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
7.5.10 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 table 2.
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.
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.
|
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.
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:
PPE should be put on before entering the room.
You may require some of these items or all of them – See Table 2.
When wearing PPE:
Removal of PPE
PPE should be removed in an order that minimises the potential for cross-contamination.
Gloves
Gown
Eye Protection
Fluid Resistant Surgical facemask
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.
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.
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:
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:
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).
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;
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:
|
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.
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.
.
| 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.
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.
Healthcare workers (HCWs) delivering vaccinations must;
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.
As per SICPs;
A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.
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.