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Overview

This summary is based on official guidance jointly issued by the Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland/National Services Scotland, Public Health England, and NHS England. It supersedes the COVID-19 UK infection prevention and control guidance (18 June 2020).

Whilst the guidance seeks to ensure a consistent and resilient UK-wide approach, some differences in operational details and organisational responsibilities may apply in Northern Ireland, England, Wales, and Scotland.

This guidance does NOT apply to adult social care settings in England. Adult social care providers in England should refer to existing guidance already in place. 

This summary has been abridged for print. View the full summary at guidelines.co.uk/455598.article

Key messages

  • Patients’/individuals’ treatment, care, and support can be managed in three COVID-19 pathways:
    • 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
  • Individuals who are clinically extremely vulnerable from COVID-19 will require protective infection prevention and control (IPC) measures depending on their medical condition and treatment whilst receiving healthcare, for example priority for single-room isolation
  • Sessional use of single-use personal protective equipment/respiratory protective equipment (PPE/RPE) items continues to be minimised and only applies to extended use of face masks (all pathways) or FFP3 respirators (together with eye/face protection) in the medium- and high-risk pathway for healthcare workers where airborne precautions are indicated
  • The use of face masks or face coverings across the UK remains as 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 
  • Physical distancing of 2 metres is considered 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 prevention control precautions (SICPs) for 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.

COVID-19 care pathways

  • Triaging and testing within all health and other care facilities must be undertaken to enable early recognition of COVID-19 cases
  • Triage should be undertaken by clinical staff who are trained and competent in the application of the clinical case definition 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
  • 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.

Community settings

  • Areas where triaging for COVID-19 is not possible, for example community pharmacy:
    • 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.

Outpatient, primary care, and day care

  • 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
  • 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
  • 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
  • Staff administering vaccinations/injections must apply hand hygiene between patients and wear a sessional face mask.

NB: SARS-CoV-2 confirmed positive patients/individuals or those self-isolating should still be assessed and reviewed following the high/medium care pathway in these settings, to ensure urgent treatment/appointments are accommodated. This is important to avoid unwarranted poor patient outcomes.

NB: in some clinical outpatient settings, such as vaccination/injection clinics, where contact with individuals is minimal, the need for PPE items for each encounter, for example gloves and aprons are only recommended when there is (anticipated) exposure to blood/body fluids or non-intact skin. Staff administering vaccinations/injections must apply hand hygiene between patients and wear a sessional face mask.

Low-risk pathway: key principles

  • This pathway applies to any facility where:
    • 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 from the test date OR
    • individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without fever or respiratory symptoms OR
    • 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.

NB: 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.

Maintaining physical distance

  • All staff and other care workers must maintain social/physical distancing of 2 metres where possible (unless providing clinical or personal care and wearing PPE).

Safe management of environment/equipment and blood/body fluids

  • During the pandemic, the frequency of cleaning of both the environment and equipment in care (patient) areas should be increased to at least twice daily; this includes frequently touched sites/points and communal facilities such as shared toilets
  • In the low-risk COVID-19 pathway, organisations may choose to revert to general purpose detergents for cleaning, as opposed to widespread use of disinfectants (with the exception of blood and body fluids, where a chlorine releasing agent (or a suitable alternative) solution should be used).

Medium-risk pathway: key principles

  • This pathway applies to any care facility where:
    • triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test result OR
    • triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure identified OR
    • testing is not required or feasible on asymptomatic individuals and therefore infectious status is unknown OR
    • asymptomatic individuals decline testing.

Maintaining physical distancing and patient placement

  • 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.

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:
      • a combined detergent/disinfectant solution at a dilution of 1000 parts per million available chlorine (ppm available chlorine [av.cl.]); or
      • a general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1000 ppm av.cl.
    • alternative cleaning agents/disinfectant products may be used with agreement of the local IPC team/health protection team
    • cleaning of care equipment as per manufacturers’ 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. 

For information on the safe management of the care environment following medium-risk contact, refer to the full guideline.

The high-risk pathway principles apply to emergency/urgent care facilities. For further information, refer to the full guideline.

Standard infection prevention control precautions

  • SICPs must be used by all staff, in all care settings, at all times and for all patients/individuals, whether infection is known or not, to ensure the safety of patients/individuals, staff and visitors
  • The elements of SICPs are:
    • patient placement and assessment for infection risk (screening/triaging/testing)
    • hand hygiene
    • respiratory and cough hygiene
    • PPE (see later)
    • safe management of the care environment (see later)
    • safe management of care equipment (see later)
    • 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 for COVID-19).

Personal protective equipment

  • All PPE should be:
    • located close to the point of use (where this does not compromise patient safety, for example, mental health/learning disabilities)
    • 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
    • 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
    • decontaminated after each use following manufactures 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[A]
    • 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 or soap between use.

NB: 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 aerosol-generating procedures (AGPs)
    • worn when a disposable apron provides inadequate cover for the procedure or task being performed
    • 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
    • not be impeded by accessories such as piercings or false eyelashes
    • not be touched when being worn

NB: 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 (manufacturers’ instructions must be followed to ensure effective fit and protection)
    • not 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 healthcare workers when entering the hospital or care setting (Type IIR is also suitable). Type I are suitable in some settings; refer to the resource section in the full guideline for country-specific guidance
  • Headwear/footwear:
    • headwear is not routinely required in clinical areas (even if undertaking an AGP) unless part of theatre 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
    • foot/shoe coverings are not required or recommended for the care of COVID-19 cases.

NB: PPE may restrict communication with some individuals and other ways of communicating to meet their needs should be considered.

For further information on AGPs, refer to the full guideline.

Table 1: PPE recommendations by risk pathway

Low-risk pathway (PPE required for SICPs)[A]

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 required if risk of spraying/splashing)

FRSM Type IIR for direct patient care and surgical mask Type II for extended use[A]

Risk assess and use if required for care procedure/task where anticipated blood/body fluids spraying/splashes

Medium-risk pathway (PPE required by type of transmission/exposure)

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[B]

Single-use apron (gown required if risk of spraying/splashing)

FRSM Type IIR[C]

Single use or reusable[E]

Airborne PPE (when undertaking or if AGPs are likely)

Single use

Single use apron or gown

FFP3[D] or respirator/hood for AGPs

Single use or reusable

[A] Sessional/extended use of face masks apply across the UK for healthcare workers in any health or other care settings

[B] Gloves are not required when undertaking administrative tasks, for example using the telephone, using a computer or tablet, and writing in the patient chart; giving oral medications; and distributing or collecting patient dietary trays

[C] FRSM can be worn sessionally if providing care for COVID-19 cohorted patients/individuals

[D] FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPsare undertaken for COVID-19 cohorted patients/individuals

[E] Risk assess and use if required for care procedure/task where anticipated blood/body fluids spraying/splashes

Transmission-based precautions

Transmission-based precautions (TBPs) are additional measures (to SICPs) required when caring for patients/individuals with a known or suspected infection such as COVID-19.

  • TBPs are based upon the route of transmission and include:
    • contact precautions —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. COVID-19 can be spread via this route
    • droplet precautions —used to prevent and control infections spread over short distances (at least 3 feet/1 metre) via droplets (greater than 5 mcm) from the respiratory tract of individuals directly onto a mucosal surfaces 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 two metres in care settings
    • airborne precautions —used to prevent and control infection spread without necessarily having close patient contact via aerosols (less than or equal to 5 mcm) 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 in the full guideline. 

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 areas 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.
 

For recommendations on occupations health and staff deployment, view the full summary online at guidelines.co.uk/455598.article

For further information, see the Guidelines summary on COVID-19: management of staff and exposed patients or residents in health and social care settings.

Full guideline:

Public Health England. COVID-19: Guidance for the remobilisation of services within health and care settings: infection prevention and control recommendations (version 1.2). June 2021.

Available at: gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

Contains public sector information licensed under the Open Government Licence v3.0.

Published date: 10 January 2020.

Last updated: 2 September 2021.

Credit: 

Lead Image: tutye/stock.adobe.com

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