NIPCM

Responsibilities for the content of this manual

ARHAI Scotland must ensure

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

Stakeholders of the ARHAI Scotland programmes must ensure

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

Responsibilities for the adoption and implementation of this manual

Organisations must ensure:

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

Managers of all services must ensure that staff:

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

Staff providing care must ensure that they:

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

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

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

 

Last updated: 4 October 2021

 

 

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

SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection.

Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes, any equipment or items in the care environment that could have become contaminated and even the environment itself if not cleaned and maintained appropriately.

The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction and/or the anticipated level of exposure to blood and/or other body fluids.

To be effective in protecting against infection risks, SICPs must be applied continuously by all staff. The application of SICPs during care delivery must take account of;

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

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

SICPs implementation monitoring must also be ongoing to demonstrate safe practices and commitment to patient, staff and visitor safety.

Further information on using SICPs for Care at Home can be found on the NHS National Education Scotland (NES) website.

 ¹The use of the word 'Persons' can be used instead of 'Patient' when using this document in non-healthcare settings.

 

Last updated: 4 October 2021

1.1 Patient Placement/Assessment for infection risk

Patients must be promptly assessed for infection risk on arrival at the care area (if possible, prior to accepting a patient from another care area) and should be continuously reviewed throughout their stay. This assessment should influence patient placement decisions in accordance with clinical/care need(s).

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

• With symptoms such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms.
• With a known (laboratory confirmed) or suspected infectious pathogen for which duration of precautions as outlined in appendix 11 are not yet complete
• Known or suspected to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
• Who have been a close contact of a person who has been colonised or infected with CPE in the last 12 months.
• Who have been in contact with a confirmed COVID-19 individual and are still within the 14-day self-isolation period.
• Who have been hospitalised outside Scotland in the last 12 months (including those who received dialysis).

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

Resources

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

1.2 Hand Hygiene

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

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

Before performing hand hygiene:

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

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

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

To perform hand hygiene:

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

Perform hand hygiene:

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

 

Some additional examples of hand hygiene moments include:

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

Resources

Download and print the 5 moments of hand hygiene poster.

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

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

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

Staff working in the community should carry a supply of Alcohol Based Hand Rub (ABHR) to enable them to perform hand hygiene at the appropriate times. 

Where staff are required to wash their hands in the service user’s own home they should do so for at least 20 seconds using any hand soap available. 

Staff should carry a supply of disposable paper towels for hand drying rather than using hand towels in the individual’s own home.  Once hands have been thoroughly dried, ABHR should be used.

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

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

Resources

For how to wash hands see Appendix 1

For how to hand rub see Appendix 2

Skin care

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

Surgical Hand Antisepsis

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

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

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

Resources

For surgical scrubbing technique see Appendix 3.

For surgical rubbing technique see Appendix 4. 

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

Information on the WHO World Hand Hygiene Day 2021 with the theme 'Achieving hand hygiene at the point of care' is available.

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

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

  (The video above demonstrating Surgical Scrubbing using ABHR was produced by Golden Jubilee National Hospital)

1.3 Respiratory and Cough Hygiene

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

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

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

Resources 

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

1.4 Personal Protective Equipment

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

All PPE should be:

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

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

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

Gloves must:

• be worn when exposure to blood and/or other body fluids is anticipated/likely;²
• be changed immediately after each task performed;
• be worn appropriately and removed after use
• never be worn inappropriately in situations such as; to go between patients, move around a care area, work at IT workstations,
• be changed if a perforation or puncture is suspected;
• be appropriate for use, fit for purpose and well-fitting.

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.

Resources

For appropriate glove use and selection see Appendix 5.

Further information can be found in the Gloves literature review.

Aprons must be:

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

Full body gowns/Fluid repellent coveralls must be:

• worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in the operating theatre;
  
  
• worn when a disposable apron provides inadequate cover for the procedure/task being performed;
  
  
• changed between patients and immediately after completion of a procedure or task.

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

Sterile surgical gowns must be:

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

Reusable gowns must:

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

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

Resources

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

Eye/face protection must:

• be worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely  and always during Aerosol Generating Procedures.
  
  
• be worn by all scrubbed members of the surgical team for all surgical procedures;
  
  
• not be impeded by accessories such as piercings/false eyelashes;
  
  
• not be touched when worn;
  
  
• cover the full peri-orbital region and wrap around the sides of the face;
  
  
• be removed or changed in accordance with manufacturer’s instructions, if vision is compromised through contamination with blood or body fluids, if the integrity of the equipment is compromised, at the end of a clinical procedure/task and/or prior to leaving the dedicated clinical area.

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

Resources

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

Fluid Resistant Type IIR surgical face masks must be:

• worn by a patient known or suspected to be infected with a micro-organism spread by the droplet or airborne route when leaving their room or when moving between clinical areas.

• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated/likely;
  (as part of SICPs a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray.)

• worn in combination with a full face shield, integrated half face shield or goggles for AGPs on non-infectious patients;
  
  
• worn to protect patients from the operator as a source of infection when performing invasive spinal procedures such as myelography, lumbar puncture and spinal anaesthesia ,inserting a Central Vascular Catheter (CVC), performing intra-articular (joint) injections;
  
  
• worn by all scrubbed members of the theatre surgical team for all surgical procedures;
  
  
• worn by non-scrubbed members of the theatre surgical team if deemed necessary following a risk assessment of exposure to blood and/or body fluids;
  
  
• well fitting and fit for purpose (fully covering the mouth and nose);
  
  
• removed or changed;
  • at the end of a procedure/task;
    
    
  • if the integrity of the mask is breached, e.g. from moisture build-up after extended use or from gross contamination with blood or body fluids;
    and
  • in accordance with specific manufacturers’ instructions.

Resources

Further information can be found in:

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

Footwear must be:

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

Resources

Further information can be found in the footwear literature review.

Headwear must be:

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

Resources

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.

1.5 Safe Management of Care Equipment

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

Care equipment is classified as either:

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

Before using any sterile equipment check that:

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

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

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

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

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

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

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

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

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

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

1.6 Safe Management of Care Environment

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

The care environment must be:

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

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

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

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

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

1.7 Safe Management of Linen

Clean linen

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

Linen used during patient transfer

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

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

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

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

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

Local guidance regarding management of linen may be available.  

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

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

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

1.8 Safe Management of Blood and Body Fluid Spillages

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

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

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

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

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

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

 

 

 

1.9 Safe Disposal of Waste (including sharps)

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

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

Categories of waste:

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

Waste Streams:

• Black – Trivial risk:
  • Domestic waste or yellow and black stripes (small quantities of hygiene waste).
  • Final disposal to Landfill.
  • Clear/opaque receptacles may also be used for domestic waste at care area level.
• Orange, Light Blue (laboratory) – Low risk
  • Orange - consists of items which are contaminated or likely to be contaminated with blood and/or body fluids including saliva . Final disposal following heat disinfection is to landfill.
  • Light Blue – laboratory/microbiological waste that must be autoclaved before disposal via the orange stream.

• Yellow– High risk:
  • Waste which poses ethical, highly infectious or contamination risks.
  • This includes anatomical and human tissue which is recognisable as body parts, medical devices and sharps waste boxes that have red, purple or blue lids.
  • Disposal is by specialist incineration.

• Red – Special waste
  • Chemical waste.

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

Safe waste disposal at care area level:

Always dispose of waste:

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

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

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

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

Sharps boxes must:

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

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

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

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

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

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

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

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

Needles must not be re-sheathed/recapped.⁴

Always dispose of needles and syringes as 1 unit.

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

A significant occupational exposure is:

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

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

For the management of an occupational exposure incident see Appendix 10

Further information can be found in the occupational exposure management (including sharps) literature review.

⁴  A local risk assessment is required if re-sheathing is undertaken using a safe technique for example anaesthetic administration in dentistry.

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

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

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

TBPs are categorised by the route of transmission of infectious agents (some infectious agents can be transmitted by more than one route): Appendix 11 provides details of the type of precautions, optimal patient placement, isolation requirements and any respiratory precautions required.  Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

Contact precautions

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

Droplet precautions

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

Airborne precautions

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

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

 

Last updated 4 October 2021

2.1 Patient Placement/Assessment for Infection Risk

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

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

• With symptoms of infection such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms.
• Known (laboratory confirmed) or suspected to have an infectious pathogen for which duration of precautions as outlined in appendix 11 are not yet complete.
• Known or suspected to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
• Who have been a close contact of a person who has been colonised or infected with CPE in the last 12 months.
• Who have been in contact with a confirmed COVID-19 individual and are still within the 14-day self-isolation period.
• Who have been hospitalised (inpatient) outside Scotland in the last 12 months (including those who received dialysis) .

Isolation facilities should be prioritised depending on the known/suspected infectious agent (refer to Aide Memoire - Appendix 11).  All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.

When single-bed rooms are limited, patients who have conditions that facilitate the transmission of infection to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, invasive devices, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) should be prioritised for placement in a single-bed room. Single-bed room prioritisation should be reviewed daily and the clinical judgement and expertise of the staff involved in a patient's management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought particularly for the application of TBPs e.g. isolation prioritisation when single rooms are in short supply. 

Hospital settings:

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

Cohorting in hospital settings

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

Patients who should not be placed in multi bed cohorts;

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

Staff cohorting; consider assigning a dedicated team of care staff to care for patients in isolation/cohort rooms/areas as an additional infection control measure during outbreaks/incidents. This can only be implemented through planning of staff rotas if there are sufficient levels of staff available to ensure consistency in staff allocation (so as not to have a negative impact on non-affected patients’ care).

Before discontinuing isolation; individual patient risk factors should be considered (e.g. there may be prolonged shedding of certain microorganisms in immunocompromised patients). Clinical and molecular tests to show the absence of microorganisms may be considered in the decision to discontinue isolation and can reduce isolation times. The clinical judgement and expertise of the staff involved in a patient’s management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought on decisions regarding isolation discontinuation.

Primary care/out-patient settings:

• Patients attending these settings with suspected/known infection/colonisation should be prioritised for assessment/treatment e.g. scheduled appointments at the start or end of the clinic session. Infectious patients should be separated from other patients whilst awaiting assessment and during care management by at least 2 metres. 
• If transfer from a primary care facility to hospital is required, the ambulance service should be informed of the infectious status of the patient.

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

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

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

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

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

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

2.3 Safe Management of the Care Environment

Routine environmental decontamination

Hospital/Care home setting:

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

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

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

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

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

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

Vacated rooms should also be decontaminated following an AGP.

Primary care/Out-patient settings:

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

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

Terminal decontamination

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

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

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

The room should be decontaminated using either:

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

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

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

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

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

When an organisation adopts practices that differ from those recommended/stated in the NIPCM with regards to cleaning agents, the individual organisation is fully responsible for ensuring safe systems of work, including the completion of local risk assessment(s) approved and documented through local governance procedures.

 

2.4 Personal Protective Equipment (PPE)

2.4.1  Surgical masks

A type IIR fluid resistant surgical mask should be worn when caring for a patient with a suspected/confirmed infectious agent spread by the droplet route.

Surgical masks worn by patients with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control, should meet type II or IIR standards.

2.4.2  Eye/face protection

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

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

Eye/face protection should be worn

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

2.4.3  Aprons/Gowns

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

Plastic aprons should be used in health and social care settings for protection against contamination with blood and/or body fluids. 

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

A full body fluid repellent gown should be worn when conducting AGPs on patients known or suspected to be infected with a respiratory infectious agent.

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

 

2.4.4  RPE

Filter Face Piece 3 (FFP3) Respirators

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

Where it is not reasonably practicable to prevent exposure to a substance hazardous to health (as may be the case where healthcare workers are caring for patients with suspected or known airborne micro-organisms) the hazard must be adequately controlled by applying protection measures appropriate to the activity and consistent with the assessment of risk. If the hazard is unknown the clinical judgement and expertise of IPC/HP staff is crucial and the precautionary principle should apply.

Respiratory Protective Equipment (RPE) i.e. FFP3 and facial protection, must be considered when:

• a patient is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route; and
• when carrying out aerosol generating procedures (AGPs) on patients with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

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

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

Poster on compatibility of facial hair and FFP3 respirators can be used when fit testing and fit checking.

 

Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.

The following risk categorisation is the minimum requirement for staff groups that require FFP3 fit testing. NHS Boards can add to this for example where high risk units are present. This categorisation is inclusive of out of hours services.

National Priority Risk Categorisation for face fit testing with FFP3

Level 1 – Preparedness for business as usual

Staff in clinical areas most likely to provide care to patients who present at healthcare facilities with an infectious pathogen spread by the airborne route; and/or undertake aerosol generating procedures i.e. A&E, ICU, paediatrics, respiratory, infectious diseases, anaesthesia, theatres, Chest physiotherapists, Special Operations Response Team (Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams, mortuary staff.

Level 2 – Preparedness in the event of emerging threat

Staff in clinical setting likely to provide care to patients admitted to hospital in the event of an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all other ambulance transport staff.

In the event of an ‘Epidemic/Pandemic’ Local Board Assessment as per their preparedness plans will apply.

• The decision to wear an FFP3 respirator/hood should be based on clinical risk assessment e.g task being undertaken, the presenting symptoms, the infectious state of the patient, risk of acquisition and the availability of treatment.

For a list of organisms spread wholly or partly by the airborne (aerosol) or droplet routes see Appendix 11.

Further information can be found in the aerosol generating procedures literature review.

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

Powered hoods must be:

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

FFP3 respirator or powered respirator hood:

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

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

Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) literature review.

Frameworks to support the assessing and recording of staff competency in PPE for HCID are available in the resources section of the NIPCM.

2.5 Infection Prevention and Control during care of the deceased

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

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)

Built environment incidents/outbreaks

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

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

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

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

 

 

3.1 Definitions of Healthcare Infection Incident, Outbreak and Data Exceedance

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

A healthcare infection incident may be:

An exceptional infection episode

• A single case of any serious illness which has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high consequence such as VHF or XDR-TB.

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

A healthcare associated infection outbreak

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

or

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

A healthcare infection exposure incident

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

A healthcare infection data exceedance

• A greater than expected rate of infection compared with the usual background rate for that healthcare location.

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

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

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

3.2.1 Assessment

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

• Undertake an initial assessment, utilising the Healthcare Infection Incident Assessment Tool (HIIAT) - Appendix 14, gather epidemiological data and clinical assessment information on the patients condition as per:
  • Section 1.1
  • Section 2.1

• Based on this initial assessment the IPCT/HPT may choose to convene a Problem Assessment Group (PAG) to further assess and determine if an IMT is required.
  • If the HIIAT is assessed as Green and there is no HPS support required then this should be reported as per DL(2019)23. If support is required this should be communicated to HPS. The HIIAT Green reporting protocol, procedure and template is available from the resources section.
  • If the HIIAT is assessed Amber or Red report to HPS. Healthcare Infection Incident and Outbreak Reporting Template (HIIORT) - Appendix 15 should be completed.

3.2.2 Investigation

The IPCT/HPT will establish an IMT if required.

• In the NHS hospital setting the ICD will usually chair the IMT and lead the investigation of healthcare incidents.  Where there are implications for the wider community e.g. TB or measles, or rare events such as CJD or a Hepatitis B/HIV look back, or where there is an actual or potential conflict of interest with the hospital service, the CPHM may chair the IMT. A draft agenda for the IMT is available.
• The membership of the IMT will vary depending on the nature of the incident.
• A case definition for the purpose of the incident will be agreed. A case definition should include the following: the people involved (e.g. patients, staff); the symptoms/pathogen/infection (e.g. with Group A Streptococci); the place (e.g. care area(s) involved); and a limit of time (e.g. between January and March year/date). The case definition(s) should be regularly reviewed and refined (if required) throughout the incident investigation as more information becomes available.
• The investigation of the incident should include: an ongoing epidemiological investigation; the nature and characteristics of the incident e.g. a microbiological investigation; and how cases were exposed to the infective agent or other hazard to inform control measures.
• Identify any change(s) in the system: staffing, procedures/processing, equipment, suppliers. A step-by-step review of procedure(s). A generic outbreak checklist is available.
• Identify and count all cases and/or persons exposed: This includes the total number of confirmed/probable/possible exposed cases. An incident/outbreak data collection tool is available.
• The IMT should receive and discuss all information gathered and epidemiological outputs e.g. an epidemiological (epi) curve, a timeline and a ward map to:
  • Generate hypotheses as to which cross-transmission pathways and clinical procedures may be involved.
  • Determine whether additional case finding and control measures may be necessary.
  • Confirm that all incident control measures are being applied effectively and are sufficient.
• If staff screening is being considered as part of the investigation DL (2020)1 must be followed.
• HAI deaths, which pose an acute and serious public health risk, must be reported to the Procurator Fiscal, refer to SGHD/CMO(2014)27.
• If no new cases arise and any remaining cases are considered to no longer pose a risk, the IMT should agree on actions prior to resumption of normal service.
• Once the incident is over the IMT/NHS Board should evaluate and report on the effectiveness and efficiency of incident management using the Hot Debrief Tool.This is not a mandatory requirement but for the purpose of sharing lessons learned across Scotland.

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

3.3 COVID-19 Definition of confirmed and suspected case

COVID-19 case definitions are regularly reviewed and can be found in the guidance for secondary care and are defined as:

Confirmed 

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

Suspected 

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

Community definition:

recent onset new continuous cough

or

fever

or

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

Definition for individuals requiring hospital admission:

clinical or radiological evidence of pneumonia

or

Acute Respiratory Distress Syndrome

or

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

or

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

 

 

 

3.4 COVID-19 Notification of positive cases

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

Reporting systems should also be in place to alert the relevant teams of any positive staff cases.  There must be a robust and clear process in place for recording and communication of results to staff members.

The Occupational Health Service (OHS) will be key to this process. Staff who have a positive result may require advice, counselling and support.  Staff confidentiality and records of test results must be maintained securely.  It is recognised that staff in some organisations such as Scottish Ambulance Service, do not fall under the remit of OHS but will be captured under the test and protect service. 

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

3.4.1 Communicating results

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

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

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

3.4.2 Communication with other care facilities and NHS boards

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

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.

3.4.3 Surveillance

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

 

3.5 COVID-19 Outbreak definitions

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

3.5.1 Criteria to declare a COVID-19 outbreak in an inpatient setting

Two or more patient 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 non-COVID-19 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

In High Risk Pathway where two or more staff cases of suspected or confirmed COVID-19 are identified.

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

3.5.2 Criteria to determine that a COVID-19 outbreak in an inpatient setting has ended

No new test-confirmed or suspected cases with illness onset date 14 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 outbreak can be declared closed provided that these criteria are met.  Stepdown guidance and further information on isolation periods can be accessed .

 

 

3.6 COVID-19 Roles and Responsibilities

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

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

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

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

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

 

3.6.2 Contact tracing responsibilities

The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing and follow up amongst the following groups of individuals:

• Inpatients
• Outpatients
• Community contacts of an inpatient prior to admission
• Visitors
• Healthcare workers and wider staff groups

Typically, IPCTs will follow up inpatient contacts, OHS will follow up staff contacts and HPTs will follow up any contacts in the exposure period prior to hospital admission and visitors.

3.6.3 Case definition for the incident

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

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

Suggested case definitions for COVID-19 as follows;

• Confirmed case (Recorded as confirmed case in reporting tool): PCR positive COVID-19 test in anyone associated with ward ** during a specified time period
• Probable case (Recorded as suspected (symptomatic) case in reporting tool): Anyone on ward ** with symptoms of COVID-19 during a specified time period
• Possible case (Recorded as contacts (asymptomatic) in reporting tool): Anyone who has been exposed to COVID-19 on ward ** during a specified time period but not yet developed symptoms

 

 

3.7 COVID-19 Investigations

3.7.1 IPC practice and compliance (including AGPs)

3.7.2 Review of visiting

3.7.3 Testing during an outbreak

3.7.4 Whole Genome Sequencing

3.7.5 Contact tracing

3.7.6 Ventilation considerations

3.7.7 Bed spacing

3.7.11 COVID-19 messaging

 

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

3.7.1 IPC practice and compliance (including AGPs)

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

Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the 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 outbreak investigation. 

Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within the Scottish COVID-19 addendum.

Ensure that patients are wearing face masks appropriately as per the Scottish COVID-19 addendum.

3.7.2 Review of visiting

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

3.7.3 Testing during an outbreak

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

LFD testing may be undertaken to enable early detection of cases during an outbreak however, regardless of LFD result, a confirmatory follow up PCR test must also be undertaken.

• Patients: All patients symptomatic of COVID-19 should be tested.
  
  
• Staff: All staff who are symptomatic of COVID-19 must be tested and excluded from work. Follow COVID-19: Management of exposed healthcare workers and patients in hospital settings.

3.7.4 Whole Genome Sequencing

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

3.7.5 Contact tracing

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

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

The case definitions below should be applied to determine who is a potential contact requiring self-isolation and should take account of all staff, patients and visitors.  IPCTs should then consider any mitigating factors which will exclude staff being identified as a contact and avoid the need for these staff having to be excluded from work.

Case definitions for contacts

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

Household contact:

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

Non-household contact

Direct contact:

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

Proximity contact:

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

Contact tracing patients

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

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

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

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

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

Contact tracing staff

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

Contact tracing visitors

It is essential that ward staff keep comprehensive lists of all visitors who have come into the ward.  These lists should be provided to Test and Protect teams when an outbreak is recognised to enable contact tracing of visitor contacts.  Teams should take into account the PPE worn by visitors when considering them as possible contacts requiring self-isolation.  Details of visitor PPE can be found within the Scottish COVID-19 addendum . 

It should be noted that whilst visitors may have worn PPE as advised by staff, they are not trained in donning and doffing and therefore there remains a higher risk of exposure.

3.7.6 Ventilation considerations

Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation.  It is important to consider best practice on ventilation and FAQs developed specifically in response to the COVID-19 pandemic.  The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated. 

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

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

3.7.7 Bed spacing

Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing are adequate. See section 5.12.1 of COVID-19 addendum.

 

3.7.11 COVID-19 messaging

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

• Physical distancing
• Hand hygiene
• Appropriate use of face masks and face coverings
• Awareness of COVID19 symptoms & requirement for patients/staff/visitors to report symptoms to staff
• No visiting if symptomatic
• Staff testing

Every opportunity to promote this messaging should be considered.

3.8 COVID-19 Formulate hypothesis

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

3.9 COVID-19 Control Measures

3.9.1 Patient placement

3.9.2 Hand hygiene

3.9.3 Personal Protective Equipment

3.9.4 Safe Management of care Equipment

3.9.5 Safe Management of Care Environment

3.9.6 Waste and Linen

3.9.7 Staff

3.9.8 Management of staff exposed to a case

3.9.9 Closure of the ward/unit

3.9.10  Other control measures which may be considered by the IMT

3.9.11 Conversion of outbreak ward to high risk pathway

 

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

3.9.1 Patient placement

• The PAG/IMT must agree the most appropriate placement for the suspected/confirmed cases and any contacts that are identified.
• Ideally, those who are confirmed cases of COVID-19 should be transferred to the High Risk (Red) Pathway as soon as possible.
• Cohort areas may be established where required and may consist of the following;
  • Confirmed positive COVID-19
  • Asymptomatic contacts of COVID-19
• Suspected cases (symptomatic) should be isolated on the ward and tested for COVID-19 as soon as possible. Symptomatic patients should not be cohorted together.  The cohorting of symptomatic patients’ risks transmission of other respiratory viruses whilst the causative pathogen remains unknown.
• Doors to isolation rooms and cohorts should be closed and signage clear.
• Patient placement is regularly reviewed and documented in patient case notes.
• Restrict transfers to any other ward or department unless essential.
• Depending on the degree of exposure to the index case/s, the number of patients exposed, type of department in which the outbreak has occurred, the clinical needs of the patients and where staffing allows, it may be necessary to leave the contacts in the low or medium risk COVID-19 pathway and apply cohort nursing – a local risk assessment should be undertaken by the IMT and take account of whether the ward will remain open or closed.

Any asymptomatic contacts should be isolated or remain cohorted together until the 14 day isolation period has elapsed. 

During the isolation period, contacts must be managed in the same manner as a confirmed case on the High risk pathway.

• If a contact develops symptoms during the 14 day isolation period, testing should be performed as soon as possible. If a contact tests positive for COVID-19 they should be transferred to the High Risk (Red) pathway as soon as possible to complete their isolation period which should be reset to commence from the day of symptom onset.
• All efforts should be made to dedicate staff to the management of the cohort and ideally those staff must not then go between the case and contacts and all other unaffected patients on the ward. These staff cohorts should be maintained wherever possible for the duration of the isolation period.

3.9.2 Hand hygiene

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

3.9.3 Personal Protective Equipment

• Reinforce appropriate PPE use as per COVID-19 IPC addendum (general use and AGP) to all staff groups
• Ensure adequate PPE supplies are available

3.9.4 Safe Management of care Equipment

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

3.9.5 Safe Management of Care Environment

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

3.9.6 Waste and Linen

• Waste associated with the affected area is disposed of as category B waste and in line with COVID-19 addendum.
• All linen used by patients in the affected area should be managed as infectious linen in line with COVID-19 addendum.
• When a bed is vacated and the linen removed, new linen should not be put in place until the ward or bed bay has been terminally cleaned and is ready to re-open to admissions and transfers.

3.9.7 Staff

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

3.9.8 Management of staff exposed to a case

• IMTs should refer to the COVID-19: Management of HCW and exposed patients or residents in health and social care settings when managing staff identified as contacts.
• Staff members who have a positive test must inform their line manager and arrangements should be made for them to stop work immediately and return home, avoiding the use of public transport. Local arrangements for transport of infected patients should be followed.
• NHS Boards should have arrangements in place to backfill staff who test positive.
• The staff member who tests positive will need to self-isolate for a period of 10 days, and their households also need to isolate for a period of 10 days as described by NHS Inform in Coronavirus (COVID-19): Guidance for households with possible coronavirus infection.
• In addition, staff who test positive will be contacted by the contact tracing team as part of the Test and Protect programme.
• More information can be found in the healthcare worker testing guidance on the Scottish Government website.

3.9.9 Closure of the ward/unit

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

3.9.10  Other control measures which may be considered by the IMT

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

3.9.11 Conversion of outbreak ward to high risk pathway

Where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a high risk pathway 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;

• If there are contacts on the ward who remain asymptomatic and do not have a confirmed COVID-19 positive test, these may be moved to other wards for the conversion to take place.  However, these contacts must be placed in single side rooms on transfer and must be managed as a high risk patient until the 14 day isolation period is complete
• There must be no patients remaining on the outbreak ward who have not yet tested positive for COVID-19 – all patients on the ward must be confirmed COVID-19 before the conversion takes place.
• The incident must remain open on the boards reporting dashboard to ensure all contacts are monitored regardless of where they are placed until the ‘ending an outbreak’ criteria is met.

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

 

 

 

 

 

3.10 COVID-19 Communications

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

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

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

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

• A cluster should be assessed using the Healthcare Infection Incident Assessment Tool (HIIAT) as per Appendix 14 of the NIPCM. 
• All confirmed clusters/possible outbreaks, must be reported to ARHAI. 
• A Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Too (HIIORT). should be completed for any HIIAT score of Red or Amber and for any HIIAT Green incident where support from ARHAI Scotland is required/requested. 
• HIIORTs must be submitted using the Healthcare Infection Incidents, Outbreaks and Data Exceedance Reporting Tool. 
  
• The data submitted above is reported through ARHAI to the Scottish Government Healthcare Associated Infection Policy Unit and it is essential that all fields within the tools are completed to enable reporting requirements to be met. 
• Any media statements prepared by the IMT in response to the incident should be shared with ARHAI.

 

3.12 COVID-19 Learning from the outbreak

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

An evaluation of the effectiveness and efficiency of outbreak investigations and control measures will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.

3.13 COVID-19 Outbreak Resources

• Outbreak checklist
• Outbreak data collection tool
• IMT generic COVID-19 Agenda
• IMT generic COVID-19 Agenda Aide-memoire

 

 

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

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

Appendix 1 - Assessing staff contacts in Acute Settings

This chapter contains links to guidance and useful tools for the delivery of appropriate infection prevention and control in the built environment and decontamination.

Decontamination within health and care settings ranges from decontamination of the general environment as well as decontamination of equipment and medical devices.

4.1 Chapter development

This chapter is in the early stages of development.

The guidance and tools in this chapter are developed via the ARHAI Scotland Infection Control in the Built Environment and Decontamination (ICBED) programme informed by stakeholder requirements, learning from outbreaks and joint working with NHS Assure.

Test 4.2 - Publications

Publications

Work undertaken and published to date has been cited here for ease of reference and use at a clinical level. Many of these publications were produced prior to development of chapter 4 and were published outwith the manual methodology.

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

Decontamination

Probes

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

Time to clean

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

Equipment and environment cleaning

• Roles & Responsibilities for Reusable Patient Care Equipment and Environmental Decontamination
• Summary Report from Pilot of Patient Equipment and Environment Compliance Monitoring Tool

Alternative approaches to decontamination

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

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

Built environment

Water

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

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

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.

Version control

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

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

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

9 December 2020: Version 1.4
5.5.8 New section on PPE requirements for delivery of vaccinations
5.14 New section on outbreaks

18 December 2020: Version 1.5
5.1 Link to RCPCH paediatric guidance for pre-operative admission assessment and testing requirements
5.2 New section on COVID-19 testing
5.3.7 New section on Patients returning from weekend/day pass
5.6.3 New FRSM poster (ways to improve fit)
5.15.1 New section on Whole Genome Sequencing (WGS)

23 December 2020: Version 1.6
5.1.3 Updated to reflect changes in stepdown guidance
5.2  Inclusion of SG link to asymptomatic staff testing information
5.3.5 New section Transferring non-COVID-19 patient between different wards and hospitals.

22 January 2021: Version 1.7
5.2 Update to the COVID-19 testing section and associated testing table
5.3.9 New section on guidance for the Discontinuation of Infection control precautions and discharging COVID-19 patients from hospital
5.6 Update to PPE guidance specifically in relation to visors
5.13 New section on the hierarchy of controls

18 February 2021: Version 1.8
Update to resources and Rapid reviews content
5.1.2  Additional wording added to definition of suspected case section to reflect wide variety of presenting symptoms
5.1.3 Strengthening of triage question relating to travel history
5.6 Additional paragraph in PPE section reinforcing need for visiting staff to seek clarity on patient pathway and PPE requirements prior to patient contact

26 March 2021: Version 1.9
5.3.9 Update to stepdown requirement for inpatient table to recognise need for clinical assessment
5.6.7 Sessional PPE use no longer accepted beyond eye protection in the high risk pathway and FRSMs across all pathways.
5.21 Useful tools section added

7 May 2021: Version 2.0
5.3 Inclusion of reference to undertaking risk assessments in clinical areas and using the hierarchy of controls.
5.13 Hierarchy of controls section has been updated to include a table providing examples in practice and resources, sections on organisational preparedness, ventilation, spacing and physical distancing and bed and chair spacing.

15 May 2021: Version 2.1
5.6.4 Change to AGP list to remove upper airway suctioning during Upper GI Endoscopy and replace with suctioning beyond the oro-pharynx.

18 May 2021: Version 2.2
Update to COVID-19 testing table to reflect the need to test all contacts of confirmed cases.

25 June 2021: Version 2.3
5.6.3 Table 4: Update to PPE table to emphasise Risk Assessment in low and medium risk pathway
5.6.5, Note 2: Addition of risk associated with valved respirators
Change in controls for management of linen, waste and environmental cleaning from TBPs to SICPs within the Medium Risk pathway

8 July 2021: Version 2.4
5.2 COVID-19 testing.  Update made to include 'or the first positive test, if asymptomatic or other symptoms, unless they develop new possible COVID-19 symptoms' regarding any patient who has previously tested positive for SARS-CoV-2 by PCR.
5.3.8 Update to table 2 - stepdown table for 'Patient discharging to a care facility including nursing homes and residential homes'
5.3.8 Inclusion of section on 'Patients discharged from hospital to a care home (non-COVID-19)

19 July 2021: Version 2.5
5.6  Inclusion of a specific paragraph advising on the use of FFP3 masks
5.13  Update to Hierarchy of control including risk assessment algorithm

31 August 2021: Version 2.6
Update to physical distancing

 

5.1 COVID-19 case definitions and triage

5.1.1 Definition of a confirmed case

5.1.2 Definition of a suspected case

5.1.3 Triaging patients

 

5.1.1 Definition of a confirmed case

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

5.1.2 Definition of a suspected case

A wide variety of clinical symptoms have been associated with COVID-19: headache, loss of smell, nasal obstruction, lethargy, myalgia (aching muscles), rhinorrhea (runny nose), taste dysfunction, sore throat, diarrhoea, vomiting and confusion; fever may not be reported in all symptomatic individuals. Patients may also be asymptomatic

The definition of a suspected case is as follows;

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

Community definition:

• Recent onset new continuous cough

or

• fever

or

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

Definition for individuals requiring hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

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

or

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

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

5.1.3 Triaging patients

Triaging of patients within all healthcare facilities must be undertaken to enable early recognition of COVID-19 cases.  Wherever possible, triage questions should be undertaken prior to arrival at the healthcare facility.  For emergency admissions, triage questions should be completed immediately on arrival where it is safe to do so without delaying any necessary immediate life-saving interventions. With the emergence of new variants of concern (VOC) it is essential that a travel history is sought and recorded.

The following are examples of triage questions:

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

If yes, wait until 10 day self-isolation period is complete before treatment or if urgent care is required, follow the high-risk pathway and isolate for 14 days.

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

If yes, ascertain if treatment can be delayed until results are known.  If urgent care is required, follow the high risk pathway and isolate for 14 days.

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

If yes, wait until 10 days self isolation period is complete before treatment.

Only urgent care should be provided during the self-isolation period. The patient should be placed in a single side room on the amber or red pathway depending on a clinical and individual assessment – see footnote 1 in section 5.1 (see Scottish Government COVID-19 international travel and quarantine  for the list of countries exempt from self-isolation) and will require 14 days self isolation.

Single side room placement is essential to prevent onward transmission of new Variants of Concern (VOC) within healthcare settings.

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

If yes, wait until 10 days self-isolation period is complete before treatment or if urgent care is required, follow the high-risk pathway and isolate for 14 days unless COVID-19 test is negative and COVID-19 is clinically ruled out .

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

If yes, provide advice on who to contact (GP/NHS111) or, if admission required, follow high-risk pathway and isolate for 14 days.

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

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

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

5.2 COVID-19 Testing

All planned adult elective surgical admissions should be tested in line with SIGN Guidance for Reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery and elective surgical paediatric admissions must be tested in line with RCPCH guidance. 

A letter was also issued to NHS Scotland Chief Executives on 27^th November detailing the staged roll out of the admission testing expansion plan to include;

• All emergency admissions
• All planned admissions to hospitals
• Routine testing of asymptomatic, patient facing healthcare workers

A table containing a summary of testing requirements in NHSScotland is available.  When using this table the following applies;

• Screening undertaken outwith national programmes which are detailed at the links above should be based on decision of clinical services e.g screening in critical care settings.
• Any patient who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested within a period of 90 days from their initial symptom onset, or the first positive test, if asymptomatic or other symptoms, 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. The exception to this is:
  
  • Discharge to care home/residential facilities where 2 negative tests must be achieved 24 hours apart prior to transfer
• It is recognised that a patient may meet different criteria for testing multiple times in a short period of time (admission screening, transfers to another ward, contact of a case, outbreak management). If an inpatient has undergone a COVID-19 test in the previous 24 hours, there is no need to repeat it and the result can be accepted for any of the testing requirements with the exception of
  • New symptoms onset – a new test should be performed as soon as symptoms are recognised
  • Pre elective screening – where the requirement for a negative test must be within a set time period (48 or 72 hours)

5.3 Patient placement/assessment of risk

5.3.1 Critical care units

5.3.2 Split pathways

5.3.3 Staff cohorting

5.3.4 Moving patients between pathways

5.3.5  Patient transfers

5.3.6 Single side room prioritisation

5.3.7 Patients returning from day or overnight pass

5.3.8 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

Table 1 - Stepdown requirements for hospital inpatients and positive staff remaining in hospital
Table 2 - Stepdown requirements for patients being discharged from hospital 
Table 3 - Stepdown requirements for outpatients

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

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

NHS Boards must also undertake risk assessments of clinical areas to help ensure that the high risk pathway is placed appropriately reducing risk to staff, patients and visitors and taking account the hierarchy of controls.

High-risk COVID-19 pathway

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

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

Low-risk COVID-19 pathway

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

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

   NB: Paediatric services refer to RCPCH guidance for pre-operative admission assessment and testing requirements only.  All other IPC guidance should be followed as per this addendum.

Medium-risk COVID-19 pathway

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

1. All other patients who have been triaged and who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic individuals who refuse testing or for whom testing cannot be undertaken for any reason.
3. See footnote 1
4. Recovered COVID-19 patients – see Discontinuation of IC precautions in section 5.3.9

5.3.1 Critical care units

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

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

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

Where AGPs on any medium and high risk patient is required on the main unit, this presents a risk to the surrounding patients and staff and unit-wide airborne precautions would be required. Segregation of patient pathways must continue to reduce exposure risk to medium risk pathway way patients from those in the high risk pathway.

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

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

5.3.2 Split pathways

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

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

5.3.3 Staff cohorting

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

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

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

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

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

5.3.4 Moving patients between pathways

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

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

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

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

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

5.3.5 Patient transfers (please also refer to testing table for testing requirements on transfer)

Non-COVID-19 patient transfers between wards and departments in the same hospitals

• Patient movement between different bed bays and transfers between different wards should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both wards/departments is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort. Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.
• Patients should continue to be tested immediately if clinically indicated. A clinical or a public health professional may consider testing even if the definition of a possible case is not met.

Non-COVID-19 patient transfers to a new hospital (either within the same Board or new Board

• Patient movement between hospitals should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both hospitals is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort.  Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• Patients who are transferred to a new hospital should follow the medium pathway. 
• If patient is a planned transfer to a clinically vulnerable area, then pre-transfer testing must be built into the pre-transfer testing must be built into the transfer plan and a test undertaken pre-transfer wherever possible.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.

NB: A negative test does not mean that the patient is not incubating the virus. Staff should practice vigilance in monitoring for any symptom onset in the patient after transfer and reinforce the importance of COVID-19 measures. This includes physical distancing, hand hygiene, wearing of facemasks and respiratory etiquette.

Transferring suspected/confirmed COVID-19 patients between wards, departments or hospitals during infectious period

Wherever possible, patients who are confirmed or suspected to have COVID-19 should not be moved from the high risk pathway ward until they have completed 14 days of isolation and meet the definition for a recovered patient as described in footnote 1 and criteria contained within section 5.3.9. There may however be instances where it is necessary to transfer a patient prior to completion of their 14 day isolation period such as;

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

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

Communication with the receiving department/NHS Board is vital to ensure appropriate IPC measures are continued during and after transfer.  The patient must continue to be managed as a high risk pathway patient. Communications must include;

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

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

There is no need to test the patient again on transfer provided symptomatic cases have already had a test taken.

5.3.6 Single side room prioritisation

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

Any patient who is required to quarantine following arrival to Scotland from overseas should be prioritised for a single side room to reduce the transmission risk of new variants of concern (VOC).

5.3.7 Patients returning from day or overnight pass

Patients who have been allowed to leave the healthcare facility for the day or for an overnight stay should be triaged in advance of their immediate return to the facility and again on arrival at the facility to determine which pathway they should be placed on.  Patients should not return to the low risk pathway and as a minimum should be placed on the medium risk pathway.

 

Footnote 1

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

5.3.8 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

It is important to note that patients deemed clinically fit for discharge can and should be discharged before resolution of symptoms and should continue to self isolate in the community for a total of 14 days.

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

Patient discharge advice leaflets are available 

Key notes below to be referred to in conjunction with tables 1 to 3;

• Number of isolation days required– All COVID-19 patients who have been in hospital must complete 14 days isolation if remaining in hospital or being discharged to a residential setting or care home.  This is because, in general, those with COVID-19 who are admitted to hospital will have more severe disease than those who remain in the community, especially if they require critical care. In addition, those admitted are more likely to have pre-existing conditions such as severe immunosuppression. In healthcare settings, including residential care facilities, there are considerable numbers of immunocompromised and vulnerable patients who will be at risk of nosocomial infection.
  
  
• COVID-19 clinical requirements for stepdown – This can be done when the patient’s clinical status is appropriate for discharge and ongoing care needs can be met at home or in the facility to which they will be transferred.  Those with COVID-19 additionally require the following; Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some individuals, and is not an indication of ongoing infection when other symptoms have resolved. If inpatient is being discharged home, they must be given clear advice directing them what to do if their symptoms worsen.
  
  
• Testing required for stepdown –some inpatients may require testing and this should be undertaken as per tables 1-3 below unless there are overriding clinical reasons where this is not appropriate.  Where testing is not possible (e.g. patient doesn’t consent or it would cause distress) and if discharged to care facility within the 14-day isolation period then there must first be a risk assessment of the discharge location and the ability of the individual being discharged to adhere with the required isolation measures in the care facility for the remaining 14 day isolation period. 

Table 1 - Stepdown requirements for COVID-19 hospital inpatients remaining in hospital and positive staff

Inpatient cohorts	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Inpatients - General	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.	Not routinely required
Inpatients - Severely Immunocompromised as determined by Chapter 14a of the Green Book	14 days from symptom onset (or first positive test i 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.
Inpatients with severe COVID-19 (requiring ITU/HDU for COVID-19 treatment)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever 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.
Staff working in healthcare	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. Resume routine testing after 90 days from first positive isolate unless symptoms develop before then in which case test should be repeated.

 

Table 2 - Stepdown requirements for COVID-19 inpatients being discharged from hospital

Discharge cohort	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 care facility including nursing homes and residential homes	14 days from symptom onset (or first positive test if symptom onset undetermined). If they have completed the14 day isolation in hospital, no further isolation should be required on return/admission to the care home.	No. If a COVID recovered patient is discharged to a care home before 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 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.Provide care as per NIPCM COVID-19 Care Home addendum	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	If a COVID recovered patient discharged to care home before 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 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 recovered patient has completed their 14 day isolation period in hospital
Patient discharging to their own home - General	14 days from symptom onset (or first positive test i symptom onset undetermined)	May complete at home and follow Stay at home guidance .  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
Patient discharging to their own home – someone in household is severely immunocompromised or at risk of severe illness	14 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’	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Testing for clearance is encouraged.

COVID-19 patients discharged from hospital to care homes (non- COVID-19)

All non-COVID-19 residents being discharged from hospital to a care home should be isolated for 14 days from or including the date of discharge from hospital.

Risk assessment prior to hospital discharge for residents with a non-COVID-19 diagnosis should be undertaken in conjunction with the care home. 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, whether the result is positive or negative, but the 14 days of isolation must be completed regardless in the care home.

For further guidance on admission of COVID-19 recovered and non COVID-19 residents from hospital or from community please refer to PHS COVID-19: Information and Guidance for Care Home Settings (Adults and Older People)

Table 3 - Stepdown requirements for COVID-19 outpatients

Discharge cohort	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Outpatient	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	Virological clearance is encouraged for those severely immunocompromised, at high risk of severe disease and those discharged from critical care. If  required to help inform actions at next OP appointment

Other than the limited scenarios described above which indicate testing prior to discontinuation of IPC precautions, any patient who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested within a period of 90 days  from their initial symptom onset, (or first positive test if symptom onset undetermined), 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.   If testing is undertaken within those 90 days despite this, and the result is COVID-19 positive in the absence of any symptoms, there is no requirement to isolate the patient or place them back on the high risk pathway unless a discussion between clinicians and the IPCT indicates that this is necessary.

Transferring between pathways on stepdown

Regardless of stepdown location remaining in hospital, care facility, home (receiving care at home or attending OPDs) all patients must remain on the high risk pathway until stepdown criteria is met at which point they may be transferred to the medium risk pathway.

Transporting COVID-19 patients home safely when still within the self-isolation period

On discharge, patients should be transferred home by the safest method possible to prevent onward transmission of COVID-19.  Transport home can be arranged via a variety of routes, e.g. if the patient has their own car at the hospital, and is well enough, they may drive home. If they are taking shared transport, the need for further isolation of discharged patients with COVID-19  who have not completed their self isolation period and who do not have virological evidence of clearance should be communicated with transport staff (e.g. ambulance crews or relatives). Those transporting them should not themselves be at greater risk of severe infection.

The following guidelines apply to all methods of transport:

• the patient should be given clear instructions on what to do when they leave the ward to minimise risk of exposure to staff, patients and visitors on their way to their transport
• the patient should wear surgical face masks for the duration of the journey, and advised that this should be left on for the entire time if tolerated (not pulled up and down)
• the patient should sit in the back of the vehicle with as much distance from the driver as possible (e.g. the back row of a multiple passenger vehicle), and where possible use vehicles that allow for optimal implementation of physical distancing measures such as those that have a partition between the driver and the passenger, or larger vehicles that allow for a greater distance between the driver and the passenger
• vehicle windows should be (at least partially) open to facilitate a continuous flow of air
• vehicles should be cleaned appropriately at the end of the journey using a household detergent active against viruses and bacteria
• ensure the patient has a supply of tissues and a waste bag for disposal for the duration of the journey. The waste bag should then be taken into their house and held for a period of 72 hours before disposal with general household waste

Discharging a contact of a case

Self isolation of contacts is no longer required in the general community if the individual is doubly vaccinated and has a negative PCR test following the exposure to COVID-19. This does not apply to inpatient care settings and inpatients will still require 14 days’ self-isolation. This recognises the vulnerability of the other inpatients within acute healthcare settings.  Patients who have been on the high risk pathway as a contact of a confirmed case of COVID-19 either during their hospital inpatient stay or prior to admission to hospital, must isolate whilst an inpatient for 14 days.  On discharge, patient no longer need to self-isolate provided they have a negative PCR test prior to discharge and are doubly vaccinated.  

5.4 Hand hygiene

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

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

5.5 Respiratory and cough hygiene

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

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

5.6 Personal Protective Equipment (PPE)

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

5.6.2 Face masks for inpatients

5.6.3 Filter Face Piece 3 (FFP3) Respirators

5.6.4 PPE determined by COVID-19 care pathway

Table 4: PPE for direct patient care determined by pathway

5.6.5 Aerosol Generating procedures (AGPs)

5.6.6 PPE for Aerosol Generating Procedures (AGPs)

Table 5: PPE for AGPs determined by pathway

5.6.7 Post AGP Fallow Times (PAGPFT)

Table 6: PAGPFT calculation

5.6.8 Sessional use of PPE

5.6.9 PPE for delivery of COVID-19 Vaccinations

 

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

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

PPE requirements during the COVID-19 pandemic are determined by the care pathways and are detailed in 5.6.3.

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 for COVID-19 and other mitigation measures as per the hierarchy of controls must be implemented and adhered to wherever possible.  More details on the hierarchy of controls can be found in section 5.13.

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

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

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

• View further Scottish Government guidance and associated FAQs.
• View a poster detailing the ‘Dos and don’ts’ of wearing a face mask.

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

• View a poster that supports the wearing of a non-medical face mask/face covering.

5.6.2 Face masks for inpatients

A surgical facemask should be worn by all inpatients across all pathways 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 COVID-19 control measure.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 patients to wear facemasks at all times and these will have to be removed for reasons such as eating and drinking or showering. There is no need for patients to wear a facemask when sleeping provided the beds are at least 2 metres apart.

A surgical facemask should be worn by all patients across all pathways during transfer between departments within the hospital. 

Where a patient is isolated in a side room, they do not need to wear a surgical facemask. However, the patient must be asked to don their mask when any staff or visitors enter the room and before they are within a 2 metre distance of the patient.

A poster promoting patient facemask use is available.

More information on physical distancing in inpatient settings can be found in section 5.14.

5.6.3 Filter Face Piece 3 (FFP3) Respirators

In the context of COVID-19, FFP3 respirators should be worn by HCWs in the following scenarios;

• When performing an Aerosol Generating Procedure (AGP) on a patient in the medium or high risk pathway (optional when performing an AGP on the low risk pathway and determined following a personal risk assessment performed by the HCW)
• When working within a medium or high risk pathway where AGPs are being performed unit wide (patients having AGPs undertaken who cannot be placed in single isolation rooms)
• When working in the high risk pathway in a clinical area deemed as having an unacceptable risk of transmission by the NHS Board (see hierarchy of controls section)

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

There is a theoretical risk of exhaled breath from the wearer of a valved respirator or powered air purifying respirator (PAPR) transmitting COVID-19 where asymptomatic carriage is present however, following introduction of staff testing and increased uptake of vaccination, this risk is likely to be low. 

There is also limited evidence to suggest a risk of transmitting other infectious bacteria from the wearer to a sterile site via a valved respirator or PAPR. More information can be found on the MHRA website. FFP3 respirators or PAPR need only be worn for sterile procedures if the procedure is also an AGP, or if an AGP is being carried out at the same time otherwise a FRSM is sufficient. If a respirator is required, a non-valved respirator should be worn when carrying out or assisting with sterile procedures. This should be taken into consideration during the face fit testing process.

5.6.4 PPE determined by COVID-19 care pathway

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

Table 4 details the PPE which should be worn when providing direct patient care in each of the COVID-19 care pathways.

Type IIR facemasks should be worn for all direct patient care regardless of the pathway.  This measure has been implemented alongside physical distancing specifically for the COVID-19 pandemic.

FRSMs can be worn sessionally when going between patients on the medium (amber) and low (green) risk pathways however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogens and when leaving high-risk (red) pathway areas’.

It is recommended that surgical masks 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.

Healthcare staff entering different pathways to provide patient consultations (AHPs) or undertake patient transfers (portering and theatre staff) throughout the course of their working day must ensure they first clarify with nurse in charge on named nurse what pathway the patient they are attending to is on and what PPE is required.

 

Table 4: PPE for direct patient care determined by pathway

PPE used	Low-risk pathway (green)	Medium-risk pathway (amber)	High-risk pathway (red)
Gloves	Risk assessment - wear if contact with blood and body fluid (BBF) anticipated.  Single-use	Risk assessment - wear if contact with BBF is anticipated. Single-use	Worn for all direct patient care. Single use.
Apron or gown	Risk assessment - wear if  direct contact with patient, their environment or BBF is anticipated. (Gown if extensive splashing  anticipated)  Single use	Risk assessment - wear if direct contact with patient, their environment or BBF  is anticipated. (Gown if extensive splashing anticipated) Single use	Always within 2 metres of a patient (Gown if exensive splashing  anticipated). Single-use
Face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask Sessional use	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask Sessional use	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask Sessional use
Eye and face protection	Risk assessment - wear if splashing or spraying with BBF including coughing/sneezing anticipated.  Single-use or reusable following decontamination.	Risk assessment - wear if splashing or spraying with BBF includuing coughing/sneezing anticipated Single-use or reusable following decontamination.	Always within 2 metres of a patient Single-use, sessional or reusable following decontamination.

5.6.5 Aerosol Generating procedures (AGPs)

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

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

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

Note 1: The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.   It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  This applies to upper gastro-intestinal endoscopy also and as such it has also been changed to reflect risk associated with suctioning beyond the oro-pharynx.

Other procedures

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

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

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

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

5.6.6 PPE for Aerosol Generating Procedures (AGPs)

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

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

Airborne precautions are required for the medium and high-risk pathways where AGPs are undertaken and the required PPE is detailed in table 5. Ongoing requirement for airborne precautions in the medium risk pathway when a patient is undergoing an AGP recognises the potential aersolisation of COVID-19 from an asymptomatic carrier.

 

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

Table 5: PPE for aerosol-generating procedures, determined by pathway

PPE used	Low-risk pathway (green)1	Medium-risk pathway (amber)	High-risk pathway (red)
Gloves	Single-use.	Single-use.	Single-use.
Apron or gown	Single-use. (Risk assess - use gown if splashing or spraying anticipated otherwise apron is sufficient)	Single-use gown.	Single-use gown.
Face mask or respirator	Type IIR.2	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.	Single-use or reusable.

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

² FFP3 masks must be fluid resistant.  Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated. There is a theoretical risk of exhaled breath from the wearer of a valved respirator transmitting COVID-19 where asymptomatic carriage is present however, following introduction of staff testing and uptake of vaccination, this risk is likely to be low.  Valved respirators should not be used when sterility directly over a surgical field/sterile site is required and instead a non-valved respirator should be worn.  

5.6.7 Post AGP Fallow Times (PAGPFT)

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

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

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

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

Table 6: Post AGP fallow time calculation

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

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

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

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

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

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

5.6.8 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between patients and for a period of time where a healthcare worker was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is no longer required other than when wearing a visor or eye protection in a communal bay on the high-risk pathway and when wearing a fluid-resistant surgical face mask (FRSM) across all pathways. Sessional use of all other PPE is associated with transmission of infection amongst patients and is considered bad practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) pathway areas. 

Visors/eye protection must be changed if damaged, soiled, compromised or uncomfortable or after having provided care for a patient isolated with any other suspected/known infectious pathogens and when leaving the high risk (red) pathway.

Unit wide Airborne precautions will require sessional use of FFP3 masks throughout the unit 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.

5.6.9 PPE for delivery of COVID-19 Vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct patient contact and where 2 metre physical distancing cannot be maintained.  This will protect both the HCWs and patient from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
  
  
• perform hand hygiene regularly including before and after each patient/individual. contact and as per 5 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
  
  
• wear a visor where there is anticipated splash or spraying to the face.  For example, when delivering nasal vaccinations which are likely to induce sneezing. 

The individual on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance. 

 

• As per SICPs;
  • Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
  • Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

 

5.7 Safe management of Care Equipment

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

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

All care equipment should be decontaminated as per Table 7.

Table 7: Equipment cleaning determined by pathway

Pathway	Product
Low-risk pathway (green)	General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids or it has been used on a patient with a known or suspected infectious pathogen.
Medium-risk pathway (amber)	General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids or it has been used on a patient with a known or suspected infectious pathogen.
High-risk pathway (red)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine. If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.

5.8 Safe Management of the Care Environment

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

The care environment must be:

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

General purpose detergent may continue to be used for cleaning in the low risk pathway.  A second clean each day consisting of touch surfaces should continue as a protective measure.

The cleaning frequency and use of general purpose detergent for cleaning in the Medium Risk pathway as per the NHS Scotland National Cleaning Services Specification is sufficient with the exception of isolation/cohort areas where patients with a known or suspected infectious agent are being nursed.  These areas require to be cleaned twice daily with a chlorine releasing agent containing 1000ppm av chlorine. 

Environmental cleaning in the High Risk COVID-19 Pathway should be undertaken using either a combined detergent/disinfectant solution at a dilution of 1000 ppm available chlorine or a general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000 ppm. Cleaning frequency of the environment in the high risk pathway should continue at least twice daily.  A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean.  Where a room has not been occupied by any staff or patients since the first daily clean was undertaken, a second daily clean is not required.

Cleaning across the pathways is summarised in table 8. It is recognised that NHS boards will have local protocols in place to determine the staff groups who have responsibility for cleaning different items and areas. 

Table 8: Environmental cleaning determined by pathway

	Low risk pathway (green)	Medium risk pathway (amber)	High risk pathway (red)
Frequency	At least twice daily 1st clean - Full clean 2nd clean* - Touch Surfaces within clinical inpatient areas	At least daily as per NHS Scotland National Cleaning Services Specification.    NB: Patient entrances to healthcare settings such as emergency department and admitting units may require an increase in frequency of cleaning.  Risk assessments should be undertaken at a local level.	At least twice daily 1st clean - Full clean 2nd clean - * Touch Surfaces within clinical inpatient areas
Product	General-purpose detergent**	General-purpose detergent**	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.

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

**Cleaning in the low and medium risk pathways should be carried out with chlorine based detergent for patient rooms where the patient is known to have any other known or suspected infectious agent as defined in Appendix 13 of the NIPCM.

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

5.9 Safe Management of Linen

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

Linen used on patients in the high pathway should be treated as infectious

5.10 Safe Management of Blood and Body Fluid Spillages

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

5.11 Safe Disposal of waste (including sharps)

Safe Disposal of waste (including sharps)

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

Care home and community settings

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

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

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

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

5.12 Occupational Safety

• Section 1.10 of SICPs remains applicable to COVID-19 patients.
• View occupational risk assessment guidance specific to COVID-19.

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

5.12.1 Car sharing for Healthcare professionals including trainees/students

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

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

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

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

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

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

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

5.13 Hierarchy of Controls

5.13.1 General organisational Preparedness and COVID-19 Risk Assessment of the healthcare Environment

5.13.2 Organisational Preparedness and COVID-19 Risk Assessment when determining appropriate location for High Risk Pathway

5.13.3 Ventilation in the healthcare setting

5.13.4 Physical distancing

5.13.5 Inpatient bed spacing and day patient chair spacing

5.13.6 Local data to inform risk assessment

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below 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 COVID-19 within healthcare settings.  The hierarchy of controls will help protect all users of the NHS facility and not just staff.  NHS Boards and NHS 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.  PPE is the last in the hierarchy of controls.

 

Hierarchy of Risk Controls

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 social care settings is as follows;

 

Table 9: Hierarchy of controls

Hierarchy of controls	Example in practice and resources
Elimination	Patients must not attend for routine appointments if they have symptoms of COVID-19 unless a dedicated pathway can be used Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate for any reason Staff who have tested asymptomatically positive using LFD test must isolate and not report to work further to confirmation via PCR test. Visitors must not enter the facility if they have symptoms of COVID-19 or have been advised to self-isolate Staff who can work from home should be supported to do so Consideration should be given to non-clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible Support adherence with isolation and testing criteria contained within SIGN guidance SIGN Guidance for Reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery.
Substitution	For any patients with respiratory symptoms in keeping with a suspected or confirmed COVID-19 definition – perform  patient consultations over phone as far as possible rather than in person
Engineering controls	Installations of partitions at appropriate places (e.g reception desks) to separate staff from presenting patients (consideration needs to be given to impact on air flow before installation and any cleaning requirements) Adhere to physical distancing laid out in section 5.13.4 and the space requirements necessary to allow adequate bed spacing for patients and physical distancing for staff working within the areas. Effective mechanical ventilation Improve ventilation by opening windows on the premises  Optimal bed spacing and chair spacing (see section 5.13.5) for further information) throughout health and care facilities, including clinical and non-clinical areas, eg. Dining and office areas. Consider availability of single room facilities for performing AGPs Resources View CIBSE guidance  View SAGE documents View HFS document
Administration controls	Reduce waiting time for individuals in waiting areas e.g practices clinic and radiology departments.  Outpatients should wait in their car or outdoors if possible until telephoned by the OPD to advise to enter the building for appointment.  Inpatient radiology departments should aim to request attendance by inpatients from wards which will limit the time waiting in the department.  Avoid face to face waiting arrangements in waiting areas Reduce movement of patients where procedures can be performed in their own room rather than requiring transfer to another department. Make efforts to reduce number of people on premises at any one time e.g consider reduction in number of staff involved in ward rounds. Consider whether MDT case conferences be undertaken using digital methods. Reduce number of deliveries to areas by coordinating as many supplies as possible in as few deliveries as possible.  Ensure measures in place to prevent wards and clinical departments being used as through corridors.  Reduce number of staff in break areas/changing rooms/offices and display maximum occupancy on entry to and within the room. Working from behind or at the side of the individual (no face to face close contact) wherever possible Development of pathways/one way systems/dedicated assessment rooms on the premises Use of various COVID-19 related signage Provision of additional hand hygiene and face mask stations Increased cleaning as per Scottish COVID-19 addendum
Personal Protective Equipment (PPE)	Use of FRSMs as per extended use of facemasks guidance Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask PPE when a risk assessment indicates this is required (see section 5.6 for further information)

5.13.1 General organisational Preparedness and COVID-19 Risk Assessment of the healthcare Environment

A structured risk assessment should be undertaken by the NHS Board/organisation with input from Health and Safety (H&S) representatives, Estates and Facilities representatives, Occupational Health Services (OHS) Infection Prevention and Control Team (IPCT) and the clinical team to systematically consider potential hazards in the context of COVID-19 which could negatively impact users of that environment including staff, patients and visitors and ensure application of mitigation measures to eliminate, reduce or control risk. 

Due to the wide variance in the lay out, structure and fabric of NHS facilities across Scotland it is not possible to be descriptive in exactly how these should be applied and a full risk assessment should be undertaken locally.  Environmental considerations should take account of;

• Ventilation within the building/room/space (see section 5.13.3 for more information)
• Ways in which patient and staff numbers within the area can be reduced
  (NB: visiting guidance -  in areas with high numbers of suspected/confirmed COVID19 cases (high risk pathway) then previous guidance on limiting support to “essential visits only” may need to apply in this area)
• Spacing to adequately allow for physical distancing and related room occupancy (see section 5.13.4) in clinical areas, non-clinical areas and staff only areas e.g office spaces, dining rooms, changing rooms.  This should take account of circulating space for staff
• Partitions and individual positioning (consideration needs to be given to impact on air flow and necessary cleaning regimes before installation of partitions)
• Inpatient bed spacing and OPD chair spacing (see section 5.13.5)
• Signage and one way systems
• Administrative controls (e.g. Hand Hygiene stations, Facemask stations, waste bins)
• The planned patient cohort e.g. consider the planned COVID-19 pathway for that setting and clinical group - patients with cognitive impairment present a higher risk of transmission in care settings
• Previous IPC healthcare incidents and outbreaks within the area

 

5.13.2 Organisational Preparedness and COVID-19 Risk Assessment when determining appropriate location for High Risk Pathway

Some clinical environments present a greater risk in terms of COVID-19 transmission if used to care for cohorts of suspected and/or confirmed COVID-19 cases.  NHS Boards must seek to identify and prepare the most suitable clinical area for planned placement of patients requiring care on the high risk (red) pathway.  This includes an assessment of areas currently in use for the High Risk Pathway. This is not required for areas used for the medium and low risk pathways where sporadic cases of ‘unexpected’ positive COVID-19 cases may arise. 

The risk assessment aims to minimise risk as far as possible for staff, patients and visitors and takes account of the World Health Organization (WHO) interim guidance on occupational health and safety for healthcare workers.

Prior to determining areas for placement of the high risk pathway a full risk assessment of the proposed area must be carried out, led by the NHS Board/organisation and involving Health and safety teams, Estates and Facilities representatives, Occupational Health Services (OHS) Infection Prevention and Control Team (IPCT) and the clinical team.  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 undertaken regularly as determined by the NHS Board to ensure no change to the level of risk.

A Risk Assessment algorithm is available to help support this process and should take account of the following ;

• Which COVID-19 risk pathway is the proposed area to be used for?
• Does the bed spacing in the area allow for all occupants to meet 2m physical distancing requirements?
• Is the area mechanically ventilated and meet a minimum of 6ACH?

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 inadequate spacing to allow for required occupancy AND ventilation of less than 6ACH) and only if there are no other more optimal low risk clinical areas suitable for the high risk pathway cohort then the NHS Boards should consider utilising the area for this purpose with provision of Respiratory Protective Equipment (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 and as a precautionary approach, the use of RPE by staff in the designated area may be considered by the organisation.  This takes account of interim guidance issued by the World Health Organization (WHO) occupational health and safety for healthcare workers.

The following subsections provide information to help support risk assessments.

5.13.3 Ventilation in the healthcare setting

Adequate ventilation reduces how much virus is in the air by dilution. It helps reduce the risk of COVID-19 transmission - the risk is greater in areas that are poorly ventilated. 6 air changes per hour (ACH) is considered adequate in healthcare settings. It is recognised that many areas of healthcare do not meet a minimum of 6ACH and NHS Boards are not required to upgrade ventilation throughout all of their NHS estate however should recognise that where mechanical ventilation provides 6ACH or more, that COVID-19 transmission risk is reduced.  Other mitigations must be in place to reduce COVID-19 transmission risk such as those described in the hierarchy of controls.

A number of studies have linked 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.

Mechanically ventilated areas

NHS Scotland Boards should seek assurance that their ventilation systems must comply with current guidance, including:

• Best practice guidance for healthcare engineering policies and principles (SHTM 00)
• Ventilation for Healthcare - Design and validation (SHTM 03-01 Part A)

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. 

Specific guidance applies to specialist ventilation areas such as theatres, ICU, isolations rooms and endoscopy suites. See here  for more information.

Naturally ventilated areas (No mechanical ventilation

Ensure areas are as ventilated as much as possible by opening windows if temperature/weather conditions allow.  NHS organisations should consider any other 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 should NEVER be propped open. Airing rooms as frequently as you can will help improve ventilation.

Aerosol Generating Procedures (AGPs) should be avoided in rooms with natural ventilation unless it is a single side room and all staff are wearing appropriate PPE, AGP fallow times are adhered to and door remains closed during the AGP and resulting AGP fallow time.

Air scrubbers (also known as HEPA units)

The Board may consider using portable industrial grade air filtration units containing HEPA filters where air-supply systems to high-risk clinical settings are suboptimal following risk assessment including assurance of the efficacy and safety of the filtration unit.  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 the equivalent of ≥12 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 NHS Assure. Boards should also assess (not limited to) the noise levels, power requirements, heat gains and potential trip hazards

Currently, the CIBSE and SAGE resources below provide the best available independent views of air cleaning devices.

“Air purifiers” should not be used.

More information on ventilation in the context of COVID19 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

 

5.13.4 Physical distancing

2 metre physical distancing within the general community and healthcare and residential settings was introduced at the start of the COVID-19 pandemic as a mitigation measure to prevent transmission of the virus between individuals. Following the roll out of the successful vaccination programme, expansion of testing and the use of face coverings by the general public, physical distancing is no longer obligatory in the general community.

However, healthcare settings house some of the most clinically vulnerable in society and whilst the COVID-19 pandemic remains a threat, it is recommended that physical distancing remains although reductions from 2 metres to 1 metre or more can now be advised in some areas. The maximum distance for cross transmission from droplets has not been fully determined, although a distance of approximately 1 metre (3 feet) around the infected individual has frequently been reported in the literature as the highest area of risk. By applying physical distancing of 1 metre or more within healthcare settings we can help mitigate against risk of transmission via pre-symptomatic and asymptomatic individuals. Physical distancing will continue to be reviewed regularly over the winter season and any changes will be informed by COVID-19 prevalence, and nosocomial transmission data of COVID-19 and other respiratory viruses.

Summary of key points

• Physical distancing of 2m must remain for:
  • all inpatient areas (low, medium and high risk pathways)
  • the high risk pathway across all settings
  • OPDs which deliver treatments for extended periods of time throughout the day e.g. oncology units, renal dialysis units, recovery areas, day surgery
  • for staff when FRSMs are removed
• Physical distancing may be reduced across all other areas not described above to 1 metre or more
• Any patient answering yes to any of the triage questions should be placed in the high risk category which will remain at 2 metres physical distancing
• Physical distancing may be reduced amongst staff to 1 metre or more when FRSMs are in use. If FRSMs are removed for any reason e.g eating, drinking, it is advised that 2 metres or more be obtained to avoid high numbers of staff being identified as contacts should a positive case arise
• Physical distancing may be reduced amongst visitors to 1 metre or more. (see exceptions below)
• These changes to physical distancing do NOT mean a return to pre pandemic practices. NHS Boards must continue to adapt processes to ensure risk of transmission is minimised.
• This is the minimum guidance – where clinical teams or services decide that maintaining 2 metres physical distancing throughout the department is necessary then they may do so.

In order for COVID-19 transmission risk to remain low in healthcare and residential settings, whilst also recommending a reduction to physical distancing, it is essential that all staff, patients and visitors adhere with other pandemic measures which remain in place to mitigate risk including:

• Continued adherence with extended use of facemasks (staff and patients) unless they have a medical exemption
• Continued adherence with use of face coverings by visitors
• Continued uptake of regular testing by staff and recommend testing for visitors
• Continued admission screening for COVID-19 for all emergency and pre elective care patients to acute settings and residential settings
• Optimise ventilation across healthcare settings in particular settings used for suspected/confirmed COVID-19 inpatients
• Avoidance of non-urgent consultations if the patient is symptomatic of suspected/confirmed COVID-19 (NB: clinicians should decide locally which suspected/confirmed COVID-19 patients need to attend for face to face consultations and ensure that where they continue as planned, that appropriate measures are taken to mitigate risk including allocation of an appointment that avoids spending time in the waiting areas and placed in a segregated area for high risk pathway where 2 metre physical distancing must be maintained.
• Application of the COVID-19 triage questions
• Continued adherence with Scottish COVID-19 IPC addenda to ensure nosocomial transmission risk is reduced in particular the application of Standard Infection Control Precautions (SICPs) and where applicable, transmission based precautions (TBPs)
• Signage should be updated throughout all areas to encourage application of physical distancing

Staff and patients are also encouraged to complete COVID-19 vaccination to further help reduce the risk of COVID-19 transmission.

Physical distancing amongst staff

Physical distancing amongst staff may now be reduced to 1 metre or more across all health and social care work settings and all COVID-19 pathways provided FRSMs are in use.

Where staff remove FRSMs for any reason e.g eating, drinking, changing, staff are advised to maintain 2 metre physical distancing. This is because 2 metres is still used to assess contacts and failure to physically distance by 2 metres or more when not wearing an FRSM may result in high numbers of staff within the same area/department being considered as a contact and requiring exclusion from work until they can return as per the appropriate requirements associated with Staff exclusion from work. The ‘Kind to Remind’ toolkit supports staff to remind their colleagues when they drop their guard and staff should be encouraged by their organisation to use this resource.

Outbreaks amongst staff have been associated with a lack of physical distancing in changing areas and recreational/rest areas during staff breaks as well as car-sharing and it is particularly important to utilise all available rooms and spaces to allow staff to change and have rest breaks without breaching 2 metre physical distancing (recognising that staff will not be wearing FRSM in these areas). Car-sharing should still be avoided whenever practical and mitigations should remain in place.

Staff previously identified as having been on the shielding list may wish to discuss how physical distancing impacts them with their line manager and/or occupational health.

Patients – inpatient cohort

Inpatients across all COVID-19 care pathways must continue to physically distance by 2 metres at all times from other patients, visitors and staff when not receiving direct care.

This applies to inpatients when within their bed space or any other area of the health care setting. During the admission process, the importance of maintaining 2 metre physical distancing to reduce risk to them and other patients whilst receiving healthcare should be explained. It is the patient’s responsibility to apply 2 metre physical distancing if they leave the ward unaccompanied by NHS staff to go to other areas of the healthcare facility.

NB: Bed spacing of 2 metres from bed centre to bed centre is the minimum. NHS Boards are reminded that they should always aim to meet the bed spacing requirements laid out in the relevant guidance.

Radiology departments should aim to request attendance by inpatients from wards in such a way which will limit the time waiting in the department. Ward staff must inform receiving radiology departments in advance if the inpatient due to attend is on the high risk pathway to ensure the department can segregate the inpatient from others in the waiting area.

Any patient answering yes to any of the triage questions should be placed in the high risk category which will also remain at 2 metres physical distancing

Emergency departments (ED’s)

It is paramount that EDs triage patients at the earliest opportunity to determine if they are symptomatic of COVID-19. Only then can physical distancing be determined for that patient. Patients who are suspected or confirmed COVID-19, or who present with other respiratory symptoms, should continue to physically distance by 2 metres. This will help prevent ‘mixing’ of patients with multiple different respiratory pathogens. Patients who are not suspected/confirmed COVID-19 and have no respiratory symptoms are advised to physically distance by 1 metre or more. Ambulance staff should inform EDs of the findings from the COVID-19 triage assessment. Receiving EDs should ensure that Ambulance Service can apply the same principles of physical distancing when dropping patients off at ED.

This is the minimum guidance – where clinical teams or services decide that maintaining 2 metres physical distancing throughout the department is necessary then they may do so.

Patients – Outpatients (OPDs), waiting areas, non-treatment areas (this list is not exhaustive)

Physical distancing amongst this cohort may now be reduced to 1 metre or more with the exception of suspected/confirmed COVID-19 cases. This will require triage questions to be undertaken on arrival. Any patient answering yes to any of the triage questions should be placed in the high risk category which will remain at 2 metres physical distancing.

Some outpatient areas will receive individuals who are considered extremely clinically vulnerable. In these areas, clinical teams may choose to maintain 2 metre physical distancing.

OPDs which deliver treatments for extended periods of time throughout the day e.g. oncology units, renal dialysis units, recovery areas, day surgery should ensure that there is a minimum of 2 metres between treatment chairs. See bed spacing requirements for relevant guidance.

Patients must be encouraged not to move around waiting areas and should remain seated until called. 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. Members of the same family/household do not need to physically distance in waiting areas.

Patients should be advised not to attend appointments too early wherever possible in order to avoid spending more than 15 minutes in waiting areas and prolonged exposure.

Avoid face to face waiting arrangements in waiting areas, e.g. chairs back-to-back or side to side will reduce risk.

Para-clinical settings (e.g. laboratory settings, pathology, pharmacy, microbiology, radiology, forensic, scanning, screening programmes. This list is not exhaustive)

Physical distancing may be reduced to 1 metre or more unless the patient is on the high risk pathway in which case 2 metres should be maintained. Where these areas are accessed by both staff and patients, it may be necessary to see inpatients and outpatients in the same setting. These areas should try to separate inpatients and outpatients either by time (different sessions allocated to inpatients and outpatients) or place, separate waiting areas wherever possible. Where this is not possible, inpatient areas must consider those who need to access the service and phone ahead to advise of individuals who are considered to be extremely clinically vulnerable (ECV). All efforts must be made to ensure these patients are seen immediately without having to spend time in the waiting area or prioritised for available segregation space.

Ward staff must inform receiving radiology departments in advance if the inpatient due to attend is on the high risk pathway to ensure the department can segregate the inpatient from others in the waiting area.

General circulation spaces such as lift halls, foyer areas, canteen, hospital shops, lecture halls, meeting rooms (this list is not exhaustive), office spaces outside of clinical areas

Physical distancing in these areas may now be reduced to 1 metre.

All individuals in these common circulating spaces (staff, patients, visitors, contractors, volunteers) must wear face coverings in line with SG guidance or FRSM in line with extended use of FRSM policy.

Hand hygiene stations should remain prominent throughout healthcare facilities to use before and after attendance.

Visitors may have touch contact with loved ones (hug/kiss) however are reminded that maintaining 1 metre or more distancing outwith direct touch contact wherever possible will help reduce the risk of transmission of COVID-19 and other respiratory pathogens to them, their loved one and others in the healthcare setting.

Visitors are asked to avoid circulating around clinical areas and remain seated at the bed/chair side of their loved one wherever possible.

Visitors must be advised not to attend the facility if they are symptomatic of a respiratory virus, unless prior agreement with clinical teams during specific circumstances.

Resident transport vehicles

Physical distancing may be reduced to 1m or more between patients and staff unless the patients are on the high risk pathway in which case 2 metre physical distancing should be maintained.

5.13.5 Inpatient bed spacing and day patient chair spacing

Health Facilities Scotland have undertaken an assessment of bed and chair spacing within NHS Scotland facilities taking account of compounding factors applied in conjunction with physical distancing.  The purpose of this document aims to help support boards in reviewing bed spacing to ensure 2 metre (m) physical distancing can be maintained for inpatient beds and treatment chairs. The summary document and the detailed technical diagrams can be accessed here including;

• SIM2108 - COVID-19 Social Distancing Diagrams & Information, 12 July 2021
• NHSS Social Distancing Guidance & Signage (nhsnss.org) DL(2021)09 & NSS, 29 Jan 21
• NHS Scotland COVID-19 remobilisation –Built Environment incl. physical distancing support diagrams (IM/2020/024), 18 Sep 20

Current NHSScotland Guidance on bed spacing include:

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

As a minimum, in terms of a COVID-19 risk assessment, spacing inpatient areas and OPDs which deliver treatments for extended periods of time throughout the day e.g. oncology units, renal dialysis units, recovery areas, day surgery must allow for 2 metre physical distancing between patients to mitigate risk of COVID-19 transmission. This does not mean that all NHS boards should not aim to meet the bed spacing requirements laid out in the guidance above.  This takes account of ergonomics within the clinical environment and not just HCAI risk.

Guidance consistently recognises that bed spacing requirements contribute towards the control of healthcare associated infections.  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 (Figure 45) states a day treatment bay should achieve 2.45m width. Assuming a 0.5m diameter zone for the patient head, this bay size achieves the minimum 2.5m centre-to-centre dimension between each day treatment couch or chair.  

For older facilities, designed post 1995, HBN 40 bed bay minimum of 2.7 x 2.9m, the preferred minimum bed centre is 2.9m. Facilities designed pre 1995, or for clinical specialties e.g. Mental Health (SHPN 35 / HBN 03-01) or Care of Older People (HBN 37), had a  bed bay minimum of 2.4 x 2.9m. For this specific group, the pragmatic minimum of 2.7m bed centres should be adhered to, and/or reduction to total patient numbers/ occupation per multi-bed room and ventilation enhancements should be considered where practicable.

 

5.13.6 Local data to inform risk assessment

Organisations should have local systems in place for monitoring COVID-19 cases in their NHS Board, triggers and a defined escalation process which takes account of bed capacity, COVID-19 cluster data and risks associated with disruption to elective services.  These considerations may be site specific or board wide.  

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

5.14 Visiting

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

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

 

Table 10: PPE for Visitors

PPE used	Low-risk pathway (green)	Medium-risk pathway (amber)	High-risk pathway (red)	Unit wide AGP Zone
Gloves	Not required1	Not required1	Not required1	Not required1
Apron or gown	Not required2	Not required2	If within 2 metres of patient	Apron Required
Face mask	Face covering or provide with FRSM if visitor arrives without a face covering	Face covering or provide with FRSM if visitor arrives without a face covering	FRSM	FRSM4
Eye and face protection	Not required3	Not required3	If within 2 metres of patient	Required to be worn alongside FRSM (or FFP3 where NHS Boards can fit test) on entry to area

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

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

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

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

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

5.15 Outbreaks

It is essential that staff remain vigilant and report any concern that there may be a possible outbreak of COVID-19 developing in their clinical area.  Where two or more patients or staff members in the low or medium risk pathways develop symptoms of suspected COVID-19 or test positive for COVID-19 (regardless of symptom status) and where the cases were not confirmed or suspected COVID-19 on admission, there may be a possible outbreak occurring.  A high degree of suspicion should be applied and staff should contact their local IPCT if they suspect an outbreak may be occurring in their area. 

Further COVID-19 outbreak guidance can be found within Chapter 3 of the NIPCM.

5.15.1 Whole Genome Sequencing

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

 

 

 

5.16 Resources

This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.

PPE

COVID-19 PPE Poster collection

• PPE poster – low-risk pathway A3 (version 1.4, October 2020)
• PPE poster – low-risk pathway A4 (version 1.4, October 2020)
• PPE poster – medium-risk pathway (version 1.5, September 2021)
• PPE poster – high-risk pathway (version 1.4, October 2020)
• PPE poster - PPE for unit wide airborne precautions (version 1.2, September 2021)
• PPE for delivery of COVID-19 vaccination (staff) 
• PPE for attending for your COVID-19 vaccination (public)

Facemask posters

• COVID-19 Wearing a facemask poster (staff) (v1.0, July 2020)
• Wearing a face mask - information for patients poster
• Poster suggested ways of wearing a face mask

FAQs

• COVID-19 Frequently Asked Questions for critical care (version 2.2, April 2021)
• COVID-19 Frequently asked questions for operating theatres (version 1.0, October 2020)
• COVID-19 Frequently asked questions for endoscopy services (version 1.0, March 2021)

Other resources

• Stop the Spread – COVID-19 Good Practice Points (Version 1.0, November 2020)
• COVID-19 Safe practice in acute healthcare settings poster (version 1.2, September 2021)

• COVID-19 Outbreak checklist
• COVID-19 Hospital testing summary table

 

5.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• SBAR: Provision of gloves for COVID-19 in health and care settings
• Rapid review of the literature - SARS-CoV-2 variants VOC-202012/01 (B.1.1.7) and 501Y.V2 (B.1.351) – implications for infection control within health and care settings
• Rapid review of the literature – Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature – Ultraviolet light technology for decontamination of health and care settings in the context of COVID-19
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

5.18 COVID-19 Education resources

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

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

• Correct use of alcohol-based hand rub
• Correct hand hygiene technique using soap and water
• Correct order for donning and doffing PPE for healthcare workers in a primary care setting
• Safe use of fluid-resistant surgical masks

5.19 COVID-19 Compendium

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

• COVID-19 compendium

 

5.20 Useful tools for IPCTs

Below is a list of tools in use by IPCTs in NHS Boards across NHS Scotland in the context of COVID-19.  NHS Boards have given permission for these to be shared here however these documents are not endorsed by ARHAI Scotland, nor do ARHAI Scotland hold any responsibility for updating these documents.  It is recognised that development of national tools are beneficial and as such, COVID19 tools will be developed as requested via the NPGO programme going forward.

• NHS A&A – COVID19 de-escalation checklist (added 26/3/21)
• NHS Grampian – Coronavirus Anxiety Workbook (added 26/3/21)
• NHS Tayside – COVID19 Incidents Reporting Template (added 26/3/21)
• NHS Tayside – COVID19 PAG IMT checklist (added 26/3/21)
• NHS Tayside – COVID19 Protocols (added 26/3/21)
• NHS Tayside – IPC COVID19 Assurance Audit Tool (added 26/3/21)
• NHS Tayside – Scoring proposals for COVID19 Impact (added 26/3/21)

Appendix 1: Think COVID. COVID-19 assessment in the older adult checklist

Think COVID: COVID-19 assessment in the older adult checklist

Draft 5.1 Introduction

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;

• Removal of the 3 distinct COVID-19 care pathways (high/red, medium/amber and low/green) to respiratory and non–respiratory pathways
• A return to Standard Infection Control Precautions (SICPs) and Transmission Based Precautions (TBPs) as per National Infection Prevention and Control Manual (NIPCM) and the Care Home Infection Prevention and Control Manual (CHIPCM)
• An algorithm to support placement of service users within health and care settings
• Respiratory screening questions to include COVID-19 AND other respiratory pathogens
• Ongoing Rapid testing for COVID-19 AND to now include other respiratory pathogens in some settings

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;

• Secondary care (Acute) including paediatrics & mental health
• Primary care
• Mental Health services
• Care homes
• GP practices/health centres
• Dental settings (across all sectors including secondary care)
• Hospice settings
• Community Optometry
• Community Pharmacy
• Specialist palliative care in-patients units/hospices
• Health and social care services provided in peoples own homes 
• Community based health and care settings
• Care at home
• Supported accommodation settings
• Rehabilitation services
• Residential children's homes
• Stand-alone residential respite for adults (settings not registered as a care home)
• Stand-alone residential respite/short break services for children
• Sheltered housing
• Health centres within Prison and detention settings
• Scottish Ambulance service (SAS) – NB: SAS also have specific setting guidance

This guidance is generic to 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 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)

 

Draft 5.2 Organisational Preparedness

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;

• The throughput of service users within the setting
• The vulnerability of service users within the setting in terms of potential exposure to respiratory viruses and risk of severe disease should they acquire a respiratory virus
• The ability to isolate service users within the setting
• Access to testing for respiratory pathogens

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 process for service user respiratory screening,
• placement and segregation of service users with respiratory symptoms or a confirmed respiratory virus/infection
• testing arrangements,
• staff resource, allocation (inclusive of plans for increased staff absence)
• the expansion of respiratory support and Intensive Care Units (ICUs) should this be required

Draft 5.3 Hierarchy of controls

5.3.1 Ventilation in health and care settings

5.3.2 Mechanically ventilated areas

5.3.3 Naturally ventilated areas (no mechanical ventilation)

5.3.4 Air scrubbers

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.

Figure 1: Hierarchy of controls diagram

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 example; not all will apply in every health and care setting and generally apply to both the respiratory and non-respiratory pathways unless otherwise stated);

Table 1: Hierarchy of controls examples in practice

Hierarchy of controls	Example in practice and resources
Elimination	Consider performing consultations for service users with respiratory symptoms by telephone or digital means if possible and not detrimental to the service user.  Services may adopt a hybrid approach whereby they choose to see some service users face to face and others via digital consultation – this should be determined locally by means of a risk assessment Service users must avoid attendance at health and care facilities whilst symptomatic of a respiratory virus where the matter is non urgent. It should be noted that postponement of urgent care is not advised Staff must not report to work if they have symptoms of COVID-19 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 patients or colleagues, this should be discussed with their line manager in the first instance Staff who have tested asymptomatically positive using Lateral Flow Device (LFD) test must isolate and not report to work subject to confirmation via PCR test.  If at work at time of testing, apply a Type IIR fluid resistant surgical mask (FRSM), inform line manager of result and leave work immediately Visitors must not enter a health and care facility if they have suspected/confirmed COVID-19 or have been advised to self-isolate for any reason (unless exceptional circumstances and essential visit pre-arranged with clinical and Infection Prevention & Control Team (IPCT)) During the COVID-19 pandemic, staff who can work from home should be supported to do so Consideration should be given to non-clinical/health and care staff who typically enter clinical/care areas as part of their job role and alternative arrangements made wherever practically possible
Substitution	Consider use of alternative venue to reduce risk wherever practicable, e.g. meet outside; use a non-shared, large, well-ventilated room near front door of the facility; arrange a home visit; move service to a room with better ventilation
Engineering controls	Implement Physical distancing in all areas of the premises for service users, visitors and staff working within the areas at all times Improve ventilation in facilities by opening windows or doors where safe to do so (NB fire doors must not be propped open) Use mechanical ventilation which is operating effectively and where available Ensure optimal bed spacing and chair spacing throughout health and care settings Consider availability of single rooms for performing aerosol generating procedures (AGPs) Ensure effective equipment cleaning and effective environmental cleaning regimes are in place
Administration controls	Reduce waiting time for service users in waiting areas e.g. practices, outpatient clinics, radiology waiting areas as far as possible e.g. consider asking service users to wait in their car or outdoors if possible until telephoned by the department to advise of safe entry to the building for appointment. Inpatient radiology departments should aim to request attendance by inpatients from wards which will limit the time waiting in the department Avoid face to face waiting arrangements in waiting areas (side by side and/or back to back preferred) Reduce movement of service users on the respiratory pathway where procedures can be performed in their own room rather than requiring transfer to another department/area Make efforts to reduce number of people on premises at any one time wherever practicable e.g. consider reduction in number of staff involved in ward rounds. Consider whether Multi-Disciplinary Team (MDT) meetings, case conferences or other staff meetings could be undertaken using digital methods Reduce number of staff in break areas/changing rooms/offices by staggering break times, shift start times and display maximum occupancy on entry to and within the room Development of dedicated respiratory pathway and dedicated assessment/consultation rooms on the premises for use by service users with respiratory symptoms Operate one way systems where possible Display appropriate signage throughout the facility Ensure provision of additional hand hygiene and face mask stations Ensure there is regular reiteration of controls and key messages associated with respiratory pathway guidance via safety huddles, communication emails
Personal Protective Equipment (PPE)	Use of Type IIR FRSMs as per extended use of facemasks guidance Use of face coverings (although not classed as PPE) by service users and visitors – in secondary care they can be provided with a Type IIR FRSM as per extended use of facemasks guidance Use appropriate PPE when a risk assessment indicates this is required Ensure adequate supply and availability of PPE including respiratory protective equipment (RPE) to protect staff, service users and visitors

Some health and care settings and service user groups present a greater risk for the transmission of respiratory viruses.  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. 

Secondary Care settings

Risk assessing placement of the inpatient respiratory pathway

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.  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. 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;

• • • Does the room capacity allow for all bed/treatment chairs to meet 2m physical distancing requirements as a minimum?
    • Is the area mechanically ventilated and meet a minimum of 6 air changes per hour (ACH)?

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. inadequate spacing to allow for required bed/treatment chair occupancy AND ventilation of less than 6ACH) and only if there are no other more optimal lower risk clinical areas suitable for the respiratory pathway, then the NHS Boards 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 and 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 healthcare workers

5.3.1 Ventilation in health and care settings

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.

5.3.2 Mechanically ventilated areas

NHS Scotland Boards/Health and Social care providers should seek assurance that their ventilation systems comply with guidance to which they were designed, including:

• Best practice guidance for healthcare engineering policies and principles (SHTM 00)
• Ventilation for Healthcare - Design and validation (SHTM 03-01 Part A)
• SHPN 36 Part 2 NHS Dental Practices in Scotland

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. 

5.3.3 Naturally ventilated areas (No mechanical ventilation)

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.

5.3.4 Air scrubbers

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

5.3.5 Bed and treatment chair spacing

As a minimum, spacing in an area must allow for adequate physical distancing between service users across all facilities (unless physical distancing is not required e.g. residential settings) to help minimise transmission risk associated with respiratory viruses.  However, it should be noted that physical distancing has been implemented as a pandemic measure and is considered separate from bed spacing guidance. All NHS boards and care providers must still 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.

 

Dental 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.

• Secondary care settings

  • Guidance consistently recognises that bed spacing requirements contribute towards the control of HAIs.  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. 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.For older facilities, designed post 1995, HBN 40 bed bay minimum of 2.7 x 2.9m, the preferred minimum bed centre is 2.9m. Facilities designed pre 1995, or for clinical specialties e.g. Mental Health (SHPN 35 / HBN 03-01) or Care of Older People (HBN 37), had a bed bay minimum of 2.4 x 2.9m. For this specific group, the pragmatic minimum of 2.7m bed centres should be adhered to, and/or reduction to total patient numbers/ occupation per multi-bed room and ventilation enhancements should be considered where practicable.Current NHS Scotland Guidance on bed spacing include:
    • Core guidance - General design for healthcare buildings (HBN 00-01)
    • Core guidance - Clinical and clinical support spaces (HBN 00-03)
    • Critical care units (HBN 04-02)
    • HAI-SCRIBE Manual information for project teams (SHFN 30 Part A)
    • HAI-SCRIBE Implementation strategy and assessment process (SHFN 30 Part B)
    • HAI-SCRIBE question sets and checklists (SHFN 30 Part C)
    • Adult in-patient facilities (SHPN 04-01)
    • In-patient accommodation - supp 1 - Isolation facilities in acute settings (SHPN 4 sup 1)

Health Facilities Scotland have undertaken an assessment of bed and chair spacing within NHS Scotland facilities taking account of compounding factors applied in conjunction with physical distancing.  The purpose of this document aims to help support boards in reviewing bed spacing to ensure 2 metre (m) physical distancing can be maintained for inpatient beds and treatment chairs. The summary document and the detailed technical diagrams can be accessed here including;

SIM2108 - COVID-19 Social Distancing Diagrams & Information , 12 July 2021NHSS Social Distancing Guidance & Signage (nhsnss.org) DL(2021)09 & NSS, 29 Jan 21NHS Scotland COVID-19 remobilisation –Built Environment incl. physical distancing support diagrams (IM/2020/024), 18 Sep 20

Draft 5.4 Physical distancing

The full guidance requirements for physical distancing are laid out in Appendix 18 of the NIPCM. 

A summary of the key points is below;

• Physical distancing of 2m must remain for
  • all inpatient areas (respiratory AND non-respiratory pathway),
  • the respiratory pathway across all health and care settings
  • outpatient departments (OPDs) which deliver treatments for extended periods of time throughout the day e.g. oncology units, renal dialysis units, recovery areas, day surgery
  • for staff across all health and care settings when Type IIR Fluid Resistant Surgical Masks (FRSMs) are removed
• Physical distancing may be reduced across all other health and care settings not described above to 1 metre or more
• Service users who share living accommodation (care homes) do not need to physically distance from each other
• Any service user answering yes to any of the respiratory screening questions should be placed in the respiratory pathway which will remain at 2 metres physical distancing
• Physical distancing may be reduced amongst staff to 1 metre or more when Type IIR FRSMs are in use. If Type IIR FRSMs are removed for any reason e.g eating, drinking, it is advised that 2 metres or more be maintained to avoid high numbers of staff being identified as contacts should a positive case arise
• Physical distancing may be reduced amongst visitors to 1 metre or more. (see exceptions within Appendix 18 allowing visitors to hug/kiss loved ones)
• These changes to physical distancing do NOT mean a return to pre pandemic practices. Health and care settings must continue to adapt processes to ensure risk of transmission is minimised
• This is the minimum guidance – where clinical teams or care teams decide that maintaining 2 metres physical distancing throughout the department is necessary then they may do so.

Draft 5.5 General Infection Prevention and Control Information

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;

• Contact transmission
• Droplet transmission
• Airborne transmission

The NIPCM also contains an A-Z list of pathogens and stipulates the mode of transmission for each.

Draft 5.6 Case definitions and symptomology

5.6.1 Definition of a confirmed COVID-19 case

5.6.2 Definition of a probable COVID-19 case

5.6.3 Definition of a possible COVID-19 case

5.6.4 Symptoms associated with other respiratory pathogens (Some of these symptoms will occur in individuals with COVID-19)

 

Case definitions for COVID-19 have been widely used throughout the course of the pandemic and these will continue to be used going forward. 

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.

Please note: Beyond recommending a confirmatory PCR for probable and possible cases, from an IPC management perspective, there is no difference between how a possible, probable or a confirmed case of COVID-19 is to be managed.  Contact tracing should take place after a positive Lateral Flow Device (LFD) test, i.e. a probable COVID-19 case.

5.6.1 Definition of a confirmed COVID-19 case

A person with laboratory confirmed detection of SARS-CoV-2 by PCR in a clinical specimen

Things to note:

• It is important to know where a PCR test is processed (e.g. tests may have been carried out in non-NHS laboratories. A list of non-NHS laboratories which have agreements in place with their local NHS laboratory can be accessed by emailing nlpq@nhs.scot). Results from non-NHS laboratories that are not aligned with their local NHS laboratories or UK-accredited need to be risk assessed or the test repeated.
• A positive PCR test may be due to fragments of the virus being present following infection in the previous 90 days

5.6.2 Definition of a probable COVID-19 case

A person with a positive LFD test.

5.6.3 Definition of a possible COVID-19 case

A person presenting recent onset of one or more of the following cardinal COVID-19 symptoms:

• new continuous cough
• fever/temperature ≥37.8°C
• loss of, or change in, sense of smell (anosmia) or taste (ageusia).

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.

5.6.4 Symptoms associated with other respiratory pathogens (Some of these symptoms will occur in individuals with COVID-19)

There are a number of symptoms associated with respiratory infection and the most common symptoms are listed below;

• Pyrexia (fever)
• Rhinorrhea (Runny nose)
• Congestion in the nasal sinuses or lungs
• Sore throat
• Cephalgia (headache)
• Coughing
• Sneezing
• Breathlessness
• Anosmia (Loss of sense of smell)
• Ageusia (Loss of sense of taste)
• Wheezing or chest tightness
• Myalgia (Muscle aches)
• Fatigue (Tiredness)
• Dyspnea (Shortness of breath)

These should be considered by clinicians’/care givers in conjunction with other underlying health conditions and any atypical symptoms associated with a possible respiratory virus/infection to determine whether the service user may have a respiratory pathogen requiring application of TBPs.

Draft 5.7 Respiratory screening assessment to determine transmission risk

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.  If the service user answers ‘Yes’ to any of the COVID-19 or the respiratory symptoms questions, place on the respiratory pathway. If the service user advises of having had a test positive pathogen in the last 14 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 the respiratory screening questions is available.

Table 2: Respiratory Screening Questions for use across all health and care settings^*

The screening questions below apply to all service users and anyone accompanying the service user to a healthcare facility e.g. parent, carer.

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 14 days? NB: Any person who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested 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 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; High temperature or fever? New, continuous cough? A loss or alteration to taste or smell?

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 See note below)
Have you been had a laboratory test  with a confirmed respiratory virus/infection such as Influenza in the last 14 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

^{* COVID-19 screening questions are separated to recognise potential asymptomatic carriage of this pathogen. The screening questions above also apply to anyone accompanying the service user to a healthcare facility e.g. parent, carer.}

¹Note for healthcare workers (HCWs) in relation to respiratory symptoms;

List of respiratory symptoms below may indicate a respiratory virus;

• • • Rhinorrhea (Runny nose)
    • Congestion in the nasal sinuses or lungs
    • Sore throat
    • Sneezing
    • Coughing

The following can also be symptoms of a respiratory virus/infection 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.

• • • Breathlessness
    • Wheezing or chest tightness
    • Myalgia (Muscle aches)
    • Fatigue (Tiredness)
    • Dyspnea (Shortness of breath)

² If the service user advises of having had a test positive pathogen in the last 14 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.

^* COVID-19 screening questions are separated to recognise potential asymptomatic carriage of this pathogen. The screening questions above also apply to anyone accompanying the service user to a healthcare facility e.g. parent, carer.

It may also be useful to collect information on the service user’s vaccination status including the date vaccination was received if available.

 

Primary Care and Community Health and Social Care settings 

Respiratory screening questions & triage

If following telephone consultation, the individual is suspected or confirmed as having COVID-19 or another respiratory virus, and if the matter is non urgent, face to face consultation should be deferred until the COVID-19 self-isolation period has elapsed. 

For other non COVID-19 respiratory viruses, defer until resolution of symptoms.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 the individual 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.

Entrances to facilities must clearly display the requirement for individuals entering the facility to don a face covering, maintain physical distancing and alcohol based hand rub (ABHR) should be provided for use prior to entry for those who are able to do so.

Respiratory screening questions should be undertaken on arrival at the facility if not carried out prior. For unplanned arrivals, respiratory screening questions should be completed immediately on arrival to the facility, where it is safe to do so without delaying any necessary immediate lifesaving interventions. 

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 keeping 1 metre from the individual where possible ensuring that a Type IIR FRSM is worn. If this is not possible, treat as having respiratory symptoms until a direct assessment can be made by the care provider.

Only the individual requiring a consultation should attend health and care facilities unless a carer or escort is required.  

Individuals living in residential facilities should be closely monitored for onset of respiratory symptoms by local care staff.

 

Dental settings – Respiratory screening questions & triage

If following telephone consultation, the patient is suspected or confirmed as having COVID-19 or another respiratory infection, and if the matter is non urgent, face to face consultation should be deferred until the COVID-19 self isolation period has elapsed.  For other non COVID-19 respiratory viruses, defer until resolution of symptoms.  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 5.15.6 Determining the IPC precautions required for AGPs.

Secondary Care settings

Respiratory screening and triage questions

Patients should be assessed for respiratory symptoms at the earliest opportunity to direct them to the safest route within the facility.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.  Service users who answer YES to any of the questions should be directed to the appropriate waiting area and the receiving clinical staff alerted to their presenting respiratory symptoms.

Only the service user requiring a consultation should attend health and care facilities unless a carer or escort is required.  

Draft 5.8 Placement and management of a service user with respiratory symptoms

5.8.1 Staff cohorting

5.8.2 Transfer of service users with respiratory symptoms/confirmed respiratory pathogen

5.8.3 Day/overnight pass

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.

A respiratory assessment algorithm is available to help determine which pathway the service user should be placed on and whether or not TBPs should be applied.

The pathway should be further split into appropriate cohorts determined by presenting symptoms and when available, test results to determine the causative pathogen.

Entrances to facilities must clearly display the requirement for individuals entering the facility to don a face covering, maintain physical distancing 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. 

Members of the same family/household do not need to physically distance in waiting areas.

Please note that prior to undertaking aerosol generating procedures (AGPs) on the non-respiratory pathway, airborne precautions are still required for service users unless there is evidence of a negative COVID-19 test within the preceding 48 hours. See section 5.15.6 Determining the IPC precautions required for AGPs.

 

Primary Care and Community Health and Social Care settings 

Patient/Individual Service user placement

Health and care facilities should identify in advance areas/routes/consultation rooms for individuals who are displaying respiratory symptoms and who 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 with respiratory symptoms.  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.

Individual Service user placement in residential facilities

All admissions from the community to a residential health and care setting should be assessed first by the health and care setting using the respiratory screening questions.  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.  

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

If the admission must go ahead, the resident should be allocated their own room preferably with en suite facilities.

Meals should be provided for the resident to eat within their room to avoid them entering any communal spaces.

Ensure that personal toiletries such as towels (unless laundered to a satisfactory standard between individuals) toothbrushes and razors are not shared. Consider a rota for showering and bathing placing the resident with respiratory symptoms last.

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.

 

Dental settings - Patient/Service user placement

Where possible, waiting areas should be segregated with an area set aside for use by patients who present with respiratory symptoms.  Markers to identify segregation should be clear and patients must be advised not to circulate around waiting areas and remain seated until called. Members of the same family/household do not need to physically distance in waiting areas. Cleaning within areas segregated for respiratory patients 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 are displaying respiratory symptoms 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 with respiratory symptoms.  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.

Secondary care settings

Inpatient placement

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 suspected/confirmed respiratory viruses from all other patients as far as possible.  Respiratory pathways may be dedicated wards or dedicated bed bays within wards. Patients with suspected or known 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.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;

• • • Ensure a respiratory screen including COVID-19 has been undertaken ideally prior to entry into the cohort or at the earliest opportunity.
    • Ensure the beds within the multi bedded area are adequately spaced
    • Ensure patients are provided with a Type IIR FRSM to wear where tolerated
    • Ensure there are adequate hand hygiene facilities for staff and patients
    • Advise all patients to remain within their bed space at all times
    • Ensure patients are advised of good respiratory etiquette and are provided with tissues and waste disposal bags.
    • Where safe to do so, curtains could be drawn between patients to create a barrier

Patients who should not be placed in multi bed bay cohorts;

• • • Patients considered high risk and previously on shielding list
    • Patients undergoing an AGP
    • Patients known to have another known infectious pathogen or symptoms of a suspected infectious pathogen e.g. C.difficile, Norovirus, loose stools, MRSA
    • Patients who are unlikely to comply with the requirements of the cohort described above

Patients with respiratory symptoms 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 with respiratory symptoms 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.

Paediatric inpatient placement

The principles applied within this guidance aim to mitigate the risk of transmission of all respiratory viruses including RSV.  The UK is experiencing a surge in RSV cases amongst the paediatric population and winter season and has commenced earlier than previous years.  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, PPE and physical distancing.

Elective care pre-admission planning

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.  The following patient information leaflet  explains some of the risk reduction measures and can be provided to patients in advance of their planned admission alongside testing advice. 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.  These should be read alongside the patient information leaflet accessed here.

 

Care Home Settings 

Admissions and resident placement

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 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).

• • • Residents who are awaiting test results to confirm which pathogen is causing respiratory symptoms, should not be placed together in cohorts if at all possible
    • Ensure a respiratory screen including COVID-19 has been undertaken ideally prior to entry into the cohort or at the earliest opportunity.
    • Ensure residents are provided with a Type IIR FRSM to wear where tolerated

5.8.1 Staff cohorting

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.

5.8.2 Transfer of service users with respiratory symptoms/confirmed respiratory pathogen

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;

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

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;

• Service user symptom onset date
• Service user positive test date (if confirmed)
• Causative pathogen if known
• Date when service user may discontinue TBPs
• Current symptom status and any test results still awaited
• Any service user details which prevent or impact on the TBPs required i.e. falls risk requiring door to remain open, service user does not adhere to isolation
• Confirm if local IPCT (or HPT where appropriate) has been informed of transfer

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

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.

5.8.3 Day/Overnight Pass

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. 

Draft 5.9 Respiratory testing for service users

5.9.1 COVID-19 Testing

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.

5.9.1 COVID-19 testing 

COVID-19 testing must continue as part of the ongoing COVID-19 pandemic efforts.

Anyone who has previously tested positive for SARS-CoV-2 by PCR should be exempt from being re-tested 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 PCR 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:

• remains asymptomatic;
• is not a contact of a confirmed case;
• is not required to isolate having returned from travel to a non-exempt country;

See section ** for determining the precautions required for AGPs and the associated testing.

Primary Care and Community Health and Social Care settings

As part of the ‘Test and Protect’ approach, everyone with symptoms of COVID-19 is encouraged to get tested. Tests can be booked through NHS inform.

If an individual has COVID-19 symptoms they should visit the NHS inform website to arrange testing.

GPs who have arranged a face to face consultation with an individual who has symptoms of COVID-19 should advise that arrange to take a COVID-19 PCR test via NHS Inform if they have not already done so.

Dental settings – COVID-19 testing

As part of the ‘Test and Protect’ approach, everyone with symptoms of COVID-19 is encouraged to get tested. Tests can be booked through NHS inform. 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 advise that they should arrange to undertake a COVID-19 PCR test via NHS Inform if they have not already done so. The patient must then follow the respiratory pathway.

 

Secondary care Settings 

A letter was issued to NHS Scotland Chief Executives on 27^th November 2020 detailing the staged roll out of admission testing expansion plan to include;

• • • All emergency admissions to hospitals
    • All planned admissions to hospitals
    • Routine testing of asymptomatic, patient facing healthcare workers (HCWs)

A table containing a summary of testing requirements in NHS Scotland is available.  When using this table the following applies;

• • • Screening undertaken out with national programmes which are detailed at the links above should be based on decision of clinical services e.g. screening in critical care settings.
    • Screening undertaken out with national programmes which are detailed at the links above should be based on decision of clinical services e.g. screening in critical care settings.
    • It is recognised that a patient may meet different criteria for testing multiple times in a short period of time (admission screening, transfers to another ward, contact of a case, outbreak management). If an inpatient has undergone a COVID-19 test in the previous 24 hours, there is no need to repeat it and the result can be accepted for any of the testing requirements with the exception of
      • New symptoms onset – a new test should be performed as soon as symptoms are recognised
      • Pre elective screening – where the requirement for a negative test must be within a set time period.

 

Care home settings

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). 

 

5.9.2 Testing for other respiratory pathogens

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.

 

Secondary Care settings

On arrival at a secondary care facility, all patients should have a COVID-19 test undertaken even if asymptomatic.  Where available, multiplex rapid testing should be undertaken (symptomatic patients only) to help determine patient placement within the respiratory pathway and establish patient cohorts where required. Clinical teams may choose to perform a full respiratory screen if clinical assessment indicates this is necessary to support diagnosis.

 

Care Home Settings 

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.

Draft 5.10 Respiratory Screening for Healthcare Workers (HCW)

Twice weekly LFD COVID-19 screening has been rolled out to all HCWs employed directly by NHS Scotland and NHS24 and SAS call handlers.  More information 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.

 

Care home settings

Weekly care home staff PCR screening for COVID-19 remains in place. Weekly PCR testing is now achieved through Regional Hubs. Care home staff should use the COVID testing portal - see http://www.covidtestingportal.scot to arrange this.

Further information on COVID-19 testing amongst care home workers can be found in the PHS Care home guidance.

Draft 5.11 Duration of Transmission Based Precautions for respiratory pathogens (excl COVID-19)

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.

Appendix 11 of the NIPCM details the duration of TBPs required for individual pathogens.  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. 

Draft 5.12 - Duration of transmission based precautions for COVID-19

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.

Table 3: Duration of precautions for hospital inpatients remaining in hospital and residents in residential care areas

Hospital Inpatients and residents in residential settings	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
General	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.	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.
Individuals with severe COVID-19 (requiring ITU/HDU for COVID-19 treatment)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery. Absence of fever 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.

Table 4: Stepdown requirements for inpatients being discharged from hospital

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	14 days from symptom onset (or first positive test if symptom onset undetermined). If they have completed the 14 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 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 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 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 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 14 day isolation period in hospital
Patients being discharged to their own home - General	14 days from symptom onset (or first positive test if symptom onset undetermined)	May complete at home and follow Stay at home guidance. 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
Patients being discharged to their own home – someone in household is severely immunocompromised or at risk of severe illness Chapter 14a of the Green Book	14 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

 

5.12.1 Non COVID-19 discharges from hospital to care homes 

All non-COVID-19 residents being discharged from hospital should be isolated for 14 days from the date of discharge from hospital. 

Risk assessment prior to hospital discharge for residents with a non-COVID-19 diagnosis should be undertaken in conjunction with the care home. 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, whether the result is positive or negative, but the 14 days of isolation must be completed regardless in the care home.

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 (Adults and Older People)

5.12.2  Management of contacts of COVID-19

Self isolation of contacts is no longer required in the general community if the individual is asymptomatic, doubly vaccinated with an MHRA approved vaccine and has a negative PCR test following the exposure to COVID-19.  This does not apply to some health and care settings.

Secondary care settings

Patients who have an overnight admission within a hospital setting who have been managed as a contact of a confirmed case of COVID-19 either

• • • during their hospital inpatient stay,
    • in the community prior to admission to hospital

must isolate for 14 days whilst in hospital from the date of exposure to the COVID-19 case.  If the patient is discharged to their own home within the 14 day self isolation period, individuals do not need to continue self-isolation provided they remain asymptomatic, have a negative PCR test after exposure to the case and are doubly vaccinated. 

Care home settings

Residential care settings and care homes will also still need to apply the 14 days’ self-isolation period for contacts of COVID-19 cases even if they meet the contact self-isolation exemption criteria.  The 14 days period starts from the date of last exposure to the case and should be agreed between the hospital and care home manager, supported by HPTs and include an negative PCR test.  This precautionary approach recognises the vulnerability of the other residents living in the care home.  

 

5.12.3 HCWs isolation and exemption requirements

HCWs who test positive for COVID-19 on an LFD test must not report to work and must arrange to have a PCR test undertaken.  If the positive LFD was undertaken whilst in the workplace, they must don a Type IIR FRSM (unless exempt), inform their line manager and go home immediately. If the PCR is COVID-19 positive, the HCW must self isolate at home for 10 days in line with advice on NHS inform.

Health and care staff who have been exposed to a case of COVID-19 should follow advice laid out in the Scottish Government DL (2021) 24 issued 27^th August 2021.

If the PCR is COVID-19 negative, the HCW should consider the risk to service users if they are to return to work particularly if the service user they care for are immunosuppressed or otherwise medically vulnerable.  If in doubt about any risk they may pose to patients or colleagues, this should be discussed with their line manager in the first instance. 

 

Draft 5.13 - Hand Hygiene

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.

Care Homes

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.

Draft 5.14 - Respiratory etiquette

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.

 

Care Homes

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.

 

Draft 5.15 - Personal Protective Equipment (PPE)

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

5.15.5 Access to PPE

5.15.6 Aerosol Generating Procedures (AGPs)

5.15.7 PPE for AGPs

5.15.8 Post AGP Fallow Times

 

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.

 

Care home settings

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. 

 

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

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). 

• View further Scottish Government guidance and associated FAQs.
• View a poster detailing the ‘Dos and donts’ of wearing a face mask.
• View a poster that supports the wearing of a non-medical face mask/face covering.

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

 

Primary Care and Community Health and Social Care settings

Face coverings for Individuals and service users

Any service users attending a health and care facility must 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.

 

Dental  settings

Any patient attending a health care facility must 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.

 

Secondary care settings

Face masks for Inpatients

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 the beds are at least 2 metres apart.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 and before they are within a 2 metre distance of the patient.

 

Care home settings

Face masks for residents

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.

 

5.15.2  Sessional use of FRSMs, FFP3 respirators and/or eye/face protection

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;

• FRSMs/FFP3 must be replaced if visibly contaminated, wet, damaged, uncomfortable, when moving between the respiratory and non-respiratory pathway
• Eye/face protection must be replaced if damaged, visibly contaminated, when moving between the respiratory and non-respiratory pathway
• HCWs must not touch their FRSM, eye/face protection or FFP3 respirator whilst in situ. If they inadvertently do so, they must perform hand hygiene immediately afterwards

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

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

Dental settings

Sessional use of FRSMs, FFP3 respirators and/or eye face protection

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.

 

Secondary care settings 

Sessional use of FFP3 respirators

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.

 

5.15.3  Filter Face Piece 3 (FFP3) Respirators

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;

• When performing an Aerosol Generating Procedure (AGP) a service user with a known or suspected respiratory infection and those on the non respiratory pathway where there is no evidence of a negative COVID-19 test in the preceding 48 hours. See section 5.15.6 Determining the IPC precautions required for AGPs.
• When working within the respiratory pathway where AGPs are being performed unit wide (service users having AGPs undertaken who cannot be placed in single isolation rooms)
• Secondary care only - When working in the respiratory pathway in a clinical area deemed as having an unacceptable risk of transmission by the NHS Board (see hierarchy of controls section)

More information can be found on RPE within chapter 2 of the NIPCM.

5.15.4 PPE worn when caring for service users on the respiratory pathway

Table 5 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.

Table 5 PPE worn for SICPs and TBPs (see table 6 for AGP PPE)

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.

5.15.5 Access to PPE

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.

 

5.15.6 Aerosol Generating Procedures (AGPs)

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

 

5.15.7 Determining the IPC precautions required for AGPs.

Prior to undertaking an AGP, clinical teams must first check that the patient has not developed any new onset respiratory symptoms.  Airborne precautions are required for all patients undergoing an AGP on the respiratory pathway.  Airborne precautions are also required for patients on the non-respiratory pathway unless there is evidence of a negative COVID-19 test in the 48 hours preceding the AGP in which case droplet precautions may be applied.  This recognises the risk of asymptomatic and pre-symptomatic carriage of COVID-19 and the resulting risk of aerosolising the virus during the AGP.  Ideally, the negative test should be as close to the point of undertaking the AGP as possible but ideally no more than 48 hours before. 

Testing methods used to de-escalate from airborne to droplet precautions during an AGP must be agreed by local board laboratory services in conjunction with Infection Prevention and Control Teams. LFDs must not be used to determine IPC precautions required for AGPs.

Table 6: Precautions required for AGPs

Service user pathway	Test result/ scenario	Precautions required	Post AGP fallow time required	Post AGP management of service users.
Respiratory pathway	Not applicable	Airborne precautions	Yes	Continue on respiratory pathway in line with guidance
Non-respiratory pathway	COVID-19  negative in previous 48 hours	Droplet Precautions	No	Continue on non -respiratory pathway in line with guidance
Non Respiratory pathway	COVID-19  positive in previous 48 hours*1	Airborne precautions	Yes	Clinical assessment and discussion with IPCT required to determine suitable pathway for the patient*2. Primary care/OPDs – should consider deferring treatment
Non Respiratory pathway	Last COVID-19 test result more than 48 hours prior to AGP being undertaken	Undertake PCR test. Airborne precautions if necessary to proceed to AGP before awaiting test result	Yes	Continue on non - respiratory pathway in line with guidance
Non Respiratory pathway	Unable to obtain COVID-19 test or service user refusal to take a COVID-19 test	Airborne precautions	Yes	Continue on non -respiratory pathway in line with guidance

^*1 Consider immediate management of patient including suitable patient placement based on a positive result.  Liaise with clinical team and IPCT to determine appropriate IPC control measures.

^*2 If a patient has been tested within 90 days of a previous positive COVID-19 test, clinical teams should consider if the patient may have developed a new respiratory virus or whether the test has detected old inactive virus.

Precautions needed for AGP's Algorithm

 

Dental Settings 

It is recognised that dental practices are unable to utilise PCR testing prior to undertaking AGPs and therefore all patients requiring an AGP regardless of whether they are on the respiratory or non-respiratory pathway will require application of airborne precautions and resulting post AGP fallow times.

 

5.15.8 PPE for AGPs

The required PPE when undertaking AGPs is listed in table 7.

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

Table 7: PPE for AGPs

PPE Item	Non Respiratory pathway (SICPs) where there is evidence of a negative COVID-19 test within the preceding 48 hours	Respiratory pathway (TBPs) and Non Respiratory pathway where there is no evidence of a COVID-19 test within the preceding 48 hours
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.

5.15.9 Post AGP Fallow Times

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.

Dental settings - AGPs

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.

Draft 5.16 Safe Management of Care Equipment

See NIPCM for routine safe management of care equipment as per SICPs.

Care Home Settings

Care homes should refer to the NIPCM for older people and adult care homes 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 8.

Table 8: Equipment cleaning determined by SICPs/TBPs

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.

Primary Care and Community Health and Social Care settings

Equipment cleaning for care at home services

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.

 

Draft 5.17 Safe Management of the care environment

See NIPCM for routine safe management of care environment as per SICPs.

Care Home Settings

Care homes should refer to the Care Home IPCM for older people and adult care homes 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 8.  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.

Table 9 - Environmental cleaning determined by SICPs/TBPs

Pathway	Frequency	Product
Routine care areas (non-respiratory pathway) – cleaning as per SICPs	At least daily as per NHS Scotland National Cleaning Services Specification.	General purpose detergent*
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 - * Touch 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.

*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.

* 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.

Draft 5.18 Safe management of linen

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

Care Home Settings

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.

 

Primary Care and Community Health and Social Care settings 

Safe Management of Laundry

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 staff uniforms.

Draft 5.19 Safe management Blood and Body Fluid spillages

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 Home Settings

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.

Draft 5.20 Safe management of waste

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 Home Settings

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.

 

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.

 

Primary Care and Community Health and Social Care settings

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.

 

Draft 5.21 Occupational Safety

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 Home Settings

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

5.21.1 Vehicle sharing for all staff during the ongoing COVID-19 pandemic

Wherever possible, vehicle sharing should be avoided with anyone outside of household or support bubbles.  This is an ongoing COVID-19 pandemic measure and exists because the close proximity of individuals sharing the small space within the vehicle increases the risk of transmission of respiratory infections including COVID-19.  All options for travelling separately should be explored and considered such as;

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

However, it is recognised that there are occasions where vehicle sharing is unavoidable such as:

• Staff who carry out community visits.
• Staff who are commuting with students as part of supported learning/mentorship.
• Staff working in emergency response vehicles (not patient vehicles).
• Staff living in areas where public transport is limited and vehicle sharing is the only means of commuting to and from the workplace.

Where vehicle sharing cannot be avoided, staff should adhere with the guidance below to reduce any risk of cross transmission:

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

 

Draft 5.22 Staff Uniforms

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:

• separately from other household linen;
• in a load not more than half the machine capacity;
• at the maximum temperature the fabric can tolerate, then ironed or tumble dried.

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.

Draft 5.23 - Caring for someone who has died

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.

 

Draft 5.24 - Visiting to health and care settings

Scottish government have guidance available for visiting which can be found at the following links;

Hospital visiting - https://www.gov.scot/publications/coronavirus-covid-19-hospital-visiting-guidance/

Care home visiting - https://www.gov.scot/publications/coronavirus-covid-19-adult-care-homes-visiting-guidance/

All visitors must be informed on arrival at any health and care facility of IPC measures and adhere to these at all times. Visitors should wear face coverings in line with current Scottish Government guidance and must not attend with COVID-19 symptoms or before a period of self-isolation has ended, whether identified as a case of COVID-19 or as a contact. 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 must:

• Not visit if they have suspected or confirmed COVID-19 or if they have been advised to self-isolate for any reason unless prior agreement with clinical teams during specific circumstances;
• Not visit if they have symptoms of another viral infection e.g. respiratory symptoms, GI symptoms unless prior agreement with clinical teams during specific circumstances.
• Wear a face covering on entering the facility;
• Be provided with appropriate PPE (see table 7);
• Perform hand hygiene at the appropriate times;
  • on entry to the facility
  • prior to putting on PPE
  • after removing PPE
• Observe physical distancing; Visitors may have touch contact with loved ones (hug/kiss) however are reminded that maintaining 1 metre or more distancing out with direct touch contact wherever possible will help reduce the risk of transmission of COVID-19 and other respiratory pathogens to them, their loved one and others in the health and care setting.
• Not move around the facility and should stay at the bed or chairside of the individual they are visiting;
• Not visit other service users in the facility;
• Not touch their face or face covering/mask once in place;
• Not eat whilst visiting;
• Avoid sharing mobile phone devices with the individual unnecessarily – if mobile devices are shared to enable communications with other friends and family members, the phone should be cleaned between uses using manufacturer’s instructions.

Table 10 – Visitor PPE

Pathway	Gloves	Apron	Face covering/mask	Eye/Face Protection
Routine care areas (SICPs)	Not required*1	Not required*2	Face covering or provide with Type IIR FRSM if visitor arrives without a face covering	Not required*3
Respiratory pathway (TBPs)	Not required*1	Not required*2	Type IIR FRSM	If within 2 metres of service user with respiratory symptoms

^*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.

Draft 5.25 - Resources

PPE posters

PPE for delivery of COVID-19 vaccination (staff)

PPE for attending for your COVID-19 vaccination (public)

Wearing a facemask poster (staff)

Wearing a facemask – information for patients’ poster

Suggested ways of wearing a facemask

Draft Appendix 1 Respiratory Algorithm for use across all health and care settings

 

A printable version of this algorithm is available.

The purpose of this addendum is to provide COVID-19 specific infection and prevention control (IPC) guidance for care home staff and providers on a single platform to improve accessibility.

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.

 

Version control

16 December 2020: Version 1.0
First publication.

25 January 2021: Version 1.1
Inclusion of new section 6.2.4 'Discontinuing IPC precautions in care homes for residents who are COVID-19 positive'

31 March 2021: Version 1.2
6.1.2 Definition of suspected case; Additional information and links included.
6.1.3   Triaging of residents being admitted to a care home. International travel isolation changed to reflect current guidance
6.2 Resident Placement/Assessment of Infection Risk section updated.
6.2.5 Residents returning from overnight stay included
6.2.4 Stepdown table renamed (Discontinuation of IPC) to be consistent with Acute Addendum. Discontinuing IPC precautions in care homes for residents who are COVID-19 positive information clarified. Residents discharged from hospital to care homes – additional information included to clarify 14 day isolation requirements.
6.2.4 Links have been removed that are no longer available.
6.5 Additional information included on PPE & link to hierarchy of control.
6.5.1 New FRSM poster (ways to improve fit) link included
6.5.2   Face masks for residents, additional advice on wearing masks when moving around the care home
6.5.3 Table 2 PPE for direct resident care determined by risk category. Update to PPE guidance specifically in relation to visors.
6.5.4 PPE – Putting on (Donning) and Taking off (Doffing) further detailed information included
6.5.5 Aerosol Generating procedures (AGPs) Additional information added under table on requirements for respirators/fluid resistant requirement.
6.5.8 Additional section added on delivery of COVID-19 vaccinations.
6.7 Safe Management of the Care Environment. Additional detail provided where items cannot stand application of chlorine releasing agents. Also additional information if an organisation adopts practices that differ from those recommended/stated.
6.8 Wording amended to clarify linen categorisation where no outbreak.
6.10 Safe disposal of waste. Wording amended to provide clarity.
6.11.2 Engineering and Administration control measures added.
6.12 New section on hierarchy of controls
6.14 Visiting in care homes updated following publication of ‘Open with Care’
6.16 Resources and Tools section updated.
6.17 Rapid reviews section added
6.18 Education resources added.

8 July 2021: Version 1.3
6.1.3 Triaging of residents admitted to a care home updated with changes to testing and self-isolation
6.2.4 - Discontinuing IPC Precautions in Care Homes for residents who are COVID-19 positive
Updated with clarification on self isolation in certain circumstances.
Admission of individuals to the care home: section has been updated with changes to testing and self-isolation in certain circumstances. 
Table 1 Discontinuation of IPC Requirements for care homes (COVID-19 positive) Requirements on Admission of COVID-19 recovered residents from hospital: discharge updated.
Residents/patients discharged from hospital to care homes (non-COVID-19) added to provide advice for self isolation requirements upon admission.
6.14 Visiting - amended to reflect the collection of guidance available.
6.5.3 Update to PPE table to emphasise Risk Assessment in medium risk pathway
6.5.5 Addition of risk associated with valved respirators
6.6, 6.7 Change in controls for environmental and care equipment cleaning from TBPs to SICPs within the Medium Risk category.
6.8, 6.9 Clarification on the safe management of linen and waste.

31 August 2021: Version 1.4
Updates to physical distancing
Inclusion of risk associated with powered air purifying respirator (PAPR) when undertaking a sterile procedure.

6.1 COVID-19 case definitions and triage

6.1.1 Definition of a confirmed case

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

6.1.2 Definition of a suspected case

An individual meeting one of the following case criteria taking into account atypical and non-specific presentations in older people with frailty, those with pre-existing conditions and residents 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).

Community definition:

• Recent onset new continuous cough

or

• fever

or

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

 

Definition for residents who may require hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

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

or

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

6.1.3 Triaging of residents being brought into a care home

To aid prioritisation for residents who may be at most risk, admission triage should be undertaken to enable early recognition of potential COVID-19 cases.  Wherever possible, triage questions should be undertaken prior to arrival at the care home.  If the resident has capacity issues this should be undertaken with the individual’s guardian or power of attorney.

The 14 day self-isolation requirement for residents on admission to the care home from the community follows a Protection Level approach as set out by the Scottish Government. This removes the blanket approach for self-isolation on admission to a care home from the community. In Protection Levels 0-2, a risk assessment should be agreed on a case by case basis by the care home manager to determine whether the resident should isolate for 14 days on admission to the care home. Given the diversity of settings, there may be some residential settings where a 14 day period of isolation is more appropriate (e.g. settings with older or clinically vulnerable residents, and communal areas where residents mix); the decision on this is at the care home manager’s discretion subject to local risk assessment as guided by the local oversight group.

In Protection Levels 3-4, the resident will need to isolate on admission for 14 days.

A risk assessment prior to admission should be undertaken to ensure that appropriate isolation facilities are available, taking into account requirements for the resident’s care. Risk assessment can include factors such as presence of COVID-related symptoms, COVID status of household they have come from, resident travel history, resident vaccination status, care home staff vaccination uptake rate, general IPC and PPE training/supplies/usage in the care home.

All admissions from the community, irrespective of Protection Level, should have one negative PCR test within 3 days of their admission date. In exceptional circumstances where testing is not possible before admission then testing on admission to the care home is acceptable and should be considered. Where it is in the clinical interest of the resident and negative testing is not feasible (e.g. resident does not consent, detrimental consequences or it would cause distress), an agreed care plan for admission to the care home will document this. Advice on this process is available from the local Health Protection Team, if needed.

For information on residents being admitted to the care home for respite purposes – see PHS COVID-19 information and guidance for care home settings.

Suggested questions for triage:

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

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

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

If yes, follow the high-risk category.

• Have you been an inpatient in hospital in the past 14 days?

If yes, follow the high-risk category.

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

If yes, should wait for 10-day quarantine before admission to care home, or if urgent transfer is required, follow high risk category.

The Scottish Government website details quarantine (self- isolation) rules and information on the process for people entering the UK.

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

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

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

If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.

6.2 Resident placement/assessment of risk

6.2.1 Staff cohorting

6.2.2 Requirements for risk categories

6.2.3 Resident Cohorting

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

6.2.5 Residents returning from day visit or overnight stay

Defined risk categories have been agreed at UK level to inform resident placement and the precautions required. Any other known or suspected infections must be taken into consideration before resident placement within each of the risk categories.

Examples of risk categories for care homes are described below and staff should familiarise themselves with these. NHS Boards must also undertake risk assessments of clinical areas to help ensure that the high risk pathway is placed appropriately reducing risk to staff, patients and visitors and taking account the hierarchy of controls. 

Details of the Low Risk Category are not included here however it is expected that all residents in care home settings will fall into the Medium (Amber) or High (Red) risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

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

1. Confirmed COVID-19 residents within the first 14 days of onset (or test date if asymptomatic). Symptomatic or suspected COVID-19 residents (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
2. Those who are known to have had close contact with a confirmed
   COVID-19 individual and are still within the 10-day self-isolation period.
3. Residents who are symptomatic or suspected COVID-19 but who decline testing or who are unable to be tested for any reason.

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

1. All residents who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic residents who refuse testing or for whom testing cannot be undertaken for any reason.

6.2.1 Staff cohorting

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

6.2.2 Requirements for risk categories

Any resident on the medium risk category who develops symptoms of COVID-19 should be isolated on the high risk category immediately and tested for COVID-19 and notify your local Health Protection Team (HPT). Any resident who is asymptomatic and tests positive for COVID-19 should be then cared for as per the high-risk category.

Care homes are likely to have residents with dementia and/or cognitive impairment and so staff are advised to conduct a local risk assessment to ascertain appropriate placement. This does not mean resident needs to move their room or be moved to a different area but advises of the relevant risk category precautions that require to be put in place.

6.2.3 Resident Cohorting

Any resident who has a coinfection with COVID-19 and any other known or suspected infectious pathogen must not be cohorted with other COVID-19 residents.

Cohorting in care homes should be undertaken with care. Residents who are shielding (extremely high risk of severe illness) 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 whilst ensuring that:

• Confirmed COVID-19 residents are placed in multi-occupancy rooms together.
• Suspected COVID-19 residents are placed in multi occupancy rooms together.
• Confirmed and suspected residents should not be cohorted together.

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

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

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

• Completing the 14 day isolation period - – Care homes residents must complete 14 days isolation.  This is because there are considerable numbers of immunocompromised and vulnerable residents who will be at risk of nosocomial infection. If they have completed their 14 days in isolation in hospital, no further isolation should be required on return/admission to the care home.
• COVID-19 clinical requirements for stepdown – Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some residents, and is not an indication of ongoing infection when other symptoms have resolved.
• Testing required for stepdown – No testing is required routinely to stepdown IPC precautions in a care home unless discharged from hospital before their 14 day isolation period has been completed.

Table 1 - Discontinuation of IPC requirements for COVID-19 residents in care homes (COVID-19)

Group	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown	Transferring between risk  categories on stepdown
Care home current residents (known COVID-19 positive)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever  for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required unless being discharged from hospital	Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category
Care home residents (known COVID-19 positive), being admitted from hospital (see further guidance)	14 days from symptom onset (or first positive test if symptom onset undetermined) If they have completed the 14 day isolation in hospital, no further isolation should be required on return/admission to the care home.	Absence of fever for 48 hours without use of antipyretics & at least some  respiratory recovery	If COVID recovered patient discharged to care home before 14 day isolation ended 2 negative PCR tests before discharge at least 24 hr apart. In addition, if not completed 14 days isolation, can do so in care home and do not require to start new isolation period, nor require further testing.	Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category
Care home staff	10 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required.	Staff can return to work as normal once criteria is met

Residents/patients discharged from hospital to care homes (COVID-19 recovered)

Since PCR testing can take several weeks to revert back to negative due to persistence of non-viable viral RNA remnants, repeat PCR testing within 90 days of a COVID diagnosis in preparation for discharge must be considered carefully. COVID recovered patients in hospital can be discharged to the care home after 14 days from symptom onset (or first positive test, if asymptomatic) without further testing. In such instances, discharge at 14 days providing the person is afebrile for 48 hours without anti-pyretics and clinically stable, is based on clinical judgment of fitness for discharge. This decision should be made in collaboration with the receiving care home manager who needs to agree to patient transfer before this occurs. If COVID recovered patients have completed their 14 days of isolation in hospital, no further isolation should be required on return to the care home.

If a COVID recovered patient is to be discharged before their 14 day isolation period has ended, they should have two negative PCR tests before discharge from hospital. Tests should be taken at least 24 hours apart. In addition, if they have not completed their 14 days isolation then they can do so in the care home, and do not require to start a new period of isolation, nor do they require further testing.

Where it is in the clinical interest of the resident and negative testing is not feasible (e.g. resident does not consent, detrimental consequences or it would cause distress) a risk assessment and a care plan for the remaining period of isolation up to 14 days in the care home must be agreed.

Note: an admission to hospital is considered to include only those patients who are admitted to a ward. An attendance at A&E that didn’t result in an admission would not constitute an admission.

Residents/Patients discharged from hospital to care homes (non-COVID-19)

All non-COVID-19 residents being discharged from hospital should be isolated for 14 days from or including the date of discharge from hospital.

Risk assessment prior to hospital discharge for residents with a non-COVID-19 diagnosis should be undertaken in conjunction with the care home. 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, whether the result is positive or negative, but the 14 days of isolation must be completed regardless in the care home.

For further guidance on admission of COVID-19 recovered and non COVID-19 residents from hospital or from community please refer to PHS COVID-19: Information and Guidance for Care Home Settings (Adults and Older People)

6.2.5 Residents returning from day visit or overnight stay

Residents who leave care home for the day or for an overnight stay should be triaged in advance of their immediate return to the care home and again on arrival at the care home to determine which category they should be placed on. 

6.3 Hand hygiene

Hand hygiene is considered one of the most important practices in preventing the onward transmission of any infectious agents including COVID-19.  Hand hygiene should be performed in line with section 1.2 of SICPs.

Hand hygiene is essential to reduce the transmission of infection in care home settings. All staff, residents 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.

Hand hygiene must be performed immediately before every episode of direct care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination and waste handling.

Before performing hand hygiene:

• expose forearms (bare below the elbows)
• remove all hand and wrist jewellery (a single, plain metal finger ring is permitted but should be removed (or moved up) during hand hygiene)
• ensure finger nails are clean, short and that artificial nails or nail products are not worn
• cover all cuts or abrasions with a waterproof dressing

If wearing an apron rather than a gown (bare below the elbows), and it is known or possible that forearms have been exposed to respiratory secretions (for example cough droplets) or other body fluids, hand washing should be extended to include both forearms. Wash the forearms first and then wash the hands.

Staff should support any residents with hand hygiene regularly where required.

6.4 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19.  The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

Residents, staff and visitors should be encouraged to minimise potential COVID-19 transmission through good respiratory hygiene measures which are:

• disposable, single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose – used tissues should be disposed of promptly in the nearest waste bin;
• tissues, waste bins (lined and foot operated) and hand hygiene facilities should be available for residents, visitors and staff;
• hands should be cleaned (using liquid soap and water if possible, otherwise using alcohol based hand rub (ABHR) after coughing, sneezing, using tissues or after any contact with respiratory secretions and contaminated objects;
• encourage residents to keep hands away from the eyes, mouth and nose.

Some residents may need assistance with containment of respiratory secretions; those who are immobile will need a container (for example a plastic bag) readily at hand for immediate disposal of tissues.

6.5 Personal Protective Equipment (PPE)

6.5.1 Extended use of face masks for staff and visitors

6.5.2 Face masks for residents

6.5.3 PPE determined by COVID-19 care pathway

Table 2: PPE for direct resident care determined by category

6.5.4 PPE - Putting on (donning) and taking off (doffing)

6.5.5 Aerosol Generating procedures (AGPs)

Table 3: PPE for AGPs determined by pathway

6.5.6 Post AGP Fallow Times (PAGPFT)

Table 4: PAGPFT calculation

6.5.7 Sessional use of PPE

6.5.8 PPE for delivery of COVID-19 Vaccinations

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

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

PPE requirements during the COVID-19 pandemic are determined by the care categories and are detailed in 6.5.1.

It is of paramount importance that PPE is worn only at the recommended appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

PPE is the least effective control measure for COVID-19 and other mitigation measures as per the hierarchy of controls must be implemented and adhered to wherever possible.  More details on the hierarchy of controls can be found in section 6.12.

6.5.1 Extended use of face masks for staff and visitors

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

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and residents.  The guidance and FAQs are available Scottish Government guidance and associated FAQs.

A poster detailing the ‘Dos and don’ts’ of wearing a face mask is available.

Extended use of face masks relates to the specific guidance that staff should wear Fluid Resistant (Type IIR) Surgical Mask (FRSM) at all times for the duration of their shift in the care home setting.  Face masks must be removed and replaced as necessary (observing hand hygiene before the mask is removed and before putting another mask on).

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

It is recommended that FRSMs should be well fitting and fit for purpose, covering the nose and mouth in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask). A ‘How to wear facemasks’ poster suggests ways to wear facemasks to help improve fit.

6.5.2 Face masks for residents

Residents in the medium or high risk category should be encouraged to wear a FRSM, if these can be tolerated and do not compromise care, when moving around the care home and when individuals enter the room.

Appropriate physical distancing and wider IPC measures are critical, with the use of face masks being a further line of defence.

Scottish Government guidance is available on the extended use of face masks in hospitals and care homes.  

Where clinical waste disposal is not available, used face masks should be double bagged and disposed of in domestic waste.

6.5.3 PPE determined by COVID-19 care category

Table 2 details the PPE which should be worn when providing direct resident care in each of the COVID-19 care risk categories.

Type IIR facemasks should be worn for all direct care regardless of the risk category.  This is a measure which has been implemented alongside physical distancing specifically for the COVID-19 pandemic. FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a resident isolated with a suspected or known infectious pathogen and when leaving resident areas on high risk categories.

Further guidance on glove use can be found in Appendix 5

Table 2: PPE for direct resident care determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	Risk assessment - if contact with BBF is anticipated. Single use	Worn for all direct care. Single use.
Apron or gown	Risk assessment - if direct contact with resident, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated). Single use.	Always within 2 metres of resident (Gown if splashing spraying anticipated). Single-use.
Face mask	Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask	Always within 2 metres of a resident - Type IIR fluid resistant surgical face mask
Eye and face protection	Risk assessment - if splashing or spraying with BBF anticipated. Single-use or reusable following decontamination.	Always within 2 metres of a resident Single-use, *sessional or reusable following decontamination.

*Sessional use see section 6.5.7  

6.5.4 PPE - putting on (donning) and taking off (doffing)

All staff must be trained in how to put on and remove PPE safely.  A short film showing the correct order for putting on and the safe order for removal of PPE is available.  The video will also describe safe disposal of PPE.  A poster describing the donning and doffing of PPE is available in the NIPCM Appendix 6 .

Putting on PPE

Before putting on PPE:

• Check what the required PPE is for the task/visit
• Select the correct size of PPE
• Perform hand hygiene

PPE should be put on before entering the room.

• The order for putting on is apron, surgical mask, eye protection (if required) and gloves – you may require some of these items or all of them
• When putting on mask, the mask should be well fitting, position the upper straps on the crown of head and the lower strap at the nape of the neck. Mould the metal strap over the bridge of the nose using both hands.  Further link to a poster on fitting masks can be found in section 6.5.1.

When wearing PPE:

• Keep hands away from face and PPE being worn.
• Change gloves when torn or heavily contaminated.
• Limit surfaces touched in the care environment.
• Always perform hand hygiene after removing gloves

Removal of PPE

PPE should be removed in an order that minimises the potential for cross-contamination.

Gloves

• Grasp the outside of the glove with the opposite gloved hand; peel off.
• Hold the removed glove in gloved hand.
• Slide the fingers of the un-gloved hand under the remaining glove at the wrist.
• Peel the glove off and discard appropriately.

 Gown

• Unfasten or break ties.
• Pull gown away from the neck and shoulders, touching the inside of the gown only.
• Turn the gown inside out, fold or roll into a bundle and discard.

Eye Protection (if worn)

• To remove, handle by headband or earpieces and discard appropriately.

Fluid Resistant Surgical facemask

• Remove after leaving care area.
• Untie or break bottom ties, followed by top ties or elastic and remove by handling the ties only (as front of mask may be contaminated) and discard as clinical waste.
• For face masks with elastic, stretch both the elastic ear loops wide to remove and lean forward slightly. Discard as clinical waste.

To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.

Perform hand hygiene immediately after removing all PPE.

6.5.5 Aerosol Generating procedures (AGPs)

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

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

• respiratory tract suctioning*
• dental procedures (using high-speed devices, for example, ultrasonic scalers/high-speed drills)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• non-invasive ventilation (NIV): Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
• Tracheal intubation and extubation
• Upper ENT airway procedures that involve respiratory suctioning

 

*Note : The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.    It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  This applies to upper gastro-intestinal endoscopy also and as such it has also been changed to reflect risk associated with suctioning beyond the oro-pharynx.

Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres. On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

This recommendation comes from Public Health England and the New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG).  The published evidence view and consensus opinion can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp--2

Certain other procedures/equipment may generate an aerosol from material other than an individual’s secretions but are not considered to represent a significant infection risk and do not require AGP PPE. Procedures in this category include:

• administration of humidified oxygen;
• administration of medication via nebulisation.

Note: During nebulisation, the aerosol derives from a non-resident source (the fluid in the nebuliser chamber) and does not carry resident-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol.

Staff should use appropriate hand hygiene when helping residents to remove nebulisers and oxygen masks.

For residents with suspected/confirmed COVID-19, any of the potentially infectious AGPs listed above should only be carried out when essential. The required PPE for AGPs should be worn by those undertaking the procedure and those in the room, as detailed above. Where possible, these procedures should be carried out in a single room with the doors shut. Only those staff who are needed to undertake the procedure should be present.

It is the responsibility of care home providers to ensure that all staff have been fit tested for FFP3 respirators, when appropriate. If you do not anticipate the need for FFP3 respirators and are not caring for anyone currently receiving AGPs such as CPAP, these should not be ordered or stockpiled and any surplus stock should be returned.

A Situation, Background, Assessment and Recommendations  (SBAR ) has been produced by Health Protection Scotland (HPS)/ARHAI Scotland and agreed by New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) specific to AGPS during COVID-19.

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

Airborne precautions are required for the medium and high-risk categories where AGPs are undertaken and the required PPE is detailed in table 3. Ongoing requirement for airborne precautions in the medium risk pathway when a patient is undergoing an AGP recognises the potential aersolisation of COVID-19 from an asymptomatic carrier.

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

Table 3: PPE for aerosol-generating procedures, determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	Single-use.	Single-use.
Apron or gown	Single-use gown.	Single-use gown.
Face mask or respirator**	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.

**FFP3 masks must be fluid resistant. Valved respirators may be shrouded or unshrouded. Respirators with unshrouded valves are not considered to be fluid-resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated. There is a theoretical risk of exhaled breath from the wearer of a valved respirator or powered air purifying respirator (PAPR) transmitting COVID-19 where asymptomatic carriage is present however, following introduction of staff testing and uptake of vaccination, this risk is likely to be low.  Valved respirators and PAPRs should not be used when sterility directly over a surgical field/surgical site is required and instead a non-valved respirator should be worn.  

6.5.6 Post AGP Fallow Times (PAGPFT)

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

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 4. It is often difficult to calculate air changes in areas that have natural ventilation only.  All point of care areas require to be well ventilated. Natural ventilation, provides an arbitrary 1-2 air changes per hour. To increase natural ventilation in many community health and social care settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

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.  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 (see table 5 and 6)

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 4). Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Table 4: Post AGP fallow time calculation

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

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

6.5.7 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between residents and for a period of time where a member of staff was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Supplies of PPE are now sufficient that sessional use of PPE is no longer recommended other than when wearing a visor or eye protection in a communal area where the resident is on the high-risk pathway and when wearing a fluid-resistant surgical face mask (FRSM) across all pathways. Sessional use of all other PPE is associated with transmission of infection amongst residents and is considered poor practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) pathway areas.

The same principles should be observed for staff post toilet and meal breaks, when a new face mask should be put on, once removed the FRSM must never be reused.

Employers are encouraged to plan breaks in such a way that allows 2 metre physical distancing and therefore staff not having to wear a face mask, with natural ventilation where possible.

6.5.8   PPE for delivery of COVID-19 vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct contact and where 2 metre physical distancing cannot be maintained.  This will protect both the HCWs and resident from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
• perform hand hygiene regularly including before and after each resident /individual contact and as per 4 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
• wear a visor where there is anticipated splashing to the face.  For example, when delivering nasal vaccinations which are likely to induce sneezing.

The resident on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance.

As per SICPs;

• Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
• Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

6.6 Safe management of Care Equipment

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

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

All care equipment should be decontaminated as per Table 5.

Table 5: Equipment cleaning determined by risk category

Risk category	Product
Medium-risk category (amber)	General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids or it has been used on a patient with a known or suspected infectious pathogen.
High-risk category (red)	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

6.7 Safe Management of the Care Environment

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

Furniture and floorings in a poor state of repair can harbour 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 litter or non-essential items and equipment.

Maintaining a high standard of environmental cleanliness is important in care homes as residents living there are often elderly and vulnerable to infections.

During this ongoing pandemic, cleaning frequency of the environment should be increased across all categories. 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 residents since the first daily clean was undertaken, a second daily clean is not required.

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

The care environment must be:

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

The cleaning frequency and use of general purpose detergent for cleaning in the Medium Risk pathway as per the NHS ScotlandSafe Management of the Care Environment Cleaning Specification for Older People and Adult Care Homes is sufficient with the exception of isolation/cohort areas where residents with a known or suspected infectious agent are being nursed.  These areas require to be cleaned twice daily with a chlorine releasing agent containing 1000ppm av chlorine.

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

Cleaning across the risk categories is summarised in table 6.

Table 6: Environmental cleaning determined by risk category

	Medium risk pathway	High risk pathway
Frequency	At least daily as per NHS Scotland Safe Management of the Care Environment Cleaning Specification for Older People and Adult Care Homes	At least twice daily 1st clean - Full clean 2nd clean - * Touch Surfaces within clinical inpatient areas
Product	General purpose detergent**	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

*High risk touch surfaces as a minimum should include door handles/push pads, taps, light switches, lift buttons.  Resident areas should include the bedroom and treatment areas and staff rest areas.

** Cleaning in the medium risk pathways should be carried out with chlorine based detergent for resident rooms where the resident is known to have any other known or suspected infectious agent.

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

Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated, you may have to discard it. 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. However, when an organisation adopts practices that differ from those recommended/stated in this national guidance 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.

6.8 Safe Management of Linen

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

Linen used on residents who are in the high risk category or known to be COVID positive or suspected or where there is a confirmed outbreak should be treated as infectious. Following local risk assessment/ if no outbreaks in the care home laundry can be processed as normal.

Care homes with their own in-house laundries may also refer to National Guidance for Safe Management of Linen in NHSScotland for more information. 

6.9 Safe Management of Blood and Body Fluid Spillages

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

6.10 Safe Disposal of waste (including sharps)

Waste should be handled in accordance with Section 1.9 of SICPs.

Waste generated from patients/individuals who are in the high risk category or known to be COVID positive, or suspected or where there is a confirmed outbreak, should be disposed of as clinical waste where clinical waste contracts are in place.   

NB: Type IIR facemasks worn as part of the extended use of facemasks policy should be disposed of as clinical waste.

If the community health and care setting does not have a clinical waste contract, or for care at home, ensure all waste items that have been in contact with the patient/ individual (e.g. used tissues and disposable cleaning cloths) are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.

 

6.11 Occupational Safety

Section 1.10 of SICPs remains applicable to COVID-19 residents.

Occupational risk assessment guidance specific to COVID-19 is available.

PPE is provided for occupational safety and should be worn as per Tables 2 and table 3.

6.11.1 Car/vehicle sharing for staff

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

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

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

• Staff who carry out community visits;
• Staff who are commuting with residents as part of supported care;
• Staff who are commuting with students as part of supported learning/mentorship;
• Staff living in areas where public transport is limited and car sharing is the only means of commuting to and from the workplace;

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

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

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

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

6.11.2   Engineering and administration control measures in care home settings

Care homes should apply administrative controls to establish separation of resident categories and minimise contact.  Due to the wide variance in the layout, structure and fabric of care homes across Scotland it is not possible to be descriptive in how these should be applied and full risk assessment should be undertaken locally.  The following bullet points provide guidance which may use when considering how best to develop pathways and promote physical distancing.

• Signage on entry to the care home advising of the necessary precautions to take (face coverings, hand hygiene, physical distancing) including advice for visitors not to enter the premises if symptomatic of COVID-19.
• Ensure signage is clearly displayed to clearly identify resident category. Floor markings may also be used, if considered appropriate.  Physical barriers may be used where appropriate to prevent cross over of categories.
• Ensure there are adequate hand hygiene facilities (wash hand basins or alcohol-based hand rub stations) available including the use of posters promoting hand hygiene and detailing the effective method for doing so. Appendix 1 how to hand wash and Appendix 2 how to hand rub.
• Where required, facilitate the use of screens to reduce exposure risk, for example at reception desks.
• Ensure areas are well ventilated where possible, open windows if a local risk assessment and temperature/weather conditions allow.

6.12 Hierarchy of Controls

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below 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 COVID-19 within healthcare settings.  NHS boards and NHS staff should employ the most effective method of control first.  Where that is not possible, all others must be considered.  PPE is the last in the hierarchy of controls.

Hierarchy of Risk Controls graphic //commons.wikimedia.org/index.curid=90190143 (original version: NIOSH Vector version: Michael Pittman)

Application of the hierarchy of control in health and social care settings is as follows;

1. Elimination
   • Patients must not attend for an appointment if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff who can work from home should be supported to do so
   • Consideration should be given to non clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible
2. Substitute
   • Patient consultations over phone as far as possible rather than in person
3. Engineering controls
• Installations of partitions at appropriate places (e.g reception desks)
• Physical distancing on the premises (see section 6.15) 
• Efforts made to reduce number of people on premises at any one time
• reduce waiting time for individuals in clinic and radiology departments
• improve ventilation by opening windows on the premises 
• Optimal bed spacing and chair spacing (see section 6.11.2) 
4. Administrative Controls (more detail in section 6.11.2) 
• Working from behind or at the side of the individual (no face to face close contact)
• development of pathways/one way systems on the premises
• use of various COVID-19 related signage
• provision of additional hand hygiene stations
• increased cleaning. 
5. PPE
• Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask
• PPE when a risk assessment indicates this (see PPE section of this addendum).

6.13 Caring for someone who has died

The IPC measures described in this document continue to apply whilst the individual who has died remains 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 individuals. 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.

For further information, please see the following guidance produced by Scottish Government Coronavirus (COVID-19): guidance for funeral directors on managing infection risks.

 

6.14 Visiting

The Scottish Government has published visiting guidance, Open with Care: supporting meaningful contact in care homes. 

Care homes should familiarise themselves with the content of this collection of guidance to ensure resident, staff and visitor safety. The guidance on visiting during the pandemic includes tools and resources on visiting, and supporting residents in homes during COVID-19.

Open with Care sets out how indoor contact in care homes will gradually increase while minimising COVID-19 risks to residents, staff and visitors. Continued attention to safety measures in relation to the pandemic are essential for everyone. This includes hand hygiene, PPE as appropriate, ensuring good airflow (as far as reasonably comfortable), and rigorous cleaning of surfaces before and after visits. 

Visitors must be informed of and adhere to IPC measures as advised, including FRSM, hand hygiene and not attending with COVID-19 symptoms or before a period of self-isolation has ended, whether identified as a case of COVID-19 or as a contact

A log of all visitors must be kept, which may be used for Test and Protect purposes.

6.15 Physical distancing

2 metre physical distancing within the general community and healthcare and residential settings was introduced at the start of the COVID-19 pandemic as a mitigation measure to prevent transmission of the virus between individuals.  Following the roll out of the successful vaccination programme, expansion of testing and the use of face coverings by the general public, physical distancing is no longer obligatory in the general community.

However, care homes house some of the most clinically vulnerable in society and whilst the COVID-19 pandemic remains a threat, it is recommended that physical distancing remains although reductions from 2 metres to 1 metre or more can now be advised in some areas.  The maximum distance for cross transmission from droplets has not been fully determined, although a distance of approximately 1 metre (3 feet) around the infected individual has frequently been reported in the literature as the highest area of risk.  By applying physical distancing of 1 metre or more within care homes we can help mitigate against risk of transmission via pre-symptomatic and asymptomatic individuals. Physical distancing will continue to be reviewed regularly over the winter season and any changes will be informed by COVID-19 prevalence, and nosocomial transmission data of COVID-19 and other respiratory viruses.

Summary of key points

• Physical distancing of 2m must remain for
• the high risk category
• for staff when FRSMs are removed
• Physical distancing amongst staff may now be reduced to 1 metre or more
• Residents and individuals who share living accommodation do not need to physically distance from each other.
• Any resident/individual answering yes to any of the triage questions should be placed in the high risk category which will remain at 2 metres physical distancing
• Staff must aim to maintain 1 metre or more physical distancing from residents/individuals when not delivering care which requires physical contact. 
• Visitors should maintain 1 metre or more distancing from staff and general residents/individuals within care homes (see exceptions below) 
• These changes to physical distancing do NOT mean a return to pre pandemic practices.  Care homes continue to adapt their processes to ensure risk of transmission is minimised.
• This is the minimum guidance – where care homes decide that maintaining 2 metres is necessary they should be allowed to do so

In order for COVID-19 transmission risk to remain low in care homes and residential settings, whilst also recommending a reduction to physical distancing, it is essential that all staff, individuals/residents and visitors adhere with other pandemic measures which remain in place to mitigate risk including;

• Continued adherence with extended use of facemasks (staff and where possible, residents) unless they have a medical exemption 
• Continued adherence with use of face coverings by visitors  
• Continued uptake of regular testing by staff and recommend testing for visitors 
• Continued admission testing for new residents being admitted to a care home 
• Maximise the amount of fresh air entering a room wherever possible. Natural ventilation can be achieved by opening windows, vents and doors (excluding fire doors). Some buildings may have mechanical ventilation systems, these should maximise the amount of fresh air being introduced and minimise the recirculation of air in rooms and throughout buildings.
• Continued adherence with Scottish COVID-19 IPC addenda for care homes and PHS COVID-19 Information and guidance for care homes settings to ensure transmission risk is reduced in particular the application of Standard Infection Control Precautions (SICPs) and where applicable, transmission based precautions (TBPs)
• Signage should be updated throughout all areas to encourage application of physical distancing

Staff and residents are also encouraged to complete COVID-19 vaccination to further help reduce the risk of COVID-19 transmission.

Physical distancing amongst staff in care homes

Physical distancing amongst staff may now be reduced to 1 metre or more across care homes and residential settings provided FRSMs are in use.

Where staff remove FRSMs for any reason e.g eating, drinking, changing, staff are advised to maintain 2 metre physical distancing.  This is because 2 metres is still used to assess contacts and failure to physically distance by 2 metres or more when not wearing an FRSM may result in high numbers of staff within the care home setting being considered as a contact and requiring exclusion from work until they can return as per the appropriate requirements associated with Staff exclusion from work. Staff should be supported by their organisation to remind their colleagues when they drop their guard during application of COVID-19 controls.

Outbreaks amongst staff have been associated with a lack of physical distancing in changing areas and recreational/rest areas during staff breaks as well as car-sharing and it is particularly important to utilise all available rooms and spaces to allow staff to change and have rest breaks without breaching 2 metre physical distancing (recognising that staff will not be wearing FRSM in these areas).  Car-sharing should still be avoided whenever practical and mitigations should remain in place.

Staff previously identified as having been on the shielding list may wish to discuss how physical distancing impacts them with their line manager and/or occupational health.

Residents/Individuals living in the care home/residential setting

Residents/individuals who live in the care home are not expected to physically distance from each other.

Where able, residents should be reminded to report any symptoms of COVID-19 to care home staff. Staff should remain vigilant for early onset of any symptoms amongst residents/individuals taking account of atypical symptoms in the elderly and where symptoms do develop, act promptly by isolating the resident/individual in their own room and following guidance within the Scottish COVID-19 addendum as per high risk category.

Staff are also reminded to encourage and where necessary support residents/individuals to perform hand hygiene regularly and practice good respiratory hygiene.

Visitors

Visitors should maintain 1 metre or more distancing from staff and general residents/individuals within care homes. 

They may have touch contact with loved ones (hug/kiss) however are reminded that maintaining 1 metre or more distancing outwith direct touch contact wherever possible will help reduce the risk of transmission of COVID-19 and other respiratory pathogens.

Visitors are asked to avoid circulating around care homes unnecessarily and remain seated at the bed/chair side of their loved one wherever possible.

Visitors answering yes to any of the triage questions should not visit until they have completed their self-isolation period.

6.16Resources and tools

• PPE poster – Low Risk Pathway
• PPE poster - Medium Risk Pathway
• PPE poster - High Risk pathway
• PPE COVID-19 Vaccinations (Staff)
• PPE for COVID-19 vaccinations (public)
• COVID-19 Safe Practice in acute healthcare settings poster
• COVID-19 Wearing a facemask poster (staff)
• Wearing a non-medical face mask or face covering
• Suggested ways of wearing a FRSM poster
• Key messages in the workplace poster
• Stop the spread: COVID-19 good practice points poster
  
• 4 moments for hand hygiene poster – residential and care home settings
• How to wash hands – Appendix 1 - NIPCM
• How to use alcohol based hand rub – Appendix 2 - NIPCM
• PHS Primary Care COVID-19 guidance
• PHS Social Care and Residential Care settings COVID-19 guidance
• COVID-19 Care Home Outbreak Checklist

6.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• SBAR: Provision of gloves for COVID-19 in health and care settings
• Rapid review of the literature - Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review of the literature - SARS-CoV-2 variants VOC-202012/01 (B.1.1.7) and 501Y.V2 (B.1.351) – implications for infection control within health and care settings
• Rapid review of the literature – Ultraviolet light technology for decontamination of health and care settings in the context of COVID-19
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

6.18 COVID-19 Compendium

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

• COVID-19 compendium

 

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

The purpose of this addendum is to provide COVID-19 specific IPC guidance for community health and care settings on a single platform improving accessibility for users.  The guidance within this addendum is in line with the UK IPC remobilisation guidance however some deviations for NHS Scotland exist.

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 if for use within the following settings;

• GP practices
• Health centres
• Health and social care services provided in peoples own homes 
• Community based settings for people with mental health needs
• Community based settings for people with learning disabilities
• Community based settings for people who misuse substances
• Supported accommodation settings
• Rehabilitation services
• Residential children's homes
• Stand-alone residential respite for adults (settings not registered as a care home)
• Stand-alone residential respite/short break services for children
• Sheltered housing
• Hospice settings
• Community Optometry
• Community Pharmacy
• Primary care dentistry (private dentistry may also follow this guidance) – any dental services operating from acute sites should follow the Scottish COVID-19 Acute addendum
• Specialist palliative care in-patients units/hospices
• Prison and detention settings

Within this document, service users are referred to as patients and/or individuals depending on the facility/setting in which care is provided.

 

Version Control

7 January 2021: Version 1.0
First publication

25 January 2021: Version 1.1
Addition of section 7.2.5 'Discontinuing IPC control measures in community health and care settings for COVID-19 individuals'

31 March 2021: Version 1.2
Health Centres included in list
Additional paragraph added clarifying position when organisations adopts practices that differ from those in this national guidance.
7.1.2 Definition of suspected case; Additional information and links included
7.1.4 Triaging individuals. International travel isolation changed to reflect current guidance
7.2    Individual placement/Assessment of Infection Risk section updated.
7.2.3 Individuals returning from day or overnight stay, new section included.
7.2.4 Providing care at home; Title amended
7.2.6 Table 1 Stepdown requirements for community health and care settings amended.
7.5.1 Extended use of Face Masks for staff, visitors and outpatients; additional information with link to new FRSM poster (ways to improve fit) link included.
7.5.2 Table 2: PPE for direct patient/individual care determined by pathway; Eye/face protection updated to include coughing & sneezing in medium pathway.
7.5.7 Table 3: PPE for Aerosol Generating Procedures determined by category; additional information below table included on respirators.
7.5.10 New section on PPE for delivery of COVID-19 Vaccinations
7.7 Safe Management of the Care Environment; Additional detail provided where items cannot stand application of chlorine releasing agents. Also additional information if an organisation adopts practices that differ from those recommended/stated.
7.7.1 Cleaning practice points; Additional detail also included where items cannot stand application of chlorine releasing agents. Additional information if an organisation adopts practices that differ from those recommended/stated.
7.8 Safe management of linen amended to clarify linen categorisation where no outbreak.
7.10 Safe Disposal of waste (including sharps). Wording amended to provide clarity.
7.11.1 Vehicle sharing for all staff; title amended
7.12 New section on hierarchy of controls added.
7.1.6 Resources and tools section updated

8 July 2021: Version 1.3
7.5.5 Change to AGP list to remove upper airway suctioning during Upper GI Endoscopy and replace with suctioning beyond the oro-pharynx.
7.5.7 Update to PPE table to emphasise Risk Assessment in medium risk pathway. Addition of risk associated with valved respirators
7.6 and 7.7 Change in controls for environmental and care equipment cleaning from TBPs to SICPs within the Medium Risk category.
7.8 and 7.10 Clarification on the safe management of linen and waste.

25 August 2021: Version 1.4
Inclusion of dental services within the addendum
Additional wording added to ‘patient placement in primary care settings’

31 August 2021: Version 1.5
Update to physical distancing

15 September 2021: Version 1.6
Update to physical distancing to include further information for visitors and residents within residential homes.

7.1 COVID-19 case definitions and triage

7.1.1 Definition of a confirmed case

7.1.2 Definition of a suspected case

7.1.3 Testing

7.1.4 Triaging individuals

7.1.1 Definition of a confirmed case

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

7.1.2 Definition of a suspected case

The case definition being used across the UK reflects current understanding from the epidemiology available and may be subject to change.  Case definitions can be found within Public Health Scotland (PHS) primary care guidance and below.

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

Community definition:

• Recent onset new continuous cough

or

• fever

or

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

Definition for individual who may require hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

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

or

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

Individuals must be assessed for bacterial sepsis of other causes of symptoms as appropriate

7.1.3 Testing

Clinicians should test all individuals who meet either of the case definitions described in section 7.1.1.  Further information on testing can be found in the PHS Primary Care guidance.

Guidance for coronavirus testing including who is eligible for a test, how to get tested and the different types of test are available on the Scottish Government web site.

If point of care testing is available in primary care settings, then it may be used to inform risk prior to any procedures being carried out eg within dentistry. It should be noted that Lateral Flow Devices are not considered point of care testing.

7.1.4 Triaging individuals

The mechanism for triage will vary dependant on both the  Healthcare facility Estate and type of service provision but wherever possible, triage questions should be undertaken by telephone prior to an arranged arrival at the facility. This will help inform the primary care team of respiratory status and potential associated risk before face to face consultation should this be deemed appropriate.   If following telephone consultation, the patient is suspected or confirmed as having COVID-19, the face to face consultation should be deferred until the self-isolation period has elapsed if the matter is non urgent.  If it is necessary to review the patient by means of a face to face consultation then they should be advised of the most suitable way to enter the healthcare facility, and on arrival be directed to a suitable waiting area identified for symptomatic individuals as per high risk category. Only the individual requiring a consultation should attend unless a carer or escort is required. See section 7.2.1 for information detailing individual placement of patients in primary care settings.

To enable early detection of suspected or confirmed COVID-19, triage questions should be undertaken again on arrival at community health facilities. 

For unplanned arrivals, triage questions should be completed immediately on arrival where it is safe to do so without delaying any necessary immediate lifesaving interventions. 

Individuals with symptoms consistent with COVID-19 could present to your facility. Information posters for NHS settings should be displayed so they can be seen before individuals enter the premises, encouraging them to return home and be advised to contact NHS24. Posters are available on NHS Inform.

If providing a home visit, staff should contact the patient/individual by telephone at home prior to the visit to undertake the triage questions.  These should be repeated on arrival at the patient/individual’s home. 

If patient lacks capacity to answer these questions by telephone, an assessment should be made on arrival.  If this is not possible, treat as medium risk category or high risk category if COVID-19 symptoms can be observed.

If it is an emergency and you need to call an ambulance for an individual, dial 999 and inform the ambulance call handler of the concerns about COVID-19 infection. While awaiting ambulance transfer, show the individual into a room and ask that they wear a fluid resistant surgical mask where it can be tolerated. Leave the room if safe to do so. If you have to enter the room, stay at least 2 metres away from the individual if possible and if not, wear PPE in line with section 7.5.  The room should be cleaned as per section 7.7 once the patient safely leaves the premises.

Staff within residential and detention settings must ensure individuals are monitored for new onset of any symptoms and action taken at the earliest opportunity.

The following are examples of triage questions:

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

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

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

If yes, ascertain if appointment/consultation/home visit can be delayed until results are known.  If urgent care is required, follow the high risk category.

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

If yes, 10 days’ self-isolation will apply.  Only urgent care should be provided during the self-isolation period.  The individual should be placed on the medium or high risk category depending on a clinical and individual assessment – see footnote 1 in section 7.2 (See Scottish Government list of countries exempt from self-isolation).

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

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

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

If yes, provide advice on who to contact (GP/HPT) and follow high-risk category.

• Is there any reason why you are unable to wear a face covering when attending for your appointment/when your care provider visits?

If No, remind individual to wear face covering on arrival or supply facemask.

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

7.2 Individual placement/assessment of infection risk

7.2.1 Category implementation and the surrounding environment

7.2.2 Managing individual placement in self-contained residential settings

7.2.3 Individuals returning from day or overnight stay

7.2.4 Providing care at home

7.2.5 Staff cohorting

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

Table 1: Stepdown requirements for community health and care settings

Risk categories must be established to ensure segregation of individuals determined by their risk of COVID-19. Any other known or suspected infections and the need for any Aerosol Generating Procedures (AGPs) must be considered before individual placement within each of the category areas. Establishing which category an individual is in will determine Personal Protective Equipment (PPE) and decontamination requirements.

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

Details of the Low Risk Category are not included here however it is expected that all patients/individuals within primary care and community settings will fall into the Medium (Amber) or High (Red) risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

Any services providing care at home should phone ahead to the individual prior to a visit and ask the triage questions in (examples in section 7.1) to determine what category they will be on. Within Acute care settings there is an additional low risk pathway which can be found in the Scottish Acute Care COVID-19 Addendum however it is expected that all individuals in community and care at home settings will fall into the Medium or High risk categories. Guidance beyond this section will only refer to the medium and high risk categories. NHS Boards must also undertake risk assessments of clinical areas to help ensure that the high risk pathway is placed appropriately reducing risk to staff, patients and visitors and taking account the hierarchy of controls.

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

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

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

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

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

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

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

7.2.1 Individual placement of patients in primary care settings

Community health and care settings should aim to have designated areas for the high risk category and designated areas for the medium risk category. 

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

As per triage questions above, patients on the high risk category should have their appointment postponed until they have completed their isolation period if the matter is non- urgent.  However, it is recognised that primary care settings may need to undertake face to face consultations with some patients/individuals meeting the case definition for COVID-19.

To allow the safe remobilisation of primary care services, primary care settings must identify areas/routes which allow segregation of suspected and confirmed patients who require a face to face consultation from all other patients attending the healthcare facility.   This segregated area/route would be identified as the high risk pathway and controls should be followed in line with this as stated within this addendum. 

Segregated reception areas, waiting areas and consultation rooms should be identified wherever possible. 

In smaller facilities, practices may choose to use screens or partitions to separate suspected/confirmed COVID-19 from all other patients.

Patients should be advised not to move around the facility including waiting areas and be encouraged to remain seated until called. 

Toys and books should be removed to discourage children to circulate around common areas and parents may be encouraged to bring a toy or book belonging to the child to keep them occupied during the wait time.

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

• Clutter and excess storage items should be removed from all areas to facilitate effective cleaning and minimise the potential for contamination.
  
  
• Soft furnishings which can’t be cleaned appropriately should be avoided where possible such as fabric chairs and carpets.
  
  
• All non-essential items including toys, books and magazines should be removed from receptions, waiting areas, consulting and treatment rooms.

7.2.2 Managing individual placement in self-contained residential settings

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

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

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

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

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

• Confirmed COVID-19 patients/individuals are placed in multi-occupancy rooms together.
• Suspected COVID-19 patients/ individuals are placed in multi occupancy rooms together.

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

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

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

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

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

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

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

7.2.3 Individuals returning from day or overnight stay

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

7.2.4 Providing care at home

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

An FRSM should be worn on entering an individual’s home.  On arrival, assess the activities and tasks to be undertaken. Physical distancing should be maintained PPE should be worn in line with table 2.  Donning and doffing of PPE in the care at home settings is covered in section 7.5.4.

Scottish Government advice on providing care at home is available.

7.2.5 Staff cohorting

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

Providers or employers delivering a service in an individual’s own home should identify individuals at extremely high risk of severe illness, assess their needs and allocate dedicated staff (if possible) to care for them. This should be reviewed regularly to ensure it is up to date. Other staff members should be allocated to consistently care for the needs of those not at extremely high risk of severe illness. This should be discussed with the relevant authorities and care providers. Where it is not possible to allocate specific staff to care for individuals who are at extremely high risk of severe illness, it may be possible to schedule visits to these groups of patients before visits to others.

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

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

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

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

• Completing the isolation period - – Individuals living in their own home should complete a period of 10 days isolation. Individuals recently discharged from hospital (within the self-isolation period) must complete a total of 14 days isolation.  This is because, in general, those with COVID-19 who are admitted to hospital will have more severe disease than those who remain in the community, especially if they require critical care. In addition, those admitted are more likely to have pre-existing conditions such as severe immunosuppression.

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

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

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

• COVID-19 clinical requirements for stepdown – Clinical improvement with at least some respiratory recovery. Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some individuals, and is not an indication of ongoing infection when other symptoms have resolved.
  
  
• Testing required for stepdown – No testing is required routinely to stepdown IPC precautions in community health and care settings.

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

Table 1 - Stepdown requirements for COVID-19 cases in community health and care settings

Group	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
COVID-19 positive individuals who have recently been discharged from hospital to either their own home or a community health and care setting	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery	Not routinely required.
COVID-19 positive individuals who are living at home or in a community health and care setting and who are severely immunocompromised as determined by Chapter 14a of the Green Book.	14 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery	Not routinely required unless returning to healthcare as an outpatient
People in prisons	10 days from symptom onset (or first positive test if symptom onset undetermined)	Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.	Not routinely required

Transferring between pathways on stepdown

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

7.3 Hand hygiene

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

Hand hygiene should be performed in line with section 1.2 of SICPs bare below the elbow and must be performed:

• before every episode of direct individual/resident care; and
  
  
• after any activity or contact that potentially results in hands becoming contaminated including;
  • removal of personal protective equipment (PPE),
  • equipment decontamination; and
  • waste handling.   

Within this section you will find videos demonstrating how to perform a hand wash and how to perform a hand rub. 

Posters detailing hand washing techniques and alcohol based hand rub (ABHR) technique can be found in the resources section of this addendum. 

Hand washing should be extended to the forearms if there has been exposure of forearms to respiratory secretions.

7.3.1 Hand hygiene in the community

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 (when visibly contaminated) in the individual’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.

Staff may also carry antimicrobial hand wipes if they are going to be attending a property where there is no running water.  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.

7.4 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of respiratory pathogens including COVID-19.  The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

The ‘Catch it, Bin it, Kill it’ poster can be downloaded.

7.5 Personal Protective Equipment (PPE)

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

7.5.2 PPE determined by COVID-19 care category

Table 2: PPE for direct resident care determined by risk category

7.5.3 PPE – Putting on (Donning) and Taking off (Doffing)

7.5.4 Putting on (donning) and taking off (doffing) in an individual’s home

7.5.5 Aerosol Generating procedures (AGPs)

7.5.6 Aerosol Generating Procedures (AGPs) in an individual’s home

7.5.7 PPE for Aerosol Generating Procedures (AGPs)

Table 3: PPE for aerosol-generating procedures, determined by risk category

7.5.8 Post AGP Fallow Times (PAGPFT)

Table 4: Post AGP fallow time calculation

7.5.9 Sessional use of PPE

7.5.10 PPE for delivery of COVID-19 vaccinations

7.5.11 Access to PPE

PPE exists to provide the wearer with protection against any risks associated with the care task being undertaken. PPE requirements as per standard infection prevention and control are detailed in section 1.4 SICPs. PPE requirements during the COVID-19 pandemic are determined by the care categories and are detailed in table 2.

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

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

The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff and residents.  The guidance and FAQs are available Scottish Government guidance and associated FAQs.

For medical grade face masks, a poster detailing the ‘Dos and don’ts’ of wearing a face mask is available.

For non-medical face masks/coverings, a  poster intended to support the wearing of a non-medical face mask/face covering is available.

Where staff are providing ‘live in’ support/care for individuals, the should maintain 1 metre physical distancing when not providing direct care.  When providing direct care, a Type IIR mask should be worn as well as any other PPE required as outlined in section 7.5.2.

7.5.2 PPE determined by COVID-19 care category

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

Table 2 details the PPE which should be worn when providing care in each of the COVID-19 care risk categories.

Type IIR facemasks should be worn for all direct care regardless of the risk category.  This is a measure which has been implemented alongside physical distancing specifically for the COVID-19 pandemic. FRSMs should be changed if wet, damaged or soiled. 

 

Table 2: PPE for direct individual/patient care determined by risk category
(see table 3 for AGP PPE)

PPE used	Medium-risk category	High-risk category
Gloves	Risk assessment - wear if contact with BBF* is anticipated. Single-use.	Worn for all direct care. Single use.
Apron or gown	Risk assessment - wear if direct contact with patient, their environment or BBF  is anticipated, (Gown if splashing spraying anticipated) Single use.	Always within 2 metres of patient (Gown if splashing spraying anticipated). Single-use.
Face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask	Always within 2 metres of a patient - Type IIR fluid resistant surgical face mask
Eye and face protection	Risk assessment - wear if splashing or spraying with BBF, including coughing/sneezing anticipated. Single use or reusable following decontamination.	Always within 2 metres of a patient Single-use, sessional** or reusable following decontamination.

* Blood and body fluids (BFF)

**Sessional use see section 7.5.9

NB: Where a physical partition is insitu e.g. at reception desks/pharmacy counters, Staff need only wear FRSM in line with extended face mask policy described in section 7.5.1.  No other PPE is required.

A flowchart detailing appropriate glove use and selection can be found in Appendix 5 of the NIPCM.

7.5.3 PPE – Putting on (Donning) and Taking off (Doffing)

All staff must be trained in how to put on and remove PPE safely.  A short film showing the correct order for putting on and the safe order for removal of PPE is available.  The video will also describe safe disposal of PPE.  A poster describing the donning and doffing of PPE is available in the NIPCM Appendix 6 and is also described below.

Putting on PPE

Before putting on PPE:

• Check what the required PPE is for the task/visit
  
  
• Select the correct size of PPE
  
  
• Perform hand hygiene

PPE should be put on before entering the room.

• The order for putting on is:

1. 1. apron,
   2. surgical mask
   3. eye protection
   4. gloves 

You may require some of these items or all of them – See Table 2.

• When putting on mask, position the upper straps on the crown of head and the lower strap at the nape of the neck. Mould the metal strap over the bridge of the nose using both hands.

When wearing PPE:

• Keep hands away from face and PPE being worn.
  
  
• Change gloves when torn or heavily contaminated.
  
  
• Limit surfaces touched in the care environment.
  
  
• Always perform hand hygiene after removing gloves.

Removal of PPE

PPE should be removed in an order that minimises the potential for cross-contamination.

Gloves

• Grasp the outside of the glove with the opposite gloved hand; peel off.
• Hold the removed glove in gloved hand.
• Slide the fingers of the un-gloved hand under the remaining glove at the wrist.
• Peel the glove off and discard appropriately.

Gown

• Unfasten or break ties.
• Pull gown away from the neck and shoulders, touching the inside of the gown only.
• Turn the gown inside out, fold or roll into a bundle and discard.

Eye Protection

• To remove, handle by headband or earpieces and discard appropriately.

Fluid Resistant Surgical facemask

• Remove after leaving care area.
• Untie or break bottom ties, followed by top ties or elastic and remove by handling the ties only (as front of mask may be contaminated) and discard as clinical waste.
• For face masks with elastic, stretch both the elastic ear loops wide to remove and lean forward slightly. Discard as clinical waste.

To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.

Perform hand hygiene immediately after removing all PPE.

7.5.4 Putting on (donning) and taking off (doffing) in an individual’s home

PPE should be put on in a safe area either inside the premises, such as a porch or a separate room, or, if there is no available area then the mask can be put on immediately prior to entering the home, and gloves and apron when in the home.

PPE should be removed before leaving the home or care setting and should not be worn out with the home or to the next visit.

If caring for more than one individual in the same house, then only the mask/eye protection can be considered sessional use until completion of the tasks/care.

Hand hygiene must be carried out on immediately after removing PPE.

Disposal of PPE can be found in section 7.10.

7.5.5 Aerosol Generating procedures (AGPs)

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

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

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

Note 1: The available evidence relating to Respiratory Tract Suctioning is associated with ventilation.  In line with a precautionary approach open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.  It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.  This applies to upper gastro-intestinal endoscopy also and as such it has also been changed to reflect risk associated with suctioning beyond the oro-pharynx.

Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres. On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

This recommendation comes from Public Health England and the New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG).  The published evidence view and consensus opinion can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp--2

Certain other procedures/equipment may generate an aerosol from material other than an individual’s secretions but are not considered to represent a significant infection risk and do not require AGP PPE. Procedures in this category include:

• administration of humidified oxygen;
• administration of Entonox or medication via nebulisation.

NERVTAG advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.

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

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

7.5.6 Aerosol Generating Procedures (AGPs) in an individual’s home

Wherever possible, staff should avoid visiting patients/individuals in the medium and high categories who require a routine consultation and where AGPs are undertaken in the home.  This is because potentially infectious aerosols will still be circulating in the air (see section 7.5.8).  The most common AGPs undertaken in the community are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).

Consider phone/digital consultations in the first instance to assess whether the individual requires a home visit. If it is safe to postpone the visit, then do so.

Care at home staff will not be able to postpone visits.  In such instances where a home visit cannot be avoided;

• Find out what time the individual is on CPAP/BiPAP and plan to visit at least an hour or more after the CPAP or BiPAP has been switched off.
  
  
• Ask the individual to move to another room in the property and close the door to the room where the CPAP or BiPAP is undertaken.
  
  
• If the visit must take place when the patient is on the CPAP/BiPAP or if the above measures cannot be followed, the member of staff must wear AGP PPE in line with section 7.5.4. It is the responsibility of care providers to ensure that all staff have been fit tested for FFP3 respirators where appropriate.

7.5.7 PPE for Aerosol Generating Procedures (AGPs)

Airborne precautions are required for the medium and high risk categories where AGPs are undertaken and the required PPE is detailed in table 3. Ongoing requirement for airborne precautions in the medium risk pathway when an individual is undergoing an AGP recognises the potential aersolisation of COVID-19 from an asymptomatic carrier.

All FFP3 respirators must be:

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

 

Table 3: PPE for aerosol-generating procedures, determined by risk category

PPE used	Medium-risk category	High-risk category
Gloves	Single-use.	Single-use.
Apron or gown	Single-use gown.	Single-use gown.
Face mask or respirator**	FFP3 mask or powered respirator hood.2	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.	Single-use or reusable.

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

There is a theoretical risk of exhaled breath from the wearer of a valved respirator or powered air purifying respirator (PAPR) transmitting COVID-19 where asymptomatic carriage is present however, following introduction of staff testing and uptake of vaccination, this risk is likely to be low.  Valved respirators and PAPR should not be used when sterility directly over a surgical field/surgical site is required and instead a non-valved respirator should be worn. More information can be found on the MHRA website.

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.

7.5.8 Post AGP Fallow Times (PAGPFT)

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

The post aerosol-generating procedure fallow time (PAGPFT) calculations are detailed in table 4. It is often difficult to calculate air changes in areas that have natural ventilation only.

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.

All point of care areas require to be well ventilated. Natural ventilation, provides an arbitrary 1-2 air changes per hour. To increase natural ventilation in many community health and social care settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

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

Dental settings should be aiming for a minimum of 10 ACH in treatment rooms.  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; cleaning and disinfection of the environment should be carried out between patients of the same household.

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  it is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.

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

As a minimum, regardless of air changes per hour (AC/h), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes (see table 4).

Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE and should be undertaken using 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.

.

Table 4: Post AGP fallow time calculation

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

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

7.5.9 Sessional use of PPE

During the peak of the pandemic, some PPE was used on a sessional basis and this meant that these items of PPE could be used moving between residents and for a period of time where a member of staff was undertaking duties in an environment where there was exposure to COVID-19.  A session ended when the healthcare worker left the clinical setting or exposure environment. 

Sessional use of PPE is no longer recommended other than when wearing a visor or eye protection in a communal area where the resident is on the high-risk category and when wearing a fluid-resistant surgical face mask (FRSM) across all categories. Sessional use of all other PPE is associated with transmission of infection amongst patients and is considered poor practice.

FRSMs can be worn sessionally when going between patients however, FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogen and when leaving high-risk (red) category areas.

The same principles should be observed for staff post toilet and meal breaks, when a new face mask should be put on, once removed the FRSM must never be reused.

Employers are encouraged to plan breaks in such a way that allows 2 metre physical distancing and therefore staff not having to wear a face mask, with natural ventilation where possible.

7.5.10 PPE for delivery of COVID-19 vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

• wear a fluid resistant surgical facemask (FRSM) for all direct contact and where
  2 metre physical distancing cannot be maintained.  This will protect both the HCWs and resident from exposure to COVID-19 should either be pre-symptomatic or an asymptomatic carrier of COVID-19.  
• perform hand hygiene regularly including before and after each patient/individual contact and as per 4 moments for hand hygiene laid out in the National Infection Prevention & Control Manual (NIPCM). 
• wear a visor where there is anticipated splashing to the face. For example  when delivering nasal vaccinations which are likely to induce sneezing.

The patient/individual on whom the nasal vaccination is being administered should be provided with disposable tissues to cover their mouth where any sneezing is likely.  They should dispose of the tissues in a suitable waste receptacle and wash hands with warm soap and water.  If there are no hand hygiene facilities available, ask the individual to use alcohol based hand rub (ABHR) and wash their hands at the earliest opportunity.

• other items of PPE are unlikely to be required for routine vaccination and a risk assessment should be carried out considering both IPC and COSHH guidance. 

As per SICPs;

• Aprons should be worn where there is anticipated contamination to the healthcare workers uniform or clothing.
• Gloves should be worn where blood and body fluid exposure is anticipated.  Tiny amounts of blood resulting from vaccination site pose little risk to a HCW where the skin of the healthcare workers hands is intact.  There is therefore no need to wear gloves when delivering a vaccination provided the skin on the HCWs hands is intact and the skin of the person receiving the vaccination is intact.  An SBAR which considered the need for HCWs to wear gloves when delivering vaccinations was produced by HPS in 2014.  

A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.

7.5.11 Access to PPE

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 Service Scotland. 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.

All services who are registered with the Care Inspectorate that are providing health and/or care support and have an urgent need for PPE after having fully explored local supply routes/discussions with NHS Board colleagues, can contact a triage centre run by NHS National Services for Scotland (NHS NSS).

Please note that in the first instance, this helpline is to be used only in cases where there is an urgent supply shortage after “business as usual” routes have been exhausted.

The following contact details will direct social care providers to the NHS NSS triage centre for social care PPE:

Email: support@socialcare-nhs.info

Phone: 0300 303 3020.

The helpline will be open (8am - 8pm) 7 days a week.

7.6 Safe management of Care Equipment

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

All care equipment should be decontaminated as per Table 5.

Re-useable care equipment used in the community setting such as stethoscopes, syringe drivers and pumps must be decontaminated prior to removal from an individual’s home.  Where this is not possible, they should be bagged and transported back to base for decontamination.

Table 5: Equipment cleaning determined by risk category

Risk category	Product
Medium-risk category	General purpose detergent for routine cleaning.  See Appendix 7 of the NIPCM for cleaning of equipment contaminated with blood or body fluids (including saliva) or it has been used on a patient with a known or suspected infectious pathogen.
High-risk category	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.

7.7 Safe Management of the Care Environment

During this ongoing pandemic, cleaning frequency of the environment should be increased across all categories. 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 residents since the first daily clean was undertaken, a second daily clean is not required.

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

The care environment must be:

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

Ideally rooms which are carpeted should be avoided when carrying out consultations in healthcare facilities.

The cleaning frequency and use of general purpose detergent for cleaning in the Medium Risk pathway as per the NHS Scotland National Cleaning Services Specification is sufficient with the exception of isolation/cohort areas where individuals with a known or suspected infectious agent are being cared for.  These areas require to be cleaned twice daily with a chlorine releasing agent containing 1000ppm av chlorine.

Environmental cleaning in the high risk category should be undertaken using either a combined detergent/disinfectant solution at a dilution of 1000 ppm available chlorine or a general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm. A minimum of 4 hours should have elapsed between the first daily clean and the second daily clean – see table 6 for cleaning requirements.  Where a room has not been occupied by any staff or patient/individuals since the first daily clean was undertaken, a second daily clean is not required.

Cleaning across the categories is summarised in table 6.

Table 6: Environmental cleaning determined by category

	Medium risk category (Amber)	High risk category (Red)
Frequency	At least daily as per NHS Scotland National Cleaning Services Specification.	At least twice daily 1st clean - Full clean 2nd clean - * Touch Surfaces within clinical inpatient areas
Product	General purpose detergent**	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

*High risk touch surfaces as a minimum should include door handles/push pads, taps, light switches, lift buttons.  Resident areas should include the bedroom and treatment areas and staff rest areas.

**Cleaning in the medium risk pathway should be carried out with chlorine based detergent for rooms where the individual is known to have any other known or suspected infectious agent and following an AGP .

Any areas contaminated with blood and body fluids (including saliva) across any of the three categories require to be cleaned as per Appendix 9 of the National Infection Prevention and Control Manual.

7.7.1 Cleaning practice points

NHS healthcare facilities will be cleaned by NHS domestic services who will adhere to the National Cleaning Specification Standards. For all other health and care facilities (excluding patient/individuals own home) the following good practice points apply:

• Use disposable cloths/paper roll/disposable mop heads, to clean and disinfect all hard surfaces/floor/chairs/door handles/reusable non-invasive care equipment/sanitary fittings in the room.
  
  
• Clean, dry and store re-usable parts of cleaning equipment, such as mop handles.
  
  
• For carpeted floors/items that cannot withstand chlorine-releasing agents, consult the manufacturer’s instructions for a suitable alternative to use following, or combined with, detergent cleaning.
  
  
• Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated, you may have to discard it. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.
  
  
• 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.

When an organisation adopts practices that differ from those recommended/stated in this national guidance 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.

7.8 Safe Management of Linen

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

Linen used on patients/individuals who are in the high risk category should be treated as infectious. Following local risk assessment/ and there is no confirmed outbreak in the setting laundry can be processed as normal.

Provided curtains around examination bays have no visible contamination and are kept tied back when not in use, they may remain insitu however regular curtain change regimes should be in place and when changed, curtains should be treated as infectious linen.

Where care providers are supporting individuals with laundering in the community, If the individual does not have a washing machine, the laundry items for those in the high risk category should be bagged, held for 72 hours before being taken to a public launderette.

Care at home staff who manage linen in the individual’s own home should wash linen as normal unless the individual is in the high risk category.  In this instance, any linen belonging to the individual should be washed separately from others living in the same household.

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 section 7.13 for staff uniforms.

7.9 Safe Management of Blood and Body Fluid Spillages

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

Waste generated during the management of blood and body fluid spillages should be disposed of as per section 7.10.

7.10 Safe Disposal of waste (including sharps)

Waste should be handled in accordance with Section 1.9 of SICPs.

Waste generated from patients/individuals who are in the high risk category or where there is a confirmed outbreak, should be disposed of as clinical waste where clinical waste contracts are in place.

Any items contaminated with BBF (including saliva) for any patient regardless of infectious status should be disposed of as clinical waste.

If the community health and care setting does not have a clinical waste contract, or for care at home, ensure all waste items that have been in contact with patients/individuals on the high risk category (e.g. used tissues and disposable cleaning cloths) are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.

7.11 Occupational Safety

Section 1.10 of SICPs remains applicable to COVID-19 individuals.

Occupational risk assessment guidance specific to COVID-19 is available.

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

7.11.1 Vehicle sharing for all staff

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

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

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

• Staff who carry out community visits;
• Staff who are commuting with residents as part of supported care;
• Staff who are commuting with students as part of supported learning/mentorship;
• Staff living in areas where public transport is limited and car sharing is the only means of commuting to and from the workplace;

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

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

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

7.12 Caring for someone who has died

The IPC measures described in this document continue to apply whilst the individual who has died remains 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 individuals.

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.

For further information, please see the following guidance produced by Scottish Government Coronavirus (COVID-19): guidance for funeral directors on managing infection risks.

 

7.13 Staff Uniforms

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. If wearing a uniform to and from work, then change as soon as possible when returning home.

Uniforms should be laundered daily, and:

• separately from other household linen;
• in a load not more than half the machine capacity;
• at the maximum temperature the fabric can tolerate, then ironed or tumble dried.

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

7.14 Hierarchy of Controls

7.14.1 Engineering and administration control measures in healthcare settings

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below 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 COVID-19 within healthcare settings.  NHS boards and NHS staff should employ the most effective method of control first.  Where that is not possible, all others must be considered.  PPE is the last in the hierarchy of controls.

Hierarchy of Risk Controls graphic //commons.wikimedia.org/index.curid=90190143 (original version: NIOSH Vector version: Michael Pittman)

Application of the hierarchy of control in health and social care settings is as follows;

1. Elimination
   • Patients must not attend for an appointment if they have symptoms of COVID-19 or have been advised to self-isolate; unless a dedicated area/pathway can be used
   • Staff must not report to work if they have symptoms of COVID-19 or have been advised to self-isolate
   • Staff who can work from home should be supported to do so
   • Consideration should be given to non clinical staff who typically enter clinical areas as part of their job role and alternative arrangements made wherever possible
2. Substitute
   • For any patients presenting with respiratory symptoms in keeping with a suspected or confirmed COVID-19 definition – perform consultations over phone as far as possible rather than in person
3. Engineering controls
   • Installations of partitions at appropriate places (e.g reception desks)
   • Physical distancing in all areas of the premises (see section 7.15) 
   • Efforts made to reduce number of people on premises at any one time
   • Reduce waiting time for individuals in in waiting areas, e.g. practices, clinic and radiology departments
   • Avoid face-to-face waiting arrangements in waiting areas where possible
   • Improve ventilation by opening windows on the premises, whilst maintaining comfort 
   • Optimal bed spacing and chair spacing (see section 7.15.1) 
     
     
4. Administrative Controls (more detail in section 7.15.1) 
   • Working from behind or at the side of the individual (no face to face close contact)
   • Development of pathways/one way systems/dedicated assessment rooms on the premises
   • Use of various COVID-19 related signage
   • Provision of additional hand hygiene stations
   • Increased cleaning. 
5. PPE
   • Use of face coverings (although not classed as PPE) by patients and visitors – in healthcare they can be provided with a Type IIR mask
   • PPE when a risk assessment indicates this (see PPE section of this addendum).

7.14.1 Engineering and administration control measures in healthcare settings

Boards and departments should apply administrative controls to establish separation of patient pathways and minimise contact between the pathways. 

Due to the wide variance in the lay out, structure and fabric of NHS facilities across Scotland it is not possible to be descriptive in exactly how these should be applied and full assessment should be undertaken locally. 

The following bullet points provide guidance which boards and departments may use when considering how best to develop pathways and promote 2 metre physical distancing.

• Signage on entry to buildings, wards and departments advising of the necessary precautions to take (face coverings, hand hygiene, physical distancing) including advice for visitors not to enter the premises if symptomatic of COVID-19.
  
  
• Ensure signage is clearly displayed to clearly identify pathways. Floor markings may also be used.  Physical barriers may be used where appropriate to prevent cross over of pathways.
  
  
• Ensure there are adequate hand hygiene facilities (wash hand basins or alcohol based hand rub stations) available including the use of posters promoting hand hygiene and detailing the effective method for doing so.
  
  
• Where required, facilitate the use of screens to reduce exposure risk, for example at admission desks or help desks.

Screens may be used in clinical care areas to help segregate patients however installation of these must not hinder the ability of staff to observe their patients and must be assessed by fire officers and health and safety teams first to ensure all other regulations remain compliant.

There is limited evidence supporting the use of partitions for face-to-face interactions or between bed spaces, but it appears logical that a physical barrier can reduce contact between individuals and reduce the spread of infected particles from an infective source.

• • Full bed length, floor to ceiling partitions are likely to be the most efficacious in preventing transmission of COVID-19. Partitions for face-to-face interactions, as a minimum, should cover both individuals breathing zone which encompasses a radius of 30cm from the middle of the face.
    
    
• Ensure areas are well ventilated where possible – open windows if temperature/weather conditions allow

7.15 Physical distancing

Two metre physical distancing within the general community and healthcare and residential settings was introduced at the start of the COVID-19 pandemic as a mitigation measure to prevent transmission of the virus between individuals.  Following the roll out of the successful vaccination programme, expansion of testing and the use of face coverings by the general public, physical distancing is no longer obligatory in the general community.

However, users of community and care at home services are amongst the most vulnerable in society and whilst the COVID-19 pandemic remains a threat, it is recommended that physical distancing remains although reductions from 2 metres to 1 metre or more can now be advised in some areas. This applies to vaccination and testing centres also. 

The maximum distance for cross transmission from droplets has not been fully determined, although a distance of approximately 1 metre (3 feet) around the infected individual has frequently been reported in the literature as the highest area of risk.  By applying physical distancing of 1 metre or more within community and care at home settings, we can help mitigate against risk of transmission via pre-symptomatic and asymptomatic individuals. Physical distancing will continue to be reviewed regularly over the winter season and any changes will be informed by COVID-19 prevalence, and nosocomial transmission data of COVID-19 and other respiratory viruses.

Summary of key points

• Physical distancing of 2m must remain for:
  • the COVID-19 high risk category across all settings
  • for staff when FRSMs are removed
• Physical distancing may be reduced across all areas (including waiting areas) to 1 metre or more with the exception of patients/individuals being managed on the high risk category
• Any individual answering yes to any of the triage questions should be placed in the high risk category which will remain at 2 metres physical distancing
• Physical distancing may be reduced amongst staff to 1 metre or more when FRSMs are in use. If FRSMs are removed for any reason e.g eating, drinking, it is advised that 2 metres or more be obtained to avoid high numbers of staff being identified as contacts should a positive case arise
• Physical distancing may be reduced amongst visitors to 1 metre or more.
• Physical distancing in a patient’s/individual’s own home may be reduced to 1 metre or more when staff are not providing direct care.
• These changes to physical distancing do NOT mean a return to pre pandemic practices. NHS Boards and independent contractors must adapt processes to ensure risk of transmission is minimised.
• This is the minimum guidance – where clinical teams or services decide that maintaining 2 metres is necessary they should be allowed to do so e.g when seeing patients/individuals who are extremely clinically vulnerable.

In order for COVID-19 transmission risk to remain low in community and care at home settings, whilst also recommending a reduction to physical distancing, it is essential that all staff, patients/individuals and visitors to healthcare settings adhere with other pandemic measures which remain in place to mitigate risk including:

• Continued adherence with extended use of facemasks (staff) and face coverings (patients & visitors) unless they have a medical exemption
• Maximise the amount of fresh air entering a room wherever possible. Natural ventilation can be achieved by opening windows, vents and doors (excluding fire doors). Some buildings may have mechanical ventilation systems, these should maximise the amount of fresh air being introduced and minimise the recirculation of air in rooms and throughout buildings.
• Avoidance of non-urgent consultations if symptomatic of suspected/confirmed COVID-19 (NB: clinicians should decide locally which suspected/confirmed COVID-19 patients need to attend for face to face consultations and ensure that where they continue as planned, that appropriate measures are taken to mitigate risk including allocation of an appointment that avoids spending time in the waiting areas and ensure there is a segregated area for high risk pathway patients.
• Continued application of the COVID-19 triage questions.
• Continued adherence with Scottish COVID-19 IPC addenda to ensure COVID-19 transmission risk is reduced in particular the application of Standard Infection Control Precautions (SICPs) and where applicable, transmission based precautions (TBPs).
• Signage should be updated throughout all areas to encourage application of physical distancing

Physical distancing amongst staff in community health and care settings

Physical distancing amongst staff may now be reduced to 1 metre or more across community health and care settings provided FRSMs are in use.

Where staff remove FRSMs for any reason e.g eating, drinking, changing, staff are advised to maintain 2 metre physical distancing.  This is because 2 metres is still used to assess contacts and failure to physically distance by 2 metres or more when not wearing an FRSM may result in high numbers of staff within community and care at home settings being considered as a contact and requiring exclusion from work until they can return as per the appropriate requirements associated with Staff exclusion from work. Staff should be supported by their organisation to remind their colleagues when they drop their guard during application of COVID-19 controls.

Outbreaks amongst staff have been associated with a lack of physical distancing in changing areas and recreational/rest areas during staff breaks as well as car-sharing and it is particularly important to utilise all available rooms and spaces to allow staff to change and have rest breaks without breaching 2 metre physical distancing (recognising that staff will not be wearing FRSM in these areas).  Car-sharing should still be avoided whenever practical and mitigations should remain in place.

Physical distancing in a patient’s/individual’s own home may be reduced to 1 metre or more when staff are not providing direct care.

Staff previously identified as having been on the shielding list may wish to discuss how physical distancing impacts them with their line manager and/or occupational health.

Patients/Individuals in Community health and care settings

Physical distancing amongst patients in community health and care settings (including waiting areas) may now be reduced to 1 metre with the exception of patients with suspected or confirmed COVID-19. This will require triage questions to be undertaken on arrival. Any individual answering yes to any of the triage questions should be placed in the high risk category which will remain at 2 metres physical distancing.   Some community care areas will receive individuals who are considered extremely clinically vulnerable.  In these areas, clinical teams may choose to maintain 2 metre physical distancing. 

Patients must be encouraged not to move around waiting areas and should remain seated until called. 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.  Members of the same family/household do not need to physically distance in waiting areas.

Patients should be advised not to attend appointments too early wherever possible in order to avoid spending more than 15 minutes in waiting areas and prolonged exposure.

Avoid face to face waiting arrangements in waiting areas, e.g. chairs back-to-back or side to side will reduce risk.

Residents/individuals living in residential home settings

Residents/individuals who live in residential homes are not expected to physically distance from each other.

Where able, residents should be reminded to report any symptoms of COVID-19 to residential home staff. Staff should remain vigilant for early onset of any symptoms amongst residents/individuals taking account of atypical symptoms and where symptoms do develop, act promptly by isolating the resident/individual in their own room and following guidance within the Scottish COVID-19 addendum as per high risk category.

Staff are also reminded to encourage and where necessary support residents/individuals to perform hand hygiene regularly and practice good respiratory hygiene.

Visitors to community and health care settings

Visitors should maintain 1 metre or more distancing from staff and patients within the healthcare facility. 

Visitors may have touch contact with loved ones (hug/kiss) however are reminded that maintaining 1 metre or more distancing outwith direct touch contact wherever possible will help reduce the risk of transmission of COVID-19 and other respiratory pathogens to them, their loved one and others in the healthcare setting.

Visitors answering yes to any of the triage questions should not visit until after they have completed their self-isolation period.

Building based Day Services

Staff working within building based day services should follow the physical distancing guidance as laid out above.  Physical distancing amongst service users of building based day services is included within Scottish Government guidance on physical distancing which can be found at the following on the Scottish Government website at Coronavirus (COVID-19): staying safe and protecting others.

Patient and service user transport vehicles

Physical distancing may be reduced to 1m between patients/service users and staff unless the patients are on the high risk pathway in which case 2 metre physical distancing should be maintained.

7.16 Visiting in residential facilities

All visitors must be informed on arrival of IPC measures and adhere to these at all times.  Visitors should wear face coverings in line with current Scottish Government guidance (see section 7.5.1) and must not attend with COVID-19 symptoms or before a period of self-isolation has ended, whether identified as a case of COVID-19 or as a contact.

Visiting may be suspended if an area moves to Level 4, or on the advice of the local HPT. Consider alternative measures of communication including telephone or video call where visiting is not possible.

Visitors must;

• Not visit if they have suspected or confirmed COVID-19 or if they have been advised to self-isolate for any reason
  
  
• Wear a face covering on entering the facility
  
  
• Be provided with appropriate PPE (see table 7)
  
  
• Perform hand hygiene at the appropriate times;     
• On entry to the facility
• Prior to putting on PPE
• After removing PPE
  
  
• Observe physical distancing.
  
  
• Not move around the facility and should stay in the areas advised by staff.
  
  
• Not visit other individuals in the facility.
  
  
• Not touch their face or face covering/mask once in place.
  
  
• Avoid sharing mobile phone devices with the individual unnecessarily – if mobile devices are shared to enable communications with other friends and family members, the phone should be cleaned between uses using manufacturer’s instructions

 

Table 7: PPE for Visitors

PPE used	Medium-risk category	High-risk category
Gloves	Not required1	Not required1
Apron or gown	Not required2	If within 2 metres of resident
Face mask	Face covering or provide with FRSM if visitor arrives without a face covering.	FRSM
Eye and face protection	Not required3	If within 2 metres of resident

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

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

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

 

 

7.16 Resources

This section contains resources and tools which can be used by clinical teams and IPCTs during the COVID-19 pandemic.

• PPE poster – medium-risk pathway
• PPE poster – high-risk pathway
• COVID-19 Safe practice in acute healthcare settings poster
• COVID-19 Wearing a facemask poster (staff)
• Wearing a non-medical face mask or face covering
• Poster suggested ways of wearing a face mask
• Key messages in the workplace poster
• 4 moments for hand hygiene poster – residential and care home settings
• How to wash hands – Appendix 1 - NIPCM
• How to use alcohol based hand rub – Appendix 2 - NIPCM
• PHS Primary Care COVID-19 guidance
• PHS Social Care and Residential Care settings COVID-19 guidance
• COVID-19 Social, Community and Residential Care Outbreak Checklist
• For dental settings only - Scottish Dental Clinical Effectiveness Programme - SDCEP

 

7.17 Rapid Reviews

This section contains rapid reviews of the literature undertaken to support the infection prevention and control response to the COVID-19 pandemic. These are all available on the Health Protection Scotland website via these links:

• Rapid Review of the Literature: Assessing the Infection Prevention and Control Measures for the Prevention and Management of COVID-19 in Healthcare Settings
• Eye protection in health and care settings for the prevention of COVID-19 transmission
• Infrared Thermal Imaging in Health and Care Settings
• SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker
• SBAR: Provision of gloves for COVID-19 in health and care settings
• Respirators in health and care settings for the prevention of COVID-19 transmission
• Rapid review: Risk of SARS-Cov-2 acquisition in healthcare workers

 

7.18 COVID-19 Education resources

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

• TURAS - COVID-19 vaccination programme
• Correct use of Alcohol Based Hand Rub
• Correct Hand Hygiene Technique using soap and water
• Correct order for putting on, the safe order for removal, and the disposal of PPE
• Obtaining a sample swab test in care homes
• Protecting yourself and your work environment

 

 

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

4.1 Placement of neonates/assessment for infection risk

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

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

• have been transferred from another unit in Scotland with an ongoing incident/outbreak or
• were born outside Scotland
• have previously been positive with a Multidrug Resistant Organism (MDRO)

From mothers who have:

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

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

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

4.2 Healthcare infection, incidents, outbreaks and data exceedence

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

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

Assigning staff to nurse only infected/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.

4.3 Personal care of neonates

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

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

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

The National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO(2012)01-update). The Scottish Government expectation is that it is mandatory for use in all NHS care settings and in all other care homes to support health and social care integration, the content of this manual must be considered best practice.

 

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

The CH IPCM contains chapters on:

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

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

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

It aims to:

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

Who should use the CH IPCM?

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

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

Is the content based on scientific literature?

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

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

• View the literature reviews

Are there any other IPC materials that can be used?

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

• View the resources

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

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

Responsibilities for the CH IPCM

ARHAI Scotland to:

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

Care Home providers to:

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

Care Home Managers to:

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

Care Home staff to:

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

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

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

Chain of infection

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

1. The Infectious Agent – or the microorganism which has the ability to cause disease.
   
   
2. The Reservoir or source of infection where the microorganism can live and thrive. This may be a person, an animal, any object in the general environment, food or water.
   
   
3. The Portal of Exit from the reservoir. This describes the way the microorganism leaves the reservoir. For example, in the case of a person with flu, this would include coughing and sneezing. In the case of someone with gastro-enteritis microorganisms would be transmitted in the faeces or vomit.
   
   
4. The Mode of Transmission. This describes how microorganisms are transmitted from one person or place to another. This could be via someone’s hands, on an object, through the air or bodily fluid contact.
   
   
5. The Portal of Entry. This is how the infection enters another individual. This could be landing on a mucous membrane, being breathed in, entering via a wound, or a tube such as a catheter.
   
   
6. The Susceptible Host. This describes the person who is vulnerable to infection.

Infection can be prevented by breaking the Chain of Infection.

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

Select image for full size version.

 

Chapter 1: Standard Infection Control Precautions (SICPs)

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

There are 10 Standard Infection Control Precautions (SICPs)

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

1. Resident placement/assessment for infection risk

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:

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

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

 

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

The Influenza (flu) guidance for care homes and norovirus guidance for care homes will help you prepare and manage these infections in your care home.

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

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

2. Hand Hygiene

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

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.

 

 

When hand hygiene should be performed

before touching a resident;

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

after body fluid exposure risk;

after touching a resident;

after touching a resident’s immediate surroundings;

before handling medication;

before preparing/serving food;

after visiting the toilet;

before putting on and after removing PPE;

between carrying out different care activities on the same resident;

after cleaning care equipment;

after disposing of individual’s personal waste;

after handling dirty linen.

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

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

Select image for full size version.

Before carrying out hand hygiene make sure:

your arms are bare below the elbow;

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

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

your finger nails are clean and short;

you cover all cuts or abrasions with a waterproof dressing;

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

Choose the correct product

Liquid soap and water must be used:

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)

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

Skin care:

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

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

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

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

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

 

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

3. Respiratory and cough hygiene

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.

 

 

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

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

put used tissues into a waste bin immediately after use;

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

keep hands away from the eyes nose and mouth.

 

Staff must:

help residents with their respiratory and cough hygiene where required;

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

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

 

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

4. Personal Protective Equipment (PPE)

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

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

Deciding which PPE to use:

Before doing any procedure or task you need to:

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

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

Examples of potential risks are:  

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

All PPE should be:

located close to the point of use

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

within expiry dates;

single-use only items unless specified by the manufacturer;

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

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

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

Gloves must be:

worn when it is likely that you will be exposed to blood and/or other body fluids (BBF);

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

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

changed if damaged or a perforation or puncture is suspected.

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

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

Choose the correct gloves

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

Select image for full size version

Aprons must be worn:

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

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

when delivering food and/or supporting residents with nutrition.

 

 

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

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

not be touched when worn.

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

Regular glasses or safety glasses are not considered eye protection.

Fluid Resistant Type IIR surgical face masks must be:

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

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

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

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

removed or changed;

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

Putting on personal protective equipment (PPE) - donning

Always perform hand hygiene before putting on PPE.

The order for putting on PPE is:

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

Taking off personal protective equipment (PPE) - doffing

The order for taking off PPE is:

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

Always carry out hand hygiene immediately after taking off PPE.

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

 

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

Select image for full size version

 

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

 

5. Safe management of care equipment

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

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.

Types of equipment

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

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

Before using any sterile equipment, you should check that:

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

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

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

Needles and syringes are single-use devices. They should never be used for more than one resident or reused to draw up additional medication.

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

 

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

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

Cleaning or decontaminating reusable non-invasive equipment

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

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

You should clean or decontaminate reusable equipment:  

between individual use;

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.

 

 

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

 

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

Select image for full size version

6. Safe management of the care environment

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

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

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

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

The care home environment should be:

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

well maintained and in a good state of repair

routinely cleaned in accordance with the specified cleaning schedules:

• • A fresh solution of general purpose neutral detergent in warm water is recommended for routine cleaning. This should be changed when dirty or at 15 minutes’ intervals or when changing tasks.

• • Routine disinfection of the environment is not recommended. However, 1,000 parts per million available chlorine (ppm available chlorine (av.cl.) should be used routinely on sanitary fittings.

Staff must:

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

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

Cleaning schedules should include:

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

Managing cleaning services:

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

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

Select the diagram for full size version

Cleaning Services

An effective service will include all of the elements above.

Care Homes Cleaning Specification

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

• A structure to identify all spaces within a care home and plan appropriate cleaning tasks and frequencies.

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

Table 1: Example cleaning schedule residents room

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

Table 2: Example cleaning SOP: Floors

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

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

Decontamination of soft furnishings

Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated with blood or body fluids, it may have to be discarded. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.  

If the item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning. Any alternative disinfectant used must meet the relevant BS EN Standards as detailed previously

 

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

7. Safe management of linen

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

• bed linen (bed sheets, duvet, duvet covers, pillowcases);
• blankets;
• curtains;
• hoist slings;
• towels;
• resident’s clothing (nightdresses, pyjama tops and bottoms).

There are three categories of linen:

Clean – Linen washed and ready for use

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

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

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

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

Clean linen:

Should be stored in a clean, allocated area.

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

Used linen:

Staff must: 

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

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

Staff must not:

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

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

re-handle used linen once bagged;

overfill laundry receptacles or trolleys;

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

Infectious linen:

Staff must:

wear disposable gloves and apron before handling infectious linen;

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

Washing linen

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.

8. Blood and body fluid spillages

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

Blood and body fluid spillages must be decontaminated:

immediately by staff trained to undertake this safely;

using body fluid spill kits/equipment available.

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

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

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

 

Select the image for full size

 

9. Safe disposal of waste (including sharps)

Different types of waste will be produced within care homes. 

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

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

Local procedures and policies on waste disposal must be followed.

Segregation (separating) of waste

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

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

Safe management of waste

Your care home should make sure that:

waste is correctly segregated according to local regulations;

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

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

waste is stored in a safe place whilst awaiting uplift;

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

Staff should:

follow the schedule for emptying domestic waste bins;

always use appropriate personal protective equipment (PPE);

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

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

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

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

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

clean waste bins regularly with a general purpose neutral detergent;

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

 

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

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

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

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

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

Safe management of sharps in your care home

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

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

sharps containers need to be assembled and labelled correctly;

use the temporary closure mechanisms in between use;

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

follow manufacturers’ instructions for safe use and disposal;

do not re-sheath used needles or lancets;

do not store sharps containers on the floor;

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

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

Significant occupational exposure

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

Examples of this would be:

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

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

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

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

 

Read the occupational exposure including sharps literature review to find out more about why we do things this way for occupational exposure.

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

Select the image for full size

Transmission based precautions (TBPs)

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

When you should use TBPs?

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

How are infections transmitted?

Infections can be transmitted or spread by:

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

Different transmission routes need different TBPs.

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

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

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

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

Different infections need different TBPs.

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

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

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

Before using transmission based precautions you need to find out:

What the suspected or known infection/colonisation is?

How is it transmitted?

How severe is the resident’s illness?

What is the care setting and procedures being done?

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

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

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

1. Individual placement/assessment for infection risk

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

Residents may be an infection risk if they have:

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

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

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

CPE guidance for a care home setting is available.  

Staff must:

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

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

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

not move residents within/between care areas unless essential.

Resident isolation requirements within the care home

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

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

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

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

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

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

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

 

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

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

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

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

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

clean and decontaminate the care equipment after each use.

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

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

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

3. Safe management of the care environment

Isolation room/area cleaning

Staff must:

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

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

make sure you are using the correct product which is:

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

or

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

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

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

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

Terminal clean

A terminal clean is carried out by:

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

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

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

The room should then be decontaminated using either:

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

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

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

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

Important words and what they mean

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

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

Aerosol Generating Procedure (AGP)

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

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

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

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

PPE for aerosol generating procedures (AGPs)

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

PPE for aerosol generating procedures

PPE	PPE used
Gloves	Single-use.
Apron or gown	Single-use gown.
Face mask or respirator	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.

All FFP3 respirators must be:

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

• Other signs that a change in respirator is required include:
• if breathing becomes difficult;
• if the respirator is wet or moist,
• if the respirator is damaged;
• if the respirator is obviously contaminated with body fluids such as respiratory secretions.

Rooms should always be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. In an isolation room with 10-12 air changes per hour (ACH) a minimum of 20 minutes is required; in a side room with 6 ACH this would be approximately one hour. It is often difficult to calculate air changes in areas that have natural ventilation only.  Natural ventilation, particularly when reliant on open windows can vary depending on the climate. An air change rate in these circumstances has been agreed as 1-2 air changes/hour. 

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

Post AGP fallow time (PAGPFT)

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

The post aerosol generating procedure fallow time (PAGPFT) calculations are detailed in the table below.  It is often difficult to calculate air changes in areas that have natural ventilation only. 

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

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  It is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.  During the PAGPFT staff should not enter this room without FFP3 masks.  Other residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately.  As a minimum, regardless of air changes per hour (ACH), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes. Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Post AGP fallow times calculation

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

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

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

 

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

5. Infection prevention and control during care of the deceased

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

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

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

 

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

How to contact us

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

Email

Telephone: 0141 300 1175