National Infection Prevention and Control Manual
Coronavirus (COVID-19)Appendix 21 summarises the remaining pandemic measures for health and social care settings which exist in addition to the NIPCM and provide links to helpful resources, guidance and policy documents.
For pathogen specific guidance see the A-Z of pathogens.
Public Health Scotland COVID-19 guidance is available.
The NHSScotland National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO (2012)1 Update).
The NIPCM provides IPC guidance to all those involved in care provision and is considered best practice across all health and care settings in Scotland.
The re-launch of the NIPCM by the CNO on 11 July 2022 emphasises the ongoing importance of application of Infection Prevention and Control (IPC) guidance within health and care settings across Scotland.
Video of Chief Nursing Officer re-launching the NIPCM
You can find out more about the NIPCM by watching the animation or going to the About the manual webpage.
Disclaimer
When an organisation e.g. when a health and care setting uses products or adopts practices that differ from those stated in this National Infection Prevention and Control Manual, that individual organisation is responsible for ensuring safe systems of work including the completion of a risk assessment approved through local governance procedures.
Last updated: 4 October 2021
Standard Infection Control Precautions (SICPs), covered in this chapter are to be used by all staff, in all care settings, at all times, for all patients1 whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care environment.
The Hierarchy of Controls detailed in appendix 20 should also be considered in controlling exposures to occupational hazards which include infection risks.
SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection.
Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes, any equipment or items in the care environment that could have become contaminated and even the environment itself if not cleaned and maintained appropriately.
The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction and/or the anticipated level of exposure to blood and/or other body fluids.
To be effective in protecting against infection risks, SICPs must be applied continuously by all staff. The application of SICPs during care delivery must take account of;
Doing so allows staff to safely apply each of the 10 SICPs by ensuring effective infection prevention and control is maintained.
SICPs implementation monitoring must also be ongoing to demonstrate safe practices and commitment to patient, staff and visitor safety.
Further information on using SICPs for Care at Home can be found on the NHS National Education Scotland (NES) website.
1The use of the word 'Persons' can be used instead of 'Patient' when using this document in non-healthcare settings.
Last updated: 10 May 2022
Patients must be promptly assessed for infection risk on arrival at the care area (if possible, prior to accepting a patient from another care area) and should be continuously reviewed throughout their stay. This assessment should influence patient placement decisions in accordance with clinical/care need(s).
Patients who may present a particular cross-infection risk should be isolated on arrival and appropriate clinical samples and screening undertaken as per national protocols to establish the causative pathogen. This includes but is not limited to patients:
For assessment of infection risk see Section 2: Transmission Based Precautions.
Further information can be found in the patient placement literature review.
Hand hygiene is considered an important practice in reducing the transmission of infectious agents which cause infections.
Hand washing sinks must only be used for hand hygiene and must not be used for the disposal of other liquids. (See Appendix 3 of Pseudomonas Guidance)
Before performing hand hygiene:
Hand washing should be extended to the forearms if there has been exposure of forearms to blood and/or body fluids.
*For health and safety reasons, Scottish Ambulance Service Special Operations Response Teams (SORT) in high-risk situations require to wear a wristwatch.
To perform hand hygiene:
Alcohol Based Hand Rubs (ABHRs) must be available for staff as near to point of care as possible. Where this is not practical, personal ABHR dispensers should be used.
Application of sufficient volume of ABHR to cover all surfaces of the hands is important to ensure effective hand hygiene. Manufacturer’s instruction should be followed for the volume of ABHR required to provide adequate coverage for the hands. In the absence of manufacturers instructions, volumes of approximately 3ml are recommended to ensure full coverage.
Perform hand hygiene:
The World Health Organization’s ‘5 moments for hand hygiene’ should be used to highlight the key indications for hand hygiene.
Some additional examples of hand hygiene moments include but are not limited to:
Download and print the 5 moments of hand hygiene poster.
Wash hands with non-antimicrobial liquid soap and water if:
Hands should be washed with warm/tepid water to mitigate the risk of dermatitis associated with repeated exposures to hot water and to maximise hand washing compliance. Compliance may be compromised where water is too hot or too cold. Hands should be dried thoroughly following hand washing using a soft, absorbent, disposable paper towel from a dispenser which is located close to the sink but beyond the risk of splash contamination.
In all other circumstances use ABHRs for routine hand hygiene during care.
Staff working in the community should carry a supply of ABHRs to enable them to perform hand hygiene at the appropriate times.
Where staff are required to wash their hands in the service user’s own home they should do so for at least 20 seconds using any hand soap available.
Staff should carry a supply of disposable paper towels for hand drying rather than using hand towels in the individual’s own home. Once hands have been thoroughly dried, ABHR should be used.
The use of antimicrobial hand wipes is only permitted where there is no access to running water. Staff must perform hand hygiene using ABHR immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.
(The video above demonstrating Hand Washing and Drying Technique was produced by NHS Ayrshire and Arran)
For how to:
Skin care:
Surgical Hand Antisepsis
Surgical scrubbing/rubbing: (applies to persons undertaking surgical and some invasive procedures)
Perform surgical scrubbing/rubbing before donning sterile theatre garments or at other times e.g. prior to insertion of central vascular access devices.
Hand Hygiene posters/leaflets can be found at Wash Your Hands of Them Resources.
Information on the WHO World Hand Hygiene Day 2022 with the theme 'Unite for safety - clean your hands' is available.
Further information can be found in the Hand Hygiene literature reviews:
Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of respiratory illness (pathogens):
Staff should promote respiratory and cough hygiene helping those (e.g. elderly, children) who need assistance with this e.g. providing patients with tissues, plastic bags for used tissues and hand hygiene facilities as necessary.
Further information can be found in the cough etiquette/respiratory hygiene literature review.
Before undertaking any care task or procedure staff should assess any likely exposure to blood and/or body fluids and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.
All PPE should be:
Reusable PPE items, e.g. non-disposable goggles/face shields/visors must have a decontamination schedule with responsibility assigned.
Further information on best practice for PPE use for SICPs can be found in Appendix 16.
Gloves must:
Double gloving is only recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and gynaecological operations or when attending major trauma incidents and when caring for a patient with a suspected or known High Consequence Infectious disease. Double gloving is not necessary at any other time.
For appropriate glove use and selection see Appendix 5.
Further information can be found in the Gloves literature review.
Aprons must be:
Full body gowns/Fluid repellent coveralls must be:
The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure. Routine sessional use of gowns/aprons is not permitted.
Sterile surgical gowns must be:
Reusable gowns must:
If hand hygiene with soap and water is required, this should not be performed whilst wearing an apron/gown in line with a risk of apron/gown contamination; hand hygiene using ABHR is acceptable.
Further information can be found in the Aprons/Gowns literature review.
Eye/face protection must:
Regular corrective spectacles and safety spectacles are not considered eye protection.
Further information can be found in the eye/face protection literature review.
Fluid Resistant Type IIR surgical face masks must be:
Transparent face masks may be used to aide communication with patients in some settings
Transparent face masks must;
Further information can be found in:
During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is not considered an element of SICPs but an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.
Footwear must be:
Further information can be found in the footwear literature review.
Headwear must be:
Further information can be found in the headwear literature review
For the recommended method of putting on and removing PPE see video below and Appendix 6.
COVID-19 - the correct order for donning, doffing and disposal of PPE for HCWs in a primary care setting from NHS National Services Scotland on Vimeo.
Sessional use of PPE
Typically, sessional use of any PPE is not permitted within health and care settings at any time as it may be associated with transmission of infection within health and care settings.
Due to the much wider and frequent use of FRSMs eye/face protection (where required) by HCWs during the ongoing COVID-19 pandemic and during periods of increased respiratory activity in health and care settings both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.
This means that FRSMs and eye/face protection (where required) can be used moving between service users and for a period of time where a HCW is undertaking duties in an environment where there is exposure to patients with suspected or confirmed respiratory infection. A session ends when the healthcare worker leaves the clinical setting or exposure environment. When using FRSMs and eye/face protection sessionally it is important to note the following;
The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.
No other PPE is permitted to be worn sessionally moving between service users or care tasks. This includes gloves, aprons and gowns.
PPE for Visitors
PPE may be offered to visitors to protect them from acquiring a transmissible infection. If a visitor declines to wear PPE when it is offered then this should be respected and the visit must not be refused. PPE use by visitors can not be enforced and there is no expectation that staff monitor PPE use amongst visitors. Below is the PPE which should be worn where it is appropriate to do so and when the visitor chooses to do so.
Visitors do not routinely require PPE unless they are providing direct care to the individual they are visiting. In line with extended use of face mask guidance, visitors are strongly recommended to continue to wear a face covering when visiting a healthcare setting. Should they arrive without one, they can be provided with a FRSM.
The table below provides a guide to PPE for use by visitors if delivering direct care.
IPC Precaution |
Gloves |
Apron |
Face covering/mask |
Eye/Face Protection |
---|---|---|---|---|
Standard Infection Control Precautions (SICPs) |
Not required*1 |
Not required*2 |
Where splash/spray to nose/mouth is anticipated during direct care Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
Not required*3 |
Transmission Based Precautions (TBPs) |
Not required*1 |
Not required*2 |
If within 2 metres of service user with suspected or known respiratory infection Encourage the use of face covering (or provide with Type IIR FRSM if visitor arrives without a face covering) in line with Extended use of face masks guidance |
If within 2 metres of service user with suspected or known respiratory infection |
*1 unless providing direct care which may expose the visitor to blood and/or body fluids i.e. toileting.
*2 unless providing care resulting in direct contact with the service user, their environment or blood and/or body fluid exposure i.e. toileting, bed bath.
*3 Unless providing direct care and splashing/spraying is anticipated
Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents. Consequently it is easy to transfer infectious agents from communal care equipment during care delivery.
Care equipment is classified as either:
Before using any sterile equipment check that:
Decontamination of reusable non-invasive care equipment must be undertaken:
Adhere to manufacturers’ guidance for use and decontamination of all care equipment.
All reusable non-invasive care equipment must be rinsed and dried following decontamination then stored clean and dry.
Decontamination protocols should include responsibility for; frequency of; and method of environmental decontamination.
An equipment decontamination status certificate will be required if any item of equipment is being sent to a third party e.g for inspection, servicing or repair.
Guidance may be required prior to procuring, trialling or lending any reusable non-invasive equipment.
Further information can be found in the management of care equipment literature review.
For how to decontaminate reusable non-invasive care equipment see Appendix 7.
It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.
The care environment must be:
Staff groups should be aware of their environmental cleaning schedules and clear on their specific responsibilities.
Cleaning protocols should include responsibility for; frequency of; and method of environmental decontamination.
When an organisation adopts decontamination processes not recommended in the NIPCM the care organisation is responsible for governance of and completion of local risk assessment(s) to ensure safe systems of work
Further information can be found in the routine cleaning of the environment in hospital setting literature review.
Clean linen
Linen used during patient transfer
For all used linen (previously known as soiled linen):
For all infectious linen (this mainly applies to healthcare linen) i.e. linen that has been used by a patient who is known or suspected to be infectious and/or linen that is contaminated with blood and/or other body fluids e.g. faeces:
Local guidance regarding management of linen may be available.
All linen that is deemed unfit for re-use e.g torn or heavily contaminated, should be categorised at the point of use and returned to the laundry for disposal.
Further information can be found in the safe management of linen literature review and National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution.
Further information about linen bagging and tagging can be found in Appendix 8.
Scottish Government uniform, dress code and laundering policy is available.
Spillages of blood and other body fluids may transmit blood borne viruses.
Spillages must be decontaminated immediately by staff trained to undertake this safely.
Responsibilities for the decontamination of blood and body fluid spillages should be clear within each area/care setting.
If superabsorbent polymer gel granules for containment of bodily waste are used these should be used in line with national guidance. In Scotland refer to Safety Action Notice - SAN(SC)19/03 | National Services Scotland (nhs.scot)
For management of blood and body fluid spillages see Appendix 9.
Further information can be found in the management of blood and body fluid in health and social care settings literature review.
Scottish Health Technical Note (SHTN) 3: NHSScotland Waste Management Guidance contains the regulatory waste management guidance for NHSScotland including waste classification, segregation, storage, packaging, transport, treatment and disposal.
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to the safe disposal of sharps.
Categories of waste:
Waste Streams:
For care/residential homes waste disposal may differ from the categories described above and guidance from local contractors will apply. Refer to SEPA guidance.
Safe waste disposal at care area level:
Always dispose of waste:
Liquid waste e.g. blood must be rendered safe by adding a self-setting gel or compound before placing in an orange lidded leak-proof bin.
Waste bags must be no more than 3/4 full or more than 4 kgs in weight; and use a ratchet tag/or tape (for healthcare waste bags only) using a ‘swan neck’ to close with the point of origin and date of closure clearly marked on the tape/tag.
Store all waste in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of waste receptacles.
Sharps boxes must:
Local guidance regarding management of waste at care level may be available.
Further information can be found in the safe disposal of waste literature review.
Exposure in relation to blood borne viruses (BBV) is the focus within this section and reflects the existing evidence base.
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to:
Sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices.
Manufacturers’ instructions for safe use and disposal must be followed.
Needles must not be re-sheathed/recapped.4
Always dispose of needles and syringes as 1 unit.
If a safety device is being used safety mechanisms must be deployed before disposal.
An occupational exposure is a percutaneous or mucocutaneous exposure to blood or other body fluids.
Occupational exposure risk can be reduced via application of other SICPs and TBPs outlined within the NIPCM.
A significant occupational exposure is a percutaneous or mucocutaneous exposure to blood or other body fluids from a source that is known, or found to be positive for a blood borne virus (BBV).
Examples of significant occupational exposures would be:
There is a potential risk of transmission of a Blood Borne Virus (BBV) from a significant occupational exposure and staff must understand the actions they should take when a significant occupational exposure incident takes place. There is a legal requirement to report all sharps injuries and near misses to line managers/employers.
Additionally, employers are obligated to minimise or eliminate workplace risks where it is reasonably practicable. Immunisation against BBV should be available to all qualifying staff, and testing (and post exposure prophylaxis when applicable) offered after significant occupational exposure incidents.
For the management of an occupational exposure incident see Appendix 10
Exposure prone procedures (EEPs) are invasive procedures where there is a risk that injury to the healthcare worker may result in the exposure of the patient’s open tissues to the blood of the worker (bleed-back).
There are some exclusions for HCWs with known BBV infection when undertaking EPPs. The details of these and further information can be found in the occupational exposure management (including sharps) literature review.
4 A local risk assessment is required if re-sheathing is undertaken using a safe technique for example anaesthetic administration in dentistry.
SICPs may be insufficient to prevent cross transmission of specific infectious agents. Therefore additional precautions TBPs are required to be used by staff when caring for patients with a known or suspected infection or colonisation.
Clinical judgement and decisions should be made by staff on the necessary precautions. This must be based on the:
TBPs are categorised by the route of transmission of infectious agents (some infectious agents can be transmitted by more than one route): Appendix 11 provides details of the type of precautions, optimal patient placement, isolation requirements and any respiratory precautions required. Application of TBPs may differ depending on the setting and the known or suspected infectious agent.
Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of cross-infection transmission.
Used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.
Used to prevent and control infections spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.
Further information on Transmission Based Precautions can be found in the definitions of Transmission Based Precautions literature reviews.
Last updated 4 October 2021
The potential for transmission of infection must be assessed at the patient’s entry to the care area. If hospitalised or in a care home setting this should be continuously reviewed throughout the stay/period of care. The assessment should influence placement decisions in accordance with clinical/care need(s).
Patients who may present a cross-infection risk in any setting includes but is not limited to those:
Isolation facilities should be prioritised depending on the known/suspected infectious agent (refer to Aide Memoire - Appendix 11). All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.
When single-bed rooms are limited, patients who have conditions that facilitate the transmission of infection to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, invasive devices, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) should be prioritised for placement in a single-bed room. Single-bed room prioritisation should be reviewed daily and the clinical judgement and expertise of the staff involved in a patient's management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought particularly for the application of TBPs e.g. isolation prioritisation when single rooms are in short supply.
Hospital settings:
Cohorting in hospital settings
Cohorting of patients should only be considered when single rooms are in short supply and should be undertaken in conjunction with the local IPCT.
Patients who should not be placed in multi bed cohorts;
Staff cohorting; consider assigning a dedicated team of care staff to care for patients in isolation/cohort rooms/areas as an additional infection control measure during outbreaks/incidents. This can only be implemented through planning of staff rotas if there are sufficient levels of staff available to ensure consistency in staff allocation (so as not to have a negative impact on non-affected patients’ care).
Before discontinuing isolation; individual patient risk factors should be considered (e.g. there may be prolonged shedding of certain microorganisms in immunocompromised patients). Clinical and molecular tests to show the absence of microorganisms may be considered in the decision to discontinue isolation and can reduce isolation times. The clinical judgement and expertise of the staff involved in a patient’s management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought on decisions regarding isolation discontinuation.
Primary care/out-patient settings:
Further information can be found in the patient placement literature review.
If an item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning.
For how to decontaminate non-invasive reusable equipment see Appendix 7.
Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.
Routine environmental decontamination
Hospital/Care home setting:
Patient isolation/cohort rooms/area must be decontaminated at least daily, this may be increased on the advice of IPCTs/HPTs. These areas must be decontaminated using either:
Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .
Increased frequency of decontamination/cleaning schedules should be incorporated into the environmental decontamination schedules for areas where there may be higher environmental contamination rates e.g.
Patient rooms must be terminally cleaned following resolution of symptoms, discharge or transfer. This includes removal and laundering of all curtains and bed screens.
Vacated rooms should also be decontaminated following an AGP.
Primary care/Out-patient settings:
The extent of decontamination between patients will depend on the duration of the consultation/assessment, the patients presenting symptoms and any visible environmental contamination.
Equipment used for environmental decontamination must be either single-use or dedicated to the affected area then decontaminated or disposed of following use e.g. cloths, mop heads.
Terminal decontamination
Following patient transfer, discharge, or once the patient is no longer considered infectious:
Remove from the vacated isolation room/cohort area, all:
The room should be decontaminated using either:
The room must be cleaned from the highest to lowest point and from the least to most contaminated point.
Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .
Unless instructed otherwise by the IPCT there is no requirement for a terminal clean of an outpatient area or theatre recovery.
Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.
When an organisation adopts practices that differ from those recommended/stated in the NIPCM with regards to cleaning agents, the individual organisation is fully responsible for ensuring safe systems of work, including the completion of local risk assessment(s) approved and documented through local governance procedures.
A type IIR fluid resistant surgical mask should be worn when caring for a patient with a suspected/confirmed infectious agent spread by the droplet route.
Surgical masks worn by patients with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control, should meet type II or IIR standards.
During the ongoing COVID-19 pandemic please also refer to the Scottish Government Extended Use of Facemask Guidance. The extended use of facemask guidance is an additional mitigation measure applied in response to the ongoing COVID-19 pandemic response.
A face visor or goggles should be used in combination with a fluid resistant type IIR surgical mask when caring for symptomatic patients infected with droplet transmitted infectious agents.
A face visor or goggles should be used in combination with a fluid resistant FFP3 respirator when caring for symptomatic patients infected with an airborne transmitted infectious agent.
Eye/face protection should be worn
An apron should be worn when caring for patients known or suspected to be colonised/infected with antibiotic resistant bacteria including contact with the patient’s environment.
Plastic aprons should be used in health and social care settings for protection against contamination with blood and/or body fluids.
A fluid repellent gown should be used if excessive splashing or spraying is anticipated.
A full body fluid repellent gown should be worn when conducting AGPs on patients known or suspected to be infected with a respiratory infectious agent.
Further information can be found in the Aprons/Gowns literature review.
Gloves must:
Double gloving is only recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and gynaecological operations or when attending major trauma incidents and when caring for a patient with a suspected or known High Consequence Infectious disease. Double gloving is not necessary at any other time.
For appropriate glove use and selection see Appendix 5.
Further information can be found in the Gloves literature review.
PPE must still be used in accordance with SICPs when using Respiratory Protective Equipment. See Chapter 1.4 for PPE use for SICPs.
Where it is not reasonably practicable to prevent exposure to a substance hazardous to health (as may be the case where healthcare workers are caring for patients with suspected or known airborne micro-organisms) the hazard must be adequately controlled by applying protection measures appropriate to the activity and consistent with the assessment of risk. If the hazard is unknown the clinical judgement and expertise of IPC/HP staff is crucial and the precautionary principle should apply.
Respiratory Protective Equipment (RPE) i.e. FFP3 and facial protection, must be considered when:
Please also see Appendix 17 for the extant list of Aerosol Generating Procedures which require the application of airborne precautions. Appendix 17 also includes details of associated Post AGP Fallow times.
Where staff have concerns about potential COVID-19 exposure to themselves during the ongoing COVID-19 pandemic, they may choose to wear an FFP3 respirator rather than a fluid-resistant surgical mask (FRSM) when providing patient care, provided they are fit tested. This is a personal PPE risk assessment, as per DL 2022 10.
All tight fitting RPE i.e FFP3 respirators must be:
Poster on compatibility of facial hair and FFP3 respirators can be used when fit testing and fit checking.
Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.
The following risk categorisation is the minimum requirement for staff groups that require FFP3 fit testing. NHS Boards can add to this for example where high risk units are present. This categorisation is inclusive of out of hours services.
National Priority Risk Categorisation for face fit testing with FFP3
Level 1 – Preparedness for business as usual
Staff in clinical areas most likely to provide care to patients who present at healthcare facilities with an infectious pathogen spread by the airborne route; and/or undertake aerosol generating procedures i.e. A&E, ICU, paediatrics, respiratory, infectious diseases, anaesthesia, theatres, Chest physiotherapists, Special Operations Response Team (Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams, mortuary staff.
Level 2 – Preparedness in the event of emerging threat
Staff in clinical setting likely to provide care to patients admitted to hospital in the event of an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all other ambulance transport staff.
In the event of an ‘Epidemic/Pandemic’ Local Board Assessment as per their preparedness plans will apply.
For a list of organisms spread wholly or partly by the airborne (aerosol) or droplet routes see Appendix 11.
Further information can be found in the aerosol generating procedures literature review.
Powered respirator hoods are an alternative to FFP3 respirators for example when fit testing cannot be achieved.
Powered hoods must be:
FFP3 respirator or powered respirator hood:
Work is currently underway by the UK Re-useable Decontamination Group examining the suitability of respirators for decontamination. This literature review will be updated to incorporate recommendations from this group when available. In the interim, ARHAI Scotland are unable to provide assurances on the efficacy of respirator decontamination methods and the use of re-useable respirators is not recommended.
Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) literature review.
Frameworks to support the assessing and recording of staff competency in PPE for HCID are available in the resources section of the NIPCM.
Sessional use of PPE
Typically, sessional use of any PPE is not permitted within health and care settings at any time as it is associated with transmission of infection between service users within health and care settings.
During periods of increased respiratory activity in health and care settings, both as part of service user direct care delivery and extended use of facemasks guidance, sessional use of FRSMs and eye/face protection is permitted at this time.
This means that FRSMs and eye/face protection (where required) can be used moving between service users and for the period of time where a HCW is undertaking duties in an environment where there is exposure to respiratory pathogens. A session ends when the healthcare worker leaves the clinical setting or exposure environment. It is important to note the following;
The above measures in conjunction with safe donning and doffing of PPE ensure the safety of the HCW and the service user.
No other PPE is permitted to be worn sessionally moving between service users or care tasks. This includes gloves, aprons and gowns.
The principles of SICPs and TBPs continue to apply whilst deceased individuals remain in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living patients.
It is important that information on the infection status of the deceased is sought and communicated at each stage of handling. Appropriate risk assessment must be carried out before performing activities that may increase the risk of transmission of infectious agents from deceased individuals (see literature review for further information on these activities).
Washing and/or dressing should be avoided when the deceased is known or suspected to have been infected with an invasive streptococcal infection, anthrax, rabies, viral haemorrhagic fevers (VHFs), Hazard Group 4 infectious agents or other HCID.
Viewing of the deceased should be avoided when the deceased is known or suspected to have been infected by Hazard Group 4 organisms, specifically those causing VHFs (including Ebola, Lassa etc.), anthrax or other HCID.
See Appendix 12. Application of transmission based precautions to key infections in the deceased.
Staff should advise relatives of the appropriate precautions when viewing and/or having physical contact with the deceased including when this should be avoided.
Deceased individuals known or suspected to have a Hazard Group 4 infectious agent should be placed in a sealed double plastic body bag with absorbent material placed between each bag. The surface of the outer bag should then be disinfected with 1000 ppm av.cl before being placed in a robust sealed coffin.
Post-mortem examination should not be performed on a deceased individual known or suspected to have Hazard Group 4 infectious agents. See Appendix 12 - Application of transmission based precautions to key infections in the deceased. Blood sampling can be undertaken in the mortuary by a competent person to confirm or exclude this diagnosis. Refer to Section 2.4 for suitable PPE.
Post-mortem examination of deceased individuals known or suspected to have been infected by transmissible spongiform encephalopathies (TSE) causing agents should be carried out in such a way as to minimise contamination of the working environment. See Literature review for further information.
The purpose of this chapter is to support the early recognition of potential infection incidents and to guide IPCT/HPTs in the incident management process within care settings; (that is, NHSScotland, independent contractors providing NHS services and private providers of care).
This guidance is aligned to the Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams
ARHAI Scotland are currently working towards delivery of comprehensive evidence-based guidance which will form Chapter 4 of the National Infection Prevention and Control Manual (NIPCM) on the built environment and decontamination.
Two Aide-Memoires currently provide best practice recommendations to be implemented in the event of a healthcare water-associated or healthcare ventilation-associated infection incident/outbreak. These will ensure clinical staff, estates and facilities staff, and Infection Prevention and Control Teams (IPCT) have an understanding of the preventative measures required and the appropriate actions that should be taken.
Prevention and management of healthcare water-associated infection incidents/outbreaks
Prevention and management of healthcare ventilation-associated infection incidents/outbreaks
The terms ‘incident’ and ‘Incident Management Team’ (IMT) are used as generic terms to cover both incidents and outbreaks
A healthcare infection incident may be:
An exceptional infection episode
See literature review for Infectious Diseases of High Consequence (IDHC)
A healthcare infection exposure incident
A healthcare associated infection outbreak
or
A healthcare infection data exceedance
A healthcare infection near miss incident
A healthcare infection incident should be suspected if there is:
Further information can be found in the literature review Healthcare infection incidents and outbreaks in Scotland.
An early and effective response to an actual or potential healthcare incident, outbreak or data exceedance is crucial. The local Board IPCT and HPT should be aware of and refer to the national minimum list of alert organisms/conditions. See Appendix 13.
Healthcare associated infection (HAI) Surveillance systems should be used to aid incident/outbreak detection using a combination of retrospective detection of cases alongside prospective enhanced surveillance in high risk settings (ICU/PICU/NICU, oncology/haematology). A risk based approach should be applied for other vulnerable groups e.g. cystic fibrosis, oncology and those undergoing renal dialysis.
Local surveillance/reporting systems should be used for recognition and detection of potential healthcare infection incidents /outbreaks within NHS Boards. Systems should make use of ‘triggers’ to allow prompt detection of any variance from normal limits.
The Infection Prevention & Control Team (IPCT)/Health Protection Team (HPT) should utilise surgical site infection (SSI) surveillance systems to identify specific post-surgical healthcare infection incidents/outbreaks (in line with national SSI surveillance program as a minimum).
Following detection/recognition of an incident/outbreak a member of IPCT or HPT will:
The IPCT/HPT will establish an IMT if required.
If staff screening is being considered as part of the investigation DL (2020)1 must be followed.
Closure of incident/outbreak with lessons learned
The IMT Chair, in discussion with the IMT, should determine whether further reporting on the incident and the incident management is required i.e. SBAR Report and full IMT report template are available in the resources section of the NIPCM website.
COVID-19 case definitions are regularly reviewed and can be found in the Public Health Scotland COVID-19 Guidance for Health Protection Teams.
Please note: People must also be assessed for other infectious or non-infectious causes of symptoms, as appropriate.
It is essential that NHS Boards have systems in place to ensure that test confirmed cases of SARS-CoV-2 isolated from patients are reported to Infection Prevention and Control Teams (IPCTs) as promptly as possible to allow any inappropriately placed patients to be identified and isolated.
COVID-19 is a notifiable disease and as such, directors of diagnostic laboratories must inform their health board, the common services agency and Public Health Scotland of all COVID-19 isolates. This is a requirement of the Public Health etc (Scotland) Act 2008 and notification of infectious disease or health risk forms are available.
On confirmation of a positive COVID-19 patient isolate, the ward staff should be informed by the reporting laboratory or IPCT if the patient is still an inpatient. There must be agreed processes in place for communicating results and IPC advice out of hours when IPCTs are not available. There must be local processes in place to ensure that IPCTs and OHS share intelligence which may indicate an outbreak is occurring in a specific ward/department.
IPCTs should agree local notification process for any patients who have been discharged home since the COVID-19 test was undertaken to ensure that the patient is contacted at home and provided with the appropriate stay at home advice.
Where a confirmed COVID-19 positive patient has been discharged or transferred to another care facility or NHS Board (e.g., care home, hospice, mental health facility), the patient and/or the receiving area must be notified at the earliest opportunity to make them aware of the positive COVID-19 result or COVID-19 exposure to ensure that the appropriate control measures can be implemented where applicable. Similarly, if a confirmed case has transferred from another board within 48 hours of symptom onset or positive test, the IPCT must inform the NHS board from which the patient transferred to allow risk assessment to be undertaken and contacts to be identified where applicable.
There should be a local agreement in place to determine whether clinical teams or IPCTs will notify the facility and HPTs where required. Local agreements should include reporting arrangements out of hours.
Active surveillance should be undertaken by IPCTs to allow clusters/incidents to be detected at the earliest possible opportunity.
The definitions below should be applied to determine if a COVID-19 cluster/incident within a healthcare setting is occurring and determine when it can end. When assessing patient and staff clusters to determine if an outbreak is occurring, a high degree of suspicion should be applied.
Note: the current COVID-19 cluster reporting system is currently under review due to changes in asymptomatic testing policy announced on 14 September 2022.
Two or more patient and/or staff cases of COVID-19 within a specific setting where nosocomial infection and ongoing transmission is suspected. For the purposes of this reporting, a high degree of suspicion should be applied and further investigation undertaken for any ward where there are unexpected cases of suspected or confirmed COVID-19. e.g., any cases that were not confirmed or suspected on admission. No time limit should be applied to determining whether a case is nosocomial e.g. 48 hours.
or
Where two or more staff cases of suspected or confirmed COVID-19 are identified and transmission between the staff members is suspected to be associated with workplace exposure/behaviours.
Note: If there is a single suspected or confirmed case in a patient who was not suspected as having COVID-19 on admission, this should initiate further investigation and risk assessment. This single case may constitute a possible cluster depending on the contacts and exposures identified. Where the patient has been in a side room with transmission based precautions in place for 48 hours prior to symptom onset, and where all staff were wearing appropriate PPE appropriately, the IPCT may decide that there is no further action needed other than active monitoring for any new unexplained cases associated with the ward.
No new test-confirmed or suspected cases with illness onset date 10 days following the last new confirmed case (from date of symptom onset or date of positive test if case has remained asymptomatic), within the affected ward or department. The cluster can be closed provided that these criteria are met.
NHS Boards should have a COVID-19 outbreak response plan which details the roles and responsibilities of Infection Prevention and Control Teams (IPCTs), Health Protection Teams (HPTs) and Occupational Health Services (OHS) within their board when responding to COVID-19 clusters/incidents.
The board COVID-19 outbreak response plan should include clarity on the responsible teams for contact tracing.
The COVID-19 Test and Protect service in Scotland ceased on the 1 May 2022 for the general community and as such contact tracing undertaken by public health will focus on outbreaks of COVID-19 associated with closed/high risk settings.
Contact tracing within acute inpatient settings should be based on local outbreak management and on the advice of the local Infection Control Doctor as per the Hospital Testing table.
3.7.1 IPC practice and compliance (including AGPs)
3.7.3 Testing during an outbreak
3.7.6 Ventilation considerations
Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission. Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed.
Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the appropriate fallow times are being observed prior to other patients using the room in which the AGP was undertaken. The IMT may choose to repeat audits as part of the investigation.
Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within the National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 21 COVID-19 pandemic controls.
Ensure that patients are wearing face masks appropriately as per the NIPCM and Scottish Government Extended use of face masks guidance.
When investigating a COVID-19 cluster, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic or declining to wear face coverings. Consider what, if any, measures need to be introduced to mitigate any risks identified.
Further hospital visiting guidance can be found here: Coronavirus (COVID-19): hospital visiting
Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.
Any patient who develops symptoms should be tested immediately using laboratory based PCR. Rapid Diagnostic Test (PCR or non-PCR based) or LFD may be used in addition to laboratory based PCR test to support rapid patient placement decisions whilst PCR results are awaited. If LFD (or other non-PCR based test) is positive at any point, a follow up PCR test is required and TBPs must commence. Further detail of current testing requirements is provided in the Hospital Testing table.
All staff who are symptomatic of COVID-19 must be tested and excluded from work and follow advice outlined in Annex B of the Directorate Letter of 14th September 2022 (DL 2022 (32)).
Public Health Scotland offer a whole genome sequencing service to support outbreak investigations and address important clinical and epidemiological questions.
Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.
In the event of a decision to undertake contact tracing, anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact.
Typically, any patients in the same bed bay as a confirmed case should be considered a contact. For larger open bedded areas such as ITUs or nightingale wards. IMTs should agree which patients should be classed as contacts, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures. Local risk assessment should be undertaken taking into consideration the Hierarchy of Controls.
Any asymptomatic contacts identified as part of local outbreak management should be observed for symptom onset. Symptom vigilance is essential for all patients, irrespective of whether a contact.
Depending on considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.
For cases who have been in a single side room for the exposure period, only staff and patients who have entered the room of the confirmed case should be considered potential contacts. If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.
IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g., radiology, other wards and consider any potential contacts in these areas.
Staff contact tracing in an outbreak situation should be based on local outbreak management and on the advice of the local Infection Control Doctor.
There is no expectation that contact tracing amongst visitors will be undertaken routinely.
Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation. It is important to consider best practice on ventilation. See Appendix 20 - Hierarchy of controls for more information.
The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated.
The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;
Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented are adequate.
See Chapter 4 of the NIPCM for more detail
The IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate. COVID-19 messaging should be in place to promote;
Every opportunity to promote this messaging should be considered.
3.8.3 Personal Protective Equipment
3.8.4 Safe Management of care Equipment
3.8.5 Safe Management of Care Environment
3.8.8 Management of staff exposed to a case
3.8.9 Closure of the ward/unit
3.8.10 Other control measures which may be considered by the IMT
3.8.11 Conversion of outbreak ward to COVID-19 ward
Control measures should be implemented immediately to prevent onward transmission of COVID-19. These must include:
During the ongoing COVID-19 pandemic when COVID-19 admissions are high and where bed capacity in the board is extremely limited, the board may consider converting the outbreak ward into a COVID-19 ward to allow confirmed COVID-19 cases to be transferred/admitted to the area and utilise bed capacity within the ward. This is an operational decision which must be carefully considered, documented and undertaken as a last resort.
In choosing to convert the outbreak ward to a COVID-19 ward, IMTs alongside hospital management must weigh up the risk associated with transferring contacts to other wards and the demand for patient beds to accommodate emergency admissions.
Note: the current COVID-19 cluster reporting system is currently under review due to changes in asymptomatic testing policy announced on 14 September 2022.
Reporting should be led by the IPCT. Reporting of COVID-19 should occur on recognition of a COVID-19 cluster
As the COVID-19 pandemic continues, it is essential that NHS Boards record and disseminate learning from clusters internally and with ARHAI Scotland for sharing nationally.
There is a field within the ORT to capture this information and this should be completed with an evaluation of the effectiveness and efficiency of investigations and control measures. This will help inform the future management of COVID-19 patients and any COVID-19 outbreaks.
Currently, chapter 4 exists as a repository for evidence reviews and tools relating to IPC in the built environment including delivery of appropriate decontamination within health and care settings and risk mitigation for water based pathogens.
Content going forward will be developed via the ARHAI Scotland Infection Control in the Built Environment and Decontamination (ICBED) programme informed by stakeholder engagement and requirements, learning from NHS Assurance programme and outbreaks and incidents.
This chapter is in the early stages of development and at this current time does not fall into the mandatory requirements for the NIPCM.
Guidance consistently recognises that bed spacing requirements contribute towards the control of HAIs. All NHS boards and care providers should aim to meet the minimum bed spacing requirements laid out in the guidance below and in keeping with the date of design and construction of the building. This takes account of ergonomics within the clinical environment and not just healthcare associated infection (HAI) risk. Some other health and care settings may choose to adopt this guidance e.g. hospice settings.
Adult in-patient facilities designed post 2010 should achieve 3.6m (width) x 3.7m (depth) dimensions of SHPN 04-01, HBN 00-03 and SHFN 30. Width of 3.6m is measured from bed centre to bed centre. Since 2014, HBN 00-03’s Figure 45 states a day treatment bay should achieve 2.45m width/centre-to-centre dimension.
Current NHS Scotland Guidance on bed spacing is listed below:
Work undertaken and published to date has been cited here for ease of reference and use at a clinical level.
Many of these publications were produced prior to development of chapter 4 and were published outwith the existing manual methodology.
Updates to publications will be made where required as part of the ARHAI programme work plans.
ARHAI Scotland will work with SG directorates responsible for these areas in planning to establish planned implementation.
The purpose of this addendum is to provide additional guidance to chapters 1,2 and 3 for NNUs
Undertake assessment for infection risk at the point of entry into the unit before placement of the neonate is decided. This assessment is the minimal microbiological testing required and any additional testing would be determined by the clinical presentation of the neonate. The potential for transmission of infection should be continuously reviewed throughout the stay/period and must be documented in the clinical notes.
Neonates who present as a cross infection risk include those who:
From mothers who have:
If a neonate is considered to be a cross infection risk then the clinical judgement of those involved in the management of the baby should assess the placement by prioritising the incubator/cot in a suitable area pending investigation i.e. place in a single room or cohort area/room with a wash hand basin.
Information/advice must be given to parents/carers of all neonates; particularly during outbreaks/incidents
In addition to the definitions in Chapter 3, in a neonatal unit investigation by IPCT is also required if:
Additionally, the local IPC team should consider the possibility of any onward transmission and potential for an incident/outbreak where there is:
Assigning a dedicated team to care for infected or colonised neonates may also be required. During outbreaks or incidents the ratio of staff to neonates may need to increase and it may be necessary to restrict admissions to the area. Prior to closing or restricting a neonatal unit, communication must be agreed across neonatal services and risk assessed.
Transfers to other units during incidents or outbreaks should be avoided, where possible; however this should take into consideration the clinical needs of neonates, and any practical or logistical issues for parents/carers.
Due to the vulnerability of some neonates the use of tap water for personal care requires consideration and this is outlined in Guidance for neonatal units (NNUs) (levels 1, 2 & 3), adult and paediatric intensive care units (ICUs) in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. For example, an assessment should be made on the neonate’s condition and whether tap water can be used or if an alternative, such as sterile water, is considered more appropriate.
In addition incubators/cots should not be placed near any water source where spraying or splashing may occur.
Further information for neonatal IPC management of healthcare incidents and outbreaks can be found in the supporting literature review.
Appendix 21 - COVID-19 Pandemic IPC controls for health and social care settings provides details of the measures still to be followed for COVID-19 and should be used alongside existing guidance.
The National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO(2012)01-update). The Scottish Government expectation is that it is mandatory for use in all NHS care settings and in all other care homes to support health and social care integration, the content of this manual must be considered best practice.
Mandatory means that you must do it.
In order to support care homes successfully adopt and implement the NIPCM, this context specific Care Home Infection Prevention and Control Manual (CH IPCM) has been co-produced with national and local stakeholders. The content of the CH IPCM is completely aligned to the evidence based NIPCM and is intended to be used by all those involved in residential care provision.
The CH IPCM contains chapters on:
There are web links in some sections taking you directly to information contained in the NIPCM.
The CH IPCM is a practice guide for use in care homes, which when used, can help reduce the risk of infections and ensure the safety of those being cared for, staff and visitors in the care home environment.
It aims to:
It should be adopted for all infection prevention and control practices and procedures.
The recommendations for practice in the manual are developed from literature reviews of the current scientific literature (for example Medical Journals) that are updated real time and are considered best practice. Any major changes identified in the scientific literature may lead to a change being made to the content.
A number of ‘SBAR’s’ are available which are short communication or guidance reports that advise on the situation, background, assessment and recommendations on a specific topic.
The resources page links to SICPs materials, education and training links and posters and other supporting tools.
You can use the glossary to find out what these words mean. Sometimes we have added the meaning of important words within the chapter or section.
The Care Home Infection Prevention and Control Manual (CH IPCM) was launched on 24 May 2021.
In order for infection to occur several things have to happen. This is often referred to as the Chain of Infection. The six links in the chain are:
Infection can be prevented by breaking the Chain of Infection.
The chain of infection diagram illustrates and gives examples of actions that can be taken to break it. The overall aim of Standard Infection Control Precautions (SICPs), is to break the Chain.
Select image for full size version.
The basic IPC measures that should be used in your care home are called Standard Infection Control Precautions (SICPs).
SICPs are used to reduce the risk of transmission of infectious agents from known and unknown sources of infection.
These should be used by all staff, in all care settings, at all times, for all residents whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care home.
SICPs should be part of everyday practice and applied consistently by all staff in the care home including, but not limited to, managers, nurses, care staff, domestics/housekeepers and volunteers.
It is essential that optimal IPC measures are applied continuously as people living in care homes may be elderly or have underlying medical conditions which could make them more at risk from infection which may then be serious and in some cases life threatening. By applying optimum IPC measures you will provide safe and effective care to the people in your care, fellow staff and visitors to your care home.
There are 10 Standard Infection Control Precautions (SICPs)
The Hierarchy of Controls detailed in Appendix 20 should also be considered in controlling exposures to occupational hazards which include infection risks.
If residents have been admitted from another care setting, for example, external care home or hospital try to pre assess them before they are admitted by speaking to the staff from the other care setting.
Before the resident comes into the care home it is important to risk assess them for infection.
Residents who may present a cross-infection risk include those with:
If you suspect or know that a resident has an infection, then details must be confirmed in order for you to put in place the correct IPC measures.
Appendix 11 of the National Infection and Prevention Control Manual tells you the precautions you need to put in place for different infections.
Use the NES SIPCEP Breaking the Chain of Infection module to learn about breaking the chain of infection in care homes.
Read the placement literature review to understand the evidence base for resident placement.
The most important thing you can do to prevent the spread of infection in a care home is to keep your hands clean. This is called hand hygiene.
Hand hygiene is essential to reduce the transmission of infection in care home settings. All staff and visitors should clean their hands with soap and water or, where this is unavailable, alcohol-based hand rub (ABHR) when entering and leaving the care home and when entering and leaving areas where care is being delivered.
before touching a resident;
before clean/aseptic procedures. If ABHR cannot be used, then antimicrobial liquid soap should be used;
after body fluid exposure risk;
after touching a resident;
after touching a resident’s immediate surroundings;
before handling medication;
before preparing/serving food;
after visiting the toilet;
before putting on and after removing PPE;
between carrying out different care activities on the same resident;
after cleaning care equipment;
after disposing of individual’s personal waste;
after handling dirty linen.
It is important that residents are routinely encouraged to perform hand hygiene and given assistance if required.
The four moments for hand hygiene poster can be used in your care home to show staff when hand hygiene should be done and the reasons why.
Select image for full size version.
your arms are bare below the elbow;
you take off all your hand and wrist jewellery (a single, plain metal finger ring is allowed but should be taken off (or moved up) during hand hygiene);
bracelets or bangles which are worn for religious reasons, such as the Kara, can be pushed higher up the arm and secured in place;
your finger nails are clean and short;
you cover all cuts or abrasions with a waterproof dressing;
you do not wear artificial nails or nail varnish/products.
if your hands look dirty;
If you are caring for a resident who is being sick or having diarrhoea or has diarrhoeal illness such as norovirus or Clostridioides difficile then you must use soap and water for hand hygiene.
Do not use ABHR as it will not work in these cases.
Make sure you wet your hands before applying liquid soap.
Use paper towels to turn off taps if the taps are not elbow operated mixer taps.
Elbow operated mixer taps are considered to provide the best temperature and flow for optimum hand hygiene and should be considered for any new build, refurbishment or if they need repaired/changed.
When you have washed your hands dry them thoroughly using paper towel and dispose of the paper towel in a foot operated waste bin.
To make sure you clean your hands properly with soap and water you must follow the steps in the poster ‘How to hand wash step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.
Select image for full size version
Alcohol based hand rub (ABHR) is a gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to stop or slow down the growth of microorganisms (germs).
If your hands look clean then you can use ABHR for routine care
Do not use ABHR if you are caring for a resident who has sickness or diarrhoeal illnesses such as norovirus or Clostridioides difficile. You must use soap and water as ABHR will not work.
To make sure you clean your hands properly with ABHR you must follow the steps in the poster ‘How to hand rub step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.
Select image for full size version
Use warm/tepid water to reduce the risk of dermatitis. Avoid using hot water.
After hand washing pat hands dry using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.
Use an emollient hand cream during breaks and when off duty.
Refillable dispensers or communal tubs of hand cream should not be provided or used in the care setting.
Staff with skin problems should seek advice from Occupational Health Department if available or their GP
Read the hand hygiene literature reviews to find out more about the evidence base for hand hygiene.
It is easy for infections to spread within a care home by coughing and sneezing so it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.
• Disposable tissues
• Waste bin and waste bags
• Hand hygiene products
If anyone has a cough, cold or other respiratory symptoms then they must:
cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose;
put used tissues into a waste bin immediately after use;
wash their hands with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions;
keep hands away from the eyes nose and mouth.
Staff must:
help residents with their respiratory and cough hygiene where required;
make sure that residents are given everything they need for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that it is close enough for them to use;
use hand wipes followed by ABHR if there is no running water available or hand hygiene facilities are out of reach then wash your hands at the first available opportunity.
Read the respiratory and cough hygiene literature review to find out the evidence for respiratory and cough hygiene practice.
Health and Safety at Work Act (1974), Control of Substances Hazardous to Health (COSHH) (2002 as amended) regulations and Personal Protective Equipment at Work Regulations 1992 (as amended) legislate that employers must provide PPE which gives you adequate protection against the risks associated with the task being undertaken.
Employees also have a responsibility under these laws which is to make sure that they wear the correct PPE for the task they are doing and wear it correctly.
Before doing any procedure or task you need to:
think about or find out if you could be exposed or come into contact with blood and/or other body fluids (BBF); and
make sure that the PPE worn gives you enough protection against the risks associated with the procedure or task you are doing.
Examples of potential risks are:
located close to the point of use
stored in a clean and dry area to prevent contamination until needed for use;
within expiry dates;
single-use only items unless specified by the manufacturer;
changed immediately after individual use and/or following completion of a procedure or task;
disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.
Reusable PPE items, for example non-disposable goggles, face shields and visors, must have a decontamination schedule with responsibility assigned.
w
orn when it is likely that you will be exposed to blood and/or other body fluids (BBF);
worn when undertaking an invasive procedure
appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct glove;
changed immediately after each individual and/or following completion of a procedure or task;
changed if damaged or a perforation or puncture is suspected.
Using gloves reduces the risk of contamination but does not remove it all. Gloves should not be used instead of carrying out hand hygiene.
Gloves should never be decontaminated or cleaned with ABHR or by washing with cleaning products.
Use the glove selection chart to support you to select the correct glove type.
Select image for full size version
by care staff when there is a risk of clothing being contaminated with blood or other body fluids;
during direct care, bed-making or when undertaking the decontamination of equipment;
when delivering food and/or supporting residents with nutrition.
be worn if blood and/or body fluid contamination to the eyes/face is expected/likely;
not be touched when worn.
Facial accessories such as piercings or false eyelashes must not be worn when using eye/face protection;
Regular glasses or safety glasses are not considered eye protection.
worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/likely;
a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray, however:
well-fitting, fully covering the mouth and nose and fit for purpose, you must follow the manufacturer’s instructions to ensure effective fit/protection.
removed or changed;
Always perform hand hygiene before putting on PPE.
The order for putting on PPE is:
The order for taking off PPE is:
Always carry out hand hygiene immediately after taking off PPE.
All PPE should be removed before leaving the area and disposed of as healthcare waste.
A poster showing the order for putting on and removing PPE is available to print.
Select image for full size version
Read the PPE literature reviews to find out more about the evidence base for PPE use.
Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents and this can spread infection.
Routine cleaning is regular cleaning which is carried out on a scheduled basis, not on an unplanned basis and not in response to an outbreak.
Cleaning is the removal of any dirt by use of an appropriate cleaning agent such as detergent.
Decontamination is removing, or killing pathogens on an item or surface to make it safe for handling, re-use or disposal, by cleaning, disinfection and/or sterilisation.
Disinfectant is a chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.
Detergent is a chemical cleansing agent that can dissolve oils and remove dirt.
For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.
If the resident has a known infection or the equipment is contaminated with blood or body fluids, then a disinfection agent needs to be used.
Do not use household bleach as the required dilution cannot be guaranteed.
Do not use refillable spray container for cleaning products as there is a risk of contamination.
Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.
or
or
There are three different types of care equipment that you will use in your care home and it is important that you know how to deal with each type.
You must use and follow manufacturers guidance for all equipment and products you use including those used for cleaning and decontamination.
Before using any sterile equipment, you should check that:
1. Single-use - equipment which is used once on a single resident and then discarded.
Single-use equipment must never be reused even on the same resident. The packaging carries the symbol.
Needles and syringes are single-use devices. They shoul
d never be used for more than one resident or reused to draw up additional medication.
Never give medications from a single-dose vial or intravenous (IV) bag to multiple residents.
2. Single individual use – equipment which can be reused by same resident e.g. nebuliser equipment and decontaminated following use as per manufacturers instructions.
3. Reusable non-invasive equipment (often referred to as ‘communal equipment’) – equipment which can be reused on more than one resident following decontamination between each use e.g. commode, moving and handling equipment or bath hoist.
Residents should be given their own reusable (communal) non-invasive equipment if possible.
Reusable equipment should be checked frequently for cleanliness and signs of integrity. This will include mattresses and pillows which should be clean, have a waterproof covering which is in a good state of repair.
You should clean or decontaminate reusable equipment:
between individual use;
after blood and/or body fluid contamination;
as part of the regular scheduled cleaning process;
before inspection, servicing or repair.
Staff must:
follow the local cleaning protocol/schedule which should include responsibility for; frequency of; and method of decontamination required;
use a general purpose detergent and water solution/detergent impregnated wipes;
or
a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.);
or
a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl;
make up cleaning/disinfection solution following manufacturers guidance;
follow the manufacturer’s contact time for the cleaning/disinfection solution;
rinse and dry reusable equipment then store it clean and dry.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
Read the management of care equipment literature review to find out more about why we do things this way for care equipment.
The decontamination of non-invasive care equipment poster can help staff decide how to clean equipment.
Select image for full size version
There are many areas in care homes that become easily contaminated with micro-organisms (germs) for example toilets, waste bins, tables.
Furniture and floorings in a poor state of repair can have micro-organisms (germs) in hidden cracks or crevices.
To reduce the spread of infection, the environment must be kept clean and dry and where possible clear from clutter and equipment.
Non-essential items should be stored and displayed in such a way as to aid effective cleaning
Keeping a high standard of environmental cleanliness is important in the care home settings as the residents are often elderly and vulnerable to infections.
visibly clean, free from non-essential items and equipment to help make cleaning effective
well maintained and in a good state of repair
routinely cleaned in accordance with the specified cleaning schedules:
Report any issues with the environment cleanliness or maintenance to the person in charge to ensure that the care environment is safe. The person in charge must then act on problems reported to them.
Be aware of the environmental cleaning schedules and clear on their specific responsibilities.
Cleaning services should be managed in a systematic way, and staff responsible for cleaning should be appropriately trained to carry out the tasks they are responsible for.
The Care Home Manager is responsible for managing the cleaning service which has a number of essential elements outlined in the cleaning services diagram.
Select the diagram for full size version
An effective service will include all of the elements above.
The Care Homes Cleaning Specification provides a guide to planning cleaning services. It has tools to help with the planning and recording of cleaning activities and with the management activities marked with a * in the diagram above. These include:
Table 2: Example cleaning SOP: Floors
The tools within the Cleaning Specification should be used by the care home manager in the planning, training of staff, delivery, and checking of standards of the cleaning services they provide.
When an organisation uses cleaning and disinfectant products that differ from those stated in this CH IPCM these products need to meet BS EN standards.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated with blood or body fluids, it may have to be discarded. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.
If the item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning. Any alternative disinfectant used must meet the relevant BS EN Standards as detailed previously
Read the routine cleaning of the care environment literature review to find out more about why we do things this way for the care environment.
Examples of linen you may have in the care home includes:
There are three categories of linen:
Clean – Linen washed and ready for use
Used – All used linen in the care setting not contaminated by blood or body fluids
Infectious – All linen used by a person known or suspected to be infectious and/or linen that is contaminated with blood or body fluids, e.g. faeces.
Used or infectious linen may also be categorised as heat-labile: usually personal clothing where the clothing may be damaged (shrinking/stretching) by washing at a higher than recommended temperature than the label advises. If such linen needs to be washed at a higher temperature for example if soiled or resident has a known infection they or their relatives need to be advised that the clothing may be damaged.
All clean, used and infectious linen should be handled with care and attention paid to the potential spread of infection.
Should be stored in a clean, allocated area.
This should be an enclosed cupboard but a trolley could be used as long as it is completely covered with a waterproof covering that is able to withstand cleaning.
Staff must:
put on disposable gloves and apron prior to handling used linen;
make sure that a laundry trolley or container is available as close as possible to the point of use for immediate linen deposit.
Staff must not:
rinse, shake or sort linen on removal from beds or trolleys;
place used linen on the floor or any other surfaces for example on a locker or table top;
re-handle used linen once bagged;
overfill laundry receptacles or trolleys;
place inappropriate items in the laundry receptacle for example used equipment/needles.
Staff must:
wear disposable gloves and apron before handling infectious linen;
put infectious linen directly into a water soluble laundry bag and secure before putting into a clear plastic bag and placing into a laundry receptacle/trolley.
Micro-organisms are destroyed by heat and detergent and also by the dilution effect of the water in the washing machine.
wash items using the highest temperature you can and following the washing instructions.
use your normal washing powder or detergent and follow the instructions on the correct amount to use.
tumble-dry (if possible) following the washing instructions.
iron according to washing instructions. If possible, use a hot steam iron.
If visitors wish to take their relatives clothes home to be laundered, place laundry in an appropriate bag and provide them with a washing clothes at home leaflet.
If the residents clothing is very soiled or infectious, staff may recommend that the clothing is washed in the care home’s laundry service if available, otherwise, the item should be disposed of in the appropriate healthcare waste stream following discussion with the resident or their relative(s).
Read the safe management of linen literature review to find out more about why we do things this way when dealing with linen.
Spillages of blood and other body fluids may transmit blood borne viruses.
A blood borne virus is a virus carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.
Body fluids are fluids produced by the body such as urine, faeces, vomit or diarrhoea. These body fluids may also contain blood.
immediately by staff trained to undertake this safely;
using body fluid spill kits/equipment available.
Responsibilities for the decontamination of blood and body fluid spillages should be clear within each area/care setting.
Read the management of blood and body fluid spillages literature review to find out more about why we do things this way for blood and body fluid spillages.
Use the poster management of blood and body fluids to help you when you clean up blood and body fluid spillages.
Select the image for full size
Different types of waste will be produced within care homes.
Some waste may be disposed of through the domestic waste route but other types of waste needs special handling and disposal for example sharps and waste from people who have or may have an infection.
Waste bags in care settings may be colour coded to denote the various categories of waste.
Local procedures and policies on waste disposal must be followed.
Care home waste disposal may differ from categories described and guidance from local contractors may apply.
Your care home should make sure that:
waste is correctly segregated according to local regulations;
the correct colour coded bags are being used according to local regulations;
there is a dedicated area for storage of clinical waste that is not accessible to residents or the public;
waste is stored in a safe place whilst awaiting uplift;
there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed.
Staff should:
follow the schedule for emptying domestic waste bins;
always use appropriate personal protective equipment (PPE);
dispose of waste immediately as close as possible to where it was produced;
dispose of clinical waste into the correct UN 3291 approved waste bin or sharps container;
ensure that waste bins are never overfilled. Once the waste bin is three quarters full, tie waste bags up and put into the main waste bin;
use a ‘swan neck’ technique for closure of the bag and label with date and location as per local policy.
clean waste bins regularly with a general purpose neutral detergent;
remove PPE and perform hand hygiene when you have finished handling waste.
Read the safe disposal of waste literature review to find out more about why we do things this way when dealing with waste.
All care homes should have policies in place to ensure that staff are protected from occupational exposure to micro-organisms (germs), particularly those that may be found in blood and body fluids.
Occupational exposure is exposure of healthcare workers or care staff to blood or body fluids in the course of their work.
A sharp is a device or instrument such as needles, lancets and scalpels which are necessary for the exercise of specific healthcare activities and are able to cut, prick and/or have the potential to cause injury.
Safety device or safer sharp is a medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury. Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.
The Health and Safety (Sharp Instruments in Healthcare) Regulations (2013) outline the regulatory requirements for employers and contractors in the healthcare sector in relation to:
sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices;
always dispose of needles and syringes as a single unit immediately at the point of use;
sharps containers need to be assembled and labelled correctly;
use the temporary closure mechanisms in between use;
if a safety device is being used safety mechanisms must be deployed before disposal;
follow manufacturers’ instructions for safe use and disposal;
do not re-sheath used needles or lancets;
do not store sharps containers on the floor;
ensure sharps containers are not accessible to residents or the public;
sharps containers must not be more than three-quarters full.
A significant occupational exposure is when someone is injured at work from using sharps or exposed to risk from blood or body fluids which may then result in a blood borne virus (BBV) or other infection.
Examples of this would be:
If you think or know you have had a significant occupational exposure you must:
report this immediately to the designated person in your care home, this is a legal requirement;
follow the local agreed process for management of an occupational exposure incident and follow the management of occupational injuries flow chart.
Read the management of occupational exposure to Blood Borne Viruses (BBVs) literature review to find out more about why we do things this way for occupational exposure.
The management of occupational exposure incidents flowchart should be used within your care home so you know what to do for an occupational exposure.
Select the image for full size
Sometimes using standard infection control precautions (SICPs) won’t be enough to stop an infection spreading and you will need to use some extra precautions. These extra precautions are called Transmission Based Precautions or TBPs.
You would use transmission based precautions if a resident has a suspected or known infection or colonisation.
Colonisation is the presence of bacteria on a body surface (such as the skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection.
Infections can be transmitted or spread by:
The three routes or ways an infection is transmitted or spread are called contact, droplet and airborne. You need to use different transmission based precautions for each route.
Contact precautions are used to prevent infections that spread through direct contact with the resident or indirectly from the resident’s immediate care environment and care equipment.
Droplet precautions are used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via small droplets from the respiratory tract of one individual directly onto the mucosal surface of another person’s mouth or nose or eyes. Droplets penetrate the respiratory system to above the alveolar level.
Airborne precautions are used to prevent and control infections spread without necessarily having close contact via from the respiratory tract of one individual directly onto the surface of another person’s mouth or nose or eyes. Aerosols penetrate the respiratory system to deep into the lung.
You might have heard of some infections like norovirus, Meticillin-resistant Staphylococcus aureus (MRSA), Clostridioides. difficile (C.diff/CDI) and flu but there are lots of others.
You can find out more information about the infection the individual has and the precautions you should use in Appendix 11 and/or A-Z of pathogens in the NIPCM.
You can also contact your local Health Protection Team or Infection Prevention and Control Team.
What the suspected or known infection/colonisation is?
How is it transmitted?
How severe is the resident’s illness?
What is the care setting and procedures being done?
There are different ways you can find out if a resident has an infection that needs TBPs to be put in place. You can get information about a resident’s infection status from:
Further information on transmission based precautions can be found in the definitions of Transmission Based Precautions literature reviews.
You need to regularly monitor the resident for infection throughout their stay so the correct precautions are in place to minimise the risk of infection being spread to other residents.
Residents may be an infection risk if they have:
CPE should be considered if the resident meets any of the following criteria within the
12-month period before admission:
CPE guidance for a care home setting is available.
Staff must:
get advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either your local Health Protection Team or Infection Prevention and Control Team;
make resident placement decisions based on advice received or sound judgement by experienced staff who are involved in the resident’s management;
let the ambulance service know of the resident’s infectious condition if they need to go to hospital;
not move residents within/between care areas unless essential.
Sometimes you will need to isolate a resident in their own room or area because of a known or suspected infection, it is important that:
Residents remain in their rooms whilst considered infectious and the door should remain closed.
If it is not possible for example the resident has dementia, then there needs to be individual risk assessments and decisions taken documented.
Suitable discrete signage is placed on the door advising others not to enter the room.
Consideration is given to the use of a dedicated team of care staff to care for residents in isolation/cohort rooms areas as an additional IPC measure. This is known as ‘staff cohorting’ and must only be done if there are enough staff available.
You do not stop isolation until you have considered individual risk factors and how this could affect other residents, staff and visitors.
You may need to contact your local health protection team or infection prevention and control team for further advice.
Read the patient placement, isolation and cohorting literature review to find out more about why we do things this way for resident placement for TBPs.
Cleaning of care equipment is essential to reduce the spread of infection when infection is confirmed/suspected
When dealing with the equipment used in the resident’s isolation room or area you should:
use dedicated reusable care equipment for the individual in isolation e.g. commodes where possible.
clean and decontaminate the care equipment after each use.
cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards
For how to decontaminate non-invasive reusable equipment prior to use on another resident see SICPs - Safe Management of Care Equipment.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
Read the management of care equipment literature review to find out more about why we do things this way for patient care equipment for TBPs.
Staff must:
clean and decontaminate the isolation/cohort rooms/area at least daily or more if advised to do so. If you have been advised to clean more than daily this should be added into the environmental cleaning schedule;
clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily;
make sure you are using the correct product which is:
a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.));
or
a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.
follow manufacturers guidance and instructions on how to use the product and what the recommended contact time is for the product to work. This may include rinsing off the disinfection solution to prevent damage to surfaces.
Do not use refillable spray container for cleaning products as there is a risk of contamination.
Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.
A terminal clean is cleaning/decontamination of the environment to ensure it is safe for the next resident or when the current resident is no longer considered infectious.
A terminal clean is carried out by:
removing all healthcare waste and other disposable items from the room;
removing bedding, curtains (bagged before removal from the room) and then wash as infectious linen;
cleaning and decontaminating all reusable care equipment in the room (before removal from the room).
The room should then be decontaminated using either:
The room must be cleaned from the highest to lowest point and from the least to most contaminated point.
This means that the product has passed tests and is shown to reduce different viruses, bacteria, fungi, yeasts and spores. If you do not use an BS EN standard product you have no assurance that it will work effectively.
Manufacturers instruction and recommended contact times must be adhered to.
BS EN standards and what they mean
In addition to PPE used for Standard Infection Control Precautions, appendix 16 of the NIPCM outlines you what type of PPE and RPE you will need to wear for infections spread by different transmission routes.
Respiratory Protective Equipment (RPE) means FFP3 masks and facial protection and must be thought about when a resident is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route and when carrying out aerosol generating procedures (AGPs) on residents with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.
An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.
The most common AGPs undertaken in the Care Home Setting are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).
The full list of medical procedures for COVID-19 that have been reported to be aerosol generating and are associated with an increased risk of respiratory transmission are:
* only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.
If the individual has an infection spread by the airborne route and an AGP is required staff should wear the following PPE:
PPE |
PPE used |
---|---|
Gloves |
Single-use. |
Apron or gown |
Single-use gown. |
Face mask or respirator |
FFP3 mask or powered respirator hood. |
Eye and face protection |
Single-use or reusable. |
Where staff have concerns about potential COVID-19 exposure to themselves during the ongoing COVID-19 pandemic, they may choose to wear an FFP3 respirator rather than a fluid-resistant surgical mask (FRSM) when providing patient care, provided they are fit tested. This is a personal PPE risk assessment, as per DL 2022 10.
Rooms should always be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. In an isolation room with 10-12 air changes per hour (ACH) a minimum of 20 minutes is required; in a side room with 6 ACH this would be approximately one hour. It is often difficult to calculate air changes in areas that have natural ventilation only. Natural ventilation, particularly when reliant on open windows can vary depending on the climate. An air change rate in these circumstances has been agreed as 1-2 air changes/hour.
To increase natural ventilation in care home settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.
Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted. This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate.
The post aerosol generating procedure fallow time (PAGPFT) calculations are detailed in the table below. It is often difficult to calculate air changes in areas that have natural ventilation only.
If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.
The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP. It is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time. During the PAGPFT staff should not enter this room without FFP3 masks. Other residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately. As a minimum, regardless of air changes per hour (ACH), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes. Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.
Duration of AGP (minutes) | 1 AC/h | 2 AC/h | 4 AC/h | 6 AC/h | 8 AC/h | 10 AC/h | 12 AC/h | 15 AC/h | 20 AC/h | 25 AC/h |
---|---|---|---|---|---|---|---|---|---|---|
3 | 230 | 114 | 56 | 37 | 27 | 22 | 18 | 14 | 10 | 8 (10)* |
5 | 260 | 129 | 63 | 41 | 30 | 24 | 20 | 15 | 11 | 8 (10)* |
7 | 279 | 138 | 67 | 44 | 32 | 25 | 20 | 16 | 11 | 9 (10)* |
10 | 299 | 147 | 71 | 46 | 34 | 26 | 21 | 16 | 11 | 9 (10)* |
15 | 321 | 157 | 75 | 48 | 35 | 27 | 22 | 16 | 12 | 9 (10)* |
*The minimum fallow time (to allow for droplet settling time) is 10 minutes
Contact your local HPT/IPCT if further advice is required.
Read the RPE literature review to find out more about why we do things this way for respiratory protective equipment
If a resident dies when in the care home, Standard Infection Control Precautions or Transmission Based Precautions must still be applied. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for the living.
It is important that information on the infection status of the deceased is sought and communicated at each stage of handling and risk assessments performed.
Viewing, washing and/or dressing of the deceased - Appendix 12 - Application of transmission based precautions to key infections in the deceased will give you guidance on the precautions that are required and what is permitted for certain types of infections.
Staff should advise relatives of the appropriate precautions to be taken when viewing and/or having physical contact with the deceased, including when this should be avoided.
Read the infection prevention and control during care of the deceased literature review to find out more about why we do things this way when dealing with the deceased.
If you have any questions or feedback about the Care Home IPCM then you can contact us by email or telephone.
Telephone: 0141 300 1175
The use of the word 'Persons' can be used instead of ‘Patient’ when using this document in non-healthcare settings.
A graze. A minor wound in which the surface of the skin or a mucous membrane has been worn away by rubbing or scraping.
This is a unique, demanding and fast-paced environment designed to accommodate a wide variety of urgent, or emergent patient care needs.
An event that could have caused or did result in harm to people or groups of people.
An AGP is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.
The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.
Very small particles (of respirable size) that may contain infectious agents. They can remain in the air for extended periods of time and can be carried over long distances by air currents. Aerosols can be released during aerosol generating procedures (AGPs).
A group of transmission based precautions to prevent the spread of airborne pathogens
A gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to inactivate microorganisms and/or temporarily suppress their growth.
An organism that is identified as being potentially significant for infection prevention and control practices. Examples of alert organisms include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff) and Group A Streptococcus.
Refers to the alveoli which are the small air sacs in the lungs. Alveoli are located at the ends of the air passageways in the lungs, and are the site at which gas exchange takes place.
An area with a door from/to the outside corridor and a second door giving access to the patient area (where both doors will never be open at the same time).
An agent that kills microorganisms, or prevents them from growing.
Antimicrobials are grouped according to the microorganisms they act against, such as, antibiotics, antivirals, antifungals and antiparasitics.
Hand wipes that are moistened with an antimicrobial solution/agent at a concentration sufficient to inactivate microorganisms and/or temporarily suppress their growth.
The ability of a microorganism to resist the action of an antimicrobial drug/agent which previously could treat the infection caused by that microorganism.
The process of preventing infection by inhibiting the growth and multiplication of infectious agents. This is usually achieved by application of a germicidal preparation known as an antiseptic.
A healthcare procedure designed to minimise the risks of exposing the person being cared for to pathogenic micro-organisms during simple (e.g dressing wounds) and complex care procedures (e.g. surgical procedures).
Not showing any symptoms of disease but where an infection may be present.
In the context of infection prevention and control, most care designated as augmented will be that where medical/nursing procedures render the patients susceptible to invasive disease from environmental and opportunistic pathogens. However, there is no fixed definition of ‘augmented care’.
Machine used for sterilising re-usable equipment using steam sterilisation. Re-usable equipment is exposed to steam at a required temperature, pressure, and time.
A partly enclosed area within a ward containing one bed (single bay) or multiple beds (multi-bed bay).
Viruses carried or transmitted by blood, for example Hepatitis B, Hepatitis C and HIV.
Fluid produced by the body such as urine, faeces, vomit or diarrhoea.
National standards specify the requirements for application in the particular country.
Includes but is not limited to general practice, dental and pharmacy (primary care), acute-care hospitals, emergency medical services, urgent-care centres and outpatient clinics (secondary care), specialist treatment centres (tertiary care), long-term care facilities such as nursing homes and skilled nursing facilities (community care), and care provided at home by professional healthcare providers (home care).
Any person who cares for patients, including healthcare support workers and nurses.
An intravenous catheter that is inserted directly into a large vein in the neck, chest or groin to give intravenous drugs, fluids and blood and to allow for quick medical tests.
A chemical that is used for disinfecting, fumigating and bleaching.
The removal of any dirt, body fluids (blood, vomit) etc by use of an appropriate cleaning agent such as detergent.
A sink designated for hand washing in clinical areas.
A bay/ward in which a group of patients (cohort) with the same infection are placed. Cohorts are created based on clinical diagnosis, microbiological confirmation when available, epidemiology, and mode of transmission of the infectious agent.
The presence of microorganisms on a body surface (such as the skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection.
Mucous membranes that cover the front of the eyes and the inside of the eyelids.
Series of procedures/interventions used in addition to routine practices to prevent transmission of infectious agents that spread by direct or indirect contact
The spread of infectious agents from one person to another by contact. When spread occurs through skin-to-skin contact, this is called direct contact transmission. When spread occurs via a contaminated object, this is called indirect contact transmission.
The presence of an infectious agent on a body surface; also on or in clothes, bedding, surgical instruments or dressings, or other inanimate articles or substances including water and food.
Source control measures intended to contain respiratory secretions in order to limit transmission of respiratory pathogens.
Spread of infection from one person, object or place to another.
The process of removing, or killing pathogens on an item or surface to make it safe for handling, re-use or disposal, by cleaning, disinfection and/or sterilisation.
A chemical cleansing agent that can dissolve oils and remove dirt.
Passing looser more frequent stools than is normal for the individual.
Spread of infectious agents from one person to another by direct skin-to-skin contact.
A chemical used to reduce the number of infectious agents from an object or surface to a level that means they are not harmful to health.
The treatment of surfaces/equipment using physical or chemical means, for example using a chemical disinfectant, to reduce the number of infectious agents from an object or surface to a level at which they are not harmful to health.
To remove (an item of clothing or an item of PPE).
Waste produced in the care setting that is similar to waste produced in the home.
To put on (an item of clothing or an item of PPE).
A small drop of moisture, larger than airborne particle, that may contain infectious agents. Droplets can be released when a person talks, coughs or sneezes, and during some medical or patient care procedures such as open suctioning and cough induction by chest physiotherapy. It is thought that droplets can travel around 1 metre (3 feet).
Droplet nuclei are aerosols formed from the rapid evaporation/desiccation of larger droplet particles when expelled/exhaled from the respiratory tract.
The spread of infection from one person to another by droplets containing infectious agents.
An agent used to soothe the skin and make it soft and supple.
En-suite facilities should contain a shower, WC and a general wash-hand basin.
A room with space for one patient with en-suite facilities.
A single case of an infection that has severe outcomes for an individual patient OR has major infection control/public health implications e.g. infectious diseases of high consequence such as extensively drug resistant tuberculosis (XDR-TB).
Waste products produced by the body such as urine and faeces (bowel movements).
The condition of being exposed to something that may have a harmful effect such as an infectious agent.
Certain medical and patient care procedures where there is a risk that injury to the healthcare worker may result in exposure of the patient’s open tissues to the healthcare worker’s blood e.g the healthcare worker’s gloved hands are in contact with sharp instruments, needle tips or sharp tissues inside a patient’s body.
A term that applies collectively to items used to cover the nose and mouth. Also referred to as a face mask.
These should not be confused with items of PPE.
The period of time required for droplets and/or aerosols to settle and be removed from the air following a procedure. It is also known as settle time.
Respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). FFP stands for filtering facepiece. There are three categories of FFP respirator: FFP1, FFP2 and FFP3. An FFP3 respirator or hood provides the highest level of protection, and is the only category of respirator legislated for use in UK healthcare settings.
A method of checking that a tight-fitting facepiece respirator fits the wearer and seals adequately to their face. This process helps identify unsuitable facepieces that should not be used.
A term applied to fabrics that resist liquid penetration, often used interchangeably with 'fluid-repellent' when describing the properties of protective clothing or equipment.
An inanimate substance or object that can transfer a pathogen to a host.
An agent capable of destroying microorganisms, particularly organisms that are pathogenic.
General practitioner (your family doctor)
Definition taken from the HSE Approved list of biological agents www.hse.gov.uk/pubns/misc208.pdf
Group 4 infections cause severe human disease and are a serious hazard to employees; they are likely to spread to the community and there is usually no effective prophylaxis or treatment available.
The process of decontaminating your hands using either alcohol based hand rub or liquid soap and water.
A team of healthcare professionals whose role it is to protect the health of the local population and limit the risk of them becoming exposed to infection and environmental dangers. Every NHS board has a HPT.
Infections that occur as a result of medical care, or treatment, in any healthcare setting.
Two or more linked cases associated with the same infectious agent, within the same healthcare setting, over a specified time period; or a higher than expected number of cases in a given healthcare area over a specified time period.
A greater than expected rate of infection compared with the usual background rate for the place and time where the incident has occurred.
An exposure of patients, staff, or the public to a possible infectious agent, as a result of a healthcare system failure or near misses e.g. ventilation, water or a decontamination incident.
Waste produced as a result of healthcare activities for example soiled dressings, sharps.
This is a systematic process which provides a consistent approach to minimizing or eliminating exposures to hazards in the workplace.
A High Consequence Infectious Disease (HCID) is defined according to the following criteria:
Previously referred to as an Infectious Diseases of High Consequence (IDHC).
Used by the IPCT or HPT to assess every healthcare infection incident i.e. all outbreaks and incidents including decontamination incidents or near misses in any healthcare setting (that is the NHS, independent contractors providing NHS Services and private providers of healthcare).
Waste that is produced from personal care. In care settings this includes feminine hygiene products, incontinence products and nappies, catheter and stoma bags. Hygiene waste may cause offence due to the presence of recognisable healthcare waste items or body fluids. It is usually assumed that hygiene waste is not hazardous or infectious.
A chlorine-based disinfectant such as bleach
To provide immunity to a disease by giving a vaccination.
Any person whose immune response is reduced or deficient, usually because they have a disease or are undergoing treatment. People who are immunocompromised are more vulnerable to infection.
Cannot be penetrated by liquid.
A multidisciplinary group with responsibility for investigating and managing an incident.
An incident/outbreak may be:
The spread of infectious agents from one person to another via a contaminated object.
Invasion of the body by a harmful organism or infectious agent such as a virus, parasite, bacterium or fungus.
A multidisciplinary team responsible for preventing, investigating and managing an infection incident or outbreak.
Any organism, such as a virus, parasite, bacterium or fungus, that is capable of causing an infection or infectious disease.
The time when an infectious agent may be transmitted directly or indirectly from an infected person to another person. Also known as “period of infectiousness” and “communicability”.
A patient is termed an inpatient when they occupy a staffed bed in a hospital and either remains overnight (whether intended or not), or is expected to remain overnight but is discharged earlier. An inpatient’s admission can be an emergency, an elective or as a transfer.
A device which penetrates the body, either through a body cavity or through the surface of the body. Central Venous Catheters (central line), Peripheral Arterial Lines and Urinary Catheters are examples of invasive devices.
A medical/healthcare procedure that penetrates or breaks the skin or enters a body cavity.
Physically separating patients to prevent the spread of infection.
An isolation room/suite consists of enhanced en-suite single bed rooms:
An en-suite single bed room is defined as: consisting of a bed; locker/wardrobe; clinical wash-hand basin and en-suite shower, WC and wash-hand basin. (In new build, space for a social support zone for overnight stay and a clinical support zone is also provided).
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A test carried out using a small medical device that tests whether or not there is a particular substance, gene, etc. in a sample. For example, to identify those who have COVID-19 but are not presenting symptoms.
Long term care facilities provide a variety of services, both medical and personal care, to people who are unable to live independently.
Mechanical ventilation brings fresh air into a building from outside via a controllable method. Basic systems consist of a fan and either collection, (extraction) or distribution (supply) ductwork.
Any living thing (organism) that is too small to be seen by the naked eye. Bacteria, viruses and some parasites are microorganisms.
The way that microorganisms spread from one person to another. The main modes or routes of transmission are airborne (aerosol) transmission, droplet transmission and contact transmission.
An incident in which the mucous membranes (e.g. mouth, nose, eyes) or non-intact skin have been contaminated with blood or other bodily fluids.
The surfaces lining the cavities of the body that are exposed to the environment such as the lining of the mouth and nose.
A room that contains more than one bed.
The acceptable maximum number of beds in a multi-bed room is four. Multi-bed rooms require two clinical wash-hand basins and must have en-suite sanitary facilities. Ideally, an assisted shower room (with WC, shower and general wash-hand basin) and a separate semi-ambulant WC (with general wash-hand basin) both en-suite.
Any device designed to reduce the risk of injury from needles. This may include needle-free devices or mechanisms on a needle, such as an automated resheathing device, that cover the needle immediately after use.
A room which maintains permanent negative pressure i.e. air flow is from the outside adjacent space (e.g. corridor) into the room and then exhausted to the outside.
The room should be used to accommodate a patient known or suspected to be infected with a microorganism spread by the airborne (aerosol) route whilst the patient is considered infectious.
A synthetic rubber material used to make non-latex gloves.
Skin that is broken by cuts, abrasions, dermatitis, chapped skin, eczema etc.
An incident in which non-intact skin is exposed to blood or body fluids.
Care procedure that does not need to be undertaken in conditions that are free from bacteria or other microorganisms.
An infection occurring in a patient during the process of care in a hospital or other health care facility, which was not present or incubating at the time of admission.
An occupational exposure is a percutaneous or mucocutaneous exposure to blood or other body fluids.
Any living thing that can grow and reproduce, such as a plant, animal, fungus or bacterium.
An outpatient is a patient who attends a consultant or other medical/healthcare clinic or has an arranged meeting with a consultant or a senior member of their team out with a clinic session. Outpatient attendances involve treatment or assessment that only take a short time to complete. Outpatient attendances are categorised as new or return (follow-up).
Within health and care settings, this is the state of being filled past capacity/comfort and therefore being burdened by excessive demands for services.
A disease outbreak that occurs over a wide geographical area (such as multiple countries and/or continents) and typically affects a significant proportion of the population.
Any disease-producing infectious agent.
Placing a group of two or more patients (a cohort) with the same infection/strain in the same bay/ward. Cohorts are created based on clinical diagnosis, microbiological confirmation, epidemiology, and mode of transmission.
Highly accurate tests used to diagnose certain infectious diseases.
An injury caused by a needle/sharp, human scratch or bite cutting or puncturing the skin.
Equipment a person wears to protect themselves from risks to their health or safety, including exposure to infections e.g. disposable gloves and disposable aprons.
Keeping a distance from other people, in order to stop transmission of a disease to another person or other people.
The time period when someone has the infection but has not yet developed symptoms but does go on to develop symptoms later in the disease.
These provide the first point of contact in the healthcare system and includes general practice, dentistry, community pharmacies etc.
A group that is convened by the Infection Prevention and Control Team (IPCT)/Health Protection Team (HPT) to assess a healthcare incident/outbreak/data exceedence and determine if further action is required.
The assessment and outcome may be:
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To put a needle or other sharp object back into its plastic sheath or cap. Also known as ‘re-sheathing’.
A small droplet >5 μm in diameter, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.
Respirators are devices that cover the nose and mouth and are designed to filter the air breathed in to protect the wearer from inhaling hazardous substances.
They provide respiratory protection from infectious agents transmissible by the airborne (aerosols) route. FPP3 respirators are recommended for use in UK health and care settings when exposure to aerosols is anticipated.
A medical sharps device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury. Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.
All sinks and furniture in a bathroom, such as a toilet, bath, shower etc.
Performing a test or enquiry to identify individuals at risk of a specific disorder or infection to warrant further investigation or direct preventive action.
Provided by health professionals who generally are not the first point of contact for a patient. These settings are usually hospitals but can also be community based.
Any body fluid that is produced by a cell or gland such as saliva or mucous, for a particular function in the organism or for excretion.
Physically separating or isolating from other people.
A life threatening condition that arises when the body’s response to a severe complication of infection e.g. pneumonia (lung infection) injures its own tissues and organs. This can lead to multiple organ failure and death. Early recognition, treatment and management is key to successful patient outcomes.
A ‘sharp’ is a device or instrument used in healthcare settings with sharp points or edges, such as needles, lancets and scalpels which have the potential to cause injury through cutting or puncturing the skin.
A type of percutaneous injury caused by a sharp instrument or device which cuts or penetrates the skin.
A percutaneous, mucocutaneous exposure or non-intact skin (abrasions, cuts, eczema) exposure to blood/other body fluids from a source that is known (or later found to be) positive for a bloodborne virus infection.
An incident which involves a used needle that has exposed, or may have exposed, the employee to blood/body fluids.
A room with space for one patient and usually contains as a minimum: a bed; locker/wardrobe; clinical wash-hand basin.
Single-bed rooms should also have en-suite sanitary facilities comprising of a shower, WC and a general wash-hand basin.
This term encompasses all physical measures used to control the transmission of an infectious agent.
A reproductive cell produced by fungi and some types of bacteria under certain environmental conditions. Spores can survive for long periods of time and are very resistant to heat, drying and chemicals.
A dedicated team of healthcare staff who care for a cohort of patients, and do not care for any other patients.
These are a group of basic infection prevention and control practices that need to be adopted by all staff in health and care settings, irrespective of infectious status of patient.
Free from live bacteria or other microorganisms.
Care procedure that is undertaken in conditions that are free from bacteria or other microorganisms.
The procedure of making some object free of all germs, live bacteria or other microorganisms (usually by heat or chemical means).
A disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious droplets and also to protect patients. When recommended for infection control purposes a 'surgical face mask' typically denotes a fluid-resistant (Type IIR) surgical mask.
The process of removing debris and sterilizing hands prior to performing a sterile or surgical procedure.
This is an infection which occurs after the surgery at the site of the surgical incision due to introduction and multiplication of pathogens at the surgical site.
Way of closing bag by twisting the top of the bag (must not be more than 2/3 full), looping the neck back on itself, holding the twist firmly, and placing a seal over the neck of the bag (such as with a tag).
Cleaning/decontamination of the environment following transfer/discharge of a patient, or when they are no longer considered infectious, to ensure the environment is safe for the next patient or for the same patient on return.
These are surfaces that are frequently touched by different people throughout the day and are therefore more likely to be contaminated with bacteria or viruses for example doorknobs, tables, phones etc. which can then easily transfer to the user.
These are additional measures that are used in conjunction with SICPs when caring for patients with a known or suspected infection or colonisation.
The use of ultraviolet (UV) radiation to kill or inactivate microorganisms.
Treatment with a vaccine to produce immunity against a disease.
A suspension that is administered in order to stimulate the immune response of the body against an infectious agent.
Any medical instrument used to access a patient’s veins or arteries such as a Central Venous Catheter or Peripheral Vascular Catheter.
Ventilation is a means of removing and replacing the air in a space. In its simplest form this may be achieved by opening windows and doors.
The viral load or viral burden is a numerical expression of the amount of virus present in biological fluids or environmental specimens.
An area forming a division of a care setting (or a suite of rooms) shared by patients who need a similar type of care.
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