5.1 COVID-19 case definitions and triage

5.1.1 Definition of a confirmed case

5.1.2 Definition of a suspected case

5.1.3 Triaging patients

 

5.1.1 Definition of a confirmed case

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

5.1.2 Definition of a suspected case

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

The definition of a suspected case is as follows;

An individual meeting one of the following case criteria taking into account atypical and
non-specific presentations in older people with frailty (further information on presentations and management of COVID-19 in older people and Scottish Government and Appendix 1 :Think COVID:Covid-19 Assessment in the Older Adult - Checklist), those with pre-existing conditions and patients who are immunocompromised;

Community definition:

• Recent onset new continuous cough

or

• fever

or

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

Definition for individuals requiring hospital admission:

• clinical or radiological evidence of pneumonia

or

• Acute Respiratory Distress Syndrome

or

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

or

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

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

5.1.3 Triaging patients

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

The following are examples of triage questions:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5.2 COVID-19 Testing

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

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

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

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

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

5.3 Patient placement/assessment of risk

5.3.1 Critical care units

5.3.2 Split pathways

5.3.3 Staff cohorting

5.3.4 Moving patients between pathways

5.3.5  Patient transfers

5.3.6 Single side room prioritisation

5.3.7 Patients returning from day or overnight pass

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

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

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

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

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

High-risk COVID-19 pathway

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

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

Low-risk COVID-19 pathway

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

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

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

Medium-risk COVID-19 pathway

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

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

5.3.1 Critical care units

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

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

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

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

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

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

5.3.2 Split pathways

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

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

5.3.3 Staff cohorting

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

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

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

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

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

5.3.4 Moving patients between pathways

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5.3.6 Single side room prioritisation

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

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

5.3.7 Patients returning from day or overnight pass

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

 

Footnote 1

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

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

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

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

Patient discharge advice leaflets are available 

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

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

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

Inpatient cohorts	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Inpatients - General	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Not routinely required
Inpatients - Severely Immunocompromised as determined by Chapter 14a of the Green Book	14 days from symptom onset (or first positive test i symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics. Individual risk assessment by clinical teams taking account of symptoms, clinical presentation, intended setting for stepdown.	Local clinical teams may consider testing as part of the stepdown process and where undertaken, 1 negative test would be  acceptable for stepdown.
Inpatients with severe COVID-19 (requiring ITU/HDU for COVID-19 treatment)	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever for 48 hours without use of antipyretics. Individual risk assessment by clinical teams taking account of symptoms, clinical presentation, intended setting for stepdown.	Local clinical teams may consider testing as part of the stepdown process and where undertaken, 1 negative test would be  acceptable for stepdown.
Staff working in healthcare	10 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Not routinely required. Resume routine testing after 90 days from first positive isolate unless symptoms develop before then in which case test should be repeated.

 

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

Discharge cohort	Number of isolation days required	Does isolation need to be completed in hospital?	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Patient discharging to a care facility including nursing homes and residential homes	14 days from symptom onset (or first positive test if symptom onset undetermined). If they have completed the14 day isolation in hospital, no further isolation should be required on return/admission to the care home.	No. If a COVID recovered patient is discharged to a care home before 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 days isolation in hospital, they can do so in care home and do not require to start new isolation period on admission, nor require further testing.Provide care as per NIPCM COVID-19 Care Home addendum	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	If a COVID recovered patient discharged to care home before 14 day isolation has ended then 2 negative PCR tests are required before discharge at least 24 hr apart. If not completed 14 days isolation in hospital, they can do so in care home and do not require to start new isolation period on admission, nor require further testing. See PHS COVID-19: information and guidance for care home settings for discharge testing details if the COVID recovered patient has completed their 14 day isolation period in hospital
Patient discharging to their own home - General	14 days from symptom onset (or first positive test i symptom onset undetermined)	May complete at home and follow Stay at home guidance .  Must be given clear advice for what to do if their symptoms worsen	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Not routinely required
Patient discharging to their own home – someone in household is severely immunocompromised or at risk of severe illness	14 days from symptom onset (or first positive test if symptom onset undetermined)	Wherever possible, patient should be discharged to a different household from anyone immunocompromised or at severe risk of infection.  If not possible – see ‘testing required’	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Testing for clearance is encouraged.

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

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

Risk assessment prior to hospital discharge for residents with a non-COVID-19 diagnosis should be undertaken in conjunction with the care home. A single negative result should be available preferably within 48 hours prior to discharge from hospital. The exception is where a resident is considered to suffer detrimental clinical consequence or distress if they were not able to be discharged to a care home. In these cases, the resident may be discharged to the care home prior to the test result being available, whether the result is positive or negative, but the 14 days of isolation must be completed regardless in the care home.

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

Table 3 - Stepdown requirements for COVID-19 outpatients

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

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

Transferring between pathways on stepdown

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

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

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

The following guidelines apply to all methods of transport:

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

Discharging a contact of a case

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

5.4 Hand hygiene

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

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

5.5 Respiratory and cough hygiene

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

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

5.6 Personal Protective Equipment (PPE)

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

5.6.2 Face masks for inpatients

5.6.3 Filter Face Piece 3 (FFP3) Respirators

5.6.4 PPE determined by COVID-19 care pathway

Table 4: PPE for direct patient care determined by pathway

5.6.5 Aerosol Generating procedures (AGPs)

5.6.6 PPE for Aerosol Generating Procedures (AGPs)

Table 5: PPE for AGPs determined by pathway

5.6.7 Post AGP Fallow Times (PAGPFT)

Table 6: PAGPFT calculation

5.6.8 Sessional use of PPE

5.6.9 PPE for delivery of COVID-19 Vaccinations

 

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

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

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

PPE must not be used inappropriately.  It is of paramount importance that PPE is worn at the appropriate times, selected appropriately and donned and doffed properly to prevent transmission of infection.

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

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

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

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

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

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

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

5.6.2 Face masks for inpatients

A surgical facemask should be worn by all inpatients across all pathways where it can be tolerated and does not compromise their clinical care for example when receiving oxygen therapy. All patients should be encouraged to adhere to this COVID-19 control measure.The purpose of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination.  This should be actively promoted throughout the healthcare setting

It is recognised that it will be impractical for patients to wear facemasks at all times and these will have to be removed for reasons such as eating and drinking or showering. There is no need for patients to wear a facemask when sleeping provided the beds are at least 2 metres apart.

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

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

A poster promoting patient facemask use is available.

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

5.6.3 Filter Face Piece 3 (FFP3) Respirators

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

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

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

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

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

5.6.4 PPE determined by COVID-19 care pathway

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

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

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

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

It is recommended that surgical masks should be well fitting and fit for purpose, covering the mouth and nose in order to prevent venting (exhaled air ‘escaping’ at the sides of the mask).  A poster provides some suggested ways to wear facemasks to help improve fit.

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

 

Table 4: PPE for direct patient care determined by pathway

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

5.6.5 Aerosol Generating procedures (AGPs)

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

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

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

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

Other procedures

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

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

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

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

5.6.6 PPE for Aerosol Generating Procedures (AGPs)

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

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

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

 

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

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

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

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

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

5.6.7 Post AGP Fallow Times (PAGPFT)

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

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

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

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

Table 6: Post AGP fallow time calculation

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

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

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

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

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

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

5.6.8 Sessional use of PPE

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

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

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

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

Unit wide Airborne precautions will require sessional use of FFP3 masks throughout the unit however all other AGP PPE should be removed when no longer within 2 metres of a patient or, if still within 2 metres of the patient, then after the AGP is complete and fallow time has elapsed. It is not necessary to wear sessional gowns moving around a unit or department.  Gowns protect against excessive splash and spray which is associated with AGPs and other direct patient care procedures.

5.6.9 PPE for delivery of COVID-19 Vaccinations

Healthcare workers (HCWs) delivering vaccinations must;

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

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

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

 

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

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

 

5.7 Safe management of Care Equipment

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

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

All care equipment should be decontaminated as per Table 7.

Table 7: Equipment cleaning determined by pathway

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

5.8 Safe Management of the Care Environment

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

The care environment must be:

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

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

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

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

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

Table 8: Environmental cleaning determined by pathway

	Low risk pathway (green)	Medium risk pathway (amber)	High risk pathway (red)
Frequency	At least twice daily 1st clean - Full clean 2nd clean* - Touch Surfaces within clinical inpatient areas	At least daily as per NHS Scotland National Cleaning Services Specification.    NB: Patient entrances to healthcare settings such as emergency department and admitting units may require an increase in frequency of cleaning.  Risk assessments should be undertaken at a local level.	At least twice daily 1st clean - Full clean 2nd clean - * Touch Surfaces within clinical inpatient areas
Product	General-purpose detergent**	General-purpose detergent**	Combined detergent/disinfectant solution at a dilution of 1000 ppm av chlorine or general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000ppm av chlorine.

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

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

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

5.9 Safe Management of Linen

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

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

5.10 Safe Management of Blood and Body Fluid Spillages

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

5.11 Safe Disposal of waste (including sharps)

Safe Disposal of waste (including sharps)

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

Care home and community settings

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

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

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

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

5.12 Occupational Safety

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

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

5.12.1 Car sharing for Healthcare professionals including trainees/students

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

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

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

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

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

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

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

5.13 Hierarchy of Controls

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

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

5.13.3 Ventilation in the healthcare setting

5.13.4 Physical distancing

5.13.5 Inpatient bed spacing and day patient chair spacing

5.13.6 Local data to inform risk assessment

Controlling exposures to occupational hazards, including the risk of infection, is the fundamental method of protecting healthcare workers.  Below is a graphic specifying the general principles of prevention legislated in the Management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1. It details the most to the least effective hierarchy of controls and can be used to help implement effective controls in preventing the spread of COVID-19 within healthcare settings.  The hierarchy of controls will help protect all users of the NHS facility and not just staff.  NHS Boards and NHS staff should first employ the most effective method of control which inherently results in safer control systems.    Where that is not possible, all others must be considered in sequence.  PPE is the last in the hierarchy of controls.

 

Hierarchy of Risk Controls

Centers for disease control and prevention. The National Institute for Occupational Safety and Health. Hierarchy of Controls. 2015.

Examples of ways in which the hierarchy of controls can be applied in health and social care settings is as follows;

 

Table 9: Hierarchy of controls

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

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

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

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

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

 

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

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

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

Prior to determining areas for placement of the high risk pathway a full risk assessment of the proposed area must be carried out, led by the NHS Board/organisation and involving Health and safety teams, Estates and Facilities representatives, Occupational Health Services (OHS) Infection Prevention and Control Team (IPCT) and the clinical team.  This should be undertaken using the hierarchy of controls and recognise that there is lowest risk where elimination can be achieved and highest risk where PPE is the only control in place. Risk assessments should be undertaken regularly as determined by the NHS Board to ensure no change to the level of risk.

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

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

If the risk assessment concludes that an unacceptable risk of transmission remains within the environment after rigorous application of the hierarchy of controls (e.g inadequate spacing to allow for required occupancy AND ventilation of less than 6ACH) and only if there are no other more optimal low risk clinical areas suitable for the high risk pathway cohort then the NHS Boards should consider utilising the area for this purpose with provision of Respiratory Protective Equipment (FFP3 respirators) for the staff working in this area. 

The evidence continues to support the most likely route of COVID-19 transmission being via the droplet and contact route.  However, it is accepted that in some high risk environments housing COVID-19 cases where mitigations in line with the hierarchy of controls cannot be applied, the level of risk is unknown and as a precautionary approach, the use of RPE by staff in the designated area may be considered by the organisation.  This takes account of interim guidance issued by the World Health Organization (WHO) occupational health and safety for healthcare workers.

The following subsections provide information to help support risk assessments.

5.13.3 Ventilation in the healthcare setting

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

A number of studies have linked transmission to recirculating air conditioners, with the high velocities created by these units potentially allowing larger viral aerosols to remain airborne over longer distances. It is also possible that directional flow from desk fans could have a similar effect however the evidence of this is weak.  Fans should be avoided as much as possible and should not be used without prior risk assessment.

Mechanically ventilated areas

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

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

Ensure ventilation systems are well maintained ensuring functionality of air handling units and correct delivery of assigned air change rates. Controls should be set to maximise the amount of fresh air coming into the space and avoid recirculation of air as much as possible. Dampers should also be opened as far as possible. 

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

Naturally ventilated areas (No mechanical ventilation

Ensure areas are as ventilated as much as possible by opening windows if temperature/weather conditions allow.  NHS organisations should consider any other risks with opening the windows where adjacent building works are in progress. If possible open windows at different sides to get a cross flow of ventilation.  Where it is safe to do so, doors may be opened.  NB fire doors should NEVER be propped open. Airing rooms as frequently as you can will help improve ventilation.

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

Air scrubbers (also known as HEPA units)

The Board may consider using portable industrial grade air filtration units containing HEPA filters where air-supply systems to high-risk clinical settings are suboptimal following risk assessment including assurance of the efficacy and safety of the filtration unit.  As yet, evidence on the use of air scrubbers is limited and as such these should be used with caution.  The units should be capable of recirculating all of the room air, without interfering with the existing pressure differential of the room and should provide the equivalent of ≥12 air changes per hour.  The unit must be sized appropriately for the room in which it will be utilised and maintenance contracts should be procured to accompany the unit.  It should be noted that these units do not provide additional fresh air into a space and there is no standard to measure the efficacy of these devices.  NHS Boards should satisfy themselves that these devices are suitable and if required, seek advice from NHS Assure. Boards should also assess (not limited to) the noise levels, power requirements, heat gains and potential trip hazards

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

“Air purifiers” should not be used.

More information on ventilation in the context of COVID19 can be found at the following resources;

CIBSE: Covid-19 Guidance: Ventilation

SAGE: Role of ventilation in controlling SARS-CoV-2

SAGE: Potential applications of air cleaning devices

 

5.13.4 Physical distancing

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

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

Summary of key points

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

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

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

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

Physical distancing amongst staff

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

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

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

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

Patients – inpatient cohort

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

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

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

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

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

Emergency departments (ED’s)

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

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

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

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

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

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

Patients must be encouraged not to move around waiting areas and should remain seated until called. Removing toys and books may help prevent children circulating in these areas and instead parents may be advised to bring a toy or book belonging to the child to help keep them occupied during the wait time. Children should be supported by parents/carers with hand and respiratory hygiene. Members of the same family/household do not need to physically distance in waiting areas.

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

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

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

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

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

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

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

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

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

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

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

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

Resident transport vehicles

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

5.13.5 Inpatient bed spacing and day patient chair spacing

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

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

Current NHSScotland Guidance on bed spacing include:

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

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

Guidance consistently recognises that bed spacing requirements contribute towards the control of healthcare associated infections.  Adult in-patient facilities designed post 2010 should achieve 3.6m (width) x 3.7m (depth) dimensions of SHPN 04-01, HBN 00-03 and SHFN 30.  Width of 3.6m is measured from bed centre to bed centre.

Since 2014, HBN 00-03 (Figure 45) states a day treatment bay should achieve 2.45m width. Assuming a 0.5m diameter zone for the patient head, this bay size achieves the minimum 2.5m centre-to-centre dimension between each day treatment couch or chair.  

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

 

5.13.6 Local data to inform risk assessment

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

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

5.14 Visiting

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

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

 

Table 10: PPE for Visitors

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

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

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

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

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

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

5.15 Outbreaks

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

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

5.15.1 Whole Genome Sequencing

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

 

 

 

5.16 Resources

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

PPE

COVID-19 PPE Poster collection

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

Facemask posters

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

FAQs

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

Other resources

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

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

 

5.17 Rapid Reviews

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

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

 

5.18 COVID-19 Education resources

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

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

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

5.19 COVID-19 Compendium

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

• COVID-19 compendium

 

5.20 Useful tools for IPCTs

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

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

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

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