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)
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.
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.
In Scotland, staff are provided with Type IIR masks for use as part of the extended wearing of facemasks.
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.
In the context of COVID-19, FFP3 respirators should be worn by HCWs in the following scenarios;
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.
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.
|
PPE used |
Low-risk pathway |
Medium-risk pathway |
High-risk pathway |
|---|---|---|---|
|
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. |
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:
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.
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).
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.
|
PPE used |
Low-risk pathway |
Medium-risk pathway |
High-risk pathway |
|---|---|---|---|
|
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.
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.
| 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.
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.
Healthcare workers (HCWs) delivering vaccinations must;
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.
A poster detailing safe PPE practice for staff vaccinators and poster aimed at those attending vaccination clinics is available.