What is the Care Home Infection Prevention and Control Manual (CH IPCM)?

The Care Home Infection Prevention and Control Manual (CH IPCM), referred to as ‘the manual’ throughout, was first published in 2021. It is evidence-based and is intended to be used by all those involved in care home provision in Scotland.

The manual is context specific and has been co-produced with national and local stakeholders. The content of the manual is completely aligned to the evidence based National Infection Prevention and Control Manual (NIPCM) which was first published in 2012, by the Chief Nursing Officer (CNO (2012)1).

The manual currently contains

• Chapter 1 – Standard Infection Control Precautions (SICPs)
• Chapter 2 – Transmission Based Precautions (TBPs)

The manual is a practice guide for use in care homes. When used, it can help reduce the risk of infections and ensure the safety of residents, as well as staff and visitors in the care home environment. It is the Scottish Government expectation that care home settings apply guidance contained within this manual to achieve the aims.

The manual aims to:

• make it easy for staff to apply effective infection prevention and control (IPC) precautions
• help reduce the risk of infection
• reduce variation, promote standardisation, and optimise IPC practices throughout care home settings
• improve the application of staff knowledge and skills in IPC
• help align practice, monitoring, quality improvement and scrutiny

The manual should be adopted for all IPC practices and procedures within care home settings.

Is the manual based on scientific literature?

The recommendations for practice made in the manual are fully aligned to the NIPCM and are based on real-time reviews of the current scientific literature (for example Medical Journals) and best practice. Any major changes identified in the scientific literature may lead to a change being made to the content, and so, it is recommended that the online version is always accessed and used locally.

What's in the appendices?

The appendices can be used as practical implementation of the manual and contain graphical representations (for example diagrams and charts) that can be used along with the contents of the manual.

Many of the appendices can be printed off as posters for local use throughout the care home.

Are there any other IPC materials that can be used?

There are links throughout the manual to additional resources and the resources page links to IPC campaign materials, education, training links and posters.

In addition you may find it useful to read the literature reviews and SBARs for the manual.

How can I find out what the scientific and medical words mean?

A glossary section has been provided.

Does the manual content work on mobile devices?

Yes, all content including appendices work on mobile devices for example laptops and smartphones.

 

Responsibilities for the CH IPCM

Responsibilities for content of the manual 

ARHAI Scotland to ensure:

• that the content of this manual remains evidence based or where evidence is lacking, content is based on consensus of expert opinion

Stakeholders of ARHAI Scotland programme working groups to ensure:

• full participation in the working groups including full engagement with the consultation process outlined in the Terms of Reference associated with each working group

Responsibilities for the adoption and implementation of this manual

The manual should be used by:

• care home organisations
• care home staff including permanent, agency and where required external contractors
• health protection teams
• infection prevention and control teams
• professionals providing support
• individuals visiting the care home

Care home providers to ensure:

• the adoption and implementation of this manual in accordance with existing local governance processes
• that systems and resources are in place to facilitate implementation and compliance monitoring of IPC as specified in this manual in all care areas
  • compliance monitoring includes all staff (permanent, agency and where required external contractors)
• there is an organisational culture which promotes incident reporting and focuses on improving systemic failures that encourage safe IPC working practices including near misses
• there is a nominated lead with responsibility for IPC within the care home

Care home managers to ensure that all staff:

• are aware of and have access to this manual
• have completed appropriate IPC training relevant to their roles and that this is centrally recorded. Training may include resources developed by your organisation, your local NHS board, Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC)
• have adequate support and resources available to enable them to implement, monitor and take corrective action to ensure full compliance with this manual
• implement a robust risk assessment including detailing any deviations from the manual and the local mitigation measures that were undertaken and post-approval  documented via local governance procedures
• with health concerns (including pregnancy) or those who have had an occupational exposure relating to IPC are timeously referred to the relevant agency, for example general practitioner (GP or doctor), occupational health or if required accident and emergency
• have undergone the required health checks or clearance (including those undertaking exposure prone procedures (EPPs))
• include IPC as an objective in their personal development plans (or equivalent)

Care home staff providing care to:

• understand, adopt and implement the principles of IPC as set out in this manual
• maintain IPC competence, skills, and knowledge through completing appropriate training relevant to their role as directed by their line manager. IPC training, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC)
• communicate the IPC practices to be taken to appropriate colleagues, residents, relatives and visitors without breaching confidentiality
• have up to date occupational immunisations/health checks/clearance requirements as appropriate
• report to line managers and document any gaps in IPC knowledge, resources, equipment and facilities or incidents that may result in transmission of infection including near misses for example sharps or PPE failures
• do not provide care while at risk of potentially transmitting infectious agents to others - if in any doubt they should consult with their line manager, occupational health department, local infection prevention and control team (IPCT) or local health protection team (HPT)
• contact the local HPT/IPCT if there is a suspected or actual HAI incident/outbreak

Local infection prevention and control teams (IPCTs) and health protection teams (HPTs) to: 

• engage with care home staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of IPC practice
• provide expert advice on the application of IPC and provide support when requested to develop individual or organisational risk assessments where deviations from the manual are necessary
• have epidemiological or surveillance systems capable of distinguishing resident case or cases requiring investigations and control
• provide local support and advice (when necessary and/or requested) and complete documentation when an incident/outbreak or data exceedance is reported

Chain of infection

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:

1. infectious agent or the microorganism which can cause disease
   
   
2. reservoir or source of infection where the microorganism can live and thrive. This may be a person, an animal, any object in the general environment, food or water
   
   
3. portal of exit from the reservoir. This describes the way the microorganism leaves the reservoir. For example, in the case of a person with flu, this would include coughing and sneezing. In the case of someone with gastroenteritis microorganisms would be transmitted in the faeces or vomit
   
   
4. mode of transmission. This describes how microorganisms are transmitted from one person or place to another. This could be via someone’s hands, on an object, through the air or bodily fluid contact
   
   
5. portal of entry. This is how the infection enters another individual. This could be landing on a mucous membrane, being breathed in, entering via a wound, or a tube such as a catheter.
   
   
6. susceptible host. This describes the person who is vulnerable to infection.

Infection can be prevented by breaking the chain of infection.

Chain of infection diagram

The overall aim of Standard Infection Control Precautions (SICPs), is to break the chain of infection.

The chain of infection diagram illustrates and gives examples of actions that can be taken to break it.

Select image for full size version.

Use the NES SIPCEP Breaking the Chain of Infection module to learn about breaking the chain of infection in care homes. 

 

Hierarchy of controls 

Reducing risk

The hierarchy of controls (HoC) is a system used to help prevent the transmission of infection. It details the most to least effective controls.  You will note that PPE is the last level of control in the hierarchy, used when all other controls have not reduced the risks sufficiently. To be effective, PPE must be used correctly which means putting it on and removing it correctly and safely.

See the Health and Safety Executive’s (HSE) toolkit on managing risks and risk assessment at work. 

 

The HoC principles can be broadly interpreted for care home settings and include:

• reducing hazards in the care home
• changing practice in the care home
• making the care home as safe as possible
• changing how we organise and work in the care home
• use of PPE

Examples of HoC principles

Here are some examples of how to apply the HoC principles in care home settings. These examples do not cover every situation where you might need to use HoC principles.

Reducing hazards in the care home

Measures such as vaccination, testing and isolation help to reduce the risk of infection. Not coming to work when ill, isolating while infectious and recognising and reporting infections promptly, all help to prevent infections spreading.

Changing practice in the care home

When faced with a particular risk, such as an outbreak, we may need to change what we do. This might include reducing communal activities, considering limiting visiting for a short period of time, or cleaning the care home environment more frequently. The local IPCT and/or HPT should always be contacted for advice and support in outbreak situations.

Making the care home as safe as possible

It is very unlikely that we will be able to change where we work but the care home setting should be made as safe as possible.

You can reduce opportunities for pathogens to survive in the care home by ensuring fixtures and fittings are in good repair and can be easily cleaned and following water safety guidelines.

Ventilation is also an effective measure to reduce the risk of some respiratory infections, by diluting and dispersing the pathogens which cause them. Consider opening windows and vents more than usual, even opening a small amount can be beneficial. Opening windows and doors may present security and safety issues and so a local risk assessment should always be undertaken.

Changing how we organise and work in the care home

Changing the way, we organise and work in the care home can also help reduce risk. This might include reducing the number of people in a space at any one time and minimising the movement of staff between different settings as well as using administrative controls.

Administrative controls include local risk assessments, staff training, IPC audits, and providing clear signage and instructions throughout the care home.

Chapter 1: Standard Infection Control Precautions (SICPs)

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 residents, staff and visitors in the care home.

SICPs should be part of everyday practice and applied consistently by everyone in the care home. 

It is essential that optimal IPC measures are applied continuously as residents living in care homes are more vulnerable, therefore increasing their risk of acquiring infections which may then be serious and potentially life threatening. By applying optimum IPC precautions you will provide a safe environment and effective care. 

There are 10 Standard Infection Control Precautions (SICPs)

1. resident placement/assessment for infection risk
2. hand hygiene
3. respiratory and cough hygiene
4. personal protective equipment
5. safe management of care equipment
6. safe management of care environment
7. safe management of linen
8. safe management of blood and body fluid spillage
9. safe disposal of waste
10. occupational safety: prevention and exposure management (including sharps)

1. Resident placement/assessment for infection risk

For residents being discharged from hospital to a care home/hospice the Public Health Scotland COVID-19 information and guidance for social, community and residential care settings should be followed.

Before a resident is admitted to the care home it is important to risk assess for infection as part of resident’s care plan, an IPC admission assessment should be undertaken by staff.

If you suspect or are aware that a resident has an infection, then details should be confirmed for the correct IPC precautions to be put in place for the safety of the resident and others.

Obtaining infection details may include appropriate clinical samples and/or screening to establish the causative organism which may be on advice from your local GP, IPCT or HPT.

Residents who may present a cross-infection risk include those with:

• diarrhoea
• vomiting, being sick
• unexplained rash
• fever or temperature of 37.8 C or higher
• respiratory symptoms such as coughing and sneezing
• known to have been previously positive with a Multi-drug Resistant Organisms (MDRO), for example Meticillin Resistant Staphylococcus aureus (MRSA), Carbapenemase Producing Enterobacterales (CPE)

Further information regarding general respiratory screening questions can be found within the resources section of the NIPCM.

 

Note: If a resident requires isolation because of infection or in an outbreak situation, this should be individually risk assessed to ensure the safety and health and wellbeing needs of the resident. Isolation periods must be monitored on daily basis and be for the minimum period specified.

 

Resources 

 

Appendix 11 of the NIPCM gives you further information on the precautions required for different infections. 

 

 

Read the placement literature review to understand the evidence base for resident placement.

 

 

2. Hand hygiene

Please note that the term ‘alcohol-based hand rub (ABHR)’ has now been updated to ‘hand rub’.  A hand rub (alcohol or non-alcohol based) can be used if it meets the required standards. Please see further information in the hand hygiene products literature review.

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.

Adherence with the following points is essential to ensure effective hand hygiene: 

• expose forearms (known as bare below the elbows)
• remove all hand/wrist jewellery including any embedded jewellery (a single, plain metal finger ring or ring dosimeter (radiation ring) is permitted but should be removed (or manipulated) during hand hygiene). Bracelets or bangles such as the Kara which are worn for religious reasons should be able to be pushed higher up the arm and secured in place to enable effective hand hygiene which includes the wrists
• ensure fingernails are clean, short and that artificial nails or nail products are not worn
• cover all cuts or abrasions with a waterproof dressing

Hand washing should be extended to the forearms if there has been exposure of forearms to blood and/or body fluids.

Hand washing sinks should only be used for hand hygiene and should not be used for the disposal of other liquids.  

To perform hand hygiene:

• hand rub should be available for staff as near to point of resident care as possible. Where this is not practical, personal hand rub dispensers should be used
• application of sufficient volume of hand rub to cover all surfaces of the hands is important to ensure effective hand hygiene
• manufacturer’s instructions should be followed for the volume of hand rub required to provide adequate coverage for the hands. In the absence of manufacturer’s instructions, volumes of approximately 3ml are recommended to ensure full coverage
• wall mounted or personal hand rub dispensers (cartridges/bottles) should not be refilled and should be replaced when empty or if outwith manufacturer expiry date 

The World Health Organization’s ‘4 moments for hand hygiene’ should be used to highlight the key indications for hand hygiene:

1. before touching a resident
2. before clean/aseptic procedures. If hand rub cannot be used, then antimicrobial liquid soap should be used
3. after body fluid exposure risk
4. after touching a resident

Some additional examples of hand hygiene moments include, but are not limited to:

• after touching a resident’s immediate surroundings
• before handling medication
• before preparing food
• before donning (putting on) and after doffing (taking off) PPE
• after visiting the toilet
• before putting on and after removing PPE
• between carrying out different care activities on the same resident
• after cleaning and disinfection procedures
• after handling used linen
• after handling waste

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.

 

 

 

 

 

Hands should be washed with liquid soap and water if/when:

• they are visibly soiled or dirty
• they are potentially contaminated with blood, other body fluids or excretions
• caring for a resident with vomiting or diarrhoeal illness
• caring for a resident with a suspected or known gastro-intestinal infection such as norovirus or a spore forming organism such as  Clostridioides difficile 

 

Note:

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.

The use of antimicrobial hand wipes is only permitted where there is no access to running water. Staff should perform hand hygiene using hand rub immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.

In all other circumstances use hand rub for routine hand hygiene. 

Skin care

• Hand rubs should contain emollients in their formulation.
• Pat hands dry after hand washing using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.
• Use an emollient hand cream during breaks and when off duty. These should be applied all over the hands including between the fingers and the back of the hands.
• Staff with skin problems should seek advice from the local occupational health department if available or their GP.
• Barrier creams should not be used in the workplace.

Do not use refillable containers or communal tubs of hand cream in the care home setting.

 

Resources

 

Read the hand hygiene literature reviews to find out more about the evidence base for hand hygiene.

 

To make sure you clean your hands properly with soap and water you should 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

 

 

To make sure you clean your hands properly with hand rub you should 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

 

3. Respiratory and cough hygiene

Infections can spread by coughing and sneezing, therefore it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.

Any resident displaying symptoms of respiratory illness should be encouraged to wear a surgical (for instance TYPE IIR FRSM) face mask where it is clinically safe and can be tolerated by the wearer, especially in communal areas.

 

What you need for respiratory and cough hygiene• disposable tissues• waste bin and waste bags• hand hygiene products

If a resident has a cough, cold or other respiratory symptoms then they should be supported and encouraged to:

• cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and/or blowing the nose.  If a disposable tissue is not available encourage the use of elbow/sleeve to cover the nose and mouth when coughing or sneezing
• put used tissues and face masks 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 contaminated hands away from the eyes nose and mouth

 

Staff should:

• promote respiratory and cough hygiene and help residents who need assistance
• ensure that residents are provided with the necessary products for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that products are in close vicinity for the resident to access 
• use hand wipes followed by hand rub if there is no running water available or if hand hygiene facilities are out of reach then wash 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.

 

 

4. Personal Protective Equipment (PPE)

 

 

PPE products you might need in the care home:• gloves• aprons• masks• eye protection

See PPE for visitors

Deciding which PPE to use

Before doing any procedure or task staff should risk 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:

• 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, this means healthcare waste or domestic waste

Reusable PPE items, for example non-disposable goggles, face shields and visors, should have a decontamination schedule with responsibility assigned.

Read further information on best practice for PPE in Appendix 15.

 

Donning (putting on) personal protective equipment (PPE) 

The order for putting on PPE is:

1. apron or gown
2. surgical mask
3. eye protection (where required)
4. gloves

Doffing (taking off) personal protective equipment (PPE) 

It is important that PPE is removed in the correct order.

The order for taking off PPE is:

1. gloves
2. apron or gown
3. eye protection (if worn)
4. surgical mask

Note:

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

Resources

A video demonstrating the order for donning and doffing PPE is available. 

The correct order for donning, doffing and disposal of PPE for healthcare workers from NHS National Services Scotland on Vimeo.

 

A poster showing the order for putting on and removing PPE is available to print.

 

Select image for full size version

Gloves

Gloves should be:

• worn when it is likely or anticipated that you will be exposed to blood,  body fluids (including but not limited to secretions and/or excretions), non-intact skin, mucous membranes, lesions and/or vesicles, hazardous drugs, and chemicals for example cleaning agents
• single-use and should be donned (put on) immediately prior to exposure risk and should be doffed (taken off) immediately after each use or upon completion of a task
• appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct gloves
• changed if damaged or a perforation or puncture is suspected

 

Note:

Using gloves reduces the risk of contamination but does not remove all risk.

Gloves should not be used instead of carrying out hand hygiene.

Gloves should not be worn inappropriately in situations such as to go between residents, move around a care area or whilst at workstations (on the telephone  or computer).

Gloves should never be decontaminated or cleaned with hand rub 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

Aprons and gowns

Aprons should be:

• worn by care staff when there is a risk of clothing being contaminated with blood or other body fluids
• worn during direct care, for example oral hygiene, bed-making or when undertaking the decontamination of equipment
• changed between residents and following completion of a procedure or task

The choice of apron or gown is based on an individual risk assessment and anticipated level of blood/body fluid exposure. Routine sessional use of gowns/aprons is not permitted.

Eye/face protection

Eye/face protection (including full face visors) should:

• be worn if blood and/or body fluid contamination to the eyes/face is expected/likely and always during aerosol generating procedures (AGPs)

Note:

Eye/face protection (including visors) should not be touched when worn.

Facial accessories such as piercings or false eyelashes should not be worn when using eye/face protection.

Regular glasses or safety glasses are not considered eye protection.

Fluid Resistant Type IIR surgical face masks (FRSM)

Fluid Resistant Type IIR surgical face masks should be:

• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/likely. (As part of SICPs a full-face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray)
• well-fitting, fully covering the mouth and nose and fit for purpose. Manufacturer’s instructions should be followed to ensure effective fit/protection
• removed or changed:
  • at the end of a procedure/task
  • if the mask is damaged or there is a build up from moisture after prolonged use or from gross contamination with blood or body fluids 
  • following specific manufacturers’ instructions

If you are using droplet precautions, you should always wear a Type IIR surgical face mask as well as the full-face visor (droplet precautions will be discussed further in Chapter 2 Transmission Based Precautions).

Transparent face masks

Transparent face masks may be used to aid communication with residents where required.

Transparent face masks should:

• meet the specification standards of the Transparent face mask technical specification 

and

• have been approved for use within health and social care settings
• only be worn in areas where Fluid Resistant Type IIR surgical face masks are used as personal protective equipment

Resources

Read the aerosol generating procedures literature review and surgical face masks literature review for further information regarding the evidence base.

 

 

See appendix 11 for further information.

 

PPE for visitors 

At times, 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 visitor should not be refused entry to the care home. PPE use by visitors cannot 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 residents they are visiting. 

Table 1 is a guide to PPE for use by visitors if delivering direct care.

Table 1: PPE for use by visitors

IPC Precaution	Gloves	Apron/Gown	Face covering/mask	Eye/face protection
Standard Infection Control Precautions (SICPs)	Not required unless providing direct care which may expose the visitor to blood and/or body fluids, for instance toileting.	Not required unless providing care resulting in direct contact with the resident, their environment or blood and/or body fluid exposure, for instance toileting, bed bath.	Where splash/spray to nose/mouth is anticipated during direct care	Not required unless providing direct care and splashing/spraying is anticipated.
Transmission Based Precautions (TBPs)	Not required unless providing direct care which may expose the visitor to blood and/or body fluids, for instance toileting.	Not required unless providing care resulting in direct contact with the resident, their environment or blood and/or body fluid exposure, for instance toileting, bed bath.	If within 2 metres of resident with suspected or known respiratory infection	If within 2 metres of resident with suspected or known respiratory infection

Read the PPE literature reviews to find out more information about the evidence base for PPE use.

 

5. Safe management of care equipment

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

Important words and what they meanRoutine cleaning is regular cleaning which is carried out on a scheduled basis, not on an unplanned basis and not in response to an outbreak. For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.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.

 

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.

Note:

Do not use household bleach as the required dilution cannot be guaranteed.

Do not refill bottles for cleaning products as there is a risk of contamination. 

What you need for safe management of care equipment

• Cleaning/disinfectant products:
  • general purpose detergent and water solution/detergent impregnated wipes

or

• • 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.
• Paper towels/disposable cloths.

Types of equipment

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 should 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:

• the packaging is intact
• there are no obvious signs of packaging contamination
• the expiry date remains valid

 

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.

Note:

Needles and syringes are single-use devices. They should 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 for example a sling 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 for example commode, moving and handling equipment or bath hoist.

Cleaning or decontaminating reusable non-invasive equipment

Residents should be given their own reusable (communal) non-invasive equipment where 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. 

Pillows used on resident’s beds may not require a waterproof cover if they are single resident use and are subject to regular checks/laundering. Resident pillows may require labelling where appropriate.

Reusable equipment should be cleaned or decontaminated:  

• between individual use
• after blood and/or body fluid contamination
• as part of the regular scheduled cleaning schedules/process
• before inspection, servicing or repair

Staff should:

• 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

 

Note: When an organisation use products or adopts practices that differ from those stated in this manual, that individual organisation is responsible for ensuring safe systems of work including the completion of risk assessments approved through local governance procedures.

Resources

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

6 - Safe management of the care environment

There are many areas in care homes that become easily contaminated with microorganisms (germs) for example door handles, toilets, waste bins, surfaces.

Furniture and floorings in a poor state of repair can have microorganisms (germs) in hidden cracks or crevices.

To reduce the spread of infection, the environment should 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 as the residents are often elderly and vulnerable to infections.

The care home environment should be:

• 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:
  • a fresh solution of general purpose neutral detergent in warm water is recommended for routine cleaning. This should be changed when dirty or at 15 minutes’ intervals or when changing tasks
  • routine disinfection of the environment is not recommended. However, 1,000 parts per million available chlorine (ppm available chlorine (av.cl.) should be used routinely on sanitary fittings

Staff should:

• 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 should then act on problems reported to them
• be aware of the environmental cleaning schedules and clear on their specific responsibilities

Cleaning schedules should include:

• staff responsibilities 
• cleaning frequencies
• cleaning methods

Managing cleaning services

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 Care Homes Cleaning Specification for full size version of cleaning services diagram.

Select the diagram for full size version

Cleaning Services

An effective service will include all of the elements above.

Care Homes Cleaning Specification

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:

• a structure to identify all spaces within a care home and plan appropriate cleaning tasks and frequencies
• a set of weekly and monthly cleaning templates to be assigned to each space within a care home. These can be used to develop a schedule and to provide a method for recording all cleaning activity

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.

Manufacturer’s instructions and recommended contact times should be adhered to.

Cleaning schedule and record

Table 2 provides an example of a cleaning schedule and record. These tools are examples and designed to support local practice, however care homes can use their own tools if preferred. If a local tool is used, it should reflect the standards set out in the Care Homes Cleaning Specification.

Table 2: Example cleaning schedule residents room

 

Standard operating procedures (SOPs) for all cleaning tasks.

Each SOP outlines the correct equipment, safety considerations, method, and outcomes required for each task. Table 3 shows the important steps that must be taken during the cleaning of floors.

Table 3: Example cleaning SOP: Floors

Process for checking

A process for checking the cleanliness of the care environment, to ensure standards are being maintained and to identify areas for improvement.

Decontamination of soft furnishings

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. 

 

Note: When an organisation adopts decontamination processes not recommended in the CH IPCM the care organisation is responsible for governance of and completion of local risk assessment(s) to ensure safe systems of work.

 

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.

 

 

7 - Safe management of linen

Examples of linen you may have in the care home includes:

• bed linen (bed sheets, duvet, duvet covers, pillowcases)
• blankets
• curtains
• hoist slings
• towels
• resident clothing 

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 for example 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 and therefore, cannot be subject to thermal disinfection. 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. Appropriate temperatures for processing all used and infectious linen should be adhered to achieve thermal disinfection.

Clean linen

• 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.

Used linen

Staff should: 

• refer to Appendix 15 for decision making regarding PPE use
• make sure that a laundry trolley or container is available as close as possible to the point of use for immediate linen deposit

Staff should 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 tabletop
• re-handle used linen once bagged
• overfill laundry receptacles or trolleys
• place inappropriate items in the laundry receptacle for example used equipment/needles.

Infectious linen

Staff should:

• 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

If using external laundry services both used and infectious linen bags/receptacles should follow local procedure and arrangements. Store all used/infectious linen in a designated, safe, lockable area whilst awaiting uplift. 

All linen that is deemed unfit for re-use, for example torn or heavily contaminated, should be categorised at the point of use and disposed of in the appropriate local healthcare waste stream.

Washing residents personal linen

Appendix 1 National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution contains information that is particularly relevant and may be useful for residential care settings where domestic-type (household) washing machines may be in place for laundering resident’s personal items and clothing.

Domestic-type washing machines are not typically programmed with the temperature settings required for thermal disinfection, therefore domestic-type machines may only be used for laundering personal items of clothing belonging to residents, such as those that are heat-labile.

Other types of used linen such as sheets should be reprocessed using a machine that is capable of a validated temperature disinfection stage.

If using a domestic type washing machine to launder resident’s personal items:

• 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.

It is considered best practise to launder a resident’s personal items separately, that means not to mix items from multiple persons within a single load.

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.

 

 

8 - Blood and body fluid spillages

Spillages of blood and other body fluids may transmit blood borne viruses.

Important words and what they meanA 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.

 

Blood and body fluid spillages must be decontaminated:

• 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.

Resources

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

 

9 - Safe disposal of waste (including sharps)

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 should be colour coded to denote the various categories of waste.

Local procedures and policies on waste disposal should be followed.

Segregation (separating) of waste

• Healthcare (including clinical) waste is produced as a direct result of healthcare activities for example soiled dressings, sharps
• Special (hazardous) waste arises from the delivery of healthcare in both clinical and non-clinical settings. Special waste includes a range of controlled wastes, defined by legislation, which contain dangerous or hazardous substances for example chemicals and pharmaceuticals
• Domestic waste – must be segregated at source into:
  • Dry materials that can be recycled (glass, paper and plastics, metals, cardboard)
  • Residual waste (any other domestic waste that cannot be recycled)

Care home waste disposal may differ from categories described and guidance from local contractors may apply.

Safe management of waste

Care home managers and staff should ensure:

• all waste is correctly segregated according to local regulations
• 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 designated, safe, lockable area whilst awaiting uplift. Uplift schedules should be acceptable to the care area and there should be no build-up of waste receptacles
• there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed

All staff should:

• follow local schedules 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
  • a ‘swan neck’ is a way of closing bag by tying in a loop and securing with a zip tie or tape to make a handle
• 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.

 

 

10. Occupational Safety: Prevention and Exposure Management (including sharps)

All care homes should have policies in place to ensure that staff are protected from occupational exposure to microorganisms (germs), particularly those that may be found in blood and body fluids.

 

 

 

 

 

 

Important words and what they meanOccupational exposure is exposure of 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:

• arrangements for the safe use and disposal of sharps
• provision of information and training to employees
• investigations and actions required in response to work related sharps injuries

Safe management of sharps in the care home

Sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices.

Sharps safety

• Always dispose of needles and syringes as a single unit immediately at the point of use.
• Always assemble and label sharps containers correctly as per manufacturers instructions.
• Always use the temporary closure mechanisms on sharps containers in between use.
• Always follow manufacturers’ instructions for safe use and disposal.

 

• Never re-sheath used needles or lancets.
• Never store sharps containers on the floor.
• Never allow access of sharps containers to residents or the public.
• Never fill sharps containers more than three-quarters full.

Significant occupational exposure

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:

• a percutaneous injury for example injuries from needles, instruments, bone fragments, or bites which break the skin
• exposure of broken skin for example abrasions, cuts, eczema
• exposure of mucous membranes including the eye from splashing of blood or other high risk body fluids

If you think or know you have had a significant occupational exposure you should:

• 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

Resources

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

Transmission-based precautions (TBPs) definitions literature review update

Why are transmission descriptors (contact, droplet, airborne) being reviewed?

The pandemic highlighted that the way in which respiratory transmission is currently described (droplet and airborne transmission) may not reflect what is happening in real life and so, there is a need to identify alternatives ways to  describe respiratory transmission routes. 

Understanding how infectious agents are released into the air and the risks associated with particle size and distance from source will help inform this. Reviewing the evidence to understand if there is increased risk associated with certain medical procedures will also inform IPC practice.

The World Health Organization (WHO) and Centers for Disease Control (CDC) have also reviewed transmission descriptors indicating a global shift in the way transmission routes are described. ARHAI Scotland were invited to meet with the WHO global IPC unit to discuss the topic and our literature review findings were well received.

What is likely to change in the CHIPCM?

ARHAI are currently developing recommendations for practice. It is likely that ‘droplet transmission’ and ‘airborne transmission’ will be replaced with new definitions to describe respiratory transmission. This will mean changes throughout the CHIPCM to update the terminology including the addition of resources to support any guidance changes.

What might this mean for care home staff in practice?

It is too early to understand what might change in practice, but it is likely that there will be a need for care home staff to consider more factors when risk assessing what PPE to wear.

The goal of the CHIPCM is to provide care home staff in Scotland with guidance that is evidence based, up-to-date, effective, practical, and as a result, safe. 

Update announcements

Use of the CHIPCM online is always advised to ensure access to up to date guidance. Updates to the CHIPCM content are communicated to stakeholders via the Care Home IPC Oversight and Advisory Group in addition to the news section of the NIPCM.

For further detail please use this link to the Transmission Based Precautions Definitions Literature Review.

 

Transmission based precautions (TBPs)

In certain circumstances 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.

Clinical judgement and decisions should be made by staff to determine the necessary IPC precautions required (the local IPCT and/or the HPT should be contacted for advice and support where required).

Clinical judgement and decisions should be based on the:

• suspected or known infectious agent
• transmission route of the infectious agent
• care setting and procedures undertaken
• severity of the illness caused

When TBPs should be used

TBPs should be used if a resident has a suspected or known infection or colonisation.  

Important words and what they meanColonisation is 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.

Infection transmission routes

Infections can be transmitted or spread by:

• contact with microorganisms (germs) on hands or from contaminated equipment or environment
• droplet infection by inhaling infectious droplets, for example flu or COVID-19
• aerosol infection which are inhaled or directly contaminate a mucosal surface or conjunctivae (eyes, nose, and mouth)

Different transmission routes need different TBPs

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 resident placement, isolation requirements and any respiratory precautions required. Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

• 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. This is the most common route of cross-infection transmission.
• 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.

Different infections need different TBPs

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 IPCT or HPT for further advice if required. 

Before using transmission based precautions you need to find out:

• 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 required procedures?

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:

• their GP 
• local health protection team
• local infection prevention and control team
• laboratory
• hospital or care homes staff from where the resident has been discharged or transferred

Local processes should be followed when obtaining this information.

 

Further information on transmission based precautions can be found in the definitions of Transmission Based Precautions literature review.

 

 

1. Resident placement/assessment for infection risk

All residents require to be regularly monitored for infection throughout their stay for the correct IPC precautions to be put in place to minimise the risk of infection being spread. 

Residents may be an infection risk if they have:

• diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms
• a known (laboratory confirmed) or suspected infectious pathogen for which appropriate duration of precautions as outlined in A-Z of pathogens  are not yet complete
• been previously positive with a Multi-drug Resistant Organism (MDRO) for example Meticillin-resistant Staphylococcus aureus (MRSA); Carbapenemase Producing Enterobacterales (CPE)*

*CPE should be considered if the resident meets any of the following criteria within the 12-month period before admission:

• been an inpatient in a hospital outside of Scotland
• received holiday dialysis outside of Scotland
• been a close contact of a person who has been colonised or infected with CPE.

See the CPE toolkit for non-acute settings for further information and requirements. 

 

Staff should do the following if any resident displays signs and/or symptoms of infection:

• obtain advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either the local HPT or IPCT
• make resident placement decisions based on advice received or sound judgement by clinical staff who are involved in the resident’s management
• advise the ambulance service of the resident’s infectious condition if transport to hospital is required

Residents should not be moved within the care home if they have signs and symptoms of infection unless essential.

Resident isolation requirements within the care home

Residents may require to be isolated in their own room because of a known or suspected infection. During this time it is important that: 

• residents remain in their rooms whilst considered infectious and the door should remain closed. If it is not possible for safety reasons, for example the resident has dementia, an individual risk assessment should be done and any decisions or actions should be documented. The local HPT or IPCT should be contacted for advice
• suitable discrete signage is placed on the door advising others not to enter the room
• there should be as much consistency in staff allocation as possible to care for residents in isolation room areas as an additional IPC measure. This is known as ‘staff cohorting’
• resident isolation requirements should remain under continuous review considering individual risk factors and the impact on the resident. The local HPT or IPCT should be contacted for advice in these circumstances

Note: If a resident requires isolation because of infection or in an outbreak situation, this should be individually risk assessed to ensure the safety and health and wellbeing needs of the resident. Isolation periods must be monitored on daily basis and be for the minimum period specified.

 

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.

 

 

2. Safe management of care equipment in an isolation room

Cleaning and decontamination 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 staff should:

• use single use or dedicated reusable care equipment, for example commodes, for the resident in isolation where possible
• clean and decontaminate all care equipment after each use as per Appendix 7

 

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.

 

3 - Safe management of the care environment

Isolation room cleaning

Staff should:

• clean and decontaminate the isolation room at least daily or more frequently if advised to do so. If you have been advised to clean more than daily this should be documented in the environmental cleaning schedule
• clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily
• use correct cleaning products which are either:

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 refill spray containers for cleaning products as there is a risk of contamination. 

Terminal clean

A terminal clean is carried out when the resident is no longer considered infectious and/or when the environment is cleaned/decontaminated to ensure it is safe for a new resident.

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 (prior to removal from the room)

The room should then be decontaminated using either:

• a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.) or
• a general purpose neutral detergent clean in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

The room should be cleaned from the highest to lowest point and from the least to most contaminated point.

Manufacturers’ guidance and recommended product "contact time" should be followed for all cleaning/disinfection solutions.

 

Appendix 7 is a poster flowchart for decontamination of reusable non-invasive care equipment that you may wish to print off and place in the care home.

 

Note: When an organisation use products or adopts practices that differ from those stated in this manual, that individual organisation is responsible for ensuring safe systems of work including the completion of risk assessments approved through local governance procedures.

 

4. Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)

In addition to PPE used for Standard Infection Control Precautions, appendix 15 of the NIPCM outlines what type of PPE and RPE you will need to wear for infections spread by different transmission routes.

AGPs

Gloves

Gloves are a single-use item and should be donned immediately prior to exposure risk and should be doffed immediately after each use or upon completion of a task.

Gloves should:

• be worn when exposure to blood, body fluids, (including but not limited to secretions and/or excretions), non-intact skin, lesions and/or vesicles, mucous membranes, hazardous drugs, and chemicals for example cleaning agents, is anticipated/likely
• never be worn inappropriately in situations such as to go between residents, move around a care area, work at IT workstations
• be changed if a perforation or puncture is suspected or identified
• be appropriate for use, fit for purpose and well-fitting
• not be worn as a substitute to hand hygiene
• never be decontaminated with ABHR

Resources

For appropriate glove use and selection see the flowchart poster which may be printed off and placed in the care home.

 

Further information can be found in the Gloves literature review.

 

 

Aprons/gowns

An apron should be worn when caring for residents known or suspected to be colonised/infected with antibiotic resistant bacteria including contact with the resident’s environment.

Plastic aprons should be used in care home 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 residents known or suspected to be infected with a respiratory infectious agent.

Further information can be found in the Aprons/Gowns literature review.

 

Eye/face protection

A face visor or goggles should be used in combination with a fluid resistant Type IIR surgical mask when caring for symptomatic residents 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 residents infected with an airborne transmitted infectious agent.

Eye/face protection should be worn:

• by all of those in the room if potentially infectious AGPs are conducted
• for the care of residents with novel infectious agents including pandemic influenza

 

Read Appendix 11 for details of the type of precautions, optimal resident placement, isolation requirements and any respiratory precautions required.

 

Surgical masks

A Type IIR fluid resistant surgical mask (FRSM) should be worn when caring for a resident with a suspected/confirmed infectious agent spread by the droplet route.

FRSMs should be worn (where tolerated) by residents with suspected/confirmed infectious agents spread by the droplet or airborne routes, as a form of source control and should meet type II or IIR standards.

Read Appendix 11 for details of the type of precautions, optimal resident placement, isolation requirements and any respiratory precautions required.

 

Respiratory Protective Equipment (RPE)

PPE should still be used in accordance with SICPs when using respiratory protective equipment (RPE). See Chapter 1.4 for PPE use for SICPs. 

The use of FFP3s is governed by health and safety regulations and they must be fit tested to the user to ensure the required protection is provided.

The Health and Safety Executive (HSE) provides information regarding fitting and fit checking of RPE.

Respiratory Protective Equipment (RPE), for instance FFP3 and facial protection, should be considered when:

• a resident is admitted or develops a known/suspected infectious agent/disease spread wholly by the airborne route
• carrying out AGPs on residents with known/suspected infectious agent spread wholly or partly by the airborne or droplet route

FFP3 respirators

It is an HSE requirement that staff who need to wear an FFP3 respirator must be fit tested.

FFP3 respirators should not be worn by staff who are not trained in their use or who have not been fit tested.

All FFP3 respirators must be:

• fit tested (by a competent fit test operator) on all staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance
• fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved
• single-use (disposable) and fluid resistant
• compatible with other facial protection used such as protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection
• put on before entry into the resident’s room and removed in a safe area once outside the resident’s room
• changed after each use

Signs that a change in respirator is required include:

• breathing becomes difficult
• the respirator is wet or moist
• the respirator is damaged
• the respirator is obviously contaminated with body fluids such as respiratory secretions

Resources

A poster containing information 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 from the Health and Safety Executive

 

Aerosol Generating Procedure (AGP)

An AGP is a medical procedure that can result in the release of airborne particles from the respiratory tract and is associated with an increased risk of transmission 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) or tracheostomy procedures (insertion or removal) and open suctioning beyond the oro-pharynx. 

The full list of medical procedures that have reported to be aerosol generating and are associated with an increased risk of respiratory transmission can be found in appendix 16.

A poster is also available on PPE when undertaking AGPs within health and social care settings.

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 mechanical ventilation 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, meaning no mechanical ventilation.  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. 

Rooms should always be decontaminated following the completion of an AGP. Regardless of the number of air changes, a period of 10 minutes should pass to allow larger droplets to settle before the room can be cleaned. Staff are required to wear the appropriate PPE until the fallow time has been met.

Resources

For further information on fallow times refer to Table 1 in  Appendix 16.

 

Further information can be found in the literature reviews aerosol generating procedures, Respiratory Protective Equipment (RPE), Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) 

 

Post AGP fallow time (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted. This is referred to as 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 appendix 16. 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, should 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 should pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff should 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.

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.

 

Use of FFP3 respirators

• Where staff have concerns, 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.

5. Infection prevention and control during care of the deceased

If a resident dies when in the care home SICPs and TBPs should 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 see Appendix 12 - Application of infection prevention precautions in the deceased for guidance on the precautions 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.

Care home appendices

These appendices from the NIPCM can be used in care homes.

Appendix 1 - How to hand wash

Appendix 2 - How to hand rub

Appendix 5 - Glove use and selection

Appendix 6 - Putting on and removing PPE

Appendix 7 - Decontamination of reusable care equipment 

Appendix 8 - Management of linen at care level 

Appendix 9 - Management of blood and body fluid spillages 

Appendix 10 - Management of occupational exposure incidents

Appendix 11 - Aide memoire for patient placement considerations and respiratory protective equipment (RPE) or fluid resistant surgical facemasks (FRSMs) for infectious agents

Appendix 12 - Application of infection control precautions in the deceased

Appendix 15 - Selection of personal protective equipment (PPE) by health and care workers (HCWs) during the provision of care 

Appendix 17 - Hierarchy of controls 

 

Care home resources

The resources section can be used as supporting tools for the Care Home Infection Prevention and Control Manual (CH IPCM).

• Aerosol Generating Procedures
  • Poster on PPE to wear when undertaking aerosol generating procedures 
• Care Home Infection Prevention and Control Resource Toolkit 
• HAI Compendium
• Hand hygiene
  • How to hand rub
  • How to hand wash 
  • 4 moments for hand hygiene
  • Washroom poster 
  • Information leaflet for the public
• Gastro-intestinal illness
  • Care home IPC resource for gastro-intestinal illness
• Information leaflets. 
  These leaflets are also available in different languages National Infection Prevention and Control Manual: Information Leaflets - language translations (scot.nhs.uk)
  • Clostridiodes difficile (CDI) - Information for people who are getting care, their visitors, and anyone else who is in a care setting
  • Group A Streptoccocal infection - information for patients
  • Healthcare associated infection (HAI) - Information for the public
  • Vancomycin-resistant enterococci VRE - Information for patients
  • Washing clothes at home - Information for people in
    hospitals or care homes and their relatives
• Respiratory hygiene
  • Catch it, bin it, kill it poster 
• Respiratory illness
  • Care home IPC resource for respiratory illness
• Scabies: Back to Basics Presentation - 23 October 2024 
• Transmission Based Precautions
  • Airborne precautions poster
  • Contact precautions poster
  • Droplet precautions poster 
• World Hand Hygiene Day 5 May 2024 - Sharing your knowledge about hand hygiene  

 

How to contact us

If you have any questions or feedback about the Care Home IPCM then you can contact us by email or telephone.

Email

Telephone: 0141 300 1175