boards/care organisations and staff should first employ the most effective method of control which inherently results in safer control systems. Where that is not possible, all others must be considered in sequence. Personal protective equipment (PPE) is the last in the hierarchy of controls and may be the only mitigating control when caring for a service user with a pathogen spread by the airborne route.
Centers for disease control and prevention. The National Institute for Occupational Safety and Health. Hierarchy of Controls. 2015.
Examples of ways in which the hierarchy of controls can be applied in health and care settings is as follows (note these are examples; not all will apply in every health and care setting and generally apply to both the respiratory and non-respiratory pathways unless otherwise stated);
Hierarchy of controls |
Example in practice and resources |
---|---|
Elimination
|
|
Substitution |
|
Engineering controls
|
|
Administration controls |
|
Personal Protective Equipment (PPE) |
|
Health and care settings must seek to identify and prepare the most suitable clinical/care area for planned placement of service users requiring care on the respiratory pathway.
Prior to determining areas for planned placement of the respiratory pathway, the NHS Board/care organisation must ensure a full structured risk assessment of the proposed area is carried out. This should be undertaken using the hierarchy of controls and recognise that there is lowest risk where elimination can be achieved and highest risk where PPE is the only control in place. Risk assessments should be periodically reviewed as determined by the NHS Board/care organisation to ensure no change to the level of risk.
If the risk assessment concludes that an unacceptable risk of transmission remains within the environment after rigorous application of the hierarchy of controls (e.g. unable to defer patient care, area poorly ventilated AND overcrowded) and only if there are no other more optimal lower risk areas suitable for the respiratory pathway, then the NHS Boards/care organisation should consider utilising the area for this purpose with provision of respiratory protective equipment (RPE) (FFP3 respirators) for the staff working in this area.
The evidence continues to support the most likely route of COVID-19 transmission being via the droplet and contact route. However, it is accepted that in some high risk environments housing COVID-19 cases where mitigations in line with the hierarchy of controls cannot be applied, the level of risk is unknown. As a precautionary approach, the use of RPE by staff in the designated area may be considered by the organisation. This takes account of guidance issued by the World Health Organization (WHO) occupational health and safety for care workers.
Primary care settings and community health and social care settings should aim to apply as many of the hierarchy of controls as possible whilst maintaining patient safety.
Work places should systematically work through the hierarchy of controls from top to bottom for each area required for the respiratory pathway e.g waiting areas, consulting rooms, treatment areas.
When selecting areas for the respiratory pathway, those which are well ventilated and have enough space to prevent overcrowding are optimal and reduce transmission risk.
These principles also apply to the delivery of care at home.
NB: Physical distancing no longer required in primary care areas including GP practices
Care home settings should plan in advance to establish how best to manage residents who require care on the respiratory pathway.
Isolation in a resident’s own room should commence if suspected or confirmed to have a respiratory virus.
Residents who have a suspected or confirmed respiratory infection should not use communal areas until de-escalation criteria is met.
Some health and care settings and service user groups present a greater risk for the transmission of respiratory viruses including inpatient settings where patients with COVID-19 spend extended periods of time and are more likley to have more severe COVID-19 disease. Prior to determining areas for planned placement of the respiratory pathway, the NHS Board/Organisation must ensure a full structured risk assessment of the proposed area is carried out, led by operational and clinical management and involving Health and safety teams, Estates and Facilities representatives, Occupational Health Services (OHS), Infection Prevention & Control Team (IPCT) and the clinical team. A Risk Assessment algorithm was developed for COVID-19 patient placement but can be applied to the respiratory pathway. The algorithm aims to help support the risk assessment process and should take account of the following;
Adequate ventilation reduces how much infectious particles are in the air by dilution. It helps reduce the risk of transmission of respiratory pathogens - the risk is greater in areas that are poorly ventilated. This guidance document is not intended to contain technical detail on ventilation but rather provide over-arching advice on the considerations for health and care settings in the context of respiratory pathogens and risk reduction. The content below should be read in conjunction with the relevant national guidance relating to ventilation in the built environment.
A number of studies have linked COVID-19 transmission to recirculating air conditioners, with the high velocities created by these units potentially allowing larger viral aerosols to remain airborne over longer distances. It is also possible that directional flow from desk fans could have a similar effect however the evidence of this is weak. Fans should be avoided as much as possible and should not be used without prior risk assessment. An SBAR details the considerations for risk assessing fan use.
(SHTM 03-01 Part A) Ventilation for Healthcare - Design and validation details the ventilation requirements for healthcare settings and notes that 6 ACH is considered adequate for general areas within health and care settings across both the respiratory and non-respiratory pathways. Some areas of healthcare e.g. theatres, treatment rooms, dental surgeries require higher specification of mechanical ventilation and further details can be found in guidance laid out in section 5.3.2. Dental settings may also refer to SDCEP Ventilation Information for Dentistry. It is recognised that many health and care areas are not installed with mechanical ventilation systems to achieve a minimum of 6 ACH and NHS Boards/care providers are not required to upgrade ventilation throughout all of their estate (unless this is part of the existing strategic plans) however it should be noted that where mechanical ventilation provides 6ACH or more, that respiratory pathogen transmission risk is reduced. Other mitigations must be in place to reduce transmission risk such as those described in the hierarchy of controls in particular where there is no mechanical ventilation.
Service users with known or suspected respiratory viruses must not be placed in a positive pressure room.
NHS Scotland Boards/Health and Social care providers should seek assurance that their ventilation systems comply with guidance to which they were designed, including:
Ensure ventilation systems are well maintained ensuring functionality of air handling units and correct delivery of assigned air change rates. Controls should be set to maximise the amount of fresh air coming into the space and avoid recirculation of air as much as possible. Dampers should also be opened as far as possible.
Ensure areas are ventilated as much as and as frequently as possible by opening windows if temperature/weather conditions allow. Where weather conditions do not allow for windows being opened, consider if other mitigations can be applied within the area to reduce risk. Organisations should consider any other safety risks with opening the windows where adjacent building works are in progress. If possible, open windows at different sides to get a cross flow of ventilation. Where it is safe to do so, doors may be opened. NB fire doors must NEVER be propped open. Airing rooms as frequently as permitted will help improve ventilation. Where only natural ventilation exists, ensure maximum application of other mitigations measures as far as possible aligned to the Hierarchy of Controls.
Aerosol Generating Procedures (AGPs) undertaken on service users with suspected/known respiratory viruses/infection should be avoided in rooms with less than 6ACH and this includes rooms limited to natural ventilation. If this cannot be avoided then a single side room should be used with all staff wearing appropriate airborne PPE, AGP fallow times adhered to and ensuring the door remains closed during the AGP and resulting AGP fallow time.
Where air-supply systems to high-risk clinical settings (in the context of respiratory transmission) are suboptimal, following risk assessment including assurance of the efficacy and safety of the filtration unit, health and care settings may consider using portable industrial grade air filtration units containing HEPA filters. As yet, evidence on the use of air scrubbers is limited and as such these should be used with caution. The units should be capable of recirculating all of the room air, without interfering with the existing pressure differential of the room and should provide a minimum of 6 air changes per hour. The unit must be sized appropriately for the room in which it will be utilised and maintenance contracts should be procured to accompany the unit. It should be noted that these units do not provide additional fresh air into a space and there is no standard to measure the efficacy of these devices. NHS Boards should satisfy themselves that these devices are suitable and if required, seek advice from estates departments. Boards should also assess (not limited to) the noise levels, power requirements, heat gains and potential trip hazards as part of the risk assessment.
Currently, the CIBSE and SAGE resources below provide the best available independent views of air cleaning devices.
“Air purifiers” are typically used in domestic settings and should not be used in health and care settings.
More information on ventilation in the context of COVID-19 can be found at the following resources;
CIBSE: Covid-19 Guidance: Ventilation
SAGE: Role of ventilation in controlling SARS-CoV-2
SAGE: Potential applications of air cleaning devices
All NHS boards and care providers must aim to meet the minimum bed spacing requirements laid out in the guidance below for secondary care settings. 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.
Since 2014, HBN 00-03’s Figure 45 states a day treatment bay should achieve 2.45m width / centre-to-centre dimension. IM/2020/024 & its supplementary SIM2108 Fig 2B, assume a 0.5m diameter zone for the patient head and up to 3 trolley/ couch/ chair(s) in a row, will achieve a 2m physical distancing, i.e. a minimum 2.5m centre-to-centre.
Physical distancing requirements remain in care homes, prisons and social community and residential care settings. The full guidance requirements for physical distancing in these areas are laid out in Appendix 18 of the NIPCM.
Across all other settings, the requirements for physical distancing will cease and is no longer required for healthcare workers, patients/service users or visitors. However, where services wish to continue physical distancing they may choose to do so particularly in settings where staff have to remove their FRSM and a COVID-19 exposure event has the ability to result in high staff isolation numbers/significant service impact.
It is important to note that overcrowding in any area of a healthcare facility including inpatient areas, waiting areas and outpatient departments increases transmission risk for respiratory viruses including COVID-19 and it is important to remain mindful of the volume of people in a space at any one time taking account of HCWs, patients and visitors. Settings must not return to pre pandemic practices which facilitated overcrowding and steps should be taken to prevent this.
Inpatient beds including those on the respiratory pathway must meet minimum bed spacing requirements.
Across ALL settings there is still a requirement to adhere to extended use of face masks guidance outlined in section 5.15.1.
SICPs covered in this chapter are to be used by all staff, in all health and care settings, at all times, for all service users whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care environment.
SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection. More information can be found in chapter 1 of the NIPCM.
SICPs may be insufficient to prevent cross transmission of specific infectious agents. Therefore, additional TBPs are required to be used by staff when caring for service users with a known or suspected infection or colonisation. More information can be found in chapter 2 of the NIPCM.
Care Home Settings
Care homes can find more information on SICPs and TBPs specific to the care home setting within the Care home IPCM.
The additional TBPs required for different infectious pathogens vary depending on the route by which they are transmitted. Respiratory pathogens can be transmitted by the following;
The NIPCM also contains an A-Z list of pathogens and stipulates the mode of transmission for each.
5.6.1 Definition of a confirmed COVID-19 case
5.6.2 Definition of a possible COVID-19 case
Case definitions for COVID-19 have been widely used throughout the course of the pandemic and these will continue to be used going forward. These align with case definitions in Public Health Scotland guidance.
Establishing which symptoms are a result of COVID-19 and which symptoms are a result of another respiratory virus is often not possible. Respiratory testing is the only way to identify the causative pathogen.
The case definitions being used across the UK reflects current understanding from the epidemiology available and may be subject to change. Case definitions can be found below.
A person with laboratory confirmed detection of SARS-CoV-2 by PCR in a clinical specimen OR a positive LFD test for SARS-CoV-2.
Things to note:
Persons with any of the symptoms of a respiratory infection and with a high temperature or not well enough to go to work or carry out normal activities, should be considered a possible case.
Symptoms of COVID-19, flu and common respiratory infections include:
A wide variety of additional clinical signs and symptoms have also been associated with COVID-19. Fever may not be reported in all symptomatic people and cases may also be asymptomatic. It is important to take into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and those who are immunocompromised. (further information on presentations and management of COVID-19 in older people and Scottish Government and Appendix 1 :Think COVID:Covid-19 Assessment in the Older Adult - Checklist).
Individuals must be assessed for bacterial sepsis or other causes of symptoms as appropriate.
Vaccination status impacts on IPC only for adults and is defined as;
Fully vaccinated: An adult (18 years and 4 months or older) who has had three doses of MHRA approved vaccines; either through completing a two-dose course of approved vaccine and received a booster, or three doses of an approved vaccine (e.g. in the case of someone who is immunocompromised), at least 14 days prior to their contact with the index case, where day 1 is the day of the most recent vaccination.
Where an individual has been fully vaccinated (as defined above) while participating in a formally approved COVID-19 vaccine clinical trial they should be treated as those who are fully vaccinated.
The process of respiratory screening assessment will vary dependant on both the health and care facility and the type of service provision but wherever possible, respiratory screening questions should be undertaken by telephone prior to an arranged arrival at the facility for all service users and any accompanying carers. If this is not possible, then these questions should be asked on arrival at reception. This will help inform the clinical/care team of service user respiratory status and potential associated risk before face to face consultation should this be deemed appropriate.
If respiratory screening is undertaken prior to arrival at a health and care facility, and if the service user answers ‘no’ to all of the respiratory screening questions, the service user should be reminded to inform a staff member should any symptoms develop prior to attendance at the facility.
Below are the required respiratory screening questions determined by setting.
Table 2 provides respiratory screening questions for care homes, prisons and social community and residential care settings.
Table 3 provides respiratory screening questions for inpatient settings
Table 4 provides respiratory screening questions for all outpatient and primary care settings inc dentistry
A word version of Table 2 is available.
COVID-19 Screening questions |
Yes |
No |
---|---|---|
Do you or any member of your household/family have a confirmed diagnosis of COVID-19 diagnosed in the last 10 days?
|
||
Do you or any member of your household/family have suspected COVID-19 and are waiting for a COVID-19 test result? | ||
Have you travelled internationally in the last 10 days to a country that is on the Government red list? | ||
Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 10 days? | ||
Do you have any of the following symptoms;
|
If the service user answers ‘Yes’ to any of the COVID-19 screening questions above, place on the respiratory pathway.
If service user answers ‘No’ to all of the COVID-19 screening questions above, proceed to general respiratory screening questions below
General respiratory screening questions
|
Yes |
No |
---|---|---|
Do you have any new or worsening respiratory symptoms not already mentioned which suggest you may have a respiratory virus? *1 | ||
Have you had a laboratory test confirmed respiratory virus/infection such as Influenza in the last 10 days?*2 |
If the service user answers ‘YES’ to any of the COVID-19 or the respiratory symptoms questions, place on the respiratory pathway.
Notes
*1 Note for healthcare workers (HCWs) in relation to respiratory symptoms;
List of respiratory symptoms below may indicate a respiratory virus/infection;
Rhinorrhea (Runny nose)
The following can also be symptoms of a respiratory virus but may also be related to a non-respiratory cause therefore caution should be applied in allocation of these patients to the respiratory pathway in the absence of any symptoms noted above.
*2 If the service user advises of having had a test positive pathogen in the last 10 days, they should be placed according to the infective period for that specific pathogen and an assessment of any ongoing infectivity. Refer to A-Z of pathogens for details of individual pathogens.
A word version of Table 3 is available.
The screening questions below apply to all service users.
COVID-19 Screening question |
Yes |
No |
---|---|---|
Have you had a confirmed diagnosis of COVID-19 in the last 10 days? If the individual answers YES, proceed to respiratory pathway. A laboratory based PCR test does not need to be repeated if there is evidence of a positive PCR in the last 10 days. If the individual answers NO, proceed to next question; NB: Any person who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested using PCR tests within a period of 90 days from their initial symptom onset, or the first positive test, if asymptomatic, unless they develop new possible COVID-19 symptoms. This is because fragments of inactive virus can be persistently detected by PCR in respiratory tract samples for some time following infection |
||
Do you have any of the following symptoms;
If the individual answers YES, proceed to respiratory pathway and undertake a laboratory based PCR test. A Rapid Diagnostic Test (including POCT) or LFD may also be undertaken in addition to a laboratory based PCR test to support rapid patient placement assessment on the respiratory pathway. If the individual answers NO, proceed on the non-respiratory pathway. |
A word version of Table 4 is available.
The screening questions below apply to all service users.
COVID-19 Screening questions |
Yes |
No |
---|---|---|
Have you had a confirmed diagnosis of COVID-19 in the last 10 days? If the individual answers YES, consider delaying appointment where the matter is non urgent or using digital consultation methods if not detrimental to the patient.. Where appointment must proceed face to face , do so via the respiratory pathway. If the individual answers NO, proceed to next question. |
||
Do you have any of the following symptoms;
If the individual answers YES, consider delaying appointment where the matter is non urgent or using digital consultation methods if not detrimental to the patient. Where appointment must proceed face to face, do so via the respiratory pathway. If the individual answers NO, proceed on the non-respiratory pathway. |
If following telephone consultation the individual meets the criteria for the respiratory pathway and if the matter is non urgent, face to face consultation should be deferred until the COVID-19 self-isolation period has elapsed or until non COVID-19 respiratory viral symptoms have resolved.
Health and care professionals should see individuals face to face or via remote consultation, whichever is felt most appropriate where they have deemed further clinical assessment is required. If it is necessary to review individuals on the respiratory pathway by means of a face to face consultation (regardless of the presenting problem) then they should be advised of the most suitable way to transfer to the facility, enter the health and care facility, and on arrival, should be directed to a suitable waiting area identified for symptomatic individuals.
NB: children with mild bronchiolitis and lower respiratory tract infections should be managed in primary care settings where possible to ensure a holistic primary care assessment. Planning should include the implementation of locally appropriate models of care enabling secondary care clinicians to support primary care colleagues. The expectation should be that children with mild and moderate bronchiolitis or lower respiratory tract infection are initially reviewed in primary care settings.
If providing a home visit, staff should contact the individual by telephone at home prior to the visit to undertake the respiratory screening if time allows. These should be repeated on arrival at the individual’s home. If an individual lacks ability to answer questions by telephone, an assessment should be made on arrival ensuring that a Type IIR FRSM is worn. If this is not possible, treat as having respiratory viral symptoms until a direct assessment can be made by the care provider. Scottish Government advice on providing care at home is available.
Individuals living in residential facilities should be closely monitored for onset of respiratory viral symptoms by local care staff.
If following telephone consultation the patient meets the criteria for placement on the respiratory pathway and if the matter is non urgent, face to face consultation should be deferred until the COVID-19 self isolation period has elapsed or other non COVID-19 respiratory viral symptoms have resolved. If the matter is urgent, the patient may be seen within the dental setting but ideally should be provided with an appointment at the end of the day/session to reduce any post Aerosol Generating Procedure (AGP) fallow time (if an AGP is performed) impacting on the remaining patient consultation list.See section 5.15.7 Determining the IPC precautions required for AGPs.
Patients should be assessed for respiratory symptoms at the earliest opportunity to direct them to the safest route within the facility in line with respiratory screening questions. SAS staff should undertake the respiratory screening questions prior to arrival at the receiving Emergency Department and accompany the patient to the appropriate waiting area dependant on outcome.It is recognised that patient placement will be dependent on clinical need in addition to respiratory status. Where a patient with respiratory symptoms cannot be placed in the respiratory cohort for clinical reasons, avoid placing the patient next to anyone high risk and previously considered to be on the shielding list, keep curtains pulled as a physical barrier if safe to do so and ensure thorough cleaning as per respiratory care pathway described in the environmental cleaning section.
Reception areas must display signage encouraging service users to report respiratory symptoms immediately on arrival and reception staff should ask all service users on arrival using the respiratory screening questions regardless of the reason for presentation at the facility and where it is safe to do so without delaying any lifesaving interventions.
Only the service user requiring a consultation should attend health and care facilities unless a carer or escort is required.
5.8.2 Transfer of service users with respiratory symptoms/confirmed respiratory pathogen
The COVID-19 patient pathways/categories will now be replaced with a respiratory pathway. This is determined as a route to which patients symptomatic of respiratory infection should be directed.
The pathway should be further split into appropriate cohorts determined by presenting symptoms and when available, test results to determine the causative pathogen. Rapid Diagnostic Testing (including POCT) or LFD testing may be undertaken in addition to a laboratory based PCR test to support rapid patient placement assessment on the respiratory pathway.
Entrances to facilities must clearly display the requirement for individuals entering the facility to don a face covering and alcohol based hand rub (ABHR) should be provided for use prior to entry for those who are able to do so.
Waiting areas should be segregated with an area set aside for use by service users who present with respiratory symptoms. Markers to identify segregation should be clear and service users must be advised not to circulate around waiting areas and remain seated until called .
Cleaning within waiting areas segregated for respiratory patients should be undertaken as laid out in environmental cleaning section.
Removing toys and books may help prevent children circulating in these areas and instead parents may be advised to bring a toy or book belonging to the child to help keep them occupied during the wait time. Children should be supported by parents/carers with hand and respiratory hygiene.
Primary Care and Community Health and Social Care settings
Health and care facilities should identify in advance areas/routes/consultation rooms for individuals who require to follow the respiratory pathway and have been assessed as requiring a face to face consultation. It is recognised that some small practices will not have space to facilitate separate waiting areas for individuals on the respiratory pathway. In this case, a local risk assessment should be undertaken to determine how best to manage these individuals and whether it is suitable for them to attend for face to face consultations.
Where possible, consultation/treatment rooms should be identified for placement of individuals who require placement on the respiratory pathway. Some health and care facilities may be very small with limited consultation rooms and the ability to dedicate a room to respiratory individuals may not be possible. If this is the case, consider allocating respiratory cases to the end of a session. Ensure cleaning of touch surfaces within the consultation room is undertaken thoroughly immediately after the patient/individual leaves the room. Particular attention should be paid to anything touched by the individual and anything within short range of individuals who are coughing/sneezing.
All admissions from the community to a residential health and care setting should be assessed first by the health and care setting team using the respiratory screening questions outlined above for care homes, prisons and social community and residential care settings. This applies to all types of residential heath and care setting admissions (including for respite).
For those residents who are displaying respiratory symptoms, the admission should be delayed if possible until they have completed their COVID-19 self-isolation period, OR if COVID-19 negative, until symptoms are resolving provided the admission is non urgent.
If the admission cannot be delayed, a local risk assessment should be conducted with the support of the local HPT to ensure all necessary mitigations can be accommodated for the individual as well as other residents, some of whom may be more vulnerable to COVID-19, in as safe a manner as possible
See PHS Social Care and Residential Care COVID-19 guidance for further information on admissions to these settings including for respite.
Isolation of a resident within their own room, if required, would ideally include provision of meals to their room, en suite facilities if available and measures to prevent the sharing of communal items and spaces. In some settings where there are limited vulnerabilities amongst the residential group, full isolation may not be required and the suspected/confirmed COVID-19 case may follow general population advice for self isolation.
Only essential staff wearing appropriate PPE should enter the rooms of residents with respiratory symptoms. All necessary care should be carried out within the resident’s room.
Where possible, waiting areas should be segregated with an area set aside for use by patients who require placement on the respiratory pathway. Markers to identify segregation should be clear and patients must be advised not to circulate around waiting areas and remain seated until called. Cleaning within areas segregated for the respiratory pathway should be undertaken as per guidance laid out in environmental cleaning section.It is recognised that some small practices will not have space to facilitate separate waiting areas for patients on the respiratory pathway. In this case, a local risk assessment should be undertaken to determine how best to manage these patients e.g. wait in car until called or schedule for end of a session, or whether it is suitable for them to attend for face to face consultations.Dental services should identify in advance areas/routes/consultation rooms for patients who require to be placed on the respiratory pathway and who have been assessed as requiring treatment. Ideally, these patients should be seen at the end of the day/session to reduce any post Aerosol Generating Procedure (AGP) fallow time (if an AGP is performed) impacting on the remaining patient consultation list.Where space allows, a dedicated consultation/treatment rooms should be identified for placement of patients on the respiratory pathway. Some dental practices may be very small with limited consultation rooms and the ability to dedicate a room to respiratory patients may not be possible.
At the point of admission to the facility it is unlikely to be known what pathogen is the cause of respiratory symptoms. Respiratory pathways should be developed in hospitals in a bid to separate patients with respiratory viral symptoms/confirmed respiratory pathogens from all other patients as far as possible. Respiratory pathways may be dedicated wards, dedicated bed bays within wards or individual single rooms within wards. Patients with respiratory viruses should be placed in a single side room. Where single side rooms facilities are lacking, patients with the same confirmed pathogen should be cohorted together. Laboratory based PCR test or optionally Rapid Diagnostic Testing (including POCT) or LFD testing may be used to help support patient placement risk assessments on the respiratory pathway.Where test results are not yet available to determine the viral pathogen causing the respiratory symptoms it may be necessary to cohort suspected respiratory infections together in the same multi bed bay. NB: This carries the risk of transmitting multiple respiratory viruses to multiple patients and should be avoided wherever possible and only used as a last resort during times of extreme bed pressures.The following principles should be followed when considering cohorting of respiratory cases still awaiting test results;
Patients who should not be placed in multi bed bay cohorts;
Patients on the respiratory pathway who require AGPs should be prioritised for a single side room. Critical care areas and wards where AGPs are undertaken more routinely should also prioritise single side rooms for those on the respiratory pathway undergoing AGPs. However, where single side room capacity is lacking and patients with respiratory symptoms on the unit increases, unit-wide application of airborne precautions should be considered where all the patients in the same bed bay are test positive for the same respiratory pathogen. Where patients are positive for different respiratory pathogens there is a risk of transmission of multiple pathogens to multiple patients.
The principles applied within this guidance aim to mitigate the risk of transmission of all respiratory viruses including RSV. Many paediatric settings will have well established RSV pathways. Wherever possible, both COVID-19 and RSV point of care testing should be undertaken as a minimum on admission to help allocate patient placement and ensure that cohorts of RSV are segregated from cohorts of COVID-19. See also cohorting principles for secondary care inpatients above. Regardless of the infectious pathogen detected, whilst the patient is symptomatic, they should be managed in line with the TBPs within this guidance. If single room capacity is limited/ being exceeded, prioritise clinically vulnerable children to a single room (See RCPCH guidance on clinically extremely vulnerable children). Children with bronchiolitis requiring a continuous AGP should be prioritised to a single room over those not requiring a continuous AGP if possible.When children require an inpatient stay, local policy should be followed regarding resident carers. Education and written information for resident carers should be made available regarding respiratory virus, local policies, and include use of communal facilities, face coverings (unless exempt), hand hygiene and PPE.
Whilst the COVID-19 pandemic continues, it is important that any risk associated with acquiring COVID-19 pre/intra/post operatively for patients being admitted for elective surgical procedures be reduced as far as possible. Some studies have shown that patients diagnosed with COVID-19 around the time of a surgical procedure have a higher than predicted mortality however, it is not possible to determine precise risk for each individual patient. In advance of patients attending for elective surgery they should be advised of ways in which they may be able to reduce their post-operative risk. Appendix 19 of the NIPCM provides details of Elective Surgery IPC principles which have been developed in conjunction with the Scottish COVID-19 Clinical cell and aim to reduce COVID-19 transmission risk during the ongoing COVID-19 pandemic.
Care Home Settings
Full guidance for admission to a care home during the COVID-19 pandemic can be found in PHS COVID-19: Information and Guidance for Care Home Settings (Adults and Older People).
Any resident who answers yes to any of the respiratory screening questions for care home settings should be placed in their own individual room until a full assessment can take place to determine the cause.
Where single rooms are limited cohorting may be considered. Cohorting in care homes should be undertaken with care. Residents who are high risk and previously considered to be on the shielding list must not be placed in cohorts and should be prioritised for single occupancy rooms.
Where all single room facilities are occupied and cohorting is unavoidable, then cohorting could be considered in conjunction with the local Health Protection Team (HPT).
Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for service users on the respiratory pathways where TBPs are applied.
There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between the respiratory pathway and all other service users.
Rotas should be planned in advance wherever possible, to take account of the respiratory pathway and staff allocation.
For staff groups who need to go between pathways, efforts should be made to see service users on the non-respiratory pathway first.
Type IIR FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a service user with any other suspected or known infectious pathogens and when leaving respiratory pathway areas.
Wherever possible, service users with respiratory symptoms or a confirmed respiratory pathogen should remain on the respiratory pathway until they meet criteria for discontinuation of precautions. There may however be instances where it is necessary to transfer a service user whilst TBPs are ongoing including;
Communication with the receiving department/NHS Board/Care provider is vital to ensure appropriate IPC measures are continued during and after transfer. The service user must continue to be managed on the respiratory pathway. Communications must include;
Ensure transferring ambulance or portering staff are advised of the necessary precautions required for PPE and decontamination of transfer equipment.
There is no need to test the service user again on transfer provided symptomatic cases have already had a test taken where the health and care setting has the ability to do so.
Service users who have been allowed to leave the healthcare facility for the day or for an overnight stay should be assessed using the respiratory screening questions in advance of their immediate return to the facility and again on arrival at the facility to determine any known or potential exposure whilst out of the healthcare facility on pass and subsequently which pathway they should be placed on.
5.9.2 Testing for other respiratory pathogens
In order to ensure prompt safe placement and treatment of service users with respiratory symptoms, testing will help to inform the clinical/care team of the causative pathogen. This will help to avoid placing multiple service users with different respiratory pathogens in the same room for extended periods of time risking transmission of multiple pathogens between service users. Testing for other respiratory pathogens beyond SARS-CoV-2 may not be routinely necessary in all settings such as residential care areas and care homes.
To ensure patients are placed appropriately within health and care settings, COVID-19 testing is required.
Rapid Diagnostic Tests (including POCT) or LFD tests may now be used in some health and care settings (see sector specific content below) to help determine any requirements for transmission based precautions and to support IPC risk assessments including patient placement, patient transfers, management of contactsin inpatient settings and outbreak management.
The use of rapid diagnostic tests (including POCT) or LFD described throughout this guidance is an option available to NHS Boards where they can be operationalised at a local level and have the ability to ease service pressures and patient flow. (Refer to section 5.2 Organisational preparedness)
COVID-19 test results should not be used as a standalone tool for risk assessment but in conjunction with symptom and clinical assessment.
Anyone who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested using PCR within a period of 90 days from their initial symptom onset, or the first positive test, if asymptomatic, unless they develop new possible COVID-19 symptoms. This is because fragments of inactive virus can be persistently detected by PCR in respiratory tract samples for up to 90 days following infection.
If an asymptomatic person is inadvertently re-tested and tests positive by LFD or PCR within 90 days of a previous positive test result, a risk assessment will likely conclude there is no need to do a confirmatory PCR, isolate or contact trace again, as long as the person with the repeat positive test:
See section 5.15.7 for determining the precautions required for AGPs and the associated testing.
If an individual has COVID-19 symptoms they should visit the NHS inform website for advice on testing and self isolation.
GPs who have arranged a face to face consultation with an individual who has symptoms of COVID-19 should proceed following the respiratory pathway and following treatment should advise that they visit NHS Inform for advise on testing if they have not already done so.
Dental teams who have arranged a face to face consultation with a patient which cannot be postponed and who has symptoms of COVID-19 should proceed following the respiratory pathway and following treatment advise that the visit NHS Inform for advice on testing and self-isolation if they have not already done so.
Testing requirements within secondary care are as follows:
A table containing a summary of testing requirements in NHS Scotland is available. When using this table the following applies;
Guidance on COVID-19 testing in care home settings can be found in the PHS COVID-19: Information and Guidance for Care Homes (Adults and Older People).
It may be necessary to test for other respiratory pathogens including COVID-19 to support service user placement but also ensure optimal treatment provision.
GPs may choose to perform a respiratory screen on an individual if clinical assessment indicates this is necessary. If so, they should continue to do so via routine processes. There is no expectation to perform respiratory testing in primary care, or dentistry beyond routine processes indicated by clinical assessment.
On arrival at a secondary care facility, all patients should have COVID-19 testing undertaken as per 5.9.1. Clinical teams may choose to perform a full respiratory screen if clinical assessment indicates this is necessary to support diagnosis.
Residents who test negative for COVID-19 but who have ongoing respiratory symptoms do not routinely require any additional testing. However, should a resident require a consultation with a GP, the GP may choose to perform a full respiratory screen if a clinical assessment indicates this is necessary. Or if there is considered to be a cluster of cases and these are COVID-19 negative then additional testing by multiplex PCR can be performed to identify the pathogen.
Where respiratory screens are performed and the service user tests positive for COVID-19 within 90 days of previous positive test, this will require careful consideration and interpretation by clinicians with microbiology support where required.
HCW COVID-19 testing continues in some settings. Detailed information on respiratory screening for HCWs can be found on the Scottish Government website.
There is no requirement for any other respiratory pathogen beyond COVID-19 screening amongst HCWs unless recommended by an Incident Management Team, HPT, or occupational health.
Information on COVID-19 testing amongst care home workers can be found in the PHS Care home guidance.
Care home staff should use the COVID testing portal to arrange this.
Before control measures are stepped down for respiratory pathogens, clinical teams and care teams must first consider any ongoing need for TBPs necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or other symptoms suggestive of possible infection such as diarrhoea.
The A-Z of pathogens within the NIPCM details the duration of TBPs required for individual pathogens where this information is available. Clinical teams and care teams should refer to this before any TBPs are discontinued. Duration of precautions for COVID-19 are given in more detail. A more cautious approach is taken when considering when to discontinue precautions for individuals with COVID-19 during the ongoing pandemic.
5.12.1 Non COVID-19 discharges from hospital to care homes
5.12.2 Management of contacts of COVID-19
5.12.3 HCWs isolation and exemption requirements
It is important to note that service users with COVID-19 deemed clinically fit for discharge can and should be discharged before resolution of symptoms.
The tables below set out number of isolation days required, the clinical requirements for discontinuing TBPs and any testing required.
Hospital Inpatients and residents in residential settings |
Number of isolation days required |
COVID-19 Clinical requirement for stepdown |
Testing required for stepdown |
---|---|---|---|
General(including critical care patients) |
10 days from symptom onset (or first positive test if symptom onset undetermined). Ceasing isolation before 10 days is possible pending clinical and testing criteria laid out in ‘testing required for stepdown’ column. |
Clinical improvement with at least some respiratory recovery. Absence of fever (>37.8oC) for 48 hours without use of antipyretics. |
Not routinely required for inpatients isolating for 10 days. Testing may be used to cease TBPs sooner where clinical criteria is met and where 2 negative tests are achieved 24 hours apart. If either tests are positive, isolation must continue to 10 days *1. Testing is not required beyond 10 days to cease TBPs provided clinical criteria met. |
Residents in residential settings |
10 days from symptom onset (or first positive test if symptom onset undetermined) |
Clinical improvement with at least some respiratory recovery. Absence of fever (>37.8oC) for 48 hours without use of antipyretics. |
Not routinely required |
Individuals severely Immunocompromised as determined by Chapter 14a of the Green Book |
14 days from symptom onset (or first positive test if symptom onset undetermined) |
Clinical improvement with at least some respiratory recovery. Absence of fever (>37.8oC) for 48 hours without use of antipyretics. Individual risk assessment by clinical teams taking account of symptoms, clinical presentation, intended setting for stepdown. |
Local clinical teams may consider testing as part of the stepdown process and where undertaken, 1 negative test would be acceptable for stepdown. |
*1 The residual risk of infection after a negative test on day 6 and 7 is similar to stepping down isolation precautions without testing at day 10. Starting testing earlier than day 6 slightly increases this risk, however organisations may wish to balance this risk against other potential harms to patients.
Discharging service users |
Number of isolation days required |
Does isolation need to be completed in hospital? |
COVID-19 Clinical requirement for stepdown |
Testing required for stepdown |
---|---|---|---|---|
Patient discharging to a residential setting |
10 days from symptom onset (or first positive test if symptom onset undetermined). If they have completed the 10 day isolation in hospital, no further isolation should be required on return/admission to the care home. |
No. If a COVID-19 recovered patient is discharged to a care home before 10 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 10 days isolation in hospital, they can do so in care home and do not require to start new isolation period on admission, nor require further testing. |
Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics |
If a COVID-19 recovered patient discharged to care home before 10 day isolation has ended then 1 negative PCR test is required preferably within 48 hours prior to discharge. If not completed 10 days isolation in hospital, they can do so in care home and do not require to start new isolation period on admission, nor require further testing. See PHS COVID-19: information and guidance for care home settings for discharge testing details if the COVID-19 recovered patient has completed their 10 day isolation period in hospital |
Patients being discharged to their own home - General |
10 days from symptom onset (or first positive test if symptom onset undetermined). Ceasing isolation before 10 days is possible pending clinical and testing criteria laid out in ‘testing required for stepdown’ column. |
May revert to community stay at home guidance once discharged if isolation period has not been completed as an inpatient. Must be given clear advice for what to do if their symptoms worsen. |
Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics. |
Not routinely required for inpatients isolating for 10 days. Testing may be used to cease TBPs sooner where clinical criteria is met and where 2 negative tests are achieved 24 hours apart. *1 If either tests are positive, isolation must continue to 10 days. Testing is not required beyond 10 days to cease TBPs provided clinical criteria met. |
Patients being discharged to their own home – someone in household is severely immunocompromised or at risk of severe illness |
10 days from symptom onset (or first positive test if symptom onset undetermined) |
Wherever possible, patient should be discharged to a different household from anyone immunocompromised or at severe risk of infection. If not possible – see ‘testing required for stepdown’ column. |
Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics. |
Testing for clearance is encouraged |
*1 The residual risk of infection after a negative test on day 6 and 7 is similar to stepping down isolation precautions without testing at day 10. Starting testing earlier than day 6 slightly increases this risk, however organisations may wish to balance this risk against other potential harms to patients.
All non-COVID-19 residents being discharged from hospital who are on the non-respiratory pathway at point of discharge do not require to complete a period of self isolation on return to the care home provided:
A single negative result should be available preferably within 48 hours prior to discharge from hospital. The exception is where a resident is considered to suffer detrimental clinical consequence or distress if they were not able to be discharged to a care home. In these cases, the resident may be discharged to the care home prior to the test result being available and transmission based precautions applied on return to the care home until a negative test result is achieved.
If a resident is admitted to hospital for a single overnight inpatient stay, they do not require to complete a period of self isolation on return to the care home provided they answer no to all of the respiratory screening questions prior to transfer.
For further guidance on admission of COVID-19 recovered and non-COVID-19 residents from hospital or from community to a care home please refer to PHS COVID-19: Information and Guidance for Care Home Settings (for older adults)
The Test and Protect contact tracing programme in the community has now ceased and there is no requirement to undertake contact tracing in health and care settings with the exception of acute inpatient settings where contact tracing should continue. An individual who has had exposure to a case of COVID-19 may go on to develop COVID-19 with or without symptoms and this presents a risk of transmission to other users of health and care facilities. Measures should be taken in secondary care settings as described below to reduce transmission risk associated with COVID-19 contacts.
Secondary care settings
Contact tracing should be performed for patients identified as COVID-19 on the non-respiratory pathway. Inpatients who have been identified as a contact of a confirmed case of COVID-19 during their hospital inpatient stay must be isolated or cohorted for 10 days from the date of exposure.
Replacing Transmission based precautions with daily testingWhere these are available, Laboratory PCR or optionally rapid diagnostic tests (including POCT) or LFD can be used to prevent the need to apply transmission based precautions for contacts.For adult contacts who are asymptomatic of respiratory viral symptoms, and for all asymptomatic children and young persons aged 0 to 18 years and 4 months, a daily Laboratory based PCR or optionally Rapid Diagnostic Test (including POCT) or LFD test should be performed for 10 days following the date of exposure. Application of transmission based precautions (TBPs) are only required should COVID-19 tests be positive at any point and a follow up COVID-19 laboratory based PCR undertaken. Whilst COVID-19 tests remain negative, application of SICPs is sufficient and there is no need to isolate the contact.Any patient who has been COVID-19 positive (confirmed by laboratory based PCR or Rapid Diagnostic Testing (including POCT) or LFD test) in the last 28 days does not need to be considered a contact should there be a subsequent exposure during that 28 period. Daily testing of these patients is therefore not required during this time period.
Contact tracing in the community has now ceased and therefore patients are less likely to know when they have been a contact of a case of COVID-19. Primary care services need only undertake respiratory screening questions detailed in section 5.7 and base Infection Prevention and Control Precautions on the presence or absence of respiratory symptoms and any notification of the patient having confirmed COVID-19.
Contact tracing will not be routinely undertaken in care homes. Asymptomatic residents who are known to have been in contact with a COVID-19 case do not require to self-isolate or be tested. All residents in a care home with a case should be carefully monitored for any symptoms of COVID-19. See PHS information and guidance for care homes for further information.
HCWs who have symptoms of a respiratory infection, a high temperature or do not feel well enough to attend work, are advised to take an LFD test, as soon as they feel unwell and report the results to their line manager.
HCWs who test positive for COVID-19 must not report to work and must follow advice in line with ‘Managing Health and Social care Staff with Symptoms of a respiratory infection, or a positive COVID-19 test, as part of the test and protect transition plan’ DL (2022) 12.
If an LFD was undertaken whilst in the workplace and returns a positive test, the HCW must don a Type IIR FRSM (unless exempt), inform their line manager and go home immediately.
Health and care staff who have been exposed to a case of COVID-19 in their household should follow advice laid out in the ‘Managing Health and Social care Staff with Symptoms of a respiratory infection, or a positive COVID-19 test, as part of the test and protect transition plan’ DL (2022) 12.
Hand hygiene is considered one of the most important practices in preventing the onward transmission of any infectious agents including respiratory viruses. Hand hygiene should be performed in line with section 1.2 of SICPs. Within this section you will find videos demonstrating how to perform a hand wash and how to perform a hand rub.
Staff in care homes settings can refer to the hand hygiene section of the Care Home IPCM (CHIPCM) for older people and adult care homes for more information and resources specific to this setting.
Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19. The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.
The ‘Catch it, Bin it, Kill it’ poster can be downloaded.
Staff in care homes settings can refer to the respiratory and cough hygiene section of the CH IPCM for older people and adult care homes for more information and resources specific to this setting.
5.15.1 Extended use of face masks for staff, visitors and outpatients
5.15.2 Sessional use of FRSMs, FFP3 respirators and/or eye/face protection
5.15.3 Filter Face Piece 3 (FFP3) Respirators
5.15.4 PPE worn when caring for service users on the respiratory pathway
5.15.6 Aerosol Generating Procedures (AGPs)
5.15.7 Determining the IPC precautions required for AGPs
PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. As part of SICPs, all staff undertaking in procedure, should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken. More information on PPE including donnng and doffing resources can be found in the NIPCM.
Staff within Care Homes can find more general information on PPE in the CHIPCM for Older People and Adult Care Homes. Staff in care homes must follow the PPE guidance below.
When caring for a service user who has respiratory symptoms PPE should be selected to protect against droplet or in some circumstances, airborne spread.
PPE must not be used inappropriately. It is of paramount importance that PPE is worn at the appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.
PPE is the least effective control measure within the hierarchy of controls and other mitigation measures must be implemented and adhered to wherever possible.
The extended use of facemasks by health and care workers and the wearing of face coverings by visitors and outpatients (unless exempt) is designed to protect staff and service users as part of the COVID-19 pandemic. This is because COVID-19 may be transmitted by individuals who are not displaying any symptoms of the illness (asymptomatic or pre-symptomatic).
In Scotland, staff are provided with Type IIR FRSM for use as part of the extended wearing of facemasks.
Any service users attending a health and care facility should be encouraged to wear a face covering in line with Scottish Government guidance unless exempt. Type II FRSM should be available should an individual or service user attend without a face covering.
Any patient attending a health care facility should be encouraged to wear a face covering in line with Scottish Government guidance unless exempt. Type II FRSM should be available should a patient attend without a face covering.
A facemask should be worn by all inpatients across all inpatient areas regardless of respiratory symptoms unless exempt and where it can be tolerated and does not compromise their clinical care for example when receiving oxygen therapy. All patients should be encouraged to adhere to this which is part of COVID-19 pandemic control measures. The purpose of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination. This should be actively promoted throughout the healthcare setting.It is recognised that it will be impractical for inpatients to wear facemasks at all times and these will have to be removed for reasons such as eating and drinking or showering. There is no need for inpatients to wear a facemask when sleeping provided bed spacing requirements in line with current guidance are met.A facemask should be worn by all inpatients across all pathways during transfer between departments within the hospital unless exempt. Where an inpatient is isolated in a single room, they do not need to wear a facemask. However, the inpatient must be asked to don their mask when any staff or visitors enter the room unless exempt.
Residents on the respiratory pathway should be encouraged to wear a facemask, if these can be tolerated and do not compromise care, when moving around the care home and when care staff, other residents or visitors enter their individual room.
FRSMs and eye/face protection (goggles/visors) may be used sessionally. This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to respiratory pathogens. A session ends when the healthcare worker leaves the clinical setting or exposure environment.
Typically, sessional use of any PPE is not permitted within health and care settings at any time as it is associated with transmission of infection between service users within health and care settings.
Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks policy, sessional use of FRSMs and eye/face protection is permitted at this time.
However, in using FRSMs/eye and face protection/RPE sessionally, it is important to note the following;
The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.
No other PPE is permitted to be worn sessionally moving between service users or care tasks. This includes gloves, aprons and gowns.
Within dental settings, HCWs may wear FRSMs sessionally to account for the extended use of facemask policy outside of direct patient care delivery and provided they are changed at the points listed above. It should be noted that due to the procedures being undertaken in dentistry and the splash/spray generated during those procedures, that FRSMs should be changed between patients in line with standard practices. FFP3 respirators should not be worn sessionally at any time.
Sessional use of FFP3 respirators is also permitted only where unit wide airborne precautions are applied throughout a unit/care area however all other AGP PPE should be removed when no longer within 2 metres of a patient or, if still within 2 metres of the patient, then after the AGP is complete and fallow time has elapsed. It is not necessary to wear sessional gowns moving around a unit or department. Gowns protect against excessive splash and spray which is associated with AGPs and other direct patient care procedures.
FFP3 respirators must only be worn by staff who have undergone and passed a fit test. FFP3 respirators must be worn by HCWs in the following scenarios;
More information can be found on RPE within chapter 2 of the NIPCM.
Table 7 details the PPE which should be worn when providing direct care for service users on the respiratory pathway.
Type IIR FRSM should be worn for all direct care delivery regardless of whether the service user is on the respiratory pathway or not. This measure has been implemented alongside physical distancing specifically for the COVID-19 pandemic.
Type IIR FRSMs can be worn sessionally when going between service users on the respiratory pathway. Type IIR FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a service user isolated with any other suspected or known infectious pathogens and when leaving respiratory pathway areas.
It is recommended that Type IIR FRSMs should be well fitting and fit for purpose, covering the mouth and nose in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask). A poster provides some suggested ways to wear facemasks to help improve fit.
Health and care staff moving between different settings, wards and departments to provide care/consultations or undertake service user transfers (e.g. portering and theatre staff) throughout the course of their working day must ensure they first clarify with the person in charge or named health and care worker what pathway the service user they are attending to is on and what PPE is required.
PPE item |
Non Respiratory pathway (SICPs)* |
Respiratory pathway (TBPs) |
---|---|---|
Gloves |
Risk assessment - wear if contact with blood and body fluid (BBF) is anticipated. Single-use |
Worn for all direct care delivery. Single use. |
Apron or gown |
Risk assessment - wear apron if direct contact with service user, their environment or BBF is anticipated. (Gown if extensive splashing anticipated) Single use |
Apron to be worn for all direct care delivery (Gown if extensive splashing anticipated) Single-use |
Face mask (FRSM)/FFP3 respirator |
Always within 2 metres of a service user- Type IIR FRSM (Wearing a Type IIR FRSM as part of SICPs would normally only be worn when splash/spray is anticipated. Use of FRSM for all service user direct care and exists as an ongoing COVID-19 pandemic measure) Single use or Sessional use |
Always within 2 metres of a service user - Type IIR FRSM FFP3 respirator required when caring for service user with a known or suspected pathogen transmitted by the airborne route e.g. pulmonary TB Single use or Sessional use |
Eye & face protection |
Risk assessment - wear if splashing or spraying with BBF including coughing/sneezing anticipated. Single-use or reusable following decontamination. |
Worn for all direct care delivery provided to service users with respiratory symptoms Single-use, sessional or reusable following decontamination. |
*Ensure that PPE is worn appropriately for TBPs as per NIPCM on the non-respiratory pathway if caring for service users with any other known or suspected infectious pathogen requiring TBPs.
NHS staff should continue to obtain PPE through their health board procurement contacts, who will raise their needs via an automated procurement portal to NHS National Services Scotland (NHS NSS). This automated internal procurement system has been specifically developed to deal with increased demand, give real time visibility to Health Boards for ordered stock, as well as enabling quick turnaround for delivery.
Those providing services within social care settings (including personal assistants and unpaid carers) who have an urgent need to access PPE, can contact the PPE support centre on 0300 303 3020 or their local HSCP PPE hub.
Please note that hubs are to be used only in cases where there is an urgent supply shortage after “business as usual” routes have been exhausted.
The contact details below will direct social care providers to the NHS National Services Scotland Social Care PPE Support Centre, and the team there will point you towards your local Hub.
Email: support@socialcare-nhs.info
Phone: 0300 303 3020.
The helpline is open (8am - 8pm) 7 days a week.
Further information can be found at: Coronavirus (COVID-19): PPE access for social care providers and unpaid carers.
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. It is also possible for asymptomatic and pre-symptomatic carriers of COVID-19 to transmit COVID-19 during AGPs.
A full list of AGPs can be found in Appendix 17 of the NIPCM.
Airborne precautions and subsequent post AGP fallow times are required for all patients undergoing an AGP on the respiratory pathway.
A risk assessment should be undertaken prior to performing an AGP on patients on the non-respiratory pathway and take account of any presenting respiratory symptoms. Optionally a laboratory based PCR test, COVID-19 Rapid Diagnostic Test (including POCT) or LFD test may also be used to support the risk assessment. Where there is no evidence of a respiratory virus, the AGP may be performed using standard infection control precautions and also negating the need for post AGP fallow times.
NB: where SICPs are applied for an AGP, HCWs are still required to wear an FRSM and eye/face protection to protect against splash/spray generated by the AGP.
Airborne precautions and post AGP fallow times must be applied for any patients requiring treatment on the respiratory pathway as outline in the respiratory screening questions. Dental teams must continue to ask patients the respiratory screening questions prior to attendance for appointments to determine the IPC precautions required prior to undertaking AGPs.
The required PPE when undertaking AGPs is listed in table 8.
**Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators, including powered respirators, for decontamination. This literature review will be updated to incorporate recommendations from this group when available. In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.
PPE Item |
Non Respiratory pathway where there is no evidence of a respiratory virus |
Respiratory pathway (TBPs) |
---|---|---|
Gloves |
Single-use |
Single use |
Apron or gown |
Single-use Risk assess – use fluid resistant gown if excessive splashing/spraying anticipated otherwise apron is sufficient |
Single-use fluid resistant gown |
Face mask (FRSM) or Respirator |
Type IIR FRSM* Single or Sessional use |
FFP3 mask or powered respirator hood Single or Sessional use |
Eye & face protection |
Single use or reusable following decontamination |
Single-use, sessional or reusable following decontamination |
*Where staff have concerns about potential COVID-19 exposure to themselves during this ongoing COVID-19 pandemic, they may choose to wear an FFP3 respirator rather than an FRSM when performing an AGP on any patient provided they are fit tested. This is a personal PPE risk assessment.
Time is required after AGPs undertaken with airborne precautions are performed to allow the actual/potential infectious aerosols still circulating to be removed/diluted. This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate. The PAGPFTs can be found in appendix 17 of the NICPM.
Staff within dental settings should refer to the ‘Mitigation of AGPs in dentistry; A Rapid Review’ which details fallow times specific to this setting and the mitigations used. The methodology work was undertaken by SDCEP and Cochrane oral Health. Post AGP down time (fallow time) is not considered necessary for successive appointments between members of the same household within dental settings; to minimise aerosol spread dentists should use mitigating measures such as high volume suction/rubber dam. It is essential that staff change their PPE and adhere to SICPs between family members.Treatment rooms in dental practices should be aiming for a minimum of 10ACH.
See NIPCM for routine safe management of care equipment as per SICPs.
Care homes should refer to the CH IPCM for more general information on safe management of care equipment in this setting as per SICPs.
Care equipment used for service users on the respiratory pathway may become contaminated with infectious transmissible pathogens and must be cleaned as per table 9.
Pathway |
Product |
---|---|
Routine care areas (non-respiratory pathway) – cleaning as per SICPs |
General purpose detergent for routine cleaning. |
Respiratory pathway -cleaning as per TBPs |
Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine for routine cleaning. |
See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids (including saliva) or if it has been used on a patient with any other known or suspected infectious pathogen.
Re-useable care equipment used on the respiratory pathway in the community health and care settings such as stethoscopes, syringe drivers and pumps must be decontaminated prior to removal from the service user’s home. Where this is not possible, they should be bagged and transported back to base for decontamination.
See NIPCM for routine safe management of care environment as per SICPs.
Care homes should refer to the CH IPCM for more general information on safe management of the care environment in this setting as per SICPs.
Environmental cleaning in the respiratory pathway should be undertaken as per table 10. A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean. Where a room has not been occupied by any staff or service user since the first daily clean was undertaken, a second daily clean is not required.
Pathway |
Frequency |
Product |
---|---|---|
Routine care areas |
At least daily as per NHS Scotland National Cleaning Services Specification.
|
General purpose detergent1
|
Respiratory pathway - cleaning as per TBPs (incl post AGP for service users requiring airborne precautions for AGPs) |
At least twice daily 1st clean - Full clean (domestic services) 2nd clean - 2Touch Surfaces within clinical and care delivery areas |
Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.
|
1 Cleaning in routine care areas should be carried out with chlorine based detergent for rooms where the service user is known to have any other known or suspected infectious agent.
2 Touch surfaces as a minimum should include door handles/push pads, taps, bed heads/bed ends, cot sides, light switches, lift buttons. Clinical and care delivery areas should include the service user’s bedroom and treatment areas and staff rest areas.
Any areas contaminated with BBF (including saliva) in any clinical/care area require to be cleaned as per Appendix 9 of the NIPCM.
In settings such as outpatient departments, GP practices, dental practices, where there are multiple service users undergoing a consultation each day, cleaning should be undertaken between service users in addition to the environmental cleaning described above using the appropriate cleaning product depending on the pathway the service user is on. Ensure that any surfaces touched by the service user are cleaned e.g. chair, treatment bed and where the service user is symptomatic of a respiratory virus, cleaning should include items in the immediate environment which may have become contaminated.
All linen should be handled routinely as per section 1.7 of SICPs – Safe Management of Linen
Care homes should refer to the Care Home IPCM for older people and adult care homes for more general information on safe management of linen in this setting as per SICPs.
Linen used on service users who are on the respiratory pathway should be treated as infectious.
Routinely on the respiratory pathway, provided curtains around examination bays have no visible contamination and are kept tied back when not in use, they may remain in situ situ between patients however regular curtain change regimes should be in place. Curtains should also be cleaned as part of terminal cleaning following discontinuation of TBPs and following discharge of a patient from inpatient settings where transmission based precautions were in place at the time of discharge. When changed, curtains should be treated as infectious linen.
Community Health and Care Settings with their own in-house laundries may also refer to National Guidance for Safe Management of Linen in NHSScotland for more information.
See also staff uniforms.
All BBF spillages should be managed as per section 1.8 of SICPs – Safe management of Blood and Body Fluid Spillages and Appendix 9.
Care homes should refer to the Care Home IPCM for older people and adult care homes for general information on safe management of Blood and Body Fluid spillages.
Waste generated during the management of BBF spillages should be disposed of as waste section.
Waste should be handled in accordance with Section 1.9 of SICPs. Any items contaminated with BBF (including saliva) for any patient regardless of infectious status should be disposed of as clinical waste.
Care homes should refer to the Care Home IPCM for older people and adult care homes for more general information on safe management of waste in this setting.
If the care home does not have a clinical waste contract ensure all waste items (e.g. used tissues and disposable cleaning cloths) that have been in contact with residents who are known or suspected to have COVID-19 are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.
Waste generated from patients/individuals who are on the respiratory pathway or where there is a confirmed outbreak, should be disposed of as clinical waste where clinical waste contracts are in place.
If the community health and care setting does not have a clinical waste contract, or for care at home, ensure all waste items (e.g. used tissues and disposable cleaning cloths) that have been in contact with service users who are known or suspected to have COVID-19 are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.
Employers have a duty of care to their staff. This is enshrined in health and safety legislation as is the requirement to undertake a risk assessment and then to mitigate any risks as low as reasonably practicable.
Section 1.10 of the NIPCM details occupational safety as per SICPs.
Care homes should refer to the Care Home IPCM for older people and adult care homes for more general information on occupational safety in this setting.
PPE is provided for occupational safety and should be worn as per Tables 7 and 8.
Staff testing negative for SARS-CoV-2 by PCR who remain symptomatic of another respiratory virus should consider the risk to service users particularly if they are immunosuppressed or otherwise medically vulnerable before returning to work. Once medically fit to return to work, if staff are in doubt about any risk they may pose to service users or colleagues, this should be discussed with their line manager in the first instance.
Decisions to deploy any staff members into areas of higher infection risk must take into account many factors. These include the nature of the biologic agent, the general risks, and the specific risks to each individual member of staff. The individual risk assessment may need to take account of age, gender, underlying health conditions, race and vaccine status amongst other factors. Occupational health expertise should be sought regarding both the overall process and for individuals deemed at significantly higher risk of either acquiring the infection or of an adverse outcome should they acquire infection.
Boards must have systems for risk assessment and mitigation with clearly defined responsibilities, routes to obtain advice from health and safety, occupational health, and other specialist advisers where required.
Occupational risk assessment guidance specific to COVID-19 is available. Further information for at risk or pregnant healthcare workers can be found in Guidance for Staff and Managers on Coronavirus
It is safe to launder uniforms at home. If the uniform is changed before leaving work, then transport this home in a disposable plastic bag or a launderable bag. If your role requires you to wear a uniform to and from work, then change as soon as possible when returning home.
Uniforms should be laundered daily, and:
Scottish Government uniform, dress code and laundering policy is available.
Contaminated uniforms and surgical scrubs should be laundered in hospital (dedicated laundry) facilities as per local policies.
For deceased who were on the respiratory pathway at the time of death, the IPC measures described in this document continue to apply whilst the deceased remains in the health and care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living service users. Where the deceased was known or suspected to have been infected with COVID-19, there is no requirement for a body bag, and viewing, hygienic preparations, post-mortem and embalming are all permitted. Body bags may be used for other practical reasons such as maintaining dignity or preventing leakage of body fluids. See IPC during care of the deceased within the NIPCM for more information.
Care Home Settings
Care homes should refer to the Care Home IPCM for older people and adult care homes for more general information on care of the deceased in this setting.
For further information see the Scottish Government Coronavirus (COVID-19): guidance for funeral directors on managing infection risks.
Scottish government have guidance available for visiting which can be found at the following links;
All visitors should be reminded on arrival at any health and care facility of good Infection Prevention and Control practice and encouraged to adhere to these.
It is strongly recommended that visitors wear face coverings in line with current Scottish Government extended use of facemask guidance and must not attend with respiratory symptoms or before a period of self-isolation has ended unless pre agreed with the clinical team in advance.
Visiting may be suspended on the advice of the local IPCT/HPT.
Consider alternative measures of communication including telephone or video call where visiting is not possible.
Visitors:
Visitors entering an AGP area in which airborne precautions are being applied, should do so after the fallow time has elapsed. Where this is not possible (continual AGP zone), visitors should be advised that there may be a risk of exposure to respiratory viruses. Visitors should be asked to wear an FRSM where respirator fit testing is not possible.
PPE may be offered to visitors to protect them from acquiring a transmissible infection.
If a visitor declines to wear PPE when it is offered then this should be respected and the visit must not be refused.
PPE use by visitors can not be enforced and there is no expectation that staff monitor PPE use amongst visitors.
Visitors should be encouraged to wear a face covering or face mask in line with the extended use of facemask guidance. Below is the PPE which should be worn where it is appropriate to do so and when the visitor chooses to do so.
Visitors do not routinely require PPE unless they are providing direct care to the individual they are visiting. In line with extended use of face mask policy, visitors are strongly recommended to continue to wear a face covering when visiting a healthcare setting. Should they arrive without one, they can be provided with a FRSM. The table below provides a guide to PPE for use by visitors if delivering direct care.
IPC Precaution |
Gloves |
Apron |
Face covering/mask |
Eye/Face Protection |
---|---|---|---|---|
Standard Infection Control Precautions (SICPs) |
Not required*1 |
Not required*2 |
Where splash/spray to nose/mouth is anticipated during direct care Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
Not required*3 |
Transmission Based Precautions (TBPs) |
Not required*1 |
Not required*2 |
If within 2 metres of service user with suspected or known respiratory infection Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
When within 2 metres of a symptomatic service user infected with droplet/airborne infectious agents |
*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.
The purpose of this addendum is to provide additional guidance to chapters 1,2 and 3 for NNUs
Undertake assessment for infection risk at the point of entry into the unit before placement of the neonate is decided. This assessment is the minimal microbiological testing required and any additional testing would be determined by the clinical presentation of the neonate. The potential for transmission of infection should be continuously reviewed throughout the stay/period and must be documented in the clinical notes.
Neonates who present as a cross infection risk include those who:
From mothers who have:
If a neonate is considered to be a cross infection risk then the clinical judgement of those involved in the management of the baby should assess the placement by prioritising the incubator/cot in a suitable area pending investigation i.e. place in a single room or cohort area/room with a wash hand basin.
Information/advice must be given to parents/carers of all neonates; particularly during outbreaks/incidents
In addition to the definitions in Chapter 3, in a neonatal unit investigation by IPCT is also required if:
Additionally, the local IPC team should consider the possibility of any onward transmission and potential for an incident/outbreak where there is:
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.
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.
Please note that to help community and care settings with the transition from the winter respiratory addendum to the use of SICPs and TBPs for COVID-19 a new appendix has been created. The winter respiratory addendum will be removed on 11 July 2022.
Appendix 22 - Community IPC COVID-19 Pandemic provides details of the measures still to be followed for COVID-19 and should be used alongside existing guidance.
The National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO(2012)01-update). The Scottish Government expectation is that it is mandatory for use in all NHS care settings and in all other care homes to support health and social care integration, the content of this manual must be considered best practice.
Mandatory means that you must do it.
In order to support care homes successfully adopt and implement the NIPCM, this context specific Care Home Infection Prevention and Control Manual (CH IPCM) has been co-produced with national and local stakeholders. The content of the CH IPCM is completely aligned to the evidence based NIPCM and is intended to be used by all those involved in residential care provision.
The CH IPCM contains chapters on:
There are web links in some sections taking you directly to information contained in the NIPCM.
The CH IPCM is a practice guide for use in care homes, which when used, can help reduce the risk of infections and ensure the safety of those being cared for, staff and visitors in the care home environment.
It aims to:
It should be adopted for all infection prevention and control practices and procedures.
The recommendations for practice in the manual are developed from literature reviews of the current scientific literature (for example Medical Journals) that are updated real time and are considered best practice. Any major changes identified in the scientific literature may lead to a change being made to the content.
A number of ‘SBAR’s’ are available which are short communication or guidance reports that advise on the situation, background, assessment and recommendations on a specific topic.
The resources page links to SICPs materials, education and training links and posters and other supporting tools.
You can use the glossary to find out what these words mean. Sometimes we have added the meaning of important words within the chapter or section.
The Care Home Infection Prevention and Control Manual (CH IPCM) was launched on 24 May 2021.
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:
Infection can be prevented by breaking the Chain of Infection.
The chain of infection diagram illustrates and gives examples of actions that can be taken to break it. The overall aim of Standard Infection Control Precautions (SICPs), is to break the Chain.
Select image for full size version.
The basic IPC measures that should be used in your care home are called Standard Infection Control Precautions (SICPs).
SICPs are used to reduce the risk of transmission of infectious agents from known and unknown sources of infection.
These should be used by all staff, in all care settings, at all times, for all residents whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care home.
SICPs should be part of everyday practice and applied consistently by all staff in the care home including, but not limited to, managers, nurses, care staff, domestics/housekeepers and volunteers.
It is essential that optimal IPC measures are applied continuously as people living in care homes may be elderly or have underlying medical conditions which could make them more at risk from infection which may then be serious and in some cases life threatening. By applying optimum IPC measures you will provide safe and effective care to the people in your care, fellow staff and visitors to your care home.
There are 10 Standard Infection Control Precautions (SICPs)
If residents have been admitted from another care setting, for example, external care home or hospital try to pre assess them before they are admitted by speaking to the staff from the other care setting.
Before the resident comes into the care home it is important to risk assess them for infection.
Residents who may present a cross-infection risk include those with:
If you suspect or know that a resident has an infection, then details must be confirmed in order for you to put in place the correct IPC measures.
Appendix 11 of the National Infection and Prevention Control Manual tells you the precautions you need to put in place for different infections.
Use the NES SIPCEP Breaking the Chain of Infection module to learn about breaking the chain of infection in care homes.
Read the placement literature review to understand the evidence base for resident placement.
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 hygiene is essential to reduce the transmission of infection in care home settings. All staff and visitors should clean their hands with soap and water or, where this is unavailable, alcohol-based hand rub (ABHR) when entering and leaving the care home and when entering and leaving areas where care is being delivered.
before touching a resident;
before clean/aseptic procedures. If ABHR cannot be used, then antimicrobial liquid soap should be used;
after body fluid exposure risk;
after touching a resident;
after touching a resident’s immediate surroundings;
before handling medication;
before preparing/serving food;
after visiting the toilet;
before putting on and after removing PPE;
between carrying out different care activities on the same resident;
after cleaning care equipment;
after disposing of individual’s personal waste;
after handling dirty linen.
It is important that residents are routinely encouraged to perform hand hygiene and given assistance if required.
The four moments for hand hygiene poster can be used in your care home to show staff when hand hygiene should be done and the reasons why.
Select image for full size version.
your arms are bare below the elbow;
you take off all your hand and wrist jewellery (a single, plain metal finger ring is allowed but should be taken off (or moved up) during hand hygiene);
bracelets or bangles which are worn for religious reasons, such as the Kara, can be pushed higher up the arm and secured in place;
your finger nails are clean and short;
you cover all cuts or abrasions with a waterproof dressing;
you do not wear artificial nails or nail varnish/products.
if your hands look dirty;
If you are caring for a resident who is being sick or having diarrhoea or has diarrhoeal illness such as norovirus or Clostridioides difficile then you must use soap and water for hand hygiene.
Do not use ABHR as it will not work in these cases.
Make sure you wet your hands before applying liquid soap.
Use paper towels to turn off taps if the taps are not elbow operated mixer taps.
Elbow operated mixer taps are considered to provide the best temperature and flow for optimum hand hygiene and should be considered for any new build, refurbishment or if they need repaired/changed.
When you have washed your hands dry them thoroughly using paper towel and dispose of the paper towel in a foot operated waste bin.
To make sure you clean your hands properly with soap and water you must follow the steps in the poster ‘How to hand wash step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.
Select image for full size version
Alcohol based hand rub (ABHR) is a gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to stop or slow down the growth of microorganisms (germs).
If your hands look clean then you can use ABHR for routine care
Do not use ABHR if you are caring for a resident who has sickness or diarrhoeal illnesses such as norovirus or Clostridioides difficile. You must use soap and water as ABHR will not work.
To make sure you clean your hands properly with ABHR you must follow the steps in the poster ‘How to hand rub step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.
Select image for full size version
Use warm/tepid water to reduce the risk of dermatitis. Avoid using hot water.
After hand washing pat hands dry using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.
Use an emollient hand cream during breaks and when off duty.
Refillable dispensers or communal tubs of hand cream should not be provided or used in the care setting.
Staff with skin problems should seek advice from Occupational Health Department if available or their GP
Read the hand hygiene literature reviews to find out more about the evidence base for hand hygiene.
It is easy for infections to spread within a care home by coughing and sneezing so it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.
• Disposable tissues
• Waste bin and waste bags
• Hand hygiene products
If anyone has a cough, cold or other respiratory symptoms then they must:
cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose;
put used tissues into a waste bin immediately after use;
wash their hands with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions;
keep hands away from the eyes nose and mouth.
Staff must:
help residents with their respiratory and cough hygiene where required;
make sure that residents are given everything they need for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that it is close enough for them to use;
use hand wipes followed by ABHR if there is no running water available or hand hygiene facilities are out of reach then wash your hands at the first available opportunity.
Read the respiratory and cough hygiene literature review to find out the evidence for respiratory and cough hygiene practice.
Health and Safety at Work Act (1974), Control of Substances Hazardous to Health (COSHH) (2002 as amended) regulations and Personal Protective Equipment at Work Regulations 1992 (as amended) legislate that employers must provide PPE which gives you adequate protection against the risks associated with the task being undertaken.
Employees also have a responsibility under these laws which is to make sure that they wear the correct PPE for the task they are doing and wear it correctly.
Before doing any procedure or task you need to:
think about or find out if you could be exposed or come into contact with blood and/or other body fluids (BBF); and
make sure that the PPE worn gives you enough protection against the risks associated with the procedure or task you are doing.
Examples of potential risks are:
located close to the point of use
stored in a clean and dry area to prevent contamination until needed for use;
within expiry dates;
single-use only items unless specified by the manufacturer;
changed immediately after individual use and/or following completion of a procedure or task;
disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.
Reusable PPE items, for example non-disposable goggles, face shields and visors, must have a decontamination schedule with responsibility assigned.
w
orn when it is likely that you will be exposed to blood and/or other body fluids (BBF);
appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct glove;
changed immediately after each individual and/or following completion of a procedure or task;
changed if damaged or a perforation or puncture is suspected.
Using gloves reduces the risk of contamination but does not remove it all. Gloves should not be used instead of carrying out hand hygiene.
Gloves should never be decontaminated or cleaned with ABHR or by washing with cleaning products.
Use the glove selection chart to support you to select the correct glove type.
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by care staff when there is a risk of clothing being contaminated with blood or other body fluids;
during direct care, bed-making or when undertaking the decontamination of equipment;
when delivering food and/or supporting residents with nutrition.
be worn if blood and/or body fluid contamination to the eyes/face is expected/likely;
not be touched when worn.
Facial accessories such as piercings or false eyelashes must not be worn when using eye/face protection;
Regular glasses or safety glasses are not considered eye protection.
worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/likely;
a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray, however:
well-fitting, fully covering the mouth and nose and fit for purpose, you must follow the manufacturer’s instructions to ensure effective fit/protection.
removed or changed;
Always perform hand hygiene before putting on PPE.
The order for putting on PPE is:
The order for taking off PPE is:
Always carry out hand hygiene immediately after taking off PPE.
All PPE should be removed before leaving the area and disposed of as healthcare waste.
A poster showing the order for putting on and removing PPE is available to print.
Select image for full size version
Read the PPE literature review to find out more about the evidence base for PPE use.
Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents and this can spread infection.
Routine cleaning is regular cleaning which is carried out on a scheduled basis, not on an unplanned basis and not in response to an outbreak.
Cleaning is the removal of any dirt by use of an appropriate cleaning agent such as detergent.
Decontamination is removing, or killing pathogens on an item or surface to make it safe for handling, re-use or disposal, by cleaning, disinfection and/or sterilisation.
Disinfectant is a chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.
Detergent is a chemical cleansing agent that can dissolve oils and remove dirt.
For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.
If the resident has a known infection or the equipment is contaminated with blood or body fluids, then a disinfection agent needs to be used.
Do not use household bleach as the required dilution cannot be guaranteed.
Do not use refillable spray container for cleaning products as there is a risk of contamination.
Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.
or
or
There are three different types of care equipment that you will use in your care home and it is important that you know how to deal with each type.
You must use and follow manufacturers guidance for all equipment and products you use including those used for cleaning and decontamination.
Before using any sterile equipment, you should check that:
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.
Needles and syringes are single-use devices. They shoul
d never be used for more than one resident or reused to draw up additional medication.
Never give medications from a single-dose vial or intravenous (IV) bag to multiple residents.
2. Single individual use – equipment which can be reused by same resident e.g. nebuliser equipment and decontaminated following use as per manufacturers instructions.
3. Reusable non-invasive equipment (often referred to as ‘communal equipment’) – equipment which can be reused on more than one resident following decontamination between each use e.g. commode, moving and handling equipment or bath hoist.
Residents should be given their own reusable (communal) non-invasive equipment if possible.
Reusable equipment should be checked frequently for cleanliness and signs of integrity. This will include mattresses and pillows which should be clean, have a waterproof covering which is in a good state of repair.
You should clean or decontaminate reusable equipment:
between individual use;
after blood and/or body fluid contamination;
as part of the regular scheduled cleaning process;
before inspection, servicing or repair.
Staff must:
follow the local cleaning protocol/schedule which should include responsibility for; frequency of; and method of decontamination required;
use a general purpose detergent and water solution/detergent impregnated wipes;
or
a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.);
or
a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl;
make up cleaning/disinfection solution following manufacturers guidance;
follow the manufacturer’s contact time for the cleaning/disinfection solution;
rinse and dry reusable equipment then store it clean and dry.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
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
There are many areas in care homes that become easily contaminated with micro-organisms (germs) for example toilets, waste bins, tables.
Furniture and floorings in a poor state of repair can have micro-organisms (germs) in hidden cracks or crevices.
To reduce the spread of infection, the environment must be kept clean and dry and where possible clear from clutter and equipment.
Non-essential items should be stored and displayed in such a way as to aid effective cleaning
Keeping a high standard of environmental cleanliness is important in the care home settings as the residents are often elderly and vulnerable to infections.
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:
Report any issues with the environment cleanliness or maintenance to the person in charge to ensure that the care environment is safe. The person in charge must then act on problems reported to them.
Be aware of the environmental cleaning schedules and clear on their specific responsibilities.
Cleaning services should be managed in a systematic way, and staff responsible for cleaning should be appropriately trained to carry out the tasks they are responsible for.
The Care Home Manager is responsible for managing the cleaning service which has a number of essential elements outlined in the cleaning services diagram.
Select the diagram for full size version
An effective service will include all of the elements above.
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:
Table 2: Example cleaning SOP: Floors
The tools within the Cleaning Specification should be used by the care home manager in the planning, training of staff, delivery, and checking of standards of the cleaning services they provide.
When an organisation uses cleaning and disinfectant products that differ from those stated in this CH IPCM these products need to meet BS EN standards.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated with blood or body fluids, it may have to be discarded. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.
If the item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning. Any alternative disinfectant used must meet the relevant BS EN Standards as detailed previously
Read the routine cleaning of the care environment literature review to find out more about why we do things this way for the care environment.
Examples of linen you may have in the care home includes:
There are three categories of linen:
Clean – Linen washed and ready for use
Used – All used linen in the care setting not contaminated by blood or body fluids
Infectious – All linen used by a person known or suspected to be infectious and/or linen that is contaminated with blood or body fluids, e.g. faeces.
Used or infectious linen may also be categorised as heat-labile: usually personal clothing where the clothing may be damaged (shrinking/stretching) by washing at a higher than recommended temperature than the label advises. If such linen needs to be washed at a higher temperature for example if soiled or resident has a known infection they or their relatives need to be advised that the clothing may be damaged.
All clean, used and infectious linen should be handled with care and attention paid to the potential spread of infection.
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.
Staff must:
put on disposable gloves and apron prior to handling used linen;
make sure that a laundry trolley or container is available as close as possible to the point of use for immediate linen deposit.
Staff must not:
rinse, shake or sort linen on removal from beds or trolleys;
place used linen on the floor or any other surfaces for example on a locker or table top;
re-handle used linen once bagged;
overfill laundry receptacles or trolleys;
place inappropriate items in the laundry receptacle for example used equipment/needles.
Staff must:
wear disposable gloves and apron before handling infectious linen;
put infectious linen directly into a water soluble laundry bag and secure before putting into a clear plastic bag and placing into a laundry receptacle/trolley.
Micro-organisms are destroyed by heat and detergent and also by the dilution effect of the water in the washing machine.
wash items using the highest temperature you can and following the washing instructions.
use your normal washing powder or detergent and follow the instructions on the correct amount to use.
tumble-dry (if possible) following the washing instructions.
iron according to washing instructions. If possible, use a hot steam iron.
If visitors wish to take their relatives clothes home to be laundered, place laundry in an appropriate bag and provide them with a washing clothes at home leaflet.
If the residents clothing is very soiled or infectious, staff may recommend that the clothing is washed in the care home’s laundry service if available, otherwise, the item should be disposed of in the appropriate healthcare waste stream following discussion with the resident or their relative(s).
Read the safe management of linen literature review to find out more about why we do things this way when dealing with linen.
Spillages of blood and other body fluids may transmit blood borne viruses.
A blood borne virus is a virus carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.
Body fluids are fluids produced by the body such as urine, faeces, vomit or diarrhoea. These body fluids may also contain blood.
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
Different types of waste will be produced within care homes.
Some waste may be disposed of through the domestic waste route but other types of waste needs special handling and disposal for example sharps and waste from people who have or may have an infection.
Waste bags in care settings may be colour coded to denote the various categories of waste.
Local procedures and policies on waste disposal must be followed.
Care home waste disposal may differ from categories described and guidance from local contractors may apply.
Your care home should make sure that:
waste is correctly segregated according to local regulations;
the correct colour coded bags are being used according to local regulations;
there is a dedicated area for storage of clinical waste that is not accessible to residents or the public;
waste is stored in a safe place whilst awaiting uplift;
there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed.
Staff should:
follow the schedule for emptying domestic waste bins;
always use appropriate personal protective equipment (PPE);
dispose of waste immediately as close as possible to where it was produced;
dispose of clinical waste into the correct UN 3291 approved waste bin or sharps container;
ensure that waste bins are never overfilled. Once the waste bin is three quarters full, tie waste bags up and put into the main waste bin;
use a ‘swan neck’ technique for closure of the bag and label with date and location as per local policy.
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.
All care homes should have policies in place to ensure that staff are protected from occupational exposure to micro-organisms (germs), particularly those that may be found in blood and body fluids.
Occupational exposure is exposure of healthcare workers or care staff to blood or body fluids in the course of their work.
A sharp is a device or instrument such as needles, lancets and scalpels which are necessary for the exercise of specific healthcare activities and are able to cut, prick and/or have the potential to cause injury.
Safety device or safer sharp is a medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury. Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.
The Health and Safety (Sharp Instruments in Healthcare) Regulations (2013) outline the regulatory requirements for employers and contractors in the healthcare sector in relation to:
sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices;
always dispose of needles and syringes as a single unit immediately at the point of use;
sharps containers need to be assembled and labelled correctly;
use the temporary closure mechanisms in between use;
if a safety device is being used safety mechanisms must be deployed before disposal;
follow manufacturers’ instructions for safe use and disposal;
do not re-sheath used needles or lancets;
do not store sharps containers on the floor;
ensure sharps containers are not accessible to residents or the public;
sharps containers must not be more than three-quarters full.
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:
If you think or know you have had a significant occupational exposure you must:
report this immediately to the designated person in your care home, this is a legal requirement;
follow the local agreed process for management of an occupational exposure incident and follow the management of occupational injuries flow chart.
Read the management of occupational exposure to Blood Borne Viruses (BBVs) literature review to find out more about why we do things this way for occupational exposure.
The management of occupational exposure incidents flowchart should be used within your care home so you know what to do for an occupational exposure.
Select the image for full size
Sometimes using standard infection control precautions (SICPs) won’t be enough to stop an infection spreading and you will need to use some extra precautions. These extra precautions are called Transmission Based Precautions or TBPs.
You would use transmission based precautions if a resident has a suspected or known infection or colonisation.
Colonisation is the presence of bacteria on a body surface (such as the skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection.
Infections can be transmitted or spread by:
The three routes or ways an infection is transmitted or spread are called contact, droplet and airborne. You need to use different transmission based precautions for each route.
Contact precautions are used to prevent infections that spread through direct contact with the resident or indirectly from the resident’s immediate care environment and care equipment.
Droplet precautions are used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via small droplets from the respiratory tract of one individual directly onto the mucosal surface of another person’s mouth or nose or eyes. Droplets penetrate the respiratory system to above the alveolar level.
Airborne precautions are used to prevent and control infections spread without necessarily having close contact via from the respiratory tract of one individual directly onto the surface of another person’s mouth or nose or eyes. Aerosols penetrate the respiratory system to deep into the lung.
You might have heard of some infections like norovirus, Meticillin-resistant Staphylococcus aureus (MRSA), Clostridioides. difficile (C.diff/CDI) and flu but there are lots of others.
You can find out more information about the infection the individual has and the precautions you should use in Appendix 11 and/or A-Z of pathogens in the NIPCM.
You can also contact your local Health Protection Team or Infection Prevention and Control Team.
What the suspected or known infection/colonisation is?
How is it transmitted?
How severe is the resident’s illness?
What is the care setting and procedures being done?
There are different ways you can find out if a resident has an infection that needs TBPs to be put in place. You can get information about a resident’s infection status from:
Further information on transmission based precautions can be found in the definitions of Transmission Based Precautions literature reviews.
You need to regularly monitor the resident for infection throughout their stay so the correct precautions are in place to minimise the risk of infection being spread to other residents.
Residents may be an infection risk if they have:
CPE should be considered if the resident meets any of the following criteria within the
12-month period before admission:
CPE guidance for a care home setting is available.
Staff must:
get advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either your local Health Protection Team or Infection Prevention and Control Team;
make resident placement decisions based on advice received or sound judgement by experienced staff who are involved in the resident’s management;
let the ambulance service know of the resident’s infectious condition if they need to go to hospital;
not move residents within/between care areas unless essential.
Sometimes you will need to isolate a resident in their own room or area because of a known or suspected infection, it is important that:
Residents remain in their rooms whilst considered infectious and the door should remain closed.
If it is not possible for example the resident has dementia, then there needs to be individual risk assessments and decisions taken documented.
Suitable discrete signage is placed on the door advising others not to enter the room.
Consideration is given to the use of a dedicated team of care staff to care for residents in isolation/cohort rooms areas as an additional IPC measure. This is known as ‘staff cohorting’ and must only be done if there are enough staff available.
You do not stop isolation until you have considered individual risk factors and how this could affect other residents, staff and visitors.
You may need to contact your local health protection team or infection prevention and control team for further advice.
Read the patient placement, isolation and cohorting literature review to find out more about why we do things this way for resident placement for TBPs.
Cleaning of care equipment is essential to reduce the spread of infection when infection is confirmed/suspected
When dealing with the equipment used in the resident’s isolation room or area you should:
use dedicated reusable care equipment for the individual in isolation e.g. commodes where possible.
clean and decontaminate the care equipment after each use.
cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards
For how to decontaminate non-invasive reusable equipment prior to use on another resident see SICPs - Safe Management of Care Equipment.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
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.
Staff must:
clean and decontaminate the isolation/cohort rooms/area at least daily or more if advised to do so. If you have been advised to clean more than daily this should be added into the environmental cleaning schedule;
clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily;
make sure you are using the correct product which is:
a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.));
or
a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.
follow manufacturers guidance and instructions on how to use the product and what the recommended contact time is for the product to work. This may include rinsing off the disinfection solution to prevent damage to surfaces.
Do not use refillable spray container for cleaning products as there is a risk of contamination.
Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.
A terminal clean is cleaning/decontamination of the environment to ensure it is safe for the next resident or when the current resident is no longer considered infectious.
A terminal clean is carried out by:
removing all healthcare waste and other disposable items from the room;
removing bedding, curtains (bagged before removal from the room) and then wash as infectious linen;
cleaning and decontaminating all reusable care equipment in the room (before removal from the room).
The room should then be decontaminated using either:
The room must be cleaned from the highest to lowest point and from the least to most contaminated point.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
In addition to PPE used for Standard Infection Control Precautions, appendix 16 of the NIPCM outlines you what type of PPE and RPE you will need to wear for infections spread by different transmission routes.
Respiratory Protective Equipment (RPE) means FFP3 masks and facial protection and must be thought about when a resident is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route and when carrying out aerosol generating procedures (AGPs) on residents with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.
An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.
The most common AGPs undertaken in the Care Home Setting are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).
The full list of medical procedures for COVID-19 that have been reported to be aerosol generating and are associated with an increased risk of respiratory transmission are:
* only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.
If the individual has an infection spread by the airborne route and an AGP is required staff should wear the following PPE:
PPE |
PPE used |
---|---|
Gloves |
Single-use. |
Apron or gown |
Single-use gown. |
Face mask or respirator |
FFP3 mask or powered respirator hood. |
Eye and face protection |
Single-use or reusable. |
Rooms should always be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. In an isolation room with 10-12 air changes per hour (ACH) a minimum of 20 minutes is required; in a side room with 6 ACH this would be approximately one hour. It is often difficult to calculate air changes in areas that have natural ventilation only. Natural ventilation, particularly when reliant on open windows can vary depending on the climate. An air change rate in these circumstances has been agreed as 1-2 air changes/hour.
To increase natural ventilation in care home settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.
Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted. This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate.
The post aerosol generating procedure fallow time (PAGPFT) calculations are detailed in the table below. It is often difficult to calculate air changes in areas that have natural ventilation only.
If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.
The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP. It is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time. During the PAGPFT staff should not enter this room without FFP3 masks. Other residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately. As a minimum, regardless of air changes per hour (ACH), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes. Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.
Duration of AGP (minutes) | 1 AC/h | 2 AC/h | 4 AC/h | 6 AC/h | 8 AC/h | 10 AC/h | 12 AC/h | 15 AC/h | 20 AC/h | 25 AC/h |
---|---|---|---|---|---|---|---|---|---|---|
3 | 230 | 114 | 56 | 37 | 27 | 22 | 18 | 14 | 10 | 8 (10)* |
5 | 260 | 129 | 63 | 41 | 30 | 24 | 20 | 15 | 11 | 8 (10)* |
7 | 279 | 138 | 67 | 44 | 32 | 25 | 20 | 16 | 11 | 9 (10)* |
10 | 299 | 147 | 71 | 46 | 34 | 26 | 21 | 16 | 11 | 9 (10)* |
15 | 321 | 157 | 75 | 48 | 35 | 27 | 22 | 16 | 12 | 9 (10)* |
*The minimum fallow time (to allow for droplet settling time) is 10 minutes
Contact your local HPT/IPCT if further advice is required.
Read the RPE literature review to find out more about why we do things this way for respiratory protective equipment
If a resident dies when in the care home, Standard Infection Control Precautions or Transmission Based Precautions must still be applied. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for the living.
Washing and/or dressing of the deceased - Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased will give you guidance on the precautions that are required and what is permitted for certain types of infections.
Staff should advise relatives of any required precautions following viewing and/or physical contact with their deceased and also when this should be avoided.
Read the infection prevention and control during care of the deceased literature review to find out more about why we do things this way when dealing with the deceased.
If you have any questions or feedback about the Care Home IPCM then you can contact us by email or telephone.
Telephone: 0141 300 1175
The use of the word 'Persons' can be used instead of ‘Patient’ when using this document in non-healthcare settings.
A graze. A minor wound in which the surface of the skin or a mucous membrane has been worn away by rubbing or scraping.
This is a unique, demanding and fast-paced environment designed to accommodate a wide variety of urgent, or emergent patient care needs.
Certain medical and patient care activities that can result in the release of airborne particles (aerosols). AGPs can create a risk of airborne transmission of infections that are usually only spread by droplet transmission.
See Appendix 11, footnote 3 for further information
The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.
Very small particles (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).
A group of transmission based precautions to prevent the spread of airborne pathogens
A gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to inactivate microorganisms and/or temporarily suppress their growth.
An organism that is identified as being potentially significant for infection prevention and control practices. Examples of alert organisms include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff) and Group A Streptococcus.
Refers to the alveoli which are the small air sacs in the lungs. Alveoli are located at the ends of the air passageways in the lungs, and are the site at which gas exchange takes place.
An area with a door from/to the outside corridor and a second door giving access to the patient area (where both doors will never be open at the same time).
An agent that kills microorganisms, or prevents them from growing. Antibiotics and disinfectants are antimicrobial agents.
Hand wipes that are moistened with an antimicrobial solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth.
The ability of a microorganism to resist the action of an antimicrobial drug/agent which previously could treat the infection caused by that microorganism.
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.
A healthcare procedure designed to minimise the risks of exposing the person being cared for to pathogenic micro-organisms during simple (e.g dressing wounds) and complex care procedures (e.g. surgical procedures).
Not showing any symptoms of disease but where an infection may be present.
Machine used for sterilising re-usable equipment using superheated steam under pressure.
A partly enclosed area within a ward containing one bed (single bay) or multiple beds (multi-bed bay).
Viruses carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.
Fluid produced by the body such as urine, faeces, vomit or diarrhoea.
A group of bacteria that have become extremely resistant to antibiotics including those called carbapenems.
Includes but is not limited to general practice, dental and pharmacy (primary care), acute-care hospitals, emergency medical services, urgent-care centres and outpatient clinics (secondary care), specialist treatment centres (tertiary care), long-term care facilities such as nursing homes and skilled nursing facilities (community care), and care provided at home by professional healthcare providers (home care).
Any person who cares for patients, including healthcare support workers and nurses.
A large, centralised facility for the decontamination and re-processing of re-usable medical equipment e.g. surgical instruments.
An intravenous catheter that is inserted directly into a large vein in the neck, chest or groin to allow intravenous drugs and fluids to be given and to allow blood monitoring.
A chemical that is used for disinfecting, fumigating and bleaching.
The removal of any dirt, body fluids (blood, vomit) etc by use of an appropriate cleaning agent such as detergent.
A sink designated for hand washing in clinical areas.
An infectious agent (bacterium) that can cause mild to severe diarrhoea which in some cases can lead to gastro-intestinal complications and death.
An area (room, bay, ward) in which two or more patients (a cohort) with the same confirmed infection are placed. A cohort area should be physically separate from other patients.
The presence of 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.
Mucous membranes that cover the front of the eyes and the inside of the eyelids.
Series of procedures/interventions used in addition to routine practices to prevent transmission of infectious agents that spread by direct or indirect contact
The spread of infectious agents from one person to another by contact. When spread occurs through skin-to-skin contact, this is called direct contact transmission. When spread occurs via a contaminated object, this is called indirect contact transmission.
The presence of an infectious agent on a body surface; also on or in clothes, bedding, surgical instruments or dressings, or other inanimate articles or substances including water and food.
Measures that are taken to minimise the spread of respiratory infections to others.
Spread of infection from one person, object or place to another.
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.
A chemical cleansing agent that can dissolve oils and remove dirt.
3 or more loose or liquid bowel movements in 24 hours or more often than is normal for the individual.
Spread of infectious agents from one person to another by direct skin-to-skin contact.
A chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.
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.
Waste produced in the care setting that is similar to waste produced in the home.
A small drop of moisture, larger than airborne particle, that may contain infectious agents. Droplets can be released when a person talks, coughs or sneezes, and during some medical or patient care procedures such as open suctioning and cough induction by chest physiotherapy. It is thought that droplets can travel around 1 metre (3 feet).
The spread of infection from one person to another by droplets containing infectious agents.
An agent used to soothe the skin and make it soft and supple.
This is a single room with space for one patient and contains a bed; locker/wardrobe; clinical wash-hand basin, en-suite shower, WC and wash-hand basin and has a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas and a lobby with positive pressure ventilation.
It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors.
The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards.
This is a single room with space for one patient and contains a bed; locker/wardrobe; clinical wash-hand basin, en-suite shower, WC and wash-hand basin and has a ventilation system that prevents uncontrolled escape of infectious aerosols from the room to adjacent areas.
It can also provide a degree of dilution of infectious aerosols in the room for the safety of staff and visitors.
The room should have extract ventilation that exceeds its supply, such that gaps in its fabric leak inwards not outwards.
A room containing a sink and toilet and sometimes a shower/wetroom or bath.
A room with space for one patient and containing a bed; locker/wardrobe, clinical wash-hand basin, en-suite shower, WC and wash-hand basin.
A single case of an infection that has severe outcomes for an individual patient OR has major infection control/public health implications e.g. infectious diseases of high consequence such as extensively drug resistant tuberculosis (XDR-TB).
Waste products produced by the body such as urine and faeces (bowel movements).
The condition of being exposed to something that may have a harmful effect such as an infectious agent.
Certain medical and patient care procedures where there is a risk that injury to the healthcare worker may result in exposure of the patient’s open tissues to the healthcare worker’s blood e.g the healthcare worker’s gloved hands are in contact with sharp instruments, needle tips or sharp tissues inside a patient’s body.
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.
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.
Respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). FFP stands for filtering facepiece. There are three categories of FFP respirator: FFP1, FFP2 and FFP3. An FFP3 respirator or hood provides the highest level of protection, and is the only category of respirator legislated for use in UK healthcare settings.
A method of checking that a tight-fitting facepiece respirator fits the wearer and seals adequately to their face. This process helps identify unsuitable facepieces that should not be used.
A term applied to fabrics that resist liquid penetration, often used interchangeably with 'fluid-repellent' when describing the properties of protective clothing or equipment.
General practitioner (your family doctor)
Definition taken from the HSE Approved list of biological agents www.hse.gov.uk/pubns/misc208.pdf
Group 4 infections cause severe human disease and are a serious hazard to employees; they are likely to spread to the community and there is usually no effective prophylaxis or treatment available.
The process of decontaminating your hands using either alcohol based hand rub or liquid soap and water.
A wash hand basin with mixer tap, paper towels and non-antimicrobial liquid soap in a single use container designed for hand washing use only.
A team of healthcare professionals whose role it is to protect the health of the local population and limit the risk of them becoming exposed to infection and environmental dangers. Every NHS board has a HPT.
Infections that occur as a result of medical care, or treatment, in any healthcare setting.
Two or more linked cases associated with the same infectious agent, within the same healthcare setting, over a specified time period; or a higher than expected number of cases in a given healthcare area over a specified time period.
A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.
An exposure of patients, staff, or the public to a possible infectious agent, as a result of a healthcare system failure or near misses e.g. ventilation, water or a decontamination incident.
Waste produced as a result of healthcare activities for example soiled dressings, sharps.
This is a systematic process which provides a consistent approach to minimizing or eliminating exposures to hazards in the workplace.
Used by the IPCT or HPT to assess every healthcare infection incident i.e. all outbreaks and incidents including decontamination incidents or near misses in any healthcare setting (that is the NHS, independent contractors providing NHS Services and private providers of healthcare).
Waste that is produced from personal care. In care settings this includes feminine hygiene products, incontinence products and nappies, catheter and stoma bags. Hygiene waste may cause offence due to the presence of recognisable healthcare waste items or body fluids. It is usually assumed that hygiene waste is not hazardous or infectious.
A chlorine-based disinfectant such as bleach
To provide immunity to a disease by giving a vaccination.
Any person whose immune response is reduced or deficient, usually because they have a disease or are undergoing treatment. People who are immunocompromised are more vulnerable to infection.
Cannot be penetrated by liquid.
A multidisciplinary group with responsibility for investigating and managing an incident.
The spread of infectious agents from one person to another via a contaminated object.
Invasion of the body by a harmful organism or infectious agent such as a virus, parasite, bacterium or fungus.
A multidisciplinary team responsible for preventing, investigating and managing an infection incident or outbreak.
Any organism, such as a virus, parasite, bacterium or fungus, that is capable of causing an infection or infectious disease.
An Infectious Disease of high consequence (IDHC) typically causes severe symptoms requiring a high level of care and a high case-fatality rate, there may not be effective prophylaxis or treatment. IDHC are transmissible from human to human (contagious) and capable of causing large-scale epidemics or pandemics.
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”.
A device which penetrates the body, either through a body cavity or through the surface of the body. Central Venous Catheters (central line), Peripheral Arterial Lines and Urinary Catheters are examples of invasive devices.
A medical/healthcare procedure that penetrates or breaks the skin or enters a body cavity.
Physically separating patients to prevent the spread of infection.
An isolation room/suite consists of enhanced en-suite single bed rooms:
An en-suite single bed room is defined as: consisting of a bed; locker/wardrobe; clinical wash-hand basin and en-suite shower, WC and wash-hand basin. (In new build, space for a social support zone for overnight stay and a clinical support zone is also provided).
No terms
No terms
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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 facilities provide a variety of services, both medical and personal care, to people who are unable to live independently.
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.
Any living thing (organism) that is too small to be seen by the naked eye. Bacteria, viruses and some parasites are microorganisms.
The way that microorganisms spread from one person to another. The main modes or routes of transmission are airborne (aerosol) transmission, droplet transmission and contact transmission.
An incident in which the mucous membranes (e.g mouth, nose, eyes) are exposed to blood/other body fluid.
The surfaces lining the cavities of the body that are exposed to the environment such as the lining of the mouth and nose.
A room that contains more than one bed.
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.
Any device designed to reduce the risk of injury from needles. This may include needle-free devices or mechanisms on a needle, such as an automated resheathing device, that cover the needle immediately after use.
A room which maintains permanent negative pressure i.e. air flow is from the outside adjacent space (e.g. corridor) into the room and then exhausted to the outside.
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.
A synthetic rubber material used to make non-latex gloves.
Skin that is broken by cuts, abrasions, dermatitis, chapped skin, eczema etc.
An incident in which non-intact skin is exposed to blood or body fluids.
Care procedure that does not need to be undertaken in conditions that are free from bacteria or other microorganisms.
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.
Exposure of healthcare workers or care staff to blood or body fluids in the course of their work.
Any living thing that can grow and reproduce, such as a plant, animal, fungus or bacterium.
When two or more people have the same infection, or more people than expected have the same infection. The cases will be linked by a place and a time period.
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.
Any disease-producing infectious agent.
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.
Highly accurate tests used to diagnose certain infectious diseases.
An injury caused by a sharp instrument or object such as a needle or scalpel, cutting or puncturing the skin.
Equipment a person wears to protect themselves from risks to their health or safety, including exposure to infections e.g. disposable gloves and disposable aprons.
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.
These provide the first point of contact in the healthcare system and includes general practice, dentistry, community pharmacies etc
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:
Fever. Rise in body temperature above the normal level >37.2°.
A period of isolation to prevent spread of a contagious disease.
To put a needle or other sharp object back into its plastic sheath or cap. Also known as ‘re-sheathing’.
A small droplet >5 μm in diameter, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.
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.
Terms used to describe the placement of patients during periods of high prevalence of respiratory viruses/infection. This is determined by the presence of respiratory symptoms or risk factors associated with respiratory viruses.
Further details can be found in the Winter (21/22), Respiratory Infections in Health and Care settings Infection Prevention and Control Addendum.
A medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury. Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.
All sinks and furniture in a bathroom, such as a toilet, bath, shower etc.
Performing a test or enquiry to identify individuals at risk of a specific disorder or infection to warrant further investigation or direct preventive action.
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.
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.
Physically separating or isolating from other people.
A life threatening condition that arises when the body’s response to a severe complication of infection e.g. pneumonia (lung infection) injures its own tissues and organs. This can lead to multiple organ failure and death. Early recognition, treatment and management is key to successful patient outcomes.
A ‘sharp’ is a device or instrument used in healthcare settings with sharp points or edges, such as needles, lancets and scalpels which have the potential to cause injury through cutting or puncturing the skin.
A type of percutaneous injury caused by a sharp instrument or device which cuts or penetrates the skin.
A percutaneous, mucocutaneous exposure or non-intact skin (abrasions, cuts, eczema) exposure to blood/other body fluids from a source that is known (or later found to be) positive for a bloodborne virus infection.
An incident which involves a used needle that has exposed, or may have exposed, the employee to blood/body fluids.
A room with space for one patient and usually contains as a minimum: a bed; locker/wardrobe; clinical wash-hand basin.
Single-bed rooms should also have en-suite sanitary facilities comprising of a shower, WC and a general wash-hand basin.
A reproductive cell produced by fungi and some types of bacteria under certain environmental conditions. Spores can survive for long periods of time and are very resistant to heat, drying and chemicals.
A dedicated team of healthcare staff who care for a cohort of patients, and do not care for any other patients.
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.
Free from live bacteria or other microorganisms
Care procedure that is undertaken in conditions that are free from bacteria or other microorganisms.
The procedure of making some object free of all germs, live bacteria or other microorganisms (usually by heat or chemical means).
A disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious droplets and also to protect patients. When recommended for infection control purposes a 'surgical face mask' typically denotes a fluid-resistant (Type IIR) surgical mask.
The process of removing debris and sterilizing hands prior to performing a sterile or surgical procedure.
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.
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).
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.
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.
These are additional measures that are used in conjunction with SICPs when caring for patients with a known or suspected infection or colonisation.
No terms
A suspension that is administered in order to stimulate the immune response of the body against an infectious agent.
Any medical instrument used to access a patient’s veins or arteries such as a Central Venous Catheter or peripheral vascular catheter.
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.
The viral load or viral burden is a numerical expression of the amount of virus present in biological fluids or environmental specimens.
An area forming a division of a care setting (or a suite of rooms) shared by patients who need a similar type of care.
No terms
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No terms