The requester asked Manx Care for clinical studies and data used to justify mask requirements in healthcare settings. The authority responded that the specific information was not held, instead providing a link to UK-wide infection prevention and control guidance.
Key Facts
The request was made to Manx Care on 2021-09-14.
The outcome was 'Information not held' as of 2021-10-11.
The response included a link to UK Health Security Agency guidance on infection prevention and control.
The guidance states that no changes to PPE recommendations were made following a review of new variant strains.
Organisations adopting practices differing from national guidance are responsible for their own risk assessments.
Data Disclosed
2021-09-14
2021-10-11
11/10/2021, 15:27
29 September 2021
1974
72 pages
3 documents
Original Request
Dear Sir,
I would like the department to provide all emails, content of and data on the exact
clinical studies used by the department for the continued requirement for masks in
healthcare settings.
Data Tables (68)
GOV.UK
Menu
Coronavirus (COVID-19) (/coronavirus)
Guidance and support
1. Home (https://www.gov.uk/)
2. Coronavirus (COVID-19) (https://www.gov.uk/coronavirus-taxon)
3. Healthcare workers, carers and care settings during coronavirus
(https://www.gov.uk/coronavirus-taxon/healthcare-workers-carers-and-care-settings)
4. COVID-19: infection prevention and control (IPC)
(https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-
and-control)
UK Health
Security
Agency (https://www.gov.uk/government/organisations/uk-health-security-agency)
Guidance
COVID-19: guidance for
maintaining services within
health and care settings –
infection prevention and control
recommendations
Updated 29 September 2021
Contents
1. Main messages and explanation of updates
2. Introduction
3. Governance and responsibilities
4. COVID-19 care pathways
5. Standard infection prevention control precautions (SICPs) - all pathways or settings
6. Aerosol generating procedures – procedures that create a higher risk of respiratory infection
transmission
7. Low risk pathway – key principles
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8. Transmission based precautions (TBPs)
9. Medium risk pathway – key principles
10. High risk pathway – key principles
11. Occupational health and staff deployment
12. Glossary of terms
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1. Main messages and explanation of updates
1.1 About this guidance
This guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health
Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland
(HPS)/National Services Scotland, Public Health England (PHE) and NHS England as official
guidance.
Amendments have been made to strengthen existing messaging and provide further clarity where
needed, including updates on the hierarchy of controls, clarity over the use of valved respirators, and
highlighting the need to protect those previously shielding and who are considered clinically
extremely vulnerable from coronavirus (COVID-19).
Following a clinical and scientific review, no changes to the recommendations, including personal
protective equipment (PPE), have been made in response to the new variant strains at this stage,
however this position will remain under constant review. Organisations who adopt practices that differ
from those recommended/stated in the national guidance are responsible for ensuring safe systems
of work, including the completion of a risk assessment approved through local governance
procedures.
All NHS organisations should ensure reliable application of all infection prevention and control (IPC)
recommendations and assurance on adherence, that PPE is available and in supply, and that all staff
training is up to date.
This guidance seeks to ensure a consistent and resilient UK wide approach, however some
differences in operational details and organisational responsibilities may apply in Northern Ireland,
England, Wales and Scotland.
Please note that this guidance is of a general nature and that an employer should consider the
specific conditions of each individual place of work and comply with all applicable legislation,
including the Health and Safety at Work etc. Act 1974
(https://www.legislation.gov.uk/ukpga/1974/37/contents).
The IPC principles in this document apply to all health and care settings including acute, diagnostics,
independent sector, mental health and learning disabilities, primary care, care homes, care at home,
maternity and paediatrics (this list is not exhaustive).
This guidance does not apply to adult social care settings in England. Adult social care providers in
England should refer to existing guidance (https://www.gov.uk/government/collections/coronavirus-covid-19-
social-care-guidance) already in place. DHSC/PHE will continuously review this guidance and update
as needed.
This IPC guidance will be updated in line with service need and as the evidence evolves. The
administrative measures outlined in the guidance are consistent with World Health Organization
(WHO) guidance (https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1).
1.2 Main messages
Local and national prevalence and incidence data will continue to guide services as advised by
country-specific/public health organisations. Identification of new variants of concern is inevitable and
on each new identification evidence for any change in transmissibility, mode of transmission, disease
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severity and any evidence of vaccine evasion will need to be considered as well as local incidence
and prevalence of any new variant of concern. It may be necessary to change the IPC measures
required on the basis of any new evidence.
For further information on the variants of concern:
Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and situation in
the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-sars-cov-2-
b1617-variants)
Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
20201201)
For further guidance on investigating and managing variants of concern:
Guidance for investigating and managing individuals with a possible or confirmed SARS-CoV-2
Variant of Concern or Variant Under Investigation (https://www.gov.uk/government/publications/sars-
cov-2-voc-investigating-and-managing-individuals-with-a-possible-or-confirmed-case/guidance-for-
investigating-and-managing-individuals-with-a-possible-or-confirmed-sars-cov-2-variant-of-concern)
This data will continue to be used to ensure patients/individuals’ treatment, care and support can be
managed in the 3 COVID-19 pathways, which remain as:
high risk - this includes patients/individuals who are confirmed COVID-19 positive by a SARS-
CoV-2 polymerase chain reaction (PCR) test or are symptomatic and suspected to have COVID-
19 (awaiting result)
medium risk - this includes patients/individuals who are waiting for their SARS-CoV-2 PCR test
result and who have no symptoms of COVID-19 and individuals who are asymptomatic with
COVID-19 contact/exposure identified
low risk - this includes patients/individuals who have been triaged/tested (negative)/clinically
assessed with no symptoms or known recent COVID-19 contact/exposure
To ensure maximum workplace risk mitigation, organisations should undertake local risk
assessments based on the measures as prioritised in the hierarchy of controls. If an unacceptable
risk of transmission remains following this risk assessment
(https://www.england.nhs.uk/coronavirus/publication/every-action-counts/), it may be necessary to consider
the extended use of respiratory protective equipment (RPE) for patient care in specific situations. The
risk assessment should include evaluation of the ventilation in the area, and prevalence of
infection/new variants of concern in the local area.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
Sessional use of single use PPE/RPE items continues to be minimised and only applies to extended
use of face masks (all pathways) or filtering face piece (FFP3) respirators (together with eye/face
protection) in the medium and high risk pathways for healthcare workers (HCWs) where airborne
precautions are indicated.
The use of face masks or face coverings across the UK remains as an IPC measure. In addition to
social distancing, hand hygiene for staff, patients/individuals and visitors is advised in both clinical
and non-clinical areas to further reduce the risk of transmission.
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Patients in all care areas should still be encouraged and supported to wear a face mask, providing it
is tolerated and is not detrimental to their medical or care needs.
Physical distancing of 2 metres remains in place as standard practice in all health and care settings,
unless providing clinical or personal care and wearing appropriate PPE.
Patients/individuals on a low-risk pathway require standard infection control precautions (SICPs) for
all care including surgery or procedures.
Triaging and SARS-CoV-2 testing must be undertaken for all patients either at point of admission or
as soon as possible/practical following admission across all the pathways.
The IPC measures recommended are underpinned by the National Infection Prevention and Control
Manual (NIPCM) practice guide and associated literature reviews (http://www.nipcm.hps.scot.nhs.uk/).
NHS England is using this an opportunity to introduce and adopt the NICPM as set out in the UK
Five-year Tackling Antimicrobial Resistance National Action Plan (2019 to 2024)
(https://www.gov.uk/government/publications/uk-5-year-action-plan-for-antimicrobial-resistance-2019-to-2024).
1.3 Explanation of the updates to IPC guidance
The guidance is issued jointly by DHSC, PHW, PHA Northern Ireland, HPS/National Services
Scotland, PHE and NHS England for health and care organisations as the UK moves to maintain
healthcare services. The content is consistent with the administrative measures outlined in WHO IPC
during healthcare when COVID-19 is suspected or confirmed: Interim Guidance, June 2020
(https://apps.who.int/iris/handle/10665/332879). In addition, the updates to this guidance are informed by
the paper produced for the Scientific Advisory Group for Emergencies Masks for healthcare workers
to mitigate airborne transmission of SARS-CoV-2 (23 April 2021)
(https://www.gov.uk/government/publications/emg-masks-for-healthcare-workers-to-mitigate-airborne-
transmission-of-sars-cov-2-25-march-2021).
Maintaining services continues to require ‘new ways’ of working during the ongoing pandemic.
Continual assessment of the available evidence/science and feedback from guidance users,
professional bodies and associations, has identified the amendments required to the guidance to
assist in supporting services in this ‘new and changing’ environment whilst COVID-19 remains a
threat. This is based upon emerging evidence, experience and expert opinion.
1.4 Main changes to the guidance
The main amendments to this version of the guidance are:
1. Inclusion of the hierarchy of controls as these apply to COVID-19, with definitions and
supporting materials for implementation. Also, where an unacceptable risk of transmission
remains following the hierarchy of controls risk assessment, it may be necessary to consider the
extended use of RPE for patient care in specific situations. The risk assessment should include
evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new
variants of concern in the local area.
2. Further advice on the use of valved respirators with examples of sterile procedures in the clinical
setting.
3. Further advice on minimising sessional or extended use of gowns where cohorts of confirmed
COVID-19 patients are managed and there is a lack of single rooms/isolation rooms.
4. Amendment to the aerosol generating procedure (AGP) list to state ‘upper gastro-intestinal
endoscopy where open suction of the upper respiratory tract occurs beyond the oro-pharynx’.
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5. Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example, priority for single room isolation.
. Introduction
.1 Scope and purpose
his document sets out the IPC advice for health and care organisations as the UK continues to
aintain healthcare services during the ongoing pandemic.
he IPC principles in this document apply to all health and care settings, including the
dependent/private sector, mental health and learning disabilities, primary care areas, care homes,
are at home, maternity and paediatrics (this list is not exhaustive, please refer to specific country
sources for setting specific guidance). It includes key IPC control recommendations and includes
sk assessed patient pathway scenarios to help guide the implementation of measures to provide
afe and effective care locally and is based on the best available evidence.
he challenge facing the NHS is to maintain healthcare services and manage NHS capacity whilst
roviding a safe and equitable service for staff, visitors and patients/individuals including those who
ay present with COVID-19, those who have recovered from COVID-19 and those with no history of
OVID-19, until public health strategies such as mass vaccination are complete.
aintaining services requires a continuous review of ways of working to respond to the pandemic
nd guidance for working in a changing environment requires continual and ongoing development
ased upon emerging evidence, experience and expert opinion.
hile this document seeks to ensure a consistent and resilient UK-wide approach, some differences
operational details and organisational responsibilities may apply, where current legislation,
uidance, for example, clinical definitions, already exists. Links can be accessed in the resources
elow.
his guidance does not apply to adult social care settings in England given existing guidance for
dult social care settings (https://www.gov.uk/government/collections/coronavirus-covid-19-social-care-
uidance) has already been provided and continues to be relevant. DHSC/PHE will continuously
view this guidance and update as needed.
his document does not provide links throughout the sections. Follow the country-specific resources,
r example visiting guidance, testing, discharge policies.
C COVID-19 resources for:
England can be found at Infection Prevention and Control supporting documentation
(https://www.england.nhs.uk/coronavirus/publication/infection-prevention-and-control-supporting-
documentation/) and coronavirus (COVID-19) (https://www.gov.uk/coronavirus)
Scotland can be found at COVID-19 compendium (https://hps.scot.nhs.uk/web-resources-
container/covid-19-compendium/) and Scottish COVID-19 Infection Prevention and Control
Addendum for Acute Settings (http://www.nipcm.hps.scot.nhs.uk/scottish-covid-19-infection-prevention-
and-control-addendum-for-acute-settings/)
Wales can be found at Health and social care professionals: coronavirus (https://gov.wales/health-
professionals-coronavirus)
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Northern Ireland can be found at Guidance for professionals and organisations
(https://www.publichealth.hscni.net/covid-19-coronavirus/guidance-professionals-and-organisations)
Further updates will be made to this document as new data/evidence emerges and as the COVID-19
alert levels change
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884352/slide
s_-_11_05_2020.pdf). This is a scale of 1 to 5 which the UK government uses to reflect the degree of
threat to the country from the current COVID-19 pandemic.
3. Governance and responsibilities
Organisations and employers including NHS Trusts, NHS Boards, Health and Social Care Trusts
(Northern Ireland), local authorities, and independent sector providers, through their Chief Executive
Officer (CEO) or equivalent, must ensure:
monitoring of IPC practices, as recommended in this guidance, and ensure that resources are in
place to implement and measure adherence to good IPC practice. This must include all care
areas and all staff (permanent, agency and external contractors)
testing and self-isolation strategies are in place with a local policy for the response if
transmission rates of COVID-19 increase
training in IPC measures is provided to all staff, including: the correct use of PPE including a
face fit test if wearing a FFP3, respirator, and the correct technique for putting on and removing
(donning/doffing) safely
risk assessment(s) is undertaken for any staff members in at risk or clinically extremely
vulnerable groups, including pregnant and Black, Asian and Minority Ethnic (BAME) staff.
Guidance on carrying out risk assessments can be found by following the links to the country
specific resources in section 2.1
patients/individuals at high risk/extremely high risk of severe illness are protected from COVID-
19. This must include consideration of families and carers accompanying patients/individuals for
treatments/procedures
health and care settings are COVID-19 secure workplaces as far as practical, that is, that any
workplace risk(s) are mitigated maximally for everyone. This may entail local risk assessments
based on the measures as prioritised in the hierarchy of controls in the context of managing
infectious agents and should be communicated to staff
Disclaimer:
When an organisation adopts practices that differ from those recommended/stated in this national
guidance, that individual organisation is responsible for ensuring safe systems of work, including the
completion of a risk assessment(s) approved through local governance procedures, for example
Integrated Care System level, Health Board.
4. COVID-19 care pathways
These pathways are specific to the COVID-19 pandemic and are examples of how organisations may
separate COVID-19 risks. It is important to note that these pathways do not necessarily define a
service to a particular pathway and should not impact the delivery and duration of care for the patient
or individual. Moving patients between pathways should be based on their infectious status (testing
required), clinical need, availability of services and this should be agreed locally. Implementation
strategies must be underpinned by patient/procedure risk assessment, appropriate testing regimens
(as per organisations or country specific) and epidemiological data. Additional information on specific
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settings can be found in: NICE (2020) COVID-19 rapid guideline: arranging planned care in hospitals
and diagnostic services (https://www.nice.org.uk/guidance/ng179/resources/covid19-rapid-guideline-
arranging-planned-care-in-hospitals-and-diagnostic-services-pdf-66141969613765).
Triaging and testing within all health and other care facilities must be undertaken to enable early
recognition of COVID-19 cases. See Appendix 1
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1021294/202
10118_COVID-19_Infection_prevention_control_Appendix_1_Sample_triage_tool.pdf) for an example of
triage questions. Triage should be undertaken by clinical staff who are trained and competent in the
application of the clinical case definition (https://www.gov.uk/government/publications/wuhan-novel-
coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-
cases-of-wuhan-novel-coronavirus-wn-cov-infection) prior to arrival at a care area, or as soon as possible
on arrival, and allocated to the appropriate pathway. This should include screening for other
infections/multi-drug resistant organisms, including as per national screening requirements.
Infection risk and IPC precautions, for example SICPs or transmission based precautions (TBPs)
must be communicated between care areas/pathways, including when discharge planning.
Patients with respiratory symptoms should be assessed in a segregated area, ideally a single room,
pending test result to define the causative organism.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
4.1 High risk COVID-19 pathway
Any care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown).
or
b) Confirmed SARS-CoV-2 PCR positive individuals are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case, who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments
GP surgeries/walk-in centres
facilities where confirmed or suspected/symptomatic COVID-19 individuals are cared for, for
example:
emergency admissions to inpatient areas (adult and children)
mental health
maternity
critical care units
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renal dialysis units
4.2 Medium risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and infectious status is unknown.
or
d) Asymptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments, GP surgeries and walk-in
centres
non-elective admissions
primary care facilities, for example general dental and general practice
facilities where individuals are cared for, for example:
inpatients (adult and children)
mental health
maternity
critical care units
outpatient departments including diagnostics and endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.3 Low risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test within 72 hours of treatment and, for planned admissions,
have self-isolated for the required period or from the test date.
or
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b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Examples of the patient (individual) groups/facilities within this pathway (this list is exhaustive):
planned/elective surgical procedures including day cases
oncology/chemotherapy patients and/or facilities
planned inpatient admissions (adult and children), mental health, maternity
outpatients including diagnostics/endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.4 Administration measures for the pathways
1. Establish separation of patient pathways and staff flow to minimise contact between pathways.
For example, this could include provision of separate entrances and exits (if available) or use of
one-way entrance and exit systems, clear signage and restricted access to communal areas:
care areas (for example, ward, clinic, GP practice, care home) may designate self-
contained area(s) or ward(s) for the treatment and care of patients/individuals at high,
medium and low risk of COVID-19. Temporal separation may be used in clinics/primary
care settings
as a minimum in smaller facilities or primary care outpatient settings physical or temporal
separation of patients/departments at high risk of COVID-19 from the rest of the
facility/patients
2. Ensure that hygiene facilities, IPC measures and messaging are available for all
patients/individuals, staff and visitors to minimise COVID-19 transmission such as:
hand hygiene facilities including instructional posters
good respiratory hygiene measures
maintaining physical distancing of 2 metres at all times (unless wearing PPE due to clinical
care or personal care as per pathways)
increasing frequent decontamination of equipment and environment
considering improving ventilation by opening windows (natural ventilation) if mechanical
ventilation is not available
clear advice on use of face coverings and face masks by patients/individuals, visitors and
by staff in non-patient facing areas - this will include:
use of face masks/coverings by all outpatients (if tolerated) and visitors when entering
a hospital, GP/dental surgery or other care settings
use of a surgical face mask (Type II or Type IIR) by all patients across all pathways, if
this can be tolerated and does not compromise their clinical care, such as when
receiving oxygen therapy. This will minimise the dispersal of respiratory secretions and
reduce environmental contamination
extended use of face masks by all staff in both clinical and non-clinical areas within the
healthcare or care setting
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where visitors are unable to wear face coverings due to physical or mental health
conditions or a disability, clinicians/person in charge should consider what other IPC
measures are in place, such as physical distancing and environmental cleaning, to
ensure sufficient access depending on the patient’s condition and the care pathway
3. Where possible and clinically appropriate remote consultations rather than face-to-face should
be offered to patients/individuals.
4. Ensure restricted access between pathways if possible (depending on size of the facility,
prevalence/incidence rates), by other patients/individuals, visitors or staff, including patient
transfer and in communal staff areas (changing rooms/restaurant). If the prevalence/incidence
rates decline this may not be necessary between pathways providing the IPC measures are
reliably maintained.
5. Ensure areas/wards are clearly signposted, using physical barriers as appropriate to ensure
patients/individuals and staff understand the different risk areas.
6. Ensure local standard operating procedures detail the measures to segregate equipment and
staff, including planning for emergency scenarios, as the prevalence/incidence of COVID-19
may increase or decrease until cessation of the pandemic.
7. Ensure a rapid and continued response through ongoing surveillance of rates of infection within
the local population and for hospital/organisation onset cases (staff and patients/individuals).
Positive cases identified after admission who fit the criteria for a healthcare associated infection
should trigger a case investigation. If 2 or more cases are linked in time and place, an outbreak
investigation should be conducted. Refer to country-specific definitions.
8. If the prevalence/incidence rate for COVID-19 is high, where possible, assign separate teams of
health and other care workers, including domestic staff, to care for individuals in isolation/cohort
rooms or areas/pathways. If a member of staff is required to move between
sites/hospitals/cohort areas due to the unique function of their role, all IPC measures including
physical distancing must be maintained.
9. Providers of planned services should be responsive to local and national prevalence/incidence
data on COVID-19 and adapt processes so that services can be stepped-up or down. This can
be assessed using the respective countries weekly COVID-19 surveillance report/SARS-CoV-2
positivity data on admission, and local capacity and resources.
10. Safe systems of work outlined in the hierarchy of controls
(https://www.cdc.gov/niosh/topics/hierarchy/default.html) including elimination, substitution,
engineering, administrative controls and PPE/RPE are an integral part of IPC measures.
Organisations should undertake risk assessments based on these measures, prioritised in the
hierarchy of controls in the context of managing infectious agents. If an unacceptable risk of
transmission remains following a risk assessment taking these controls into account, it may be
necessary to consider the extended use of RPE for patient care in specific situations. The risk
assessment should include evaluation of the ventilation in the area, operational capacity, and
prevalence of infection/new variants of concern in the local area.
Supporting tools for local risk assessment are available at NHS England Every Action Counts
Resources (https://www.england.nhs.uk/coronavirus/publication/every-action-counts/).
4.5 Community settings
Areas where triaging for COVID-19 is not possible, for example community pharmacies:
signage at entry points advising of the necessary precautions
staff should maintain 2 metres physical distance with customers/service users, using floor
markings, clear screens or wear surgical face masks (Type IIR) where this is not possible
patients/individuals with symptoms should be advised not to enter the premises
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Outpatient/primary/day care
outpatient, primary care and day care settings:
where possible and appropriate, services should utilise virtual consultation
if attending outpatients or diagnostics, service providers should consider timed appointments
and strategies such as asking patients/individuals to wait to be called to the waiting area with
minimum wait times
patients/individuals should not attend if they have symptoms of COVID-19 or are isolating as a
contact/exposure and communications should advise actions to take in such circumstances for
example for patients/individuals receiving chemotherapy and renal dialysis
communications prior to appointments should provide advice on what to do if patients/individuals
suspect they have come into contact with someone who has COVID-19 prior to their
appointment
outpatient letters should be altered to advise patients/individuals on parking, entrances, IPC
precautions and COVID-19 symptoms
patients/individuals must be instructed to remain in waiting areas and not visit other parts of the
facility
prior to admission to the waiting area, all patients/individuals and accompanying persons should
be triaged for COVID-19 symptoms and assessed for exposure to contacts
patients/individuals and accompanying persons will also be asked to wear a mask/face covering
at all times
RS-CoV-2 confirmed positive patients/individuals or those self-isolating should still be assessed
d reviewed following the high/medium care pathway in these settings, to ensure urgent
atment/appointments are accommodated. This is important to avoid unwarranted poor patient
comes.
ome clinical outpatient settings, such as vaccination/injection clinics, where contact with
ividuals is minimal, the need for PPE items for each encounter, for example gloves and aprons are
y recommended when there is (anticipated) exposure to blood/body fluids or non-intact skin. Staff
ministering vaccinations/injections must apply hand hygiene between patients and wear a
sional face mask.
Standard infection prevention control precautions (SICPs) - all pathways or
ttings
Ps are the basic IPC measures necessary to reduce the risk of transmitting infectious agents
m both recognised and unrecognised sources of infection and are required across all COVID-19
hways. Sources of (potential) infection include blood and other body fluids secretions or
retions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in
care environment that could have become contaminated.
e application of SICPs during care delivery is determined by an assessment of risk to and from
ividuals and includes the task, level of interaction and/or the anticipated level of exposure to blood
d/or other body fluids.
Ps must therefore be used by all staff, in all care settings, at all times and for all
ients/individuals, whether infection is known or not, to ensure the safety of patients/individuals,
ff and visitors. This section highlights the key measures for the COVID-19 pathways. Please refer
he practice guide* for additional information on the other elements which remain unchanged.
e elements of SICPs are:
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patient placement and assessment for infection risk (screening/triaging/testing)
hand hygiene
respiratory and cough hygiene
personal protective equipment
safe management of the care environment
safe management of care equipment
safe management of healthcare linen
safe management of blood and body fluids
safe disposal of waste (including sharps)
occupational safety: prevention and exposure management
maintaining social/physical distancing (new SICP due to COVID-19)
*Practice guides and literature reviews to support SICPs can be found for England and Scotland
(http://www.nipcm.hps.scot.nhs.uk/), Wales (https://phw.nhs.wales/services-and-teams/harp/infection-
prevention-and-control/nipcm/) and Northern Ireland (https://www.niinfectioncontrolmanual.net/).
5.1 Personal protective equipment (PPE)
For the purpose of this document, the term ‘personal protective equipment’ is used to describe
products that are either PPE or medical devices that are approved by the Health and Safety
Executive (HSE) and the Medicines and Healthcare products Regulatory Agency (MHRA) as
protective solutions in managing the COVID-19 pandemic.
Local or national uniform policies (https://www.england.nhs.uk/about/equality/equality-hub/uniforms-and-
workwear/) should be considered when wearing PPE.
All PPE should be:
located close to the point of use (where this does not compromise patient safety, for example,
mental health/learning disabilities). In domiciliary care PPE must be transported in a clean
receptacle
stored safely and in a clean, dry area to prevent contamination
within expiry date (or had the quality assurance checks prior to releasing stock outside this date)
single use unless specified by the manufacturer or as agreed for extended/sessional use
including surgical face masks
changed immediately after each patient and/or after completing a procedure or task (unless
sessional use has been agreed and local risk assessment undertaken)
disposed into the correct waste stream depending on setting, for example domestic
waste/offensive (non-infectious) or infectious clinical waste
discarded if damaged or contaminated
safely doffed (removed) to avoid self-contamination. See guidance on donning (putting on) and
doffing (removing) (https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-
use-for-aerosol-generating-procedures)
decontaminated after each use following manufacturer’s guidance if reusable PPE is used,
specifically non-disposable goggles/face shields/visors
Gloves must:
be worn when exposure to blood and/or other body fluids, non-intact skin or mucous
membranes is anticipated or likely*
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be changed immediately after each patient and/or after completing a procedure/task even on the
same patient
be put on immediately before performing an invasive procedure and removed on completion
not be decontaminated with alcohol based hand rub (ABHR) or soap between use
Double gloving is not recommended for routine clinical care of COVID-19 cases.
*Vinyl medical gloves should only be worn in care situations where there is no anticipated exposure
to blood and/or body fluids.
Aprons must be:
worn to protect uniform or clothes when contamination is anticipated or likely
worn when providing direct care within 2 metres of suspected/confirmed COVID-19 cases
changed between patients and/or after completing a procedure or task
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed (surgical procedures)
changed between patients/individuals and immediately after completing a procedure or task
Eye or face protection (including full-face visors) must:
be worn if blood and/or body fluid contamination to the eyes or face is anticipated or likely – for
example, by members of the surgical theatre team and always during AGPs
not be impeded by accessories such as piercings or false eyelashes
not be touched when being worn
Regular corrective spectacles are not considered as eye protection.
Fluid resistant surgical face mask (FRSM Type IIR) masks must:
be worn with eye protection if splashing or spraying of blood, body fluids, secretions or
excretions onto the respiratory mucosa (nose and mouth) is anticipated or likely
be worn when providing direct care within 2 metres of a suspected/confirmed COVID-19 case
be well-fitting and fit for purpose, fully cover the mouth and nose (manufacturer’s instructions
must be followed to ensure effective fit and protection)
not be touched once put on or allowed to dangle around the neck
be replaced if damaged, visibly soiled, damp, uncomfortable or difficult to breathe through
Surgical face masks Type II must be:
worn for extended use by HCWs when entering the hospital or care setting (Type IIR is also
suitable). Type I is suitable in some settings, refer to the country specific resources in section
2.1
Head/footwear:
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t
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headwear is not routinely required in clinical areas (even if undertaking an AGP) unless part of
heatre attire or to prevent contamination of the environment such as in clean rooms
headwear worn for religious reasons (for example, turban, kippot veil, headscarves) are
permitted provided patient safety is not compromised - these must be washed and/or changed
between each shift or immediately if contaminated and comply with additional attire in, for
example, theatres
oot/shoe coverings are not required or recommended for the care of COVID-19 cases
may restrict communication with some individuals and other ways of communicating to meet
needs should be considered.
erosol generating procedures – procedures that create a higher risk of
iratory infection transmission
GP is a medical procedure that can result in the release of airborne particles (aerosols) from the
atory tract when treating someone who is suspected or known to be suffering from an infectious
transmitted wholly or partly by the airborne or droplet route.
s the list of medical procedures for COVID-19 that have been reported to be aerosol generating
re associated with an increased risk of respiratory transmission:
racheal intubation and extubation
manual ventilation
racheotomy or tracheostomy procedures (insertion or removal)
bronchoscopy
dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills)
non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and
continuous positive airway pressure ventilation (CPAP)
high flow nasal oxygen (HFNO)
high frequency oscillatory ventilation (HFOV)
nduction of sputum using nebulised saline
espiratory tract suctioning*
upper ear, nose and throat (ENT) airway procedures that involve respiratory suctioning*
upper gastro-intestinal endoscopy where open suction of the upper respiratory tract* occurs
beyond the oro-pharynx
high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses
nvolved
available evidence relating to respiratory tract suctioning is associated with ventilation. In line
precautionary approach, open suctioning of the respiratory tract regardless of association with
ation has been incorporated into the current (COVID-19) AGP list. It is the consensus view of
K IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP,
s oral/pharyngeal suctioning is not an AGP. The evidence on respiratory tract suctioning is
ntly being reviewed by the AGP Panel which is an independent panel set up by the 4 Chief
cal Officers (CMOs) to review new or further evidence for consideration.
in other procedures or equipment may generate an aerosol from material other than patient
tions but are not considered to represent a significant infectious risk for COVID-19. Procedures
category include administration of humidified oxygen, administration of Entonox or medication
ebulisation.
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The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during
nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and
does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a
contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an
aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and
oxygen masks. In addition, the current expert consensus from NERVTAG
(https://www.swast.nhs.uk/assets/1/cpr_as_an_agp_-
_evidence_review_and_nervtag_consensus.pdf#:~:text=NERVTAG%20consensus%20statement%20on%20Car
ute%20respiratory%20infections) is that chest compressions are not considered to be procedures that
pose a higher risk for respiratory infections including COVID-19.
Further information on AGPs for neonates (https://hubble-live-
assets.s3.amazonaws.com/bapm/redactor2_assets/files/729/COVID__FAQ_19.10.20.docx.pdf) and a
literature review for AGPs during COVID-19 (https://hps.scot.nhs.uk/web-resources-container/sbar-
assessing-the-evidence-base-for-medical-procedures-which-create-a-higher-risk-of-respiratory-infection-
transmission-from-patient-to-healthcare-worker/) are available.
7. Low risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test result within 72 hours of treatment and, for planned
admissions, have self-isolated for the required period or from the test date.
or
b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Clinicians should advise people who are at greater risk of getting COVID-19, or having a poorer
outcome from it, that they may want to self-isolate for 14 days before a planned procedure. The
decision to self-isolate will depend on their individual risk factors and requires individualised care and
shared decision making.
Some individuals who have recovered from COVID-19 may continue to test positive for SARS-CoV-2
by PCR for up to 90 days from their initial illness onset. If they do not have any new COVID-19
symptoms and have not had a known COVID-19 exposure they are unlikely to be infectious.
However, advice should be sought from an infection specialist (infectious
disease/virologist/microbiologist) for severely immunosuppressed individuals who continue to test
positive.
Patients/individuals on a low risk pathway require SICPs for all care including surgery or procedures.
7.1 Maintaining physical distancing
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ll staff and other care workers must maintain social/physical distancing of 2 metres where possible
nless providing clinical or personal care and wearing PPE as per care pathway).
.2 Personal protective equipment
PE required for SICPs when following the low risk pathway is as follows:
SICPs/PPE (all
settings / all
patients/individuals
Disposable
gloves
)
Disposable
apron/gown
Face masks
Eye/face protection
(visor)
If contact with blood
and/or body fluids is
anticipated
Single use
Single use
apron (gown
if risk of
spraying /
splashing)
FRSM Type IIR
for direct patien
care and surgic
mask Type II* fo
extended use
Risk assess and use if
t required for care
al procedure/task where
r anticipated blood/body
fluids spraying/splashes
Sessional/extended use of face masks applies across the UK for HCWs in any health or other care
ettings.
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
.3 Safe management of environment/equipment and blood/body fluids
uring the pandemic, the frequency of cleaning of both the environment and equipment in care
atient) areas should be increased to at least twice daily, this includes frequently touched
tes/points and communal facilities such as shared toilets.
the low risk COVID-19 pathway, organisations may choose to revert to general purpose detergents
r cleaning, as opposed to widespread use of disinfectants (with the exception of blood and body
uids, where a chlorine releasing agent (or a suitable alternative) solution should be used).
.3.1 Safe management of waste
aste must be segregated in line with the respective countries’ national regulation and there is no
quirement to dispose of all waste as infectious waste in the low risk pathway.
.3.2 Operating theatres and procedure rooms
ithin the low risk COVID-19 pathway, standard theatre cleaning and time for air changes provides
ppropriate levels of IPC and there is no requirement for additional cleaning or theatre down time
nless the patient has another infectious agent that requires additional IPC measures.
.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
f respiratory infection transmission
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
ps://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-guidance-for-maintaining-servi… 18/35
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ere is no additional requirement for ventilation or downtime in this pathway, providing safe systems
work, including engineering controls are in place.
.1 Critical care areas
oviding suspected/confirmed COVID-19 cases can be cared for in single rooms or isolation rooms,
department should no longer be classified as an AGP ‘hot spot’ or ‘high risk area’. This should be
fined locally depending on prevalence/incidence data and the subsequent pathway assigned. This
gates the requirement for the routine wearing of airborne PPE including a respirator in the low risk
VID-19 pathway.
.2 Operating theatres
tients/individuals in the low risk COVID-19 pathway do not need to be anaesthetised or recovered
the operating theatre if intubation/extubation (AGP) is required.
5 Visitor guidance
outlined in the administration measures for the pathways (section 4.4), hand hygiene and
spiratory hygiene, and the wearing of a face covering (if tolerated) along with social distancing
ould be encouraged and maintained. Therefore visitors require no additional PPE. Visitors should
triaged.
6 Discharge or transfer
ere is no restriction on discharge unless the patient/individual is entering a long-term care facility
ere testing may be required. If someone in the patient’s household has COVID-19 or is a contact
a COVID-19 case and is self-isolating, the discharge guidance will be provided by the clinician.
England, to ensure testing does not delay a timely discharge to a care home, all patients who have
eviously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
munocompetent patients who have tested positive within the previous 90 days, and remain
ymptomatic, do not need to be re-tested. The information from the test results, with any supporting
re information, must be communicated and transferred to the relevant care home. No one should
discharged from hospital directly to a care home without the involvement of the local authority.
scharge arrangements may differ between countries, refer to country specific resources in section
.
Transmission based precautions (TBPs)
Ps are additional measures (to SICPs) required when caring for patients/individuals with a known
suspected infection such as COVID-19.
Ps are based upon the route of transmission and include the following precautions:
Contact precautions
ed to prevent and control infections that spread via direct contact with the patient or indirectly from
patient’s immediate care environment (including care equipment). This is the most common route
cross-infection transmission. COVID-19 can be spread via this route.
Droplet precautions
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Used to prevent and control infections spread over short distances (at least 3 feet/1 metre) via
droplets (>5µm) from the respiratory tract of individuals directly onto a mucosal surface or
conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar
level. COVID-19 is predominantly spread via this route and the precautionary distance has been
maintained at 2 metres in care settings.
c) Airborne precautions
Used to prevent and control infection spread without necessarily having close patient contact via
aerosols (≤5µm) from the respiratory tract of one individual directly onto a mucosal surface or
conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.
COVID-19 can spread via this route. This can be mitigated by safe systems of work outlined in the
hierarchy of controls. AGPs increase the risk of spread by the airborne route.
8.1 Transmission characteristics
Transmission of SARS-CoV-2 implications for infection prevention precautions is contained within the
WHO scientific briefing paper (https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-
2-implications-for-infection-prevention-precautions) and CDC’s scientific brief
(https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html).
Literature reviews to support evidence for transmission characteristics
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/979441/S116
9_Facemasks_for_health_care_workers.pdf) and TBPs (http://www.nipcm.hps.scot.nhs.uk/resources/literature-
reviews/) are available.
New SARS-CoV-2 variants of concern have been identified in the UK. For further information on the
variants refer to Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and
situation in the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-
sars-cov-2-b1617-variants) and Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
202012011).
9. Medium risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and therefore infectious status is
unknown.
or
d) Asymptomatic individuals decline testing.
9.1 Maintaining physical distancing and patient placement
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It is important to:
maintain physical distancing of 2 metres at all times (unless the member of staff is wearing
appropriate PPE to provide clinical care) and to advise other patients/visitors to comply
ensure cohorted patients/individuals are physically separated from each other, for example with
screens and privacy curtains between the beds to minimise opportunities for close contact - this
should be locally risk assessed to ensure patient safety is not compromised
9.2 Personal protective equipment: patients/individuals with no COVID-19
symptoms and no test results
PPE required by type of
transmission/exposure
Disposable
gloves
Disposable apron/gown
Face masks
Eye/face
protection
(visor)*
Droplet/contact PPE for
direct patient care <2
metres
Single
use**
Single use apron (gown
required if risk of
spraying/splashing)
FRSM Type
IIR†
Single use
or
reusable*
Airborne PPE (when
undertaking or if AGPs
are likely)
Single use
Single use apron or gown
FFP3†† or
respirator/
hood for AGPs
Single use
or reusable
† FRSM can be worn sessionally if providing care for COVID-19 cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Risk assess and use if required for care procedure/task where anticipated blood/body fluids
spraying/splashes.
**Gloves are not required when: undertaking administrative tasks, for example using the telephone,
using a computer or tablet, writing in the patient chart; giving oral medications, distributing or
collecting patient dietary trays.
9.3 Safe management of care environment/equipment/blood and body fluids
9.3.1 Equipment
Important considerations in the use of equipment are:
patient care equipment should be single use items where practicable
reusable (communal) non-invasive equipment should be allocated to an individual patient or
cohort of patients/individuals
all reusable (communal) non-invasive equipment must be decontaminated:
between each and after patient/individual
after blood and body fluid contamination
at regular intervals as part of routine equipment cleaning
decontamination of equipment must be performed using either:
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a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available
chlorine (ppm av.cl.); or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl.
alternative cleaning agents/disinfectant products may be used with agreement of the IPC
team/health protection team (HPT)
cleaning of care equipment as per manufacturer’s guidance/instruction and recommended
product ‘contact time’ must be followed for all cleaning/disinfectant solutions/products
an increased frequency of decontamination should be considered for all reusable non-invasive
care equipment when used in isolation/cohort areas
the use of fans in high and medium risk pathways should be risk assessed - refer to Estates
guidance
9.3.2 Environment
Important considerations for environmental cleaning and disinfection are:
cleaning frequencies of the care environment in COVID-19 care areas must be enhanced and
single rooms, cohort areas and clinical rooms (including rooms where PPE is removed) cleaned
at least twice daily
routine cleaning must be performed using either:
a combined detergent/disinfectant solution at a dilution of 1,000ppm av.cl.; or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl
alternative cleaning agents/disinfectants may be used with agreement of the local IPC
team/HPT
the increased frequency of decontamination/cleaning should be incorporated into the
environmental decontamination schedules for all COVID-19 areas, including where there may
be higher environmental contamination rates, including for example:
toilets/commodes particularly if patients/individuals have diarrhoea
‘frequently touched’ surfaces such as medical equipment, door/toilet handles, locker tops,
patient call bells, over bed tables, bed rails, phones, lift buttons/communal touch points and
communication devices (for example, mobile phones, tablets, desktops, keyboards)
particularly where these are used by many people, should be cleaned at least twice daily
with solution of detergent and 1,000ppm chlorine or an agreed alternative when known to
be contaminated with secretions, excretions or body fluids
dedicated or disposable equipment (such as mop heads, cloths) must be used for environmental
decontamination
reusable equipment (such as mop handles, buckets) must be decontaminated after use with a
chlorine-based disinfectant or locally agreed disinfectant
single (isolation) rooms must be terminally cleaned as above following resolution of symptoms,
discharge or transfer (this includes removal and laundering of all curtains and bed screens)
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4 Aerosol generating procedures (AGPs): procedures that create a higher risk
respiratory infection transmission
Ps should only be carried out when essential and only staff who are needed to undertake the
ocedure should be present, wearing airborne PPE/RPE precautions (see information in the high
k pathway guidance).
4.1 Critical care areas
oplet precautions apply when within 2 metres and providing direct patient care. Airborne
ecautions are required when undertaking AGPs. However, consideration may need to be given to
e application of sessional use of FFP3 masks where the number of cases of suspected/possible
OVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or
lation rooms that is patient cohort. Sessional use of FFP3 masks (includes eye/face protection)
ay be considered. All other items of PPE (gloves/gown) must be changed between patients and/or
er completing a procedure or task.
4.2 Operating theatres
tients/individuals should be anaesthetised and recovered in the operating theatre if
ubation/extubation (AGP) is required. For local, neuraxial or regional anaesthesia the patient is not
quired to be anaesthetised/recovered in theatre.
5 Duration of TBPs
Ps should only be discontinued in consultation with clinicians and should take into consideration
e individual’s PCR test results and clinical symptoms. If test results are not available (for example
e patient/individual declines) TBPs can be discontinued after 14 days (inpatients) depending on
ntact exposure and providing the patient/individual remains symptom free.
6 Visitor guidance
siting may be limited during increases in incidence and prevalence of COVID-19, however as cases
cline and restrictions ease, visitors should be permitted to enter the facility and be educated in the
C measures required as outlined in the information on administration measures for the pathways.
visitors should be triaged.
is includes accompanying individuals when attending outpatient appointments, such as antenatal
pointments and therapy groups.
7 Discharge or transfer
ere is no restriction on discharge if the patient/individual is well, unless the patient/individual is
tering a long-term facility and testing may be required. If someone in the patient’s household has
OVID-19 or is a contact of a COVID-19 case and is self-isolating, the discharge guidance will be
ovided by the clinician.
scharge information for patients/individuals should include an understanding of their need for any
lf-isolation, as well as their family members (where applicable).
bulance services and the receiving facilities must be informed of the infectious status of the
ividual.
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Discharge arrangements may differ between countries, refer to country specific resources in section
2.1.
In England, to ensure testing does not delay a timely discharge to a care home, all patients who have
previously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
Immunocompetent patients who have tested positive within the previous 90 days, and remain
asymptomatic, do not need to be re-tested. The information from the test results, with any supporting
care information, must be communicated and transferred to the relevant care home. No one should
be discharged from hospital directly to a care home without the involvement of the local authority.
10. High risk pathway – key principles
This pathway applies to any emergency/urgent care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown*).
or
b) Confirmed SARS-CoV-2 (COVID-19) PCR positive patients are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
*Once assessed, if asymptomatic with no contact history, patients/individuals may move to the
medium risk pathway awaiting test result.
10.1 Patient placement
If the patient/individual has symptoms or a history of contact/exposure with a case, they should be
prioritised for single room isolation or cohorted (if an isolation room is unavailable) until their test
results are known, for example use privacy curtains between bed spaces to minimise opportunities
for close contact between patients/individuals. This should be locally risk assessed to ensure this
does not compromise patient safety.
If single rooms are in short supply, priority should be given to patients with excessive cough and
sputum production, diarrhoea or vomiting and to those at high risk/extremely high risk of severe
illness.
Local risk assessments and clinical decisions must be made regarding placement of
patients/individuals with availability of single rooms taken into consideration.
10.2 Personal protective equipment (PPE): suspected/confirmed COVID-19
patient/individual
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PPE required by type of
transmission/exposure
Disposable
gloves
Disposable
apron/gown
Face
masks
Eye/face
protection
(visor)
Droplet/contact PPE
Single use
Single use apron
and gown if risk
of spraying /
splashing)
FRSM
Type IIR
for direc
patient
care†
Single use
t
or reusable
Airborne PPE (when undertaking or if
AGPs are likely)*
If an unacceptable risk of
transmission remains following
rigorous application of the hierarchy
of control**
Single use
Single use gown
FFP3††
respirato
/ hood fo
AGPs
or
r Single use
r or reusable
†FRSM can be worn sessionally (includes eye/face protection) if providing care for COVID -19
cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Consideration may need to be given to the application of airborne precautions where the number of
cases of COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single
or isolation rooms.
**Or if an unacceptable risk of transmission remains following rigorous application of the hierarchy of
control, taking these controls into account, it may be necessary to consider the extended use of RPE
for patient care in this situation.
10.2.1 Respiratory protective equipment (RPE)/FFP3 (filtering face piece or hood)
Respirators are used to prevent inhalation of small airborne particles arising from AGPs.
Respirators should:
be well fitting, covering both nose and mouth
always be worn when undertaking an AGP on a COVID-19 confirmed or suspected
patient/individual
not be allowed to dangle around the neck of the wearer or hang from one ear after or between
each use
not be touched once put on
be removed outside the patient’s/individual’s room or cohort area or COVID-19 ward
respirators can be single use or single session use (disposable or reusable) and fluid-resistant
all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to
ensure an adequate seal or fit (according to the manufacturer’s guidance)
where fit testing fails, suitable alternative equipment must be provided, or the HCW should be
moved to an area where FFP3 respirators are not required
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fit checking (according to the manufacturer’s guidance) is necessary when a respirator is put on
(donned) to ensure an adequate seal has been achieved
respirators should be compatible with other facial protection used (protective eyewear) so that
this does not interfere with the seal of the respiratory protection
the respirator should be discarded and replaced and not be subject to continued use if the facial
seal is compromised, it is uncomfortable, or it is difficult to breathe through
reusable respirators can be utilised by individuals if they comply with HSE recommendations -
reusable respirators should be decontaminated according to the manufacturer’s instructions
Valved respirators are not fluid-resistant unless they are also ‘shrouded’. Valved non-shrouded FFP3
respirators should be worn with a full-face shield if blood or body fluid splashing is anticipated. Valved
respirators should not be worn by an HCW/operator when sterility directly over the surgical field is
required, for example in theatres/surgical settings or when undertaking a sterile procedure, as the
exhaled breath is unfiltered.
Examples of sterile procedures include:
any surgical or invasive procedure that routinely requires maximal sterile barrier precautions to
prevent infection, for example sterile gowns, sterile gloves, face mask as required for surgical
antisepsis/ANTT - these are commonly but not exclusively undertaken in operating theatres,
critical care or emergency departments
those sterile percutaneous or invasive procedures such as interventional radiology/cardiac
catheterisation, PICC or other central venous catheter insertions
The ongoing use of valved respirators in theatres and surgical settings should be based on a local
risk assessment. The risk of an asymptomatic HCW transmitting COVID-19 infection if wearing a
valved respirator is considered ‘very small’, as the HCW would need to be excreting virus and the
patient would need to be negative for COVID-19 (FFP3 use is when an HCW is managing a
suspected/confirmed COVID-19 positive patient undergoing AGPs in the medium or high risk
pathway).
10.2.2 Full body gowns or fluid repellent coveralls
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed for example, surgery changed between patients/individuals and immediately after
completing a procedure or task
Sessional or extended use of gowns must be minimised and only used in areas where cohorts of
confirmed COVID-19 patients are managed and there is a lack of single rooms/isolation rooms. If
sessional use is required, an individual patient risk assessment must be undertaken and reviewed
daily. Gowns are not required when moving around a unit or department.
10.3 Safe management of care environment/equipment/blood and body fluids
Please refer to information given in the medium risk pathway.
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In addition if there are clusters or outbreaks of COVID-19 (2 or more cases linked by time and place)
with significant respiratory symptoms in communal settings cleaning frequencies should be
increased.
10.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
of respiratory infection transmission and operating theatres
10.4.1 Critical care
Droplet precautions would apply, however consideration may need to be given to the application of
airborne precautions where the number of cases of COVID-19 requiring AGPs increases and
patients/individuals cannot be managed in single or isolation rooms.
10.4.2 Operating theatres (including day surgery)
Patients/individuals should be anaesthetised and recovered in the theatre if intubation/extubation
(AGP) is required using airborne precautions. This is not required for regional, neuraxial or local
anaesthesia.
Ventilation in both laminar flow and conventionally ventilated theatres should remain in full operation
during surgical procedures where patients/individuals have suspected/confirmed COVID-19. Air
passing from operating theatres to adjacent areas will be highly diluted and is not considered to be a
risk.
10.5 Duration of precautions
In general, patients with COVID-19 who are admitted to hospital will have more severe disease than
those who can remain in the community, especially if they have been severely unwell or have pre-
existing conditions such as severe immunosuppression. Therefore, it is recommended that these
individuals should be isolated within hospital or remain in self-isolation on discharge for 14 days from
their first positive SARS-CoV-2 PCR test.
Whilst in hospital patients/individuals should remain in isolation/cohort with TBPs applied for at least
14 days after onset of symptoms and should be 48 hours without a fever (without use of antipyretic
medication) or respiratory symptoms. The decision to modify the duration of, or ‘stand down’ TBPs
(contact/droplet/airborne) should be made by the clinical team managing the individual’s care.
For clinically suspected COVID-19 patients who have tested negative or have not been tested for
SARS-CoV-2 and whose condition is severe enough to require hospitalisation, then the 14 day
isolation period should be measured from the day of admission.
Testing for virological clearance is encouraged in severely immunosuppressed patients. For these
patients, IPC measures should be continued unless there is evidence of virological clearance prior to
discharge or there has been a complete resolution of all symptoms. This is different to other advice
sections but reflects the complex health needs of such patients and likelihood for prolonged
shedding, with risk of spread in healthcare settings. Upon discharge such patients may be retested at
first follow-up appointment to help inform actions at any next medical appointment.
10.6 Visitor guidance
In this pathway, visiting should continue to be limited to only essential visitors, for example birthing
partner, carer/parent/guardian. Hospitals/organisations will provide advice and guidance to support
patients during these restrictions. Visitor guidance may differ between countries, refer to country
specific resources in section 2.1.
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Whilst face masks/coverings are recommended the need for visitors to wear additional PPE should
be individually assessed.
10.7 Discharge or transfer
Discharge from an inpatient facility can occur when the individual is well enough and the clinician has
provided them with discharge such as advice to self-isolate for at least 14 days from the date of the
positive SARS-CoV-2 PCR test (providing their symptoms resolve during this period). Refer to
country specific resources in section 2.1.
Advice should include written information, such as patients with a cough or a loss of, or change in,
normal sense of smell or taste (anosmia), may persist in some individuals for several weeks following
COVID-19 recovery, and is not currently considered an indication of ongoing infection when other
symptoms have resolved.
Prior to discharge (if the patient is within the 14 days) clinicians should ascertain if there are any
clinically extremely vulnerable individuals who live in the household and are currently not infected. If
so, it is highly advisable for patients to be discharged to a different home until they have finished their
self-isolation period. If these individuals cannot be moved to a different household, then ensure that
the discharged patient is advised on IPC measures as outlined in the Stay at home guidance
(https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-
households-with-possible-coronavirus-covid-19-infection).
Advice on ongoing medical needs should be provided for patients who are discharged within their
self-isolation period. If patients deteriorate at home or in a care setting, they or their carer should
seek advice from NHS 111 online (https://111.nhs.uk/) or by telephone, or through pre-existing services
such as GP practice links with care homes. In an emergency, 999 should be called. In either case,
they should inform the call attendant that they have been recently discharged from hospital with
confirmed COVID-19.
Discharge information for patients/individuals to their own home should include an understanding of
their need for any self-isolation, as well as their family/household members.
Ambulance services and the receiving facilities must be informed of the infectious status of the
individual and the ongoing need to continue with infection control precautions.
Discharge arrangements may differ between countries as discharge to other areas is dependent on
testing and/or isolation facilities available. Refer to country specific resources in section 2.1.
In England, to ensure testing does not delay a timely discharge to a care home, patients who have
tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge. All SARS-
CoV-2 positive patients who are discharged within their 14 day self-isolation period will need to be
discharged to a designated setting. The information from the test results, with any supporting care
information, must be communicated and transferred to the relevant care home. No one should be
discharged from hospital directly to a care home without the involvement of the local authority.
11. Occupational health and staff deployment
Prompt recognition of cases of COVID-19 among healthcare staff is essential to limit the spread.
Health and social care staff with symptoms of COVID-19 or a positive COVID-19 test result should
not come to work. Refer to country specific testing requirements.
As a general principle, healthcare staff who provide care in settings for suspected or confirmed
patients/individuals should not care for other patients. However, this has to be a local decision based
on local epidemiology and the configuration of the organisation.
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A risk assessment is required for health and social care staff at high risk of complications from
COVID-19, or clinically extremely vulnerable groups, including pregnant and BAME staff. Guidance
on carrying out risk assessments can be found by following the links to the country specific resources
in section 2.1.
Employers should:
discuss with employees who are clinically extremely vulnerable, including those who are
pregnant and of BAME origin, the need to be deployed away from areas used for the care of
those who have, or are clinically suspected of having, COVID-19; or, in primary care settings,
clinics set up to manage people with COVID-19 symptoms
ensure that advice is available to all health and social care staff, including specific advice to
those at risk from complications
Bank, agency and locum staff who fall into these categories should follow the same deployment
advice as permanent staff.
As part of their employer’s duty of care, providers have a role to play in ensuring that staff understand
and are adequately trained in safe systems of working, including donning and doffing of PPE. A fit
testing programme should be in place for those who may need to wear respiratory protection.
In the event of a breach in infection control procedures, staff should be reviewed by occupational
health.
Occupational health departments should lead on the implementation of systems to monitor staff
illness, absence and vaccination against COVID-19.
12. Glossary of terms
Aerosol generating procedures (AGPs)
Certain medical and patient care activities that can result in the release of airborne particles
(aerosols). AGPs can increase the risk transmission of infections.
Airborne transmission
The spread of infection from one person to another by airborne particles (aerosols) containing
infectious agents.
Airborne particles
Very small particles that may contain infectious agents. They can remain in the air for long periods of
time and can be carried over long distances by air currents. Airborne particles can be released when
a person coughs or sneezes, and during AGPs. ‘Droplet nuclei’ are aerosols formed from the
evaporation of larger droplet particles (see droplet transmission). Aerosols formed from droplet
particles in this way behave as other aerosols.
Airborne precautions
Measures used to prevent and control infection spread without necessarily having close patient
contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly
onto a mucosal surface or conjunctivae of another individual. Aerosols can penetrate the respiratory
system to the alveolar level.
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BS/EN standards
Mandatory technical specifications created by either the British Standards Institute (BS) or European
Standardisation Organisations (EN) in collaboration with government bodies, industry experts and
trade associations. They aim to ensure the quality and safety of products, services and systems.
Clinically vulnerable or extremely clinically vulnerable
People who are defined as clinically extremely vulnerable
(https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-
persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#cev)
are at very high risk of severe illness from COVID-19. Those included in this category will been
identified by:
having one or more of conditions list, or
a clinician or GP has added the individual to the Shielded Patient List
Cohort area
An area (room, bay, ward) in which 2 or more patients (a cohort) with the same confirmed infection
are placed. A cohort area should be physically separate from other patients.
Contact precautions
Measures used to prevent and control infections that spread via direct contact with the patient or
indirectly from the patient’s immediate care environment (including care equipment). This is the most
common route of infection transmission.
Contact transmission
Contact transmission is the most common route of transmission, and consists of 2 distinct types:
direct contact and indirect contact. Direct transmission occurs when microorganisms are transmitted
directly from an infectious individual to another individual without the involvement of another
contaminated person or object (fomite). Indirect transmission occurs when microorganisms are
transmitted from an infectious individual to another individual through a contaminated object (fomite)
or person.
COVID-19
COVID-19 is a highly infectious respiratory disease caused by a novel coronavirus. The disease was
discovered in China in December 2019 and has since spread around the world.
Droplet precautions
Measures used to prevent and control infections spread over short distances (at least 1 metre or 3
feet) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a
mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to
above the alveolar level. COVID-19 is predominantly spread via this route and the precautionary
distance has been maintained at 2 metres in care settings.
Droplet transmission
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e spread of infection from one person to another by droplets containing infectious agents.
e or face protection
orn when there is a risk from splashing of secretion (including respiratory secretions). Eye or face
tection can be achieved using any one of:
a surgical mask with integrated visor
a full face visor or shield
goggles
id-resistant (Type IIR) surgical face mask (FRSM)
disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes
the wearer’s nose and mouth from splashes and infectious droplets. FRSMs can also be used to
tect patients. When recommended for infection control purposes a ‘surgical face mask’ typically
notes a fluid-resistant (Type IIR) surgical mask.
id-resistant
erm applied to fabrics that resist liquid penetration, often used interchangeably with ‘fluid-repellent’
en describing the properties of protective clothing or equipment.
equently touched surfaces
rfaces of the environment which are commonly touched or come into contact with human hands.
althcare or clinical waste
ste produced as a result of healthcare activities, for example soiled dressings, sharps.
erarchy of controls
e hierarchy of controls is used to identify the appropriate controls with Elimination, Substitution,
gineering Controls, Administrative Controls, Personal Protective Equipment.
erarchy of Controls: The National Institute for Occupational Safety and Health (NIOSH), Centers for
ease Control and Prevention (CDC) (https://www.cdc.gov/niosh/topics/hierarchy/default.html)
gh-flow nasal cannula (HFNC) therapy
NC is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at
low rate of up to 60 litres per minute.
gher risk acute care area/units
ensive care units, intensive therapy units, high dependency units, emergency department
uscitation areas, wards with non-invasive ventilation, operating theatres, endoscopy units for
per respiratory, ENT or upper GI endoscopy, and other clinical areas where AGPs are regularly
rformed. Referred to as ‘AGP hot spots’.
ubation period
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The period between the infection of an individual by a pathogen and the manifestation of the illness
or disease it causes.
Induction of sputum
Induction of sputum typically involves the administration of nebulised saline to moisten and loosen
respiratory secretions (this may be accompanied by chest physiotherapy (percussion and vibration))
to induce forceful coughing.
Infectious linen
Linen that has been used by a patient who is known or suspected to be infectious and/or linen that is
contaminated with blood/other body fluids, for example faeces.
Long term health condition
This covers:
chronic obstructive pulmonary disease, bronchitis, emphysema or asthma
heart disease
kidney disease
liver disease
stroke or a transient ischaemic attack (TIA)
diabetes
lowered immunity as a result of disease or medical treatment, such as steroid medication or
cancer treatment
a neurological condition, such as Parkinson’s disease, motor neurone disease, multiple sclerosis
(MS), cerebral palsy, or a learning disability
any problem with the spleen, including sickle cell disease, or had spleen removed
a BMI of 40 or above (obese)
Personal protective equipment (PPE)
Equipment a person wears to protect themselves from risks to their health or safety, including
exposure to infectious agents. The level of PPE required depends on the:
suspected or known infectious agent
severity of the illness caused
transmission route of the infectious agent
procedure or task being undertaken
Respiratory droplets
A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or
speaking.
Respiratory protective equipment
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espiratory protection that is worn over the nose and mouth designed to protect the wearer from
haling hazardous substances, including airborne particles (aerosols). There are 2 types of
spiratory protection that can be used, tight-fitting disposable FFP respirators and loose-fitting
owered hoods (TH2).
FP stands for filtering face piece. There are 3 categories of FFP respirator: FFP1, FFP2 and FFP3.
FP3 and loose-fitting powered hoods provide the highest level of protection and are recommended
hen caring for patients in areas where high risk AGPs are being performed.
espiratory symptoms
espiratory symptoms include:
rhinorrhoea (runny nose)
sore throat
cough
difficulty breathing or shortness of breath
egregation
hysically separating or isolating from other people.
ARS-CoV
evere acute respiratory syndrome coronavirus, the virus responsible for the 2003 outbreak of
uman coronavirus disease.
ARS-CoV-2
evere acute respiratory syndrome coronavirus 2, the virus responsible for the COVID-19 pandemic.
everely immunosuppressed
everely immunosuppressed is defined in the Green Book on Immunisation as:
immunosuppression due to acute and chronic leukaemias and lymphoma (including Hodgkin’s
lymphoma)
severe immunosuppression due to HIV/AIDS (British HIV Association advice
(https://www.bhiva.org/BHIVA-and-THT-statement-on-COVID-19-and-advice-for-the-extremely-vulnerable))
cellular immune deficiencies (such as severe combined immunodeficiency, Wiskott-Aldrich
syndrome, 22q11 deficiency/DiGeorge syndrome)
being under follow up for a chronic lymphoproliferative disorder including haematological
malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma and other
plasma cell dyscrasias
having received an allogenic (cells from a donor) stem cell transplant in the past 24 months and
only then if they are demonstrated not to have ongoing immunosuppression or graft versus host
disease (GVHD)
having received an autologous (using their own stem cells) haematopoietic stem cell transplant
in the past 24 months and only then if they are in remission
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those who are receiving, or have received in the past 6 months, immunosuppressive
chemotherapy or radiotherapy for malignant disease or non-malignant disorders
those who are receiving, or have received in the past 6 months, immunosuppressive therapy for
a solid organ transplant (with exceptions, depending upon the type of transplant and the immune
status of the patient)
those who are receiving, or have received in the past 12 months, immunosuppressive biological
therapy (such as monoclonal antibodies), unless otherwise directed by a specialist
those who are receiving, or have received in the past 3 months, immunosuppressive therapy
including:
adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/
kg/day in children under 20kg) for more than 1 week
adults and children on lower dose corticosteroids (>20mg prednisolone per day or
1mg/kg/day in children under 20kg) for more than 14 days
adults on non-biological oral immune modulating drugs, for example methotrexate >25mg
per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day
children on high doses of non-biological oral immune modulating drugs
ndard infection control precautions (SICPs)
Ps are the basic IPC measures necessary to reduce the risk of transmission of an infectious
ent from both recognised and unrecognised sources of infection.
gle room
oom with space for one patient and usually contains (as a minimum) a bed, a locker or wardrobe
d a clinical wash-hand basin.
ff cohorting
en staff care for one specific group of patients and do not move between different patient cohorts.
tient cohorts may include for example ‘symptomatic’, ‘asymptomatic and exposed’, or
ymptomatic and unexposed’ patient groups.
nsmission based precautions
ditional precautions to be used in addition to SICPs when caring for patients with a known or
pected infection or colonisation.
Coronavirus (COVID-19) (/coronavirus)
Guidance and support
1. Home (https://www.gov.uk/)
2. Coronavirus (COVID-19) (https://www.gov.uk/coronavirus-taxon)
3. Healthcare workers, carers and care settings during coronavirus
(https://www.gov.uk/coronavirus-taxon/healthcare-workers-carers-and-care-settings)
4. COVID-19: infection prevention and control (IPC)
(https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-
and-control)
UK Health
Security
Agency (https://www.gov.uk/government/organisations/uk-health-security-agency)
Guidance
COVID-19: guidance for
maintaining services within
health and care settings –
infection prevention and control
recommendations
Updated 29 September 2021
Contents
1. Main messages and explanation of updates
2. Introduction
3. Governance and responsibilities
4. COVID-19 care pathways
5. Standard infection prevention control precautions (SICPs) - all pathways or settings
6. Aerosol generating procedures – procedures that create a higher risk of respiratory infection
transmission
7. Low risk pathway – key principles
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8. Transmission based precautions (TBPs)
9. Medium risk pathway – key principles
10. High risk pathway – key principles
11. Occupational health and staff deployment
12. Glossary of terms
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1. Main messages and explanation of updates
1.1 About this guidance
This guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health
Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland
(HPS)/National Services Scotland, Public Health England (PHE) and NHS England as official
guidance.
Amendments have been made to strengthen existing messaging and provide further clarity where
needed, including updates on the hierarchy of controls, clarity over the use of valved respirators, and
highlighting the need to protect those previously shielding and who are considered clinically
extremely vulnerable from coronavirus (COVID-19).
Following a clinical and scientific review, no changes to the recommendations, including personal
protective equipment (PPE), have been made in response to the new variant strains at this stage,
however this position will remain under constant review. Organisations who adopt practices that differ
from those recommended/stated in the national guidance are responsible for ensuring safe systems
of work, including the completion of a risk assessment approved through local governance
procedures.
All NHS organisations should ensure reliable application of all infection prevention and control (IPC)
recommendations and assurance on adherence, that PPE is available and in supply, and that all staff
training is up to date.
This guidance seeks to ensure a consistent and resilient UK wide approach, however some
differences in operational details and organisational responsibilities may apply in Northern Ireland,
England, Wales and Scotland.
Please note that this guidance is of a general nature and that an employer should consider the
specific conditions of each individual place of work and comply with all applicable legislation,
including the Health and Safety at Work etc. Act 1974
(https://www.legislation.gov.uk/ukpga/1974/37/contents).
The IPC principles in this document apply to all health and care settings including acute, diagnostics,
independent sector, mental health and learning disabilities, primary care, care homes, care at home,
maternity and paediatrics (this list is not exhaustive).
This guidance does not apply to adult social care settings in England. Adult social care providers in
England should refer to existing guidance (https://www.gov.uk/government/collections/coronavirus-covid-19-
social-care-guidance) already in place. DHSC/PHE will continuously review this guidance and update
as needed.
This IPC guidance will be updated in line with service need and as the evidence evolves. The
administrative measures outlined in the guidance are consistent with World Health Organization
(WHO) guidance (https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1).
1.2 Main messages
Local and national prevalence and incidence data will continue to guide services as advised by
country-specific/public health organisations. Identification of new variants of concern is inevitable and
on each new identification evidence for any change in transmissibility, mode of transmission, disease
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severity and any evidence of vaccine evasion will need to be considered as well as local incidence
and prevalence of any new variant of concern. It may be necessary to change the IPC measures
required on the basis of any new evidence.
For further information on the variants of concern:
Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and situation in
the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-sars-cov-2-
b1617-variants)
Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
20201201)
For further guidance on investigating and managing variants of concern:
Guidance for investigating and managing individuals with a possible or confirmed SARS-CoV-2
Variant of Concern or Variant Under Investigation (https://www.gov.uk/government/publications/sars-
cov-2-voc-investigating-and-managing-individuals-with-a-possible-or-confirmed-case/guidance-for-
investigating-and-managing-individuals-with-a-possible-or-confirmed-sars-cov-2-variant-of-concern)
This data will continue to be used to ensure patients/individuals’ treatment, care and support can be
managed in the 3 COVID-19 pathways, which remain as:
high risk - this includes patients/individuals who are confirmed COVID-19 positive by a SARS-
CoV-2 polymerase chain reaction (PCR) test or are symptomatic and suspected to have COVID-
19 (awaiting result)
medium risk - this includes patients/individuals who are waiting for their SARS-CoV-2 PCR test
result and who have no symptoms of COVID-19 and individuals who are asymptomatic with
COVID-19 contact/exposure identified
low risk - this includes patients/individuals who have been triaged/tested (negative)/clinically
assessed with no symptoms or known recent COVID-19 contact/exposure
To ensure maximum workplace risk mitigation, organisations should undertake local risk
assessments based on the measures as prioritised in the hierarchy of controls. If an unacceptable
risk of transmission remains following this risk assessment
(https://www.england.nhs.uk/coronavirus/publication/every-action-counts/), it may be necessary to consider
the extended use of respiratory protective equipment (RPE) for patient care in specific situations. The
risk assessment should include evaluation of the ventilation in the area, and prevalence of
infection/new variants of concern in the local area.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
Sessional use of single use PPE/RPE items continues to be minimised and only applies to extended
use of face masks (all pathways) or filtering face piece (FFP3) respirators (together with eye/face
protection) in the medium and high risk pathways for healthcare workers (HCWs) where airborne
precautions are indicated.
The use of face masks or face coverings across the UK remains as an IPC measure. In addition to
social distancing, hand hygiene for staff, patients/individuals and visitors is advised in both clinical
and non-clinical areas to further reduce the risk of transmission.
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Patients in all care areas should still be encouraged and supported to wear a face mask, providing it
is tolerated and is not detrimental to their medical or care needs.
Physical distancing of 2 metres remains in place as standard practice in all health and care settings,
unless providing clinical or personal care and wearing appropriate PPE.
Patients/individuals on a low-risk pathway require standard infection control precautions (SICPs) for
all care including surgery or procedures.
Triaging and SARS-CoV-2 testing must be undertaken for all patients either at point of admission or
as soon as possible/practical following admission across all the pathways.
The IPC measures recommended are underpinned by the National Infection Prevention and Control
Manual (NIPCM) practice guide and associated literature reviews (http://www.nipcm.hps.scot.nhs.uk/).
NHS England is using this an opportunity to introduce and adopt the NICPM as set out in the UK
Five-year Tackling Antimicrobial Resistance National Action Plan (2019 to 2024)
(https://www.gov.uk/government/publications/uk-5-year-action-plan-for-antimicrobial-resistance-2019-to-2024).
1.3 Explanation of the updates to IPC guidance
The guidance is issued jointly by DHSC, PHW, PHA Northern Ireland, HPS/National Services
Scotland, PHE and NHS England for health and care organisations as the UK moves to maintain
healthcare services. The content is consistent with the administrative measures outlined in WHO IPC
during healthcare when COVID-19 is suspected or confirmed: Interim Guidance, June 2020
(https://apps.who.int/iris/handle/10665/332879). In addition, the updates to this guidance are informed by
the paper produced for the Scientific Advisory Group for Emergencies Masks for healthcare workers
to mitigate airborne transmission of SARS-CoV-2 (23 April 2021)
(https://www.gov.uk/government/publications/emg-masks-for-healthcare-workers-to-mitigate-airborne-
transmission-of-sars-cov-2-25-march-2021).
Maintaining services continues to require ‘new ways’ of working during the ongoing pandemic.
Continual assessment of the available evidence/science and feedback from guidance users,
professional bodies and associations, has identified the amendments required to the guidance to
assist in supporting services in this ‘new and changing’ environment whilst COVID-19 remains a
threat. This is based upon emerging evidence, experience and expert opinion.
1.4 Main changes to the guidance
The main amendments to this version of the guidance are:
1. Inclusion of the hierarchy of controls as these apply to COVID-19, with definitions and
supporting materials for implementation. Also, where an unacceptable risk of transmission
remains following the hierarchy of controls risk assessment, it may be necessary to consider the
extended use of RPE for patient care in specific situations. The risk assessment should include
evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new
variants of concern in the local area.
2. Further advice on the use of valved respirators with examples of sterile procedures in the clinical
setting.
3. Further advice on minimising sessional or extended use of gowns where cohorts of confirmed
COVID-19 patients are managed and there is a lack of single rooms/isolation rooms.
4. Amendment to the aerosol generating procedure (AGP) list to state ‘upper gastro-intestinal
endoscopy where open suction of the upper respiratory tract occurs beyond the oro-pharynx’.
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5. Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example, priority for single room isolation.
. Introduction
.1 Scope and purpose
his document sets out the IPC advice for health and care organisations as the UK continues to
aintain healthcare services during the ongoing pandemic.
he IPC principles in this document apply to all health and care settings, including the
dependent/private sector, mental health and learning disabilities, primary care areas, care homes,
are at home, maternity and paediatrics (this list is not exhaustive, please refer to specific country
sources for setting specific guidance). It includes key IPC control recommendations and includes
sk assessed patient pathway scenarios to help guide the implementation of measures to provide
afe and effective care locally and is based on the best available evidence.
he challenge facing the NHS is to maintain healthcare services and manage NHS capacity whilst
roviding a safe and equitable service for staff, visitors and patients/individuals including those who
ay present with COVID-19, those who have recovered from COVID-19 and those with no history of
OVID-19, until public health strategies such as mass vaccination are complete.
aintaining services requires a continuous review of ways of working to respond to the pandemic
nd guidance for working in a changing environment requires continual and ongoing development
ased upon emerging evidence, experience and expert opinion.
hile this document seeks to ensure a consistent and resilient UK-wide approach, some differences
operational details and organisational responsibilities may apply, where current legislation,
uidance, for example, clinical definitions, already exists. Links can be accessed in the resources
elow.
his guidance does not apply to adult social care settings in England given existing guidance for
dult social care settings (https://www.gov.uk/government/collections/coronavirus-covid-19-social-care-
uidance) has already been provided and continues to be relevant. DHSC/PHE will continuously
view this guidance and update as needed.
his document does not provide links throughout the sections. Follow the country-specific resources,
r example visiting guidance, testing, discharge policies.
C COVID-19 resources for:
England can be found at Infection Prevention and Control supporting documentation
(https://www.england.nhs.uk/coronavirus/publication/infection-prevention-and-control-supporting-
documentation/) and coronavirus (COVID-19) (https://www.gov.uk/coronavirus)
Scotland can be found at COVID-19 compendium (https://hps.scot.nhs.uk/web-resources-
container/covid-19-compendium/) and Scottish COVID-19 Infection Prevention and Control
Addendum for Acute Settings (http://www.nipcm.hps.scot.nhs.uk/scottish-covid-19-infection-prevention-
and-control-addendum-for-acute-settings/)
Wales can be found at Health and social care professionals: coronavirus (https://gov.wales/health-
professionals-coronavirus)
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Northern Ireland can be found at Guidance for professionals and organisations
(https://www.publichealth.hscni.net/covid-19-coronavirus/guidance-professionals-and-organisations)
Further updates will be made to this document as new data/evidence emerges and as the COVID-19
alert levels change
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884352/slide
s_-_11_05_2020.pdf). This is a scale of 1 to 5 which the UK government uses to reflect the degree of
threat to the country from the current COVID-19 pandemic.
3. Governance and responsibilities
Organisations and employers including NHS Trusts, NHS Boards, Health and Social Care Trusts
(Northern Ireland), local authorities, and independent sector providers, through their Chief Executive
Officer (CEO) or equivalent, must ensure:
monitoring of IPC practices, as recommended in this guidance, and ensure that resources are in
place to implement and measure adherence to good IPC practice. This must include all care
areas and all staff (permanent, agency and external contractors)
testing and self-isolation strategies are in place with a local policy for the response if
transmission rates of COVID-19 increase
training in IPC measures is provided to all staff, including: the correct use of PPE including a
face fit test if wearing a FFP3, respirator, and the correct technique for putting on and removing
(donning/doffing) safely
risk assessment(s) is undertaken for any staff members in at risk or clinically extremely
vulnerable groups, including pregnant and Black, Asian and Minority Ethnic (BAME) staff.
Guidance on carrying out risk assessments can be found by following the links to the country
specific resources in section 2.1
patients/individuals at high risk/extremely high risk of severe illness are protected from COVID-
19. This must include consideration of families and carers accompanying patients/individuals for
treatments/procedures
health and care settings are COVID-19 secure workplaces as far as practical, that is, that any
workplace risk(s) are mitigated maximally for everyone. This may entail local risk assessments
based on the measures as prioritised in the hierarchy of controls in the context of managing
infectious agents and should be communicated to staff
Disclaimer:
When an organisation adopts practices that differ from those recommended/stated in this national
guidance, that individual organisation is responsible for ensuring safe systems of work, including the
completion of a risk assessment(s) approved through local governance procedures, for example
Integrated Care System level, Health Board.
4. COVID-19 care pathways
These pathways are specific to the COVID-19 pandemic and are examples of how organisations may
separate COVID-19 risks. It is important to note that these pathways do not necessarily define a
service to a particular pathway and should not impact the delivery and duration of care for the patient
or individual. Moving patients between pathways should be based on their infectious status (testing
required), clinical need, availability of services and this should be agreed locally. Implementation
strategies must be underpinned by patient/procedure risk assessment, appropriate testing regimens
(as per organisations or country specific) and epidemiological data. Additional information on specific
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settings can be found in: NICE (2020) COVID-19 rapid guideline: arranging planned care in hospitals
and diagnostic services (https://www.nice.org.uk/guidance/ng179/resources/covid19-rapid-guideline-
arranging-planned-care-in-hospitals-and-diagnostic-services-pdf-66141969613765).
Triaging and testing within all health and other care facilities must be undertaken to enable early
recognition of COVID-19 cases. See Appendix 1
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1021294/202
10118_COVID-19_Infection_prevention_control_Appendix_1_Sample_triage_tool.pdf) for an example of
triage questions. Triage should be undertaken by clinical staff who are trained and competent in the
application of the clinical case definition (https://www.gov.uk/government/publications/wuhan-novel-
coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-
cases-of-wuhan-novel-coronavirus-wn-cov-infection) prior to arrival at a care area, or as soon as possible
on arrival, and allocated to the appropriate pathway. This should include screening for other
infections/multi-drug resistant organisms, including as per national screening requirements.
Infection risk and IPC precautions, for example SICPs or transmission based precautions (TBPs)
must be communicated between care areas/pathways, including when discharge planning.
Patients with respiratory symptoms should be assessed in a segregated area, ideally a single room,
pending test result to define the causative organism.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
4.1 High risk COVID-19 pathway
Any care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown).
or
b) Confirmed SARS-CoV-2 PCR positive individuals are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case, who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments
GP surgeries/walk-in centres
facilities where confirmed or suspected/symptomatic COVID-19 individuals are cared for, for
example:
emergency admissions to inpatient areas (adult and children)
mental health
maternity
critical care units
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renal dialysis units
4.2 Medium risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and infectious status is unknown.
or
d) Asymptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments, GP surgeries and walk-in
centres
non-elective admissions
primary care facilities, for example general dental and general practice
facilities where individuals are cared for, for example:
inpatients (adult and children)
mental health
maternity
critical care units
outpatient departments including diagnostics and endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.3 Low risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test within 72 hours of treatment and, for planned admissions,
have self-isolated for the required period or from the test date.
or
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b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Examples of the patient (individual) groups/facilities within this pathway (this list is exhaustive):
planned/elective surgical procedures including day cases
oncology/chemotherapy patients and/or facilities
planned inpatient admissions (adult and children), mental health, maternity
outpatients including diagnostics/endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.4 Administration measures for the pathways
1. Establish separation of patient pathways and staff flow to minimise contact between pathways.
For example, this could include provision of separate entrances and exits (if available) or use of
one-way entrance and exit systems, clear signage and restricted access to communal areas:
care areas (for example, ward, clinic, GP practice, care home) may designate self-
contained area(s) or ward(s) for the treatment and care of patients/individuals at high,
medium and low risk of COVID-19. Temporal separation may be used in clinics/primary
care settings
as a minimum in smaller facilities or primary care outpatient settings physical or temporal
separation of patients/departments at high risk of COVID-19 from the rest of the
facility/patients
2. Ensure that hygiene facilities, IPC measures and messaging are available for all
patients/individuals, staff and visitors to minimise COVID-19 transmission such as:
hand hygiene facilities including instructional posters
good respiratory hygiene measures
maintaining physical distancing of 2 metres at all times (unless wearing PPE due to clinical
care or personal care as per pathways)
increasing frequent decontamination of equipment and environment
considering improving ventilation by opening windows (natural ventilation) if mechanical
ventilation is not available
clear advice on use of face coverings and face masks by patients/individuals, visitors and
by staff in non-patient facing areas - this will include:
use of face masks/coverings by all outpatients (if tolerated) and visitors when entering
a hospital, GP/dental surgery or other care settings
use of a surgical face mask (Type II or Type IIR) by all patients across all pathways, if
this can be tolerated and does not compromise their clinical care, such as when
receiving oxygen therapy. This will minimise the dispersal of respiratory secretions and
reduce environmental contamination
extended use of face masks by all staff in both clinical and non-clinical areas within the
healthcare or care setting
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where visitors are unable to wear face coverings due to physical or mental health
conditions or a disability, clinicians/person in charge should consider what other IPC
measures are in place, such as physical distancing and environmental cleaning, to
ensure sufficient access depending on the patient’s condition and the care pathway
3. Where possible and clinically appropriate remote consultations rather than face-to-face should
be offered to patients/individuals.
4. Ensure restricted access between pathways if possible (depending on size of the facility,
prevalence/incidence rates), by other patients/individuals, visitors or staff, including patient
transfer and in communal staff areas (changing rooms/restaurant). If the prevalence/incidence
rates decline this may not be necessary between pathways providing the IPC measures are
reliably maintained.
5. Ensure areas/wards are clearly signposted, using physical barriers as appropriate to ensure
patients/individuals and staff understand the different risk areas.
6. Ensure local standard operating procedures detail the measures to segregate equipment and
staff, including planning for emergency scenarios, as the prevalence/incidence of COVID-19
may increase or decrease until cessation of the pandemic.
7. Ensure a rapid and continued response through ongoing surveillance of rates of infection within
the local population and for hospital/organisation onset cases (staff and patients/individuals).
Positive cases identified after admission who fit the criteria for a healthcare associated infection
should trigger a case investigation. If 2 or more cases are linked in time and place, an outbreak
investigation should be conducted. Refer to country-specific definitions.
8. If the prevalence/incidence rate for COVID-19 is high, where possible, assign separate teams of
health and other care workers, including domestic staff, to care for individuals in isolation/cohort
rooms or areas/pathways. If a member of staff is required to move between
sites/hospitals/cohort areas due to the unique function of their role, all IPC measures including
physical distancing must be maintained.
9. Providers of planned services should be responsive to local and national prevalence/incidence
data on COVID-19 and adapt processes so that services can be stepped-up or down. This can
be assessed using the respective countries weekly COVID-19 surveillance report/SARS-CoV-2
positivity data on admission, and local capacity and resources.
10. Safe systems of work outlined in the hierarchy of controls
(https://www.cdc.gov/niosh/topics/hierarchy/default.html) including elimination, substitution,
engineering, administrative controls and PPE/RPE are an integral part of IPC measures.
Organisations should undertake risk assessments based on these measures, prioritised in the
hierarchy of controls in the context of managing infectious agents. If an unacceptable risk of
transmission remains following a risk assessment taking these controls into account, it may be
necessary to consider the extended use of RPE for patient care in specific situations. The risk
assessment should include evaluation of the ventilation in the area, operational capacity, and
prevalence of infection/new variants of concern in the local area.
Supporting tools for local risk assessment are available at NHS England Every Action Counts
Resources (https://www.england.nhs.uk/coronavirus/publication/every-action-counts/).
4.5 Community settings
Areas where triaging for COVID-19 is not possible, for example community pharmacies:
signage at entry points advising of the necessary precautions
staff should maintain 2 metres physical distance with customers/service users, using floor
markings, clear screens or wear surgical face masks (Type IIR) where this is not possible
patients/individuals with symptoms should be advised not to enter the premises
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Outpatient/primary/day care
outpatient, primary care and day care settings:
where possible and appropriate, services should utilise virtual consultation
if attending outpatients or diagnostics, service providers should consider timed appointments
and strategies such as asking patients/individuals to wait to be called to the waiting area with
minimum wait times
patients/individuals should not attend if they have symptoms of COVID-19 or are isolating as a
contact/exposure and communications should advise actions to take in such circumstances for
example for patients/individuals receiving chemotherapy and renal dialysis
communications prior to appointments should provide advice on what to do if patients/individuals
suspect they have come into contact with someone who has COVID-19 prior to their
appointment
outpatient letters should be altered to advise patients/individuals on parking, entrances, IPC
precautions and COVID-19 symptoms
patients/individuals must be instructed to remain in waiting areas and not visit other parts of the
facility
prior to admission to the waiting area, all patients/individuals and accompanying persons should
be triaged for COVID-19 symptoms and assessed for exposure to contacts
patients/individuals and accompanying persons will also be asked to wear a mask/face covering
at all times
RS-CoV-2 confirmed positive patients/individuals or those self-isolating should still be assessed
d reviewed following the high/medium care pathway in these settings, to ensure urgent
atment/appointments are accommodated. This is important to avoid unwarranted poor patient
comes.
ome clinical outpatient settings, such as vaccination/injection clinics, where contact with
ividuals is minimal, the need for PPE items for each encounter, for example gloves and aprons are
y recommended when there is (anticipated) exposure to blood/body fluids or non-intact skin. Staff
ministering vaccinations/injections must apply hand hygiene between patients and wear a
sional face mask.
Standard infection prevention control precautions (SICPs) - all pathways or
ttings
Ps are the basic IPC measures necessary to reduce the risk of transmitting infectious agents
m both recognised and unrecognised sources of infection and are required across all COVID-19
hways. Sources of (potential) infection include blood and other body fluids secretions or
retions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in
care environment that could have become contaminated.
e application of SICPs during care delivery is determined by an assessment of risk to and from
ividuals and includes the task, level of interaction and/or the anticipated level of exposure to blood
d/or other body fluids.
Ps must therefore be used by all staff, in all care settings, at all times and for all
ients/individuals, whether infection is known or not, to ensure the safety of patients/individuals,
ff and visitors. This section highlights the key measures for the COVID-19 pathways. Please refer
he practice guide* for additional information on the other elements which remain unchanged.
e elements of SICPs are:
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patient placement and assessment for infection risk (screening/triaging/testing)
hand hygiene
respiratory and cough hygiene
personal protective equipment
safe management of the care environment
safe management of care equipment
safe management of healthcare linen
safe management of blood and body fluids
safe disposal of waste (including sharps)
occupational safety: prevention and exposure management
maintaining social/physical distancing (new SICP due to COVID-19)
*Practice guides and literature reviews to support SICPs can be found for England and Scotland
(http://www.nipcm.hps.scot.nhs.uk/), Wales (https://phw.nhs.wales/services-and-teams/harp/infection-
prevention-and-control/nipcm/) and Northern Ireland (https://www.niinfectioncontrolmanual.net/).
5.1 Personal protective equipment (PPE)
For the purpose of this document, the term ‘personal protective equipment’ is used to describe
products that are either PPE or medical devices that are approved by the Health and Safety
Executive (HSE) and the Medicines and Healthcare products Regulatory Agency (MHRA) as
protective solutions in managing the COVID-19 pandemic.
Local or national uniform policies (https://www.england.nhs.uk/about/equality/equality-hub/uniforms-and-
workwear/) should be considered when wearing PPE.
All PPE should be:
located close to the point of use (where this does not compromise patient safety, for example,
mental health/learning disabilities). In domiciliary care PPE must be transported in a clean
receptacle
stored safely and in a clean, dry area to prevent contamination
within expiry date (or had the quality assurance checks prior to releasing stock outside this date)
single use unless specified by the manufacturer or as agreed for extended/sessional use
including surgical face masks
changed immediately after each patient and/or after completing a procedure or task (unless
sessional use has been agreed and local risk assessment undertaken)
disposed into the correct waste stream depending on setting, for example domestic
waste/offensive (non-infectious) or infectious clinical waste
discarded if damaged or contaminated
safely doffed (removed) to avoid self-contamination. See guidance on donning (putting on) and
doffing (removing) (https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-
use-for-aerosol-generating-procedures)
decontaminated after each use following manufacturer’s guidance if reusable PPE is used,
specifically non-disposable goggles/face shields/visors
Gloves must:
be worn when exposure to blood and/or other body fluids, non-intact skin or mucous
membranes is anticipated or likely*
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be changed immediately after each patient and/or after completing a procedure/task even on the
same patient
be put on immediately before performing an invasive procedure and removed on completion
not be decontaminated with alcohol based hand rub (ABHR) or soap between use
Double gloving is not recommended for routine clinical care of COVID-19 cases.
*Vinyl medical gloves should only be worn in care situations where there is no anticipated exposure
to blood and/or body fluids.
Aprons must be:
worn to protect uniform or clothes when contamination is anticipated or likely
worn when providing direct care within 2 metres of suspected/confirmed COVID-19 cases
changed between patients and/or after completing a procedure or task
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed (surgical procedures)
changed between patients/individuals and immediately after completing a procedure or task
Eye or face protection (including full-face visors) must:
be worn if blood and/or body fluid contamination to the eyes or face is anticipated or likely – for
example, by members of the surgical theatre team and always during AGPs
not be impeded by accessories such as piercings or false eyelashes
not be touched when being worn
Regular corrective spectacles are not considered as eye protection.
Fluid resistant surgical face mask (FRSM Type IIR) masks must:
be worn with eye protection if splashing or spraying of blood, body fluids, secretions or
excretions onto the respiratory mucosa (nose and mouth) is anticipated or likely
be worn when providing direct care within 2 metres of a suspected/confirmed COVID-19 case
be well-fitting and fit for purpose, fully cover the mouth and nose (manufacturer’s instructions
must be followed to ensure effective fit and protection)
not be touched once put on or allowed to dangle around the neck
be replaced if damaged, visibly soiled, damp, uncomfortable or difficult to breathe through
Surgical face masks Type II must be:
worn for extended use by HCWs when entering the hospital or care setting (Type IIR is also
suitable). Type I is suitable in some settings, refer to the country specific resources in section
2.1
Head/footwear:
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t
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headwear is not routinely required in clinical areas (even if undertaking an AGP) unless part of
heatre attire or to prevent contamination of the environment such as in clean rooms
headwear worn for religious reasons (for example, turban, kippot veil, headscarves) are
permitted provided patient safety is not compromised - these must be washed and/or changed
between each shift or immediately if contaminated and comply with additional attire in, for
example, theatres
oot/shoe coverings are not required or recommended for the care of COVID-19 cases
may restrict communication with some individuals and other ways of communicating to meet
needs should be considered.
erosol generating procedures – procedures that create a higher risk of
iratory infection transmission
GP is a medical procedure that can result in the release of airborne particles (aerosols) from the
atory tract when treating someone who is suspected or known to be suffering from an infectious
transmitted wholly or partly by the airborne or droplet route.
s the list of medical procedures for COVID-19 that have been reported to be aerosol generating
re associated with an increased risk of respiratory transmission:
racheal intubation and extubation
manual ventilation
racheotomy or tracheostomy procedures (insertion or removal)
bronchoscopy
dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills)
non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and
continuous positive airway pressure ventilation (CPAP)
high flow nasal oxygen (HFNO)
high frequency oscillatory ventilation (HFOV)
nduction of sputum using nebulised saline
espiratory tract suctioning*
upper ear, nose and throat (ENT) airway procedures that involve respiratory suctioning*
upper gastro-intestinal endoscopy where open suction of the upper respiratory tract* occurs
beyond the oro-pharynx
high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses
nvolved
available evidence relating to respiratory tract suctioning is associated with ventilation. In line
precautionary approach, open suctioning of the respiratory tract regardless of association with
ation has been incorporated into the current (COVID-19) AGP list. It is the consensus view of
K IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP,
s oral/pharyngeal suctioning is not an AGP. The evidence on respiratory tract suctioning is
ntly being reviewed by the AGP Panel which is an independent panel set up by the 4 Chief
cal Officers (CMOs) to review new or further evidence for consideration.
in other procedures or equipment may generate an aerosol from material other than patient
tions but are not considered to represent a significant infectious risk for COVID-19. Procedures
category include administration of humidified oxygen, administration of Entonox or medication
ebulisation.
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The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during
nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and
does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a
contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an
aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and
oxygen masks. In addition, the current expert consensus from NERVTAG
(https://www.swast.nhs.uk/assets/1/cpr_as_an_agp_-
_evidence_review_and_nervtag_consensus.pdf#:~:text=NERVTAG%20consensus%20statement%20on%20Car
ute%20respiratory%20infections) is that chest compressions are not considered to be procedures that
pose a higher risk for respiratory infections including COVID-19.
Further information on AGPs for neonates (https://hubble-live-
assets.s3.amazonaws.com/bapm/redactor2_assets/files/729/COVID__FAQ_19.10.20.docx.pdf) and a
literature review for AGPs during COVID-19 (https://hps.scot.nhs.uk/web-resources-container/sbar-
assessing-the-evidence-base-for-medical-procedures-which-create-a-higher-risk-of-respiratory-infection-
transmission-from-patient-to-healthcare-worker/) are available.
7. Low risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test result within 72 hours of treatment and, for planned
admissions, have self-isolated for the required period or from the test date.
or
b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Clinicians should advise people who are at greater risk of getting COVID-19, or having a poorer
outcome from it, that they may want to self-isolate for 14 days before a planned procedure. The
decision to self-isolate will depend on their individual risk factors and requires individualised care and
shared decision making.
Some individuals who have recovered from COVID-19 may continue to test positive for SARS-CoV-2
by PCR for up to 90 days from their initial illness onset. If they do not have any new COVID-19
symptoms and have not had a known COVID-19 exposure they are unlikely to be infectious.
However, advice should be sought from an infection specialist (infectious
disease/virologist/microbiologist) for severely immunosuppressed individuals who continue to test
positive.
Patients/individuals on a low risk pathway require SICPs for all care including surgery or procedures.
7.1 Maintaining physical distancing
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ll staff and other care workers must maintain social/physical distancing of 2 metres where possible
nless providing clinical or personal care and wearing PPE as per care pathway).
.2 Personal protective equipment
PE required for SICPs when following the low risk pathway is as follows:
SICPs/PPE (all
settings / all
patients/individuals
Disposable
gloves
)
Disposable
apron/gown
Face masks
Eye/face protection
(visor)
If contact with blood
and/or body fluids is
anticipated
Single use
Single use
apron (gown
if risk of
spraying /
splashing)
FRSM Type IIR
for direct patien
care and surgic
mask Type II* fo
extended use
Risk assess and use if
t required for care
al procedure/task where
r anticipated blood/body
fluids spraying/splashes
Sessional/extended use of face masks applies across the UK for HCWs in any health or other care
ettings.
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
.3 Safe management of environment/equipment and blood/body fluids
uring the pandemic, the frequency of cleaning of both the environment and equipment in care
atient) areas should be increased to at least twice daily, this includes frequently touched
tes/points and communal facilities such as shared toilets.
the low risk COVID-19 pathway, organisations may choose to revert to general purpose detergents
r cleaning, as opposed to widespread use of disinfectants (with the exception of blood and body
uids, where a chlorine releasing agent (or a suitable alternative) solution should be used).
.3.1 Safe management of waste
aste must be segregated in line with the respective countries’ national regulation and there is no
quirement to dispose of all waste as infectious waste in the low risk pathway.
.3.2 Operating theatres and procedure rooms
ithin the low risk COVID-19 pathway, standard theatre cleaning and time for air changes provides
ppropriate levels of IPC and there is no requirement for additional cleaning or theatre down time
nless the patient has another infectious agent that requires additional IPC measures.
.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
f respiratory infection transmission
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
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ere is no additional requirement for ventilation or downtime in this pathway, providing safe systems
work, including engineering controls are in place.
.1 Critical care areas
oviding suspected/confirmed COVID-19 cases can be cared for in single rooms or isolation rooms,
department should no longer be classified as an AGP ‘hot spot’ or ‘high risk area’. This should be
fined locally depending on prevalence/incidence data and the subsequent pathway assigned. This
gates the requirement for the routine wearing of airborne PPE including a respirator in the low risk
VID-19 pathway.
.2 Operating theatres
tients/individuals in the low risk COVID-19 pathway do not need to be anaesthetised or recovered
the operating theatre if intubation/extubation (AGP) is required.
5 Visitor guidance
outlined in the administration measures for the pathways (section 4.4), hand hygiene and
spiratory hygiene, and the wearing of a face covering (if tolerated) along with social distancing
ould be encouraged and maintained. Therefore visitors require no additional PPE. Visitors should
triaged.
6 Discharge or transfer
ere is no restriction on discharge unless the patient/individual is entering a long-term care facility
ere testing may be required. If someone in the patient’s household has COVID-19 or is a contact
a COVID-19 case and is self-isolating, the discharge guidance will be provided by the clinician.
England, to ensure testing does not delay a timely discharge to a care home, all patients who have
eviously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
munocompetent patients who have tested positive within the previous 90 days, and remain
ymptomatic, do not need to be re-tested. The information from the test results, with any supporting
re information, must be communicated and transferred to the relevant care home. No one should
discharged from hospital directly to a care home without the involvement of the local authority.
scharge arrangements may differ between countries, refer to country specific resources in section
.
Transmission based precautions (TBPs)
Ps are additional measures (to SICPs) required when caring for patients/individuals with a known
suspected infection such as COVID-19.
Ps are based upon the route of transmission and include the following precautions:
Contact precautions
ed to prevent and control infections that spread via direct contact with the patient or indirectly from
patient’s immediate care environment (including care equipment). This is the most common route
cross-infection transmission. COVID-19 can be spread via this route.
Droplet precautions
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Used to prevent and control infections spread over short distances (at least 3 feet/1 metre) via
droplets (>5µm) from the respiratory tract of individuals directly onto a mucosal surface or
conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar
level. COVID-19 is predominantly spread via this route and the precautionary distance has been
maintained at 2 metres in care settings.
c) Airborne precautions
Used to prevent and control infection spread without necessarily having close patient contact via
aerosols (≤5µm) from the respiratory tract of one individual directly onto a mucosal surface or
conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.
COVID-19 can spread via this route. This can be mitigated by safe systems of work outlined in the
hierarchy of controls. AGPs increase the risk of spread by the airborne route.
8.1 Transmission characteristics
Transmission of SARS-CoV-2 implications for infection prevention precautions is contained within the
WHO scientific briefing paper (https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-
2-implications-for-infection-prevention-precautions) and CDC’s scientific brief
(https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html).
Literature reviews to support evidence for transmission characteristics
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/979441/S116
9_Facemasks_for_health_care_workers.pdf) and TBPs (http://www.nipcm.hps.scot.nhs.uk/resources/literature-
reviews/) are available.
New SARS-CoV-2 variants of concern have been identified in the UK. For further information on the
variants refer to Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and
situation in the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-
sars-cov-2-b1617-variants) and Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
202012011).
9. Medium risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and therefore infectious status is
unknown.
or
d) Asymptomatic individuals decline testing.
9.1 Maintaining physical distancing and patient placement
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It is important to:
maintain physical distancing of 2 metres at all times (unless the member of staff is wearing
appropriate PPE to provide clinical care) and to advise other patients/visitors to comply
ensure cohorted patients/individuals are physically separated from each other, for example with
screens and privacy curtains between the beds to minimise opportunities for close contact - this
should be locally risk assessed to ensure patient safety is not compromised
9.2 Personal protective equipment: patients/individuals with no COVID-19
symptoms and no test results
PPE required by type of
transmission/exposure
Disposable
gloves
Disposable apron/gown
Face masks
Eye/face
protection
(visor)*
Droplet/contact PPE for
direct patient care <2
metres
Single
use**
Single use apron (gown
required if risk of
spraying/splashing)
FRSM Type
IIR†
Single use
or
reusable*
Airborne PPE (when
undertaking or if AGPs
are likely)
Single use
Single use apron or gown
FFP3†† or
respirator/
hood for AGPs
Single use
or reusable
† FRSM can be worn sessionally if providing care for COVID-19 cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Risk assess and use if required for care procedure/task where anticipated blood/body fluids
spraying/splashes.
**Gloves are not required when: undertaking administrative tasks, for example using the telephone,
using a computer or tablet, writing in the patient chart; giving oral medications, distributing or
collecting patient dietary trays.
9.3 Safe management of care environment/equipment/blood and body fluids
9.3.1 Equipment
Important considerations in the use of equipment are:
patient care equipment should be single use items where practicable
reusable (communal) non-invasive equipment should be allocated to an individual patient or
cohort of patients/individuals
all reusable (communal) non-invasive equipment must be decontaminated:
between each and after patient/individual
after blood and body fluid contamination
at regular intervals as part of routine equipment cleaning
decontamination of equipment must be performed using either:
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a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available
chlorine (ppm av.cl.); or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl.
alternative cleaning agents/disinfectant products may be used with agreement of the IPC
team/health protection team (HPT)
cleaning of care equipment as per manufacturer’s guidance/instruction and recommended
product ‘contact time’ must be followed for all cleaning/disinfectant solutions/products
an increased frequency of decontamination should be considered for all reusable non-invasive
care equipment when used in isolation/cohort areas
the use of fans in high and medium risk pathways should be risk assessed - refer to Estates
guidance
9.3.2 Environment
Important considerations for environmental cleaning and disinfection are:
cleaning frequencies of the care environment in COVID-19 care areas must be enhanced and
single rooms, cohort areas and clinical rooms (including rooms where PPE is removed) cleaned
at least twice daily
routine cleaning must be performed using either:
a combined detergent/disinfectant solution at a dilution of 1,000ppm av.cl.; or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl
alternative cleaning agents/disinfectants may be used with agreement of the local IPC
team/HPT
the increased frequency of decontamination/cleaning should be incorporated into the
environmental decontamination schedules for all COVID-19 areas, including where there may
be higher environmental contamination rates, including for example:
toilets/commodes particularly if patients/individuals have diarrhoea
‘frequently touched’ surfaces such as medical equipment, door/toilet handles, locker tops,
patient call bells, over bed tables, bed rails, phones, lift buttons/communal touch points and
communication devices (for example, mobile phones, tablets, desktops, keyboards)
particularly where these are used by many people, should be cleaned at least twice daily
with solution of detergent and 1,000ppm chlorine or an agreed alternative when known to
be contaminated with secretions, excretions or body fluids
dedicated or disposable equipment (such as mop heads, cloths) must be used for environmental
decontamination
reusable equipment (such as mop handles, buckets) must be decontaminated after use with a
chlorine-based disinfectant or locally agreed disinfectant
single (isolation) rooms must be terminally cleaned as above following resolution of symptoms,
discharge or transfer (this includes removal and laundering of all curtains and bed screens)
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4 Aerosol generating procedures (AGPs): procedures that create a higher risk
respiratory infection transmission
Ps should only be carried out when essential and only staff who are needed to undertake the
ocedure should be present, wearing airborne PPE/RPE precautions (see information in the high
k pathway guidance).
4.1 Critical care areas
oplet precautions apply when within 2 metres and providing direct patient care. Airborne
ecautions are required when undertaking AGPs. However, consideration may need to be given to
e application of sessional use of FFP3 masks where the number of cases of suspected/possible
OVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or
lation rooms that is patient cohort. Sessional use of FFP3 masks (includes eye/face protection)
ay be considered. All other items of PPE (gloves/gown) must be changed between patients and/or
er completing a procedure or task.
4.2 Operating theatres
tients/individuals should be anaesthetised and recovered in the operating theatre if
ubation/extubation (AGP) is required. For local, neuraxial or regional anaesthesia the patient is not
quired to be anaesthetised/recovered in theatre.
5 Duration of TBPs
Ps should only be discontinued in consultation with clinicians and should take into consideration
e individual’s PCR test results and clinical symptoms. If test results are not available (for example
e patient/individual declines) TBPs can be discontinued after 14 days (inpatients) depending on
ntact exposure and providing the patient/individual remains symptom free.
6 Visitor guidance
siting may be limited during increases in incidence and prevalence of COVID-19, however as cases
cline and restrictions ease, visitors should be permitted to enter the facility and be educated in the
C measures required as outlined in the information on administration measures for the pathways.
visitors should be triaged.
is includes accompanying individuals when attending outpatient appointments, such as antenatal
pointments and therapy groups.
7 Discharge or transfer
ere is no restriction on discharge if the patient/individual is well, unless the patient/individual is
tering a long-term facility and testing may be required. If someone in the patient’s household has
OVID-19 or is a contact of a COVID-19 case and is self-isolating, the discharge guidance will be
ovided by the clinician.
scharge information for patients/individuals should include an understanding of their need for any
lf-isolation, as well as their family members (where applicable).
bulance services and the receiving facilities must be informed of the infectious status of the
ividual.
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Discharge arrangements may differ between countries, refer to country specific resources in section
2.1.
In England, to ensure testing does not delay a timely discharge to a care home, all patients who have
previously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
Immunocompetent patients who have tested positive within the previous 90 days, and remain
asymptomatic, do not need to be re-tested. The information from the test results, with any supporting
care information, must be communicated and transferred to the relevant care home. No one should
be discharged from hospital directly to a care home without the involvement of the local authority.
10. High risk pathway – key principles
This pathway applies to any emergency/urgent care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown*).
or
b) Confirmed SARS-CoV-2 (COVID-19) PCR positive patients are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
*Once assessed, if asymptomatic with no contact history, patients/individuals may move to the
medium risk pathway awaiting test result.
10.1 Patient placement
If the patient/individual has symptoms or a history of contact/exposure with a case, they should be
prioritised for single room isolation or cohorted (if an isolation room is unavailable) until their test
results are known, for example use privacy curtains between bed spaces to minimise opportunities
for close contact between patients/individuals. This should be locally risk assessed to ensure this
does not compromise patient safety.
If single rooms are in short supply, priority should be given to patients with excessive cough and
sputum production, diarrhoea or vomiting and to those at high risk/extremely high risk of severe
illness.
Local risk assessments and clinical decisions must be made regarding placement of
patients/individuals with availability of single rooms taken into consideration.
10.2 Personal protective equipment (PPE): suspected/confirmed COVID-19
patient/individual
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PPE required by type of
transmission/exposure
Disposable
gloves
Disposable
apron/gown
Face
masks
Eye/face
protection
(visor)
Droplet/contact PPE
Single use
Single use apron
and gown if risk
of spraying /
splashing)
FRSM
Type IIR
for direc
patient
care†
Single use
t
or reusable
Airborne PPE (when undertaking or if
AGPs are likely)*
If an unacceptable risk of
transmission remains following
rigorous application of the hierarchy
of control**
Single use
Single use gown
FFP3††
respirato
/ hood fo
AGPs
or
r Single use
r or reusable
†FRSM can be worn sessionally (includes eye/face protection) if providing care for COVID -19
cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Consideration may need to be given to the application of airborne precautions where the number of
cases of COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single
or isolation rooms.
**Or if an unacceptable risk of transmission remains following rigorous application of the hierarchy of
control, taking these controls into account, it may be necessary to consider the extended use of RPE
for patient care in this situation.
10.2.1 Respiratory protective equipment (RPE)/FFP3 (filtering face piece or hood)
Respirators are used to prevent inhalation of small airborne particles arising from AGPs.
Respirators should:
be well fitting, covering both nose and mouth
always be worn when undertaking an AGP on a COVID-19 confirmed or suspected
patient/individual
not be allowed to dangle around the neck of the wearer or hang from one ear after or between
each use
not be touched once put on
be removed outside the patient’s/individual’s room or cohort area or COVID-19 ward
respirators can be single use or single session use (disposable or reusable) and fluid-resistant
all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to
ensure an adequate seal or fit (according to the manufacturer’s guidance)
where fit testing fails, suitable alternative equipment must be provided, or the HCW should be
moved to an area where FFP3 respirators are not required
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fit checking (according to the manufacturer’s guidance) is necessary when a respirator is put on
(donned) to ensure an adequate seal has been achieved
respirators should be compatible with other facial protection used (protective eyewear) so that
this does not interfere with the seal of the respiratory protection
the respirator should be discarded and replaced and not be subject to continued use if the facial
seal is compromised, it is uncomfortable, or it is difficult to breathe through
reusable respirators can be utilised by individuals if they comply with HSE recommendations -
reusable respirators should be decontaminated according to the manufacturer’s instructions
Valved respirators are not fluid-resistant unless they are also ‘shrouded’. Valved non-shrouded FFP3
respirators should be worn with a full-face shield if blood or body fluid splashing is anticipated. Valved
respirators should not be worn by an HCW/operator when sterility directly over the surgical field is
required, for example in theatres/surgical settings or when undertaking a sterile procedure, as the
exhaled breath is unfiltered.
Examples of sterile procedures include:
any surgical or invasive procedure that routinely requires maximal sterile barrier precautions to
prevent infection, for example sterile gowns, sterile gloves, face mask as required for surgical
antisepsis/ANTT - these are commonly but not exclusively undertaken in operating theatres,
critical care or emergency departments
those sterile percutaneous or invasive procedures such as interventional radiology/cardiac
catheterisation, PICC or other central venous catheter insertions
The ongoing use of valved respirators in theatres and surgical settings should be based on a local
risk assessment. The risk of an asymptomatic HCW transmitting COVID-19 infection if wearing a
valved respirator is considered ‘very small’, as the HCW would need to be excreting virus and the
patient would need to be negative for COVID-19 (FFP3 use is when an HCW is managing a
suspected/confirmed COVID-19 positive patient undergoing AGPs in the medium or high risk
pathway).
10.2.2 Full body gowns or fluid repellent coveralls
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed for example, surgery changed between patients/individuals and immediately after
completing a procedure or task
Sessional or extended use of gowns must be minimised and only used in areas where cohorts of
confirmed COVID-19 patients are managed and there is a lack of single rooms/isolation rooms. If
sessional use is required, an individual patient risk assessment must be undertaken and reviewed
daily. Gowns are not required when moving around a unit or department.
10.3 Safe management of care environment/equipment/blood and body fluids
Please refer to information given in the medium risk pathway.
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In addition if there are clusters or outbreaks of COVID-19 (2 or more cases linked by time and place)
with significant respiratory symptoms in communal settings cleaning frequencies should be
increased.
10.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
of respiratory infection transmission and operating theatres
10.4.1 Critical care
Droplet precautions would apply, however consideration may need to be given to the application of
airborne precautions where the number of cases of COVID-19 requiring AGPs increases and
patients/individuals cannot be managed in single or isolation rooms.
10.4.2 Operating theatres (including day surgery)
Patients/individuals should be anaesthetised and recovered in the theatre if intubation/extubation
(AGP) is required using airborne precautions. This is not required for regional, neuraxial or local
anaesthesia.
Ventilation in both laminar flow and conventionally ventilated theatres should remain in full operation
during surgical procedures where patients/individuals have suspected/confirmed COVID-19. Air
passing from operating theatres to adjacent areas will be highly diluted and is not considered to be a
risk.
10.5 Duration of precautions
In general, patients with COVID-19 who are admitted to hospital will have more severe disease than
those who can remain in the community, especially if they have been severely unwell or have pre-
existing conditions such as severe immunosuppression. Therefore, it is recommended that these
individuals should be isolated within hospital or remain in self-isolation on discharge for 14 days from
their first positive SARS-CoV-2 PCR test.
Whilst in hospital patients/individuals should remain in isolation/cohort with TBPs applied for at least
14 days after onset of symptoms and should be 48 hours without a fever (without use of antipyretic
medication) or respiratory symptoms. The decision to modify the duration of, or ‘stand down’ TBPs
(contact/droplet/airborne) should be made by the clinical team managing the individual’s care.
For clinically suspected COVID-19 patients who have tested negative or have not been tested for
SARS-CoV-2 and whose condition is severe enough to require hospitalisation, then the 14 day
isolation period should be measured from the day of admission.
Testing for virological clearance is encouraged in severely immunosuppressed patients. For these
patients, IPC measures should be continued unless there is evidence of virological clearance prior to
discharge or there has been a complete resolution of all symptoms. This is different to other advice
sections but reflects the complex health needs of such patients and likelihood for prolonged
shedding, with risk of spread in healthcare settings. Upon discharge such patients may be retested at
first follow-up appointment to help inform actions at any next medical appointment.
10.6 Visitor guidance
In this pathway, visiting should continue to be limited to only essential visitors, for example birthing
partner, carer/parent/guardian. Hospitals/organisations will provide advice and guidance to support
patients during these restrictions. Visitor guidance may differ between countries, refer to country
specific resources in section 2.1.
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Whilst face masks/coverings are recommended the need for visitors to wear additional PPE should
be individually assessed.
10.7 Discharge or transfer
Discharge from an inpatient facility can occur when the individual is well enough and the clinician has
provided them with discharge such as advice to self-isolate for at least 14 days from the date of the
positive SARS-CoV-2 PCR test (providing their symptoms resolve during this period). Refer to
country specific resources in section 2.1.
Advice should include written information, such as patients with a cough or a loss of, or change in,
normal sense of smell or taste (anosmia), may persist in some individuals for several weeks following
COVID-19 recovery, and is not currently considered an indication of ongoing infection when other
symptoms have resolved.
Prior to discharge (if the patient is within the 14 days) clinicians should ascertain if there are any
clinically extremely vulnerable individuals who live in the household and are currently not infected. If
so, it is highly advisable for patients to be discharged to a different home until they have finished their
self-isolation period. If these individuals cannot be moved to a different household, then ensure that
the discharged patient is advised on IPC measures as outlined in the Stay at home guidance
(https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-
households-with-possible-coronavirus-covid-19-infection).
Advice on ongoing medical needs should be provided for patients who are discharged within their
self-isolation period. If patients deteriorate at home or in a care setting, they or their carer should
seek advice from NHS 111 online (https://111.nhs.uk/) or by telephone, or through pre-existing services
such as GP practice links with care homes. In an emergency, 999 should be called. In either case,
they should inform the call attendant that they have been recently discharged from hospital with
confirmed COVID-19.
Discharge information for patients/individuals to their own home should include an understanding of
their need for any self-isolation, as well as their family/household members.
Ambulance services and the receiving facilities must be informed of the infectious status of the
individual and the ongoing need to continue with infection control precautions.
Discharge arrangements may differ between countries as discharge to other areas is dependent on
testing and/or isolation facilities available. Refer to country specific resources in section 2.1.
In England, to ensure testing does not delay a timely discharge to a care home, patients who have
tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge. All SARS-
CoV-2 positive patients who are discharged within their 14 day self-isolation period will need to be
discharged to a designated setting. The information from the test results, with any supporting care
information, must be communicated and transferred to the relevant care home. No one should be
discharged from hospital directly to a care home without the involvement of the local authority.
11. Occupational health and staff deployment
Prompt recognition of cases of COVID-19 among healthcare staff is essential to limit the spread.
Health and social care staff with symptoms of COVID-19 or a positive COVID-19 test result should
not come to work. Refer to country specific testing requirements.
As a general principle, healthcare staff who provide care in settings for suspected or confirmed
patients/individuals should not care for other patients. However, this has to be a local decision based
on local epidemiology and the configuration of the organisation.
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A risk assessment is required for health and social care staff at high risk of complications from
COVID-19, or clinically extremely vulnerable groups, including pregnant and BAME staff. Guidance
on carrying out risk assessments can be found by following the links to the country specific resources
in section 2.1.
Employers should:
discuss with employees who are clinically extremely vulnerable, including those who are
pregnant and of BAME origin, the need to be deployed away from areas used for the care of
those who have, or are clinically suspected of having, COVID-19; or, in primary care settings,
clinics set up to manage people with COVID-19 symptoms
ensure that advice is available to all health and social care staff, including specific advice to
those at risk from complications
Bank, agency and locum staff who fall into these categories should follow the same deployment
advice as permanent staff.
As part of their employer’s duty of care, providers have a role to play in ensuring that staff understand
and are adequately trained in safe systems of working, including donning and doffing of PPE. A fit
testing programme should be in place for those who may need to wear respiratory protection.
In the event of a breach in infection control procedures, staff should be reviewed by occupational
health.
Occupational health departments should lead on the implementation of systems to monitor staff
illness, absence and vaccination against COVID-19.
12. Glossary of terms
Aerosol generating procedures (AGPs)
Certain medical and patient care activities that can result in the release of airborne particles
(aerosols). AGPs can increase the risk transmission of infections.
Airborne transmission
The spread of infection from one person to another by airborne particles (aerosols) containing
infectious agents.
Airborne particles
Very small particles that may contain infectious agents. They can remain in the air for long periods of
time and can be carried over long distances by air currents. Airborne particles can be released when
a person coughs or sneezes, and during AGPs. ‘Droplet nuclei’ are aerosols formed from the
evaporation of larger droplet particles (see droplet transmission). Aerosols formed from droplet
particles in this way behave as other aerosols.
Airborne precautions
Measures used to prevent and control infection spread without necessarily having close patient
contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly
onto a mucosal surface or conjunctivae of another individual. Aerosols can penetrate the respiratory
system to the alveolar level.
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BS/EN standards
Mandatory technical specifications created by either the British Standards Institute (BS) or European
Standardisation Organisations (EN) in collaboration with government bodies, industry experts and
trade associations. They aim to ensure the quality and safety of products, services and systems.
Clinically vulnerable or extremely clinically vulnerable
People who are defined as clinically extremely vulnerable
(https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-
persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#cev)
are at very high risk of severe illness from COVID-19. Those included in this category will been
identified by:
having one or more of conditions list, or
a clinician or GP has added the individual to the Shielded Patient List
Cohort area
An area (room, bay, ward) in which 2 or more patients (a cohort) with the same confirmed infection
are placed. A cohort area should be physically separate from other patients.
Contact precautions
Measures used to prevent and control infections that spread via direct contact with the patient or
indirectly from the patient’s immediate care environment (including care equipment). This is the most
common route of infection transmission.
Contact transmission
Contact transmission is the most common route of transmission, and consists of 2 distinct types:
direct contact and indirect contact. Direct transmission occurs when microorganisms are transmitted
directly from an infectious individual to another individual without the involvement of another
contaminated person or object (fomite). Indirect transmission occurs when microorganisms are
transmitted from an infectious individual to another individual through a contaminated object (fomite)
or person.
COVID-19
COVID-19 is a highly infectious respiratory disease caused by a novel coronavirus. The disease was
discovered in China in December 2019 and has since spread around the world.
Droplet precautions
Measures used to prevent and control infections spread over short distances (at least 1 metre or 3
feet) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a
mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to
above the alveolar level. COVID-19 is predominantly spread via this route and the precautionary
distance has been maintained at 2 metres in care settings.
Droplet transmission
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e spread of infection from one person to another by droplets containing infectious agents.
e or face protection
orn when there is a risk from splashing of secretion (including respiratory secretions). Eye or face
tection can be achieved using any one of:
a surgical mask with integrated visor
a full face visor or shield
goggles
id-resistant (Type IIR) surgical face mask (FRSM)
disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes
the wearer’s nose and mouth from splashes and infectious droplets. FRSMs can also be used to
tect patients. When recommended for infection control purposes a ‘surgical face mask’ typically
notes a fluid-resistant (Type IIR) surgical mask.
id-resistant
erm applied to fabrics that resist liquid penetration, often used interchangeably with ‘fluid-repellent’
en describing the properties of protective clothing or equipment.
equently touched surfaces
rfaces of the environment which are commonly touched or come into contact with human hands.
althcare or clinical waste
ste produced as a result of healthcare activities, for example soiled dressings, sharps.
erarchy of controls
e hierarchy of controls is used to identify the appropriate controls with Elimination, Substitution,
gineering Controls, Administrative Controls, Personal Protective Equipment.
erarchy of Controls: The National Institute for Occupational Safety and Health (NIOSH), Centers for
ease Control and Prevention (CDC) (https://www.cdc.gov/niosh/topics/hierarchy/default.html)
gh-flow nasal cannula (HFNC) therapy
NC is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at
low rate of up to 60 litres per minute.
gher risk acute care area/units
ensive care units, intensive therapy units, high dependency units, emergency department
uscitation areas, wards with non-invasive ventilation, operating theatres, endoscopy units for
per respiratory, ENT or upper GI endoscopy, and other clinical areas where AGPs are regularly
rformed. Referred to as ‘AGP hot spots’.
ubation period
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The period between the infection of an individual by a pathogen and the manifestation of the illness
or disease it causes.
Induction of sputum
Induction of sputum typically involves the administration of nebulised saline to moisten and loosen
respiratory secretions (this may be accompanied by chest physiotherapy (percussion and vibration))
to induce forceful coughing.
Infectious linen
Linen that has been used by a patient who is known or suspected to be infectious and/or linen that is
contaminated with blood/other body fluids, for example faeces.
Long term health condition
This covers:
chronic obstructive pulmonary disease, bronchitis, emphysema or asthma
heart disease
kidney disease
liver disease
stroke or a transient ischaemic attack (TIA)
diabetes
lowered immunity as a result of disease or medical treatment, such as steroid medication or
cancer treatment
a neurological condition, such as Parkinson’s disease, motor neurone disease, multiple sclerosis
(MS), cerebral palsy, or a learning disability
any problem with the spleen, including sickle cell disease, or had spleen removed
a BMI of 40 or above (obese)
Personal protective equipment (PPE)
Equipment a person wears to protect themselves from risks to their health or safety, including
exposure to infectious agents. The level of PPE required depends on the:
suspected or known infectious agent
severity of the illness caused
transmission route of the infectious agent
procedure or task being undertaken
Respiratory droplets
A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or
speaking.
Respiratory protective equipment
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espiratory protection that is worn over the nose and mouth designed to protect the wearer from
haling hazardous substances, including airborne particles (aerosols). There are 2 types of
spiratory protection that can be used, tight-fitting disposable FFP respirators and loose-fitting
owered hoods (TH2).
FP stands for filtering face piece. There are 3 categories of FFP respirator: FFP1, FFP2 and FFP3.
FP3 and loose-fitting powered hoods provide the highest level of protection and are recommended
hen caring for patients in areas where high risk AGPs are being performed.
espiratory symptoms
espiratory symptoms include:
rhinorrhoea (runny nose)
sore throat
cough
difficulty breathing or shortness of breath
egregation
hysically separating or isolating from other people.
ARS-CoV
evere acute respiratory syndrome coronavirus, the virus responsible for the 2003 outbreak of
uman coronavirus disease.
ARS-CoV-2
evere acute respiratory syndrome coronavirus 2, the virus responsible for the COVID-19 pandemic.
everely immunosuppressed
everely immunosuppressed is defined in the Green Book on Immunisation as:
immunosuppression due to acute and chronic leukaemias and lymphoma (including Hodgkin’s
lymphoma)
severe immunosuppression due to HIV/AIDS (British HIV Association advice
(https://www.bhiva.org/BHIVA-and-THT-statement-on-COVID-19-and-advice-for-the-extremely-vulnerable))
cellular immune deficiencies (such as severe combined immunodeficiency, Wiskott-Aldrich
syndrome, 22q11 deficiency/DiGeorge syndrome)
being under follow up for a chronic lymphoproliferative disorder including haematological
malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma and other
plasma cell dyscrasias
having received an allogenic (cells from a donor) stem cell transplant in the past 24 months and
only then if they are demonstrated not to have ongoing immunosuppression or graft versus host
disease (GVHD)
having received an autologous (using their own stem cells) haematopoietic stem cell transplant
in the past 24 months and only then if they are in remission
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those who are receiving, or have received in the past 6 months, immunosuppressive
chemotherapy or radiotherapy for malignant disease or non-malignant disorders
those who are receiving, or have received in the past 6 months, immunosuppressive therapy for
a solid organ transplant (with exceptions, depending upon the type of transplant and the immune
status of the patient)
those who are receiving, or have received in the past 12 months, immunosuppressive biological
therapy (such as monoclonal antibodies), unless otherwise directed by a specialist
those who are receiving, or have received in the past 3 months, immunosuppressive therapy
including:
adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/
kg/day in children under 20kg) for more than 1 week
adults and children on lower dose corticosteroids (>20mg prednisolone per day or
1mg/kg/day in children under 20kg) for more than 14 days
adults on non-biological oral immune modulating drugs, for example methotrexate >25mg
per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day
children on high doses of non-biological oral immune modulating drugs
ndard infection control precautions (SICPs)
Ps are the basic IPC measures necessary to reduce the risk of transmission of an infectious
ent from both recognised and unrecognised sources of infection.
gle room
oom with space for one patient and usually contains (as a minimum) a bed, a locker or wardrobe
d a clinical wash-hand basin.
ff cohorting
en staff care for one specific group of patients and do not move between different patient cohorts.
tient cohorts may include for example ‘symptomatic’, ‘asymptomatic and exposed’, or
ymptomatic and unexposed’ patient groups.
nsmission based precautions
ditional precautions to be used in addition to SICPs when caring for patients with a known or
pected infection or colonisation.
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1. Home (https://www.gov.uk/)
2. Coronavirus (COVID-19) (https://www.gov.uk/coronavirus-taxon)
3. Healthcare workers, carers and care settings during coronavirus
(https://www.gov.uk/coronavirus-taxon/healthcare-workers-carers-and-care-settings)
4. COVID-19: infection prevention and control (IPC)
(https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-
and-control)
UK Health
Security
Agency
(https://www.gov.uk/government/organisations/uk-health-security-agency)
Guidance
COVID-19: guidance for
maintaining services within
health and care settings –
infection prevention and control
recommendations
Updated 29 September 2021
Contents
1.
Main messages and explanation of updates
2.
Introduction
3.
Governance and responsibilities
4.
COVID-19 care pathways
5.
Standard infection prevention control precautions (SICPs) - all pathways or settings
6.
Aerosol generating procedures – procedures that create a higher risk of respiratory infection
transmission
7.
Low risk pathway – key principles