Overview

g logo nhs blue

This Guidelines summary outlines the infection prevention and control (IPC) principles required to prevent transmission of COVID-19 and other respiratory viruses and minimise disruption to health and care services.

The guidance supersedes the previous UK IPC COVID-19 guidance for maintaining services within health and care settings, to allow organisations to assess and manage the ongoing delivery of service provision throughout the winter period 2021–2022. It considers SARS-CoV-2 (including variants of concern) and other seasonal respiratory infections, including flu and respiratory syncytial virus.

In response to Omicron and other variants of concern, it is recommended that staff and organisations continue to undertake risk assessments using the hierarchy of controls, which include an evaluation of the ventilation in the area, operational capacity, physical distancing, and prevalence. Where an unacceptable risk of transmission remains following this risk assessment, it may be necessary to consider the use of respiratory protective equipment in clinical areas where suspected or confirmed COVID-19 patients are being managed.

This summary only contains key recommendations for primary care. For a complete set of recommendations, refer to the full guideline. 

View this summary online at guidelines.co.uk/456607.article

Infection control precautions for seasonal respiratory infections

  • Signage should be displayed prior to—and on entry to—all health and care settings instructing patients with respiratory symptoms to inform receiving/reception staff immediately on their arrival.

Universal masking

  • Universal masking with face coverings or surgical masks (type II or IIR) to prevent the transmission of SARS-CoV-2 and other respiratory infectious agents in health and care settings, as a source control measure, should continue to be applied for all staff, patients, and visitors
  • Patients with suspected or confirmed respiratory infection should be provided with a surgical facemask (type II or type IIR) to be worn in multi-bedded bays and communal areas if this can be tolerated
  • Surgical facemasks are not required to be worn by patients in single rooms unless another person enters, or the room door is required to remain open. All patients transferring to another care area should wear a surgical facemask (if tolerated) to minimise the dispersal of respiratory secretions and reduce environmental contamination
  • Patients should be provided with a new surgical mask at least daily, or when soiled or damaged
  • The requirement for patients to wear a surgical facemask must never compromise their clinical care, such as when oxygen therapy is required
  • Organisations in NHS Scotland should refer to Coronavirus (COVID-19): Guidance on the extended use of facemasks and face coverings in hospitals, primary care and wider community care settings.

Screening for COVID-19

  • Screening for early recognition of patients with COVID-19 should be undertaken wherever possible prior to attendance at the health or care facility to ensure rapid implementation of recommended control measures.

An example screening tool is available on the UK Government website.

  • Screening for other infections/multi-drug-resistant organisms should be included as per national screening guidance/requirements.

Triaging

  • Organisations/employers may wish to utilise care pathways—examples of this could include respiratory/emergency/elective pathways
  • Triaging within all healthcare facilities must be undertaken to enable early recognition of patients with respiratory infections. Triage should be undertaken by clinical staff who are trained and competent in the application of clinical case definitions prior to the patient’s arrival at a care area, or as soon as possible on arrival, and used to inform patient placement to the appropriate care area or pathway
  • Patients with respiratory symptoms should be assessed in a segregated area, ideally a single room, and away from other patients pending their test result
  • Patients with excessive cough and sputum production and those at higher risk of severe outcomes should be prioritised for placement in single rooms while awaiting testing
  • Placement in any care area should not impact the delivery and duration of care for the patient. Patients should not be transferred unnecessarily between care areas unless, for example, there is a change in their infectious status, clinical need, or availability of services. This should be agreed locally
  • If treatment can be deferred, and this is not detrimental to the patient’s care, then this should be considered.

Testing

  • Organisations/employers should, where available, include testing (ideally rapid or near-patient testing) as part of their IPC risk mitigation strategy at times of increased infection prevalence.

Standard infection control precautions

  • Patients attending for an appointment/admission who have been screened (and have answered ‘no’ to all screening questions), triaged (and have no clinical signs or symptoms of respiratory infection), and tested (with a negative result) as per country or local testing strategies only require the application of standard infection control precautions (SICPs) at the point of care
  • The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction, and/or the anticipated level of exposure to blood and/or other body fluids
  • The elements of SICPs are:
    • patient placement and assessment for infection risk (screening/triaging/testing)
    • hand hygiene
    • respiratory and cough hygiene
    • personal protective equipment (PPE)
    • 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.

Transmission-based precautions

This section describes specific actions that should be taken when applying transmission-based precautions (TBPs). TBPs are applied when SICPs alone are insufficient to prevent transmission of an infectious agent. TBPs are additional infection control precautions required when caring for a patient with a suspected or confirmed infectious agent. TBPs are categorised by the route of transmission of the infectious agent.

Physical distancing

  • In health and care settings, physical distancing is the recommended distance that should be maintained between staff, patients, and visitors unless mitigations are in place such as the use of PPE
  • The World Health Organization continues to advise that a physical distance of at least 1 metre should be maintained between and among patients, staff, and all other persons in healthcare settings. This distance should be increased wherever feasible, especially in indoor settings
  • Physical distancing is recommended to remain at 2 metres where infectious respiratory patients are cared for.

Patient placement in primary care and outpatient settings

  • Where patient treatment or appointment cannot be deferred, patients with symptoms of respiratory infection should be triaged to a segregated waiting and assessment area with physical distancing at 2 metres. This may be achieved by:
    • creating separate waiting and reception areas or use of physical barriers. Patients should be instructed to stay in these areas and not visit public areas such as cafes. Signage should be used as appropriate
    • staggering clinic times for patients with and without respiratory symptoms, ensuring disinfection of communal areas between clinics.

For recommendations on the safe management of care equipment and the care environment, refer to the full guideline.

Personal protective equipment

Principles of personal protective equipment

  • Before undertaking any procedure, staff should assess any likely blood and body fluid exposure risk, and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken
  • All PPE should be:
    • compliant with the relevant BS/EN standards (technical standards as adopted in the UK post-Brexit)
    • located close to the point of use
    • stored to prevent contamination in a clean/dry area until required for use (expiry dates must be adhered to)
    • single use only, unless specified by the manufacturer
    • changed immediately after each patient and/or following completion of a procedure or task
    • disposed of after use into the correct waste stream of healthcare waste
  • Hand hygiene must be performed after removal of PPE
  • Any reusable PPE/respiratory protective equipment (RPE) must have a decontamination and maintenance process in place and responsibility assigned.

 Disposable gloves

  • Gloves are not an alternative to hand hygiene. Inappropriate use of gloves, including not changing them as recommended above, risks the gloves contributing to the transfer of infectious agents and cross-infection
  • Gloves are not required unless exposure to blood and/or other body fluids, non-intact skin, or mucous membranes is anticipated or likely. 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 or vaccinations, and distributing or collecting patient dietary trays. The unnecessary use of gloves generates excessive waste
  • Disposable gloves must:
    • 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
    • be changed if damaged or punctured
    • not be decontaminated with alcohol-based hand rub or soap between use.

Aprons and gowns

  • Disposable plastic aprons must be worn to protect staff uniform or clothes from contamination when providing direct patient care for patients with suspected or confirmed respiratory infection, and during environmental and equipment decontamination
  • Aprons 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 or vaccinations, and distributing or collecting patient dietary trays. The unnecessary use of aprons generates excessive waste
  • Fluid-resistant gowns must be worn:
    • when a disposable plastic apron provides inadequate cover of staff uniform or clothes for the procedure/task being performed
    • when performing aerosol-generating procedures (AGPs) on patients with a suspected or confirmed respiratory infection
    • when there is a risk of extensive splashing of blood and/or other body fluids, for example, during AGPs
  • Disposable aprons and gowns must be changed between patients and immediately after completion of a procedure or task.

Eye and face protection

  • Eye or face protection (including full-face visors or goggles) must:
    • be worn if blood or body fluid contamination to the eyes or face is anticipated or likely
    • be worn by staff when caring for patients with a suspected or confirmed infection spread by the droplet or airborne route, as deemed necessary by a risk assessment
    • be worn 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.

Surgical face masks

  • In addition to universal masking, a fluid-resistant surgical mask (type IIR) must be worn by staff when caring for patients with a suspected or confirmed infection spread by the droplet route
  • Surgical masks must:
    • be well fitted, covering both nose and mouth
    • not be allowed to dangle around the neck at any time
    • not be touched once put on
    • be changed when they become moist or damaged
    • be worn once and then discarded in line with country-specific guidance or policy (hand hygiene must always be performed after disposal).

Respiratory protective equipment/FFP3 or powered air purifying respirator hood

  • A respirator with an assigned protection factor of 20—that is, a filtering face piece 3 (FFP3) respirator (or equivalent)—must be worn by staff when:
    • caring for patients with a suspected or confirmed infection spread wholly by the airborne route, such as tuberculosis (during the infectious period)
    • performing AGPs on a patient with a suspected or confirmed infection spread wholly or partly by the droplet or airborne route
  • Where a risk assessment indicates it, RPE should be available to all relevant staff. The risk assessment should include evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new SARS-CoV-2 variants of concern in the local area. The hierarchy of controls can be used to inform the risk assessment. Staff should be provided with training on correct use
  • An FFP3 respirator or powered respirator hood must never be worn by an infectious patient
  • Respirators can be single use or sessional use (disposable or reusable)
  • All tight fitting RPE, that is, FFP3 respirators, must:
    • be fluid-resistant
    • be fit-tested on all health and care staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturer’s guidance[A]
    • be fit-checked (according to the manufacturer’s guidance) every time a respirator is donned to ensure an adequate seal has been achieved
    • be compatible with other facial protection used (protective eyewear) so that this does not interfere with the seal of the respiratory protection
    • be disposed of and replaced if breathing becomes difficult, the respirator is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained
    • not be touched once put on. If adjustments are needed, ensure hand hygiene is undertaken
    • be removed outside the patient’s room or cohort area
  • In the absence of an anteroom/lobby, remove RPE and eye protection in a safe area (for example, outside the isolation/cohort room/area). All other PPE should be removed in the patient care area. Perform hand hygiene after removing and disposing of RPE
  • Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website
  • Respirators with exhalation valves are not fluid-resistant unless they are also ‘shrouded’. Valved non-shrouded respirators should be worn with a full-face shield if blood or body fluid splashing is anticipated.

Table 1: PPE required while providing direct care for patients with suspected or confirmed respiratory infection

PPE required by type of transmission/exposureDisposable glovesDisposable/reusable fluid-resistant apron/gownFRSM/RPEEye/face protection (goggles or visor)

Abbreviations: AGP=aerosol-generating procedure; FFP3=filtering face piece 3; FRSM=fluid-resistant (type IIR) surgical mask; PPE=personal protective equipment; RPE=respiratory protective equipment

[A] FRSM can be worn sessionally (includes eye/face protection) if providing care for cohorted patients. All other items of PPE (gloves/gown) must be changed between patients and/or after completing a procedure or task.

[B] RPE can be worn sessionally (includes eye/face protection) in high-risk areas where AGPs are undertaken for cohorted patients (see footnote D). All other items of PPE (gloves/gown) must be changed between patients and/or after completing a procedure or task.

[C] Consideration may need to be given to the application of airborne precautions where the number of cases of respiratory infections requiring AGPs increases and patients cannot be managed in single or isolation rooms.

[D] Where an unacceptable risk of transmission remains following the hierarchy of controls risk assessment, it may be necessary to consider the use of RPE for patient care in specific situations when managing respiratory infectious agents. The risk assessment should include evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new SARS-CoV-2 variants of concern in the local area.

Droplet PPE

Single use

Single-use apron or fluid-resistant gown if risk of extensive spraying/splashing

Single-use FRSM type IIR for direct patient care[A]

Single use or reusable[A]

Airborne PPE
(When undertaking AGPs or if AGPs are likely,[C]  or if an unacceptable risk of transmission remains following rigorous application of the hierarchy of controls)[D]

Single use

Single-use fluid-resistant gown

Single-use FFP3[B] or reusable respirator/powered respirator hood (RPE)

Single use or reusable[B]

Aerosol-generating procedures

  • An AGP is a medical procedure that can result in the release of airborne particles (aerosols) from the respiratory tract when treating someone who is suspected or confirmed to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route. Only staff who are needed to undertake the procedure should be present, wearing airborne PPE/RPE precautions
  • Airborne precautions are not required for AGPs on patients/individuals if screening, triaging, and testing have confirmed the absence of respiratory infection.

For a list of medical procedures that are considered to be aerosol-generating, refer to the full guideline.

Duration of precautions

  • In general, patients should remain in isolation or cohorted, and TBPs should be applied until resolution of fever and respiratory symptoms, or until they are established on or have completed an appropriate course of treatment. This will be dependent on the infectious agent
  • Some patients with more severe illness or underlying immune problems may remain infectious for a longer period. The duration of TBPs may require modification based on available pathogen-specific guidance and patient information
  • TBPs should only be discontinued in consultation with clinicians (including microbiology/IPC team), and should take into consideration the infectious agent, individual’s test results (if available), and resolution of clinical symptoms.

For recommendations on visitors, refer to the full guideline.

Occupational health and vaccination

  • Prompt recognition of cases of respiratory infection among health and care staff is essential to limit transmission
  • All staff should be vigilant for any signs of respiratory infection and should not come to work if they have respiratory symptoms. They should seek advice from their IPC teams/occupational health department/GP or employer as per the local policy
  • Symptomatic staff should avoid contact with people both in the hospital and in the general community. Bank, agency, and locum staff should follow the same deployment advice as permanent staff
  • Systems should be in place to ensure that country-specific vaccination and testing policies are in place, as advised by occupational health/public health teams. Staff who are fully vaccinated against COVID-19 and are a close contact of a case of COVID-19 may be allowed to return to work without the need to self-isolate
  • There are country-specific variations on the requirements for polymerase chain reaction and lateral flow device testing, and these policies are under continual review
  • Refer to country-specific policy for:
  • As part of an employer’s duty of care, they 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
  • The vaccination status of staff may be considered when making staffing decisions for cohort areas. Regardless of whether staff have had and recovered from or have received vaccination for a specific respiratory pathogen, they must continue to follow the infection control precautions, including PPE, as outlined in this guidance
  • A risk assessment is required for health and care staff who may be at high risk of complications from respiratory infections such as flu and severe illness from COVID-19. Employers should:
    • discuss and complete a risk assessment with employees who are in the COVID-19 at-risk groups, for example, those who are pregnant or of Black, Asian, or minority ethnic origin
    • ensure that advice is available to all health and 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.

For recommendations on surveillance and monitoring, refer to the full guideline.

For recommendations on the hierarchy of controls, refer to the full guideline.

Hierarchy of controls

  • Risk assessments must be carried out in all areas by a competent person with the skills, knowledge, and experience to be able to recognise the hazards associated with respiratory infectious agents. This can be the employer, or a person specifically appointed to complete the risk assessment. During development and on completion this risk assessment needs to be communicated to employees. This can be used to populate local risk management systems
  • The hierarchy of controls can be used to help implement effective controls and reduce the spread of respiratory pathogens in health and care settings, these are applied in order and are used to identify the appropriate controls
  • Safe systems of work outlined in the hierarchy of controls, including elimination, substitution, engineering, administrative controls, and PPE/RPE, are an integral part of IPC measures. 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.

For more information on the hierarchy of controls, refer to the full guideline.

Footnote

[A] Where fit testing fails, suitable alternative equipment must be provided. Reusable respirators can be used by individuals if they comply with Health and Safety Executive recommendations, and should be decontaminated and maintained according to the manufacturer’s instructions, which may be country-specific.

Full guideline:

DHSC, Public Health Wales, Public Health Agency Northern Ireland, NHS National Services Scotland, UK Health Security Agency, NHS England. Infection prevention and control for seasonal respiratory infections in health and care settings (including SARS-CoV-2) for winter 2021 to 2022. 2022. Available at: gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-guidance-for-maintaining-services-within-health-and-care-settings-infection-prevention-and-control-recommendations

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

Published date: 24 November 2021.

Last updated: 17 January 2022.

Credit:

Lead image: tutye/stock.adobe.com