National Infection Prevention and Control Manual
SICPs may be insufficient to prevent cross-transmission of specific infectious agents. Therefore, additional precautions known as transmission based precautions (TBPs) are required to be used by staff when caring for patients with a known or suspected infection or colonisation.
The way in which we describe transmission routes has changed. You can find out more about this in our ‘What’s changed?’ guide. Our Frequently Asked Questions (FAQs) resource provides answers to some of the common queries associated with the changes.
Transmission routes are the ways in which an infectious agent spreads from one place or person to another. Some infectious agents can be transmitted by more than one route.
Transmission of infectious agents from one person to another by direct physical contact (direct contact transmission) or indirectly through contact with a contaminated object or surface (indirect contact transmission).
Transmission of infectious agents from one person to another (without touching) via body fluids that travel from the infected person through the air. Air-transmitted infectious agents can be transmitted by splashing or spraying of body fluid particles onto the mucosa and/ or by inhaling body fluid aerosols.
Application of TBPs may differ depending on several factors. Clinical judgement and decisions should be made by staff on the necessary precautions. This should be based on the:
Respiratory infectious agents are mainly transmitted via the air transmission route. To support the application of TBPs, respiratory infectious agents have been grouped into three respiratory (R) categories: R1, R2 and R3.
These categories take into account:
Appendix 11 provides details of infectious agents, associated presentation or disease, the type of precautions, optimal patient placement, isolation requirements and respiratory (‘R’) category (for respiratory infectious agents).
If you want to understand more about how each pathogen is categorised, this is described in the NIPCM glossary under 'respiratory categories'.
Further information can be found in the Transmission Based Precautions Definitions literature review.
The potential for transmission of infection must be assessed on the patient's arrival to the care area (or before arrival if possible), before transferring a patient to another care area and should be continuously reviewed throughout their stay. The assessment should support placement decisions in accordance with clinical or care need(s).
Patients who may present a transmission risk in any setting may include those:
This is not an exhaustive list, and risks need to be assessed for each patient.
Further information regarding respiratory symptoms screening questions can be found within the resources section of the NIPCM.
Within healthcare settings, different types of specialised ventilation isolation facilities are used to prevent transmission of infection. Those most commonly found in NHS Scotland are;
A description of these rooms and their intended use can be found in the glossary.
Isolation facilities should be prioritised depending on the suspected or confirmed infectious agent (refer to Appendix 11). All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.
Patients who present transmission risk should be risk assessed and placed in appropriate isolation as follows:
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:
Patients with suspected infection should not be cohorted alongside those with confirmed infection even if the same infectious agent is suspected.
Where possible, consider assigning a dedicated team of care staff to patients in isolation or cohort rooms as an additional infection control measure during outbreaks/incidents.
Individual patient risk factors should be considered, for example there may be prolonged shedding of certain infectious agents in immunocompromised patients. Clinical and, where appropriate, 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.
If a patient vacating a room has a suspected or confirmed respiratory infection, the room may need to be left vacant for a period of time to ensure that any remaining potentially infectious particles are adequately cleared from the air to minimise the exposure risk to the next occupant. The clinical team should assess:
If a vacancy period is required, and should a healthcare worker need to enter the room during the vacancy period, healthcare workers should wear appropriate PPE: a surgical mask or respiratory protective equipment (RPE) should be used in line with the respiratory category associated with the vacating patient. Refer to Appendix 15. This would include when undertaking cleaning post discharge.
See Hierarchy of Controls (engineering controls) for information on the impact of ventilation on clearance times.
Ensure a minimum of 10 minutes has passed to allow the largest particles to settle on surfaces before terminal decontamination – see terminal decontamination for additional information.
Further information can be found in the patient placement literature review.
For how to decontaminate non-invasive reusable equipment see Appendix 7.
Patient isolation/cohort rooms/area should be decontaminated at least daily, this may be further increased on the advice of IPCTs/HPTs. These areas should be decontaminated using either:
or
Manufacturer’s instructions should always be followed regarding preparation and use of a detergent, disinfectant or combination products.
Increased frequency of decontamination/cleaning schedules should be incorporated into the environmental decontamination schedules for areas where there may be higher environmental contamination rates, for example
Patient rooms must be terminally decontaminated following resolution of symptoms, discharge or transfer. This includes removal and laundering of all curtains and bed screens.
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 for example cloths, mop heads.
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:
or
The room should be cleaned from the highest to lowest point and from the least to most contaminated point.
Manufacturer’s instructions should always be followed regarding preparation and use of detergent, disinfectant or combination products.
If a patient vacating a room has a suspected or confirmed respiratory infection, healthcare workers should wait a minimum of 10 minutes before commencing terminal decontamination. This allows larger respiratory particles to settle onto surfaces.
For longer vacancy periods, see patient placement considerations.
All PPE should:
Gloves should:
Double gloving is only recommended during some Exposure Prone Procedures (EPPs), for example 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.
The type of aprons or gowns used in health and care settings should be selected based on the task being undertaken, and the anticipated levels of body fluid exposure.
A disposable apron should be worn when in contact with a patient’s environment or when providing direct care to those suspected or confirmed to be colonised or infected with a transmissible infectious agent.
A fluid repellent gown should be used if excessive splashing or spraying is anticipated.
Further information can be found in the Aprons/Gowns literature review.
Eye and face protection should be worn:
Types of eye or face protection suitable for use include goggles, face shields or visors, and surgical face masks with integrated face shields. Prescription eyeglasses and contact lenses should not be considered a form of eye or face protection.
Fluid resistant surgical masks should be:
FRSMs may be worn sessionally when providing care to a cohort of patients with the same confirmed respiratory infection. Sessional use of a FRSM means that staff do not need to change these when moving between patients within the cohort however the FRSM should be changed if it becomes damaged or contaminated. Other items of PPE should not be used sessionally and should be changed between procedures/tasks and patients as indicated.
Transparent face masks may be used
RPE should be worn when caring for a person with a suspected or confirmed R2 or R3 respiratory infection.
RPE may be worn when caring for a person with a suspected or confirmed R1 respiratory infection if the staff member has been advised to do so by occupational health, GP, or another personal medical practitioner.
RPE should be changed after each use. Other indications that a change is required include:
Staff may choose to wear RPE where FRSM is indicated for use when caring for a patient with a suspected or confirmed R1 respiratory infection, based on personal choice. Refer to Appendix 15.
RPE should never be worn by an infectious person as the respirator filters incoming air and not the air being expelled by the wearer.
There are two main types of respirators used within health and care settings in Scotland:
RPE should be changed after each use. Other indications that a change is required include:
FFP3 respirators with unshrouded valves are not considered to be fluid resistant. Where there is a risk of splash contamination for the wearer with blood or body fluids additional PPE should be worn, such as a full face shield/visor.
Valved RPE respirators should not be worn when a sterile field is required. An MHRA safety alert can be viewed.
FFP3 respirators should be compatible with other facial protection used, for instance eye protection, so that this does not interfere with the seal of the respiratory protection.
The wearer should be clean shaven and free of any jewellery or piercings to support effective fit testing by ensuring a smooth surface area for a seal. The Facial Hairstyles and Filtering Facepiece Respirators poster gives further information on compatibility of facial hair and FFP3 respirators and can be used when fit testing and fit checking.
All tight-fitting RPE (for instance FFP3 respirators) must be face fit tested. Face fit testing should be:
A fit check should be performed each time tight fitting RPE is donned, to ensure a tight seal has been achieved. A fit check is not a substitute for fit testing.
If a fit test or check fails, then the RPE should be adjusted and fit test/check repeated. If a tight seal cannot be achieved then other types of RPE that offer equivalent protection may be considered.
Staff should not undertake tasks where RPE is required if a fit test or a fit check has failed and alternative RPE is unavailable.
Poster on Facial Hairstyles and Filtering Facepiece Respirators can be used when fit testing and fit checking
See Appendix 6 for donning and doffing advice.
Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.
Powered respirator hoods are an alternative to FFP3 respirators for example when fit testing cannot be undertaken or achieved.
Powered respirator hoods may be single-use (disposable) or reusable. Where feasible, reusable components (for example, powered hoods and helmets) should be issued for individual use.
Powered hoods should:
Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for High Consequence Infectious Diseases (HCIDs) Literature review.
PPE should always be used in line with SICPs and as below as part of TBPs.
| Gloves | Aprons | Gowns | Eye/Face protection | Fluid Resistant Surgical Masks (FRSM) | Respiratory Protective Equipment (RPE) |
| As per SICPs | As per SICPs | As per SICPs | When there is an anticipated risk of splashing and/or spraying of blood or bodily fluids. |
When caring for a person with suspected or confirmed respiratory infection and the infectious agent has not yet been determined. When caring for a person with suspected or confirmed R1 respiratory infection. |
Worn when caring for a person with a suspected or confirmed R2 or R3 respiratory infection. Worn following a personal assessment (medical or choice) – see Appendix 15. |
Visitors do not routinely require PPE unless they are providing direct care to the individual they are visiting.
However, if visiting a patient with a suspected or confirmed respiratory infection, visitors may be offered a FRSM to wear for the duration of the visit. Consideration should be given to providing visitors with RPE when visiting a patient with a suspected or confirmed infection caused by a category R2 or R3 respiratory infectious agent. Note: If the R2 or R3 infectious agent is a HCID, visiting must be discussed with your local IPCT.
If the need for PPE is identified, staff should provide advice on its correct use. This must include fit testing for FFP3 (if required), advice on fit checking and appropriate donning and doffing for all PPE.
If, following an explanation of potential risks, a visitor declines to wear PPE when it is offered, then this should be respected, and the visit should not be refused. PPE use by visitors cannot be enforced and there is no expectation that staff monitor PPE use amongst visitors.
The table below shows the PPE which should be worn where appropriate and when the visitor chooses to do so.
| Gloves | Apron | FRSM | RPE | Eye or Face Protection |
|---|---|---|---|---|
| Not required unless providing direct care, which may expose the visitor to blood and/or body fluids, for instance assisted toileting or feeding. | Not required unless providing care resulting in direct contact with the service user, their environment or blood and/or body fluid exposure, for instance toileting, bed bath. A gown may be used where excessive splashing or spraying may be anticipated. |
Where splash or spray to nose or mouth is anticipated AND for the duration of a visit to a patient with suspected or confirmed respiratory infection. During essential visiting arrangements when the visitor has a suspected or confirmed transmissible respiratory infection. |
When visiting someone who has a suspected or confirmed R2, R3 infection | Where splash or spray to the visitor's eyes/face is anticipated |
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 the contact route.
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 not be carried out when the deceased is known or suspected to have been infected by any of the following key infectious agents: ACDP Hazard Group 4 organisms, anthrax, and rabies. For other HCIDs a local risk assessment should be undertaken to inform any decision making on washing and/or dressing of the deceased.
Viewing of the deceased should be avoided when the deceased is known or suspected to have been infected by ACDP Hazard Group 4 organisms, specifically those causing VHFs (including Ebola, Lassa etc.) and anthrax. For other HCIDs a local risk assessment should be undertaken to inform any decision making on viewing of the deceased.
See Appendix 12 Application of infection control precautions 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 ACDP Hazard Group 4 infectious agent should be placed in a sealed double plastic body bag with absorbent material placed between each bag. A product should then be used to decontaminate the outside of the bag, following the manufacturer’s instructions. Once it has been disinfected, place the bag into a robust, sealed coffin.
Post-mortem examination should not be performed on a deceased individual known or suspected to have a ACDP Hazard Group 4 infectious agents. See Appendix 12 Application of infection control precautions 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 or, for suspected or confirmed HCIDs, the HCID addendum 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.