Government issues infection control guidance for hospitals and health providers in light of COVID-19 outbreak

Good hand hygiene, the use of personal protective equipment, and decontamination of medical devices and care environments 'crucial' to containing spread of virus in health and care settings

Government and public health bodies have issued official guidance for hospitals on infection prevention and control during the coronavirus outbreak

Good hand hygiene, the use of personal protective equipment (PPE), and decontamination of medical devices and care environments are crucial to reducing the spread of coronavirus in hospitals, GP clinics and care homes.

Official guidance has now been issued by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), the Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS), and Public Health England (PHE), giving infection prevention and control advice for healthcare workers involved in receiving, assessing and caring for patients with a possible, or confirmed, case of COVID-19.

Considered good practice, the information is based on the reasonable assumption that the transmission characteristics of COVID-19 are similar to those of the 2003 SARS-CoV outbreak.

And it puts protective measures, in particular handwashing and decontamination, high on the agenda.

It states that, according to scientific evidence, the transmission of COVID-19 occurs mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces.

The right level of protection

The guidance states that, in the UK, FFP3 respirators – compliant with BS EN149:200.1 – should be worn for airborne precautions.

And, it reveals that, with SARS-CoV, evidence suggested that the use of both respirators and surgical facemasks offered a similar level of protection – both associated with up to an 80% reduction in the risk of infection.

During aerosol generation procedures (AGPs), those that stimulate coughing and promote the generation of aerosols, there is an increased risk of aerosol spread of infectious agents, irrespective of the mode of transmission, and airborne precautions must be implemented when performing these procedures, including those carried out on a suspected, or confirmed, case of COVID-19.

Before undertaking any procedure, staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken

It adds: “In light of the above, the Department of Health and Social Care’s New and Emerging Respiratory Virus Threat Assessment Group has recommended that airborne precautions should be implemented at all times in clinical areas considered aerosol generation procedure (AGP) ‘hotspots’, for example intensive care units, intensive therapy units, and high dependency units that are managing COVID-19 patients, unless patients are isolated in a negative pressure isolation room or single room, where only staff entering the room need wear a respirator.”

Scientific research into the similar SARS epidemic showed the most-likely transmission of COVID-19 is through coughing and sneezing

In other areas a fluid-resistant (Type IIR) surgical mask is recommended; with these to be worn by all general ward staff, community, ambulance and social care staff for close patient contact.

In addition, initial research has identified the presence of live COVID-19 virus in the stools and conjunctival secretions of confirmed cases. Therefore, all secretions (except sweat) and excretions, including diarrhoeal stools from patients with known or suspected COVID-19, should be regarded as potentially infectious.

In terms of a timescale for the virus, the evidence puts the median time from symptom onset to clinical recovery for mild cases at approximately two weeks and 3-6 weeks for severe or critical cases.

And it reveals that human coronaviruses can survive on inanimate objects and remain viable for up to five days at temperatures of 22- 25°C and relative humidity of 40-50%, which is typical of air-conditioned indoor environments such as hospitals.

But, ultimately, its survival is also dependent on the surface type.

On the surface

An experimental study using a SARS-CoV-2 strain reported viability on plastic for up to 72 hours, for 48 hours on stainless steel, and for up to eight hours on copper.

However, the rate of clearance of aerosols in an enclosed space was dependent on the extent of any mechanical or natural ventilation – the greater the number of air changes per hour, the sooner any aerosol will be cleared.

As outlined in WHO guidance; in general wards and single rooms there should be a minimum of six air changes per hour, while, in negative-pressure isolation rooms, there should be a minimum of 12 air changes per hour.

In addition, where feasible, environmental decontamination should be performed when it is considered appropriate to enter a room or area without an FFP3 respirator.

A single air change is estimated to remove 63% of airborne contaminants, so, after five air changes, less than 1% of airborne contamination is thought to remain.

Hand hygiene will also be of great importance moving forward.

All staff, patients and visitors are advised to wash their hands thoroughly with soap and water and to decontaminate with an alcohol-based rub when entering and leaving areas where cases of COVID-19 are suspected or have been confirmed.

Wherever possible, patients with suspected or confirmed COVID-19 should be placed in single rooms

Hand hygiene, including a full handwash, must also be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination, and waste handling.

When handwashing, it is important to expose the forearms, remove all hand and wrist jewellery, ensure finger nails are clean and short, and cover all cuts and abrasions with a waterproof dressing.

Wash your hands

And each handwashing session should be for between 40-60 seconds and should be carried out as close to the point of care as possible.

The guidance also covers respiratory hygiene and personal protective equipment (PPE). On this issue it states: “Before undertaking any procedure, staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken. All staff should be trained in the proper use of all PPE that they may be required to wear.”

All PPE, including disposable gloves, aprons, gowns and facemasks, should be located as near to the point of care as possible, be of single-use design, be changed immediately between patients or following the completion of a task, and must be compliant with the relevant BS/EN standards and properly disposed of after use.

It goes on to give advice on the safe management of laundry, which should be treated as ‘infectious linen’; the management of bodily fluids and spills, and waste management.

But the work of estates managers will be most impacted by the guidance on the built environment.

In a section headed ‘Segregation and cohorting (inpatient settings)’, the document looks at the challenge facing a range of environments, including negative pressure isolation rooms, single rooms, patient cohort areas, staffing areas, and visitor areas.

It states: “Special environmental controls, such as negative pressure isolation rooms, are not necessary to prevent the transmission of COVID-19. However, in the early stages, and in high risk settings, patients with suspected or confirmed COVID-19 may be isolated in negative pressure rooms.

“Wherever possible, patients with suspected or confirmed COVID-19 should be placed in single rooms. In an escalating situation there is, however, likely to be a lack of single rooms/isolation facilities. Where these are in short supply, and cohorting is not yet considered possible (patient(s) awaiting laboratory confirmation), prioritise patients who have excessive cough and sputum production for single/isolation room placement.”

Personal protective equipment, such as facemasks and disposable gloves must be work by all staff to help prevent the spread of coronavirus in health settings

Staying single

These single rooms in COVID-19 segregated areas should, wherever possible, be reserved for performing AGPs; while those in non-COVID-19 areas should be reserved for patients requiring isolation for reasons other than influenza symptoms.

Where patients are treated in multi-occupancy areas, they should be ‘physically separated’ at a distance of 1m, with privacy curtains between the beds to minimise the opportunities for close contact.

COVID-19 areas should also include a reception separated from the rest of the facilities, preferably with a separate entrance and exit; must not be used as a cut-through by patients, staff or visitors; and should have signage warning of controlled entry.

Alongside this, hospital managers need to consider other factors including the desire to continue to provide care in single-sex environments, create age-appropriate settings for children and young people, and be aware of possible immunocompromised patients.

All of this creates a massive juggling act for hospital bosses, and puts increased pressure on estates and facilities professionals.

Equipment, too, must be fully cleaned and single-use products utilised where possible.

Non-invasive equipment must be decontaminated after each patient and each patient use and after any bodily contamination.

And the frequency of this cleaning should be increased for reusable non-invasive care equipment in all isolation and cohort areas.

In an escalating situation there is likely to be a lack of single rooms/isolation facilities. Where these are in short supply, and cohorting is not yet considered, prioritise patients who have excessive cough and sputum production for single/isolation room placement

Specifically, ventilators must be protected with a high-efficiency filter, such as BS EN 13328-1 and closed-system suction should be used.

The type of decontamination or cleaning necessary depends on the risk and the type of product, ranging from chlorine disinfectants to general-purpose detergents or detergent-impregnated wipes.

Flow charts are provided within the guidance for many of the most-frequent examples.

Other care settings

Hospitals are not the only settings where additional measures need to be taken.

For care homes, the guidance states: “Isolation within a care home for a known/suspected infection can be achieved in the persons’ bedroom in most cases. Residents should remain in their bedroom while considered infectious and the door should remain closed. If unable to isolate the individual then this should be documented.

While, in primary care settings, suspected COVID-19 patients should be segregated in place or time from other patients through the creation of a separate area with controlled entry or by seeing suspected patients at a different time from other patients, with areas disinfected between clinics.

Dental surgeries and outpatient clinics are cutting back services to emergencies only, or carrying out video consultations.

To read the full guidance, click here.