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