COVID-19: infection prevention and control recommendations

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• Patients’/individuals’ treatment, care and support to be managed in 3 COVID-19 pathways:
  • High risk: there is no change in recommendations for IPC or for the use of PPE by staff when managing patients/individuals who have, or are likely to have, COVID-19
  • Medium risk: this includes patients/individuals who have no symptoms of COVID-19 but do not have a COVID-19 SARS- CoV-2 PCR test result
  • Low risk: patients/individuals with no symptoms and a negative COVID-19 SARS- CoV-2 PCR test who have self-isolated prior to admission for example following NICE guidance

• Sessional use of single-use personal protective equipment (PPE) items has been minimised and only applies to extended use of facemasks for healthcare workers

• 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. 

Care pathways

• Screening and triaging 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.

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/day care

• In outpatient, primary care and day care settings:
  • where possible 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 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 screened 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 facemask.

Standard infection prevention control precautions (SICPs)

• 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)
  • hand hygiene
  • respiratory and cough hygiene
  • personal protective equipment (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 due to COVID-19)

Personal protective equipment (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)
  • 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 facemasks
  • 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. See here for guidance on donning (putting on) and doffing (removing)
  • decontaminated after each use following manufactures guidance if reusable PPE is used, such as 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
  • changed immediately after each patient and/or after completing a procedure/task even on the same patient
  • never decontaminated with alcohol based hand rub (ABHR) or soap between use.

Double gloving is NOT recommended for routine clinical care of COVID-19 cases and 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 unless sessional use is advised due to local/national data

• 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—regular corrective spectacles are not considered eye protection
  • not be impeded by accessories such as piercings or false eyelashes
  • not be touched when being worn

• 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 delivering 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, a Type IIR is also suitable. Type I are suitable in some settings, refer to the resource section for country specific guidance (England and Scotland)

• Head/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.

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

For further information on aerosol generating procedures, refer to the full guideline.

Low-risk pathway: key principles

• This pathway applies to:
  • individuals triaged/clinically assessed prior to treatment (inpatient/outpatient) with no COVID-19 contacts or symptoms who have isolated/shielded, AND
  • patients who have a negative SARS-CoV-2 (COVID-19) test result within 72 hours of care and, for planned admissions, have self-isolated since the test date, OR
  • individuals who have recovered from COVID-19 AND have had at least three consecutive days without fever or respiratory symptoms AND a negative SARS-CoV-2 test result, OR
  • patients or individuals in any care facility where testing is undertaken regularly (remains negative).

• 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 a longer period before a planned procedure. The length of self-isolation will depend on their individual risk factors and requires individualised care and shared decision making

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 patient areas should be increased to at least twice daily, in particular, frequently touched sites/points
• 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 the following:
  • any facility where triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 (COVID-19) test result and have no known recent COVID-19 contact, OR
  • any care facility where testing is not required or feasible on asymptomatic individuals and therefore infectious status is unknown, OR
  • asymptomatic individuals who decline testing in any care facility.

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 advise other patients/visitors to comply
  • ensure cohorted patients/individuals are physically separated from each other, for example use screens, 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 1,000 parts per million available chlorine (ppm available chlorine (av.cl.)); or
    • a general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1,000ppm av.cl.
  • alternative cleaning agents/disinfectant products may be used with agreement of the local IPC Team/HPT

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

High-risk pathway: key principles

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

Table 1: PPE recommendations by risk pathway

Transmission-based precautions (TBPs)

• 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 cross-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 (>5μm) 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 increased to 2 metres
  • 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 has the potential to spread via this route when AGPs are undertaken

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 should not come to work
• 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 further information, see the Guidelines summary on COVID-19: management of staff and exposed patients or residents in health and social care settings.