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Coronavirus (COVID 19) infection prevention and control guidance part 1

1. Scope
This guidance outlines infection prevention and control advice for healthcare providers assessing possible cases of Coronavirus (COVID 19). It should be used in conjunction with local policies.

This guidance will remain under review as further scientific information is published about Coronavirus (COVID 19).
2. Introduction
Coronaviruses are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. They have also been detected in blood, faeces and urine and, under certain circumstances, airborne transmission is thought to have occurred from aerosolised respiratory secretions and faecal material.
As coronaviruses have a lipid envelope, a wide range of disinfectants are effective. Personal protective equipment (PPE) and good infection prevention and control precautions are effective at minimising risk but can never eliminate it.
As Coronavirus (COVID 19) has only been recently identified, there is currently limited information about the precise routes of transmission. Therefore, this guidance is based on knowledge gained from experience in responding to coronaviruses with significant epidemic potential such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV).
Coronavirus (COVID 19) infection is classified as an airborne high consequence infectious disease (HCID) in the UK.
It is known that both SARS-CoV and MERS-CoV can transmit person to person; although this is not yet confirmed for Coronavirus (COVID 19), it is reasonable to assume that human-to-human transmission is possible.
Emerging information from these experiences has highlighted factors that could increase the risk of nosocomial transmission, such as delayed implementation of appropriate infection prevention and control measures combined persistence of coronavirus in the clinical setting (such as positive PCR detection of MERS-CoV RNA for up to 5 days after patients’ last positive respiratory specimen).
In the absence of effective drugs or a vaccine, control of this disease relies on the prompt identification, appropriate risk assessment, management and isolation of possible cases, and the investigation and follow up of close contacts to minimise potential onward transmission.
Effective infection prevention and control measures, including transmission-based precautions (airborne, droplet and contact precautions) with the recommended personal protective equipment (PPE) are essential to minimise these risks. Appropriate cleaning and decontamination of the environment is also essential in preventing the spread of this virus.
3. Preparedness measures
In preparation, healthcare professionals or facilities that may be involved in the investigation or management and care of possible cases should:
• review their local policies and ensure that operational procedures are described, and staff are familiar with them; for example, where PPE is stored and how it should be used
• review procedures for rapidly decontaminating parts of the healthcare environment where a possible case has been located
• ensure there is a process that would ensure possible cases are identified at presentation leading to the triggering of relevant case management and infection control policies.
• ensure that staff are aware of where a possible case will be isolated and the need for a negative pressure room, if it is available.
• ensure that staff who are assessing or caring for suspected Coronavirus (COVID 19) cases are familiar with an FFP3 respirator conforming to EN149, and that fit testing has been undertaken before using this equipment. If an individual cannot use an FFP3 respirator due to inadequate fit, then an alternative with equivalent protection (such as powered hood respirator) must be identified prospectively
• ensure that staff caring for patients with suspected Coronavirus (COVID 19) are trained in the safe donning and removal of PPE
• ensure staff know who to contact within their organisation to discuss possible cases
• ensure there is a clear internal procedure for co-ordinating infection control, liaising with the local health protection team and arranging testing with PHE for possible cases to exclude Coronavirus (COVID 19)
Ensure that adequate supplies or equipment are available (with appropriate training provided), including:
FFP3 respirators
• gloves with long tight-fitting cuffs
• gowns - disposable fluid-resistant full-sleeve gowns and single-use
• eye protection, for example single use goggles or face visor
• clinical waste bags
• hand hygiene supplies
• general-purpose detergent and chlorine based disinfectant solutions.
4. Key principles
Coronavirus (COVID 19) specific infection control measures for inpatients should include the following:
4.1 Standard infection control precautions (in addition to enhanced precautions)
• standard precautions to include careful attention to hand hygiene
• standard precautions when handling any clinical waste, which must be placed in leak-proof clinical waste bags or bins and disposed of safely
• used laundry should be classified as infectious
4.2 Respiratory and cough hygiene
Respiratory and cough hygiene will minimise the risk of cross-transmission of respiratory illness:
• the patient should be encouraged to cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose
• all used tissues should be disposed of promptly into a waste bin
• give the patient the opportunity to clean their hands after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions
4.3 Combined airborne, contact and droplet precautions
• either an isolation room with negative-pressure relative to the surrounding area or a neutral pressure single room. Both should have en-suite bathroom and toilet facilities, and preferably anterooms
• use of FFP3 respirators conforming to EN 149 for persons entering the room. Staff must be fit tested prior to using this equipment. These should be single use (disposable) and fluid repellent
• use of long-sleeved fluid-repellent gown
• disposable gloves with long tight-fitting cuffs for contact with the patient or their environment
• eye protection to be worn for all patient contacts
• refrain from touching mouth, eyes or nose with potentially contaminated gloves
specimens should be double bagged and delivered by hand to the laboratory
This advice covers the period from initial identification of a patient with an epidemiological risk factor for Coronavirus (COVID 19), through initial isolation, assessment, and the period of time until the test result is available. PHE will advise on further management for any confirmed cases.
5. Isolation (patient placement)
• a possible case should be managed in negative pressure single room if available. If this is not possible then a single room with en-suite facilities should be used. Room doors should be kept closed
• positive-pressure, single rooms must not be used
• the nature of the area adjoining the side room should be taken in to account to minimise the risk of inadvertent exposure (such as high footfall areas, confused patients, vulnerable patient groups)
• if on a critical care unit, the patient should be nursed in a negative-pressure single or side room where available, or, if not available, a neutral-pressure side room with the door closed
• if there is no en-suite toilet, a dedicated commode (which should be cleaned as per local cleaning schedule) should be used with arrangements in place for the safe removal of the bedpan to an appropriate disposal point
• avoid storing any extraneous equipment in the patient’s room
5.1 Anterooms and putting on and removing PPE
Anterooms (otherwise known as a 'lobbies') also have the potential to become contaminated and should be regularly decontaminated as described in environmental decontamination.
It is strongly advised that staff progress through ‘dirty’ to ‘clean’ areas within the anteroom as they remove their PPE and wash hands after they leave the patient room. To this effect, movements within the anteroom should be carefully monitored and any unnecessary equipment should not be kept in this space.
A buddy system to observe for inadvertent contamination is recommended, especially during high risk procedures and PPE removal.
In the event that no anteroom or lobby exists for the single room used for Coronavirus (COVID 19) patients, then local infection prevention and control teams (IPCT) will need to consider alternative ways of accommodating these recommendations to suit local circumstances.
Recommendations regarding ventilatory support are provided in the critical care section.
5.2 Notices about infection risks
Written information must be placed on the isolation room door indicating the need for isolation, including the infection prevention and control precautions which must be adhered to prior to entering the room. Patient confidentiality must be maintained.
5.3 Entry records
Only essential staff should enter the isolation room.
A record should be kept of all staff in contact with a possible case, and this record should be accessible to occupational health should the need arise.
6. Staff considerations
The use of bank or agency staff should be avoided.
Staff involved in care of possible cases should be given emergency contact details if they develop Coronavirus (COVID 19) compatible symptoms while away from the hospital. Further details of this and other requirements for managing healthcare contacts by the employer will be provided by PHE.
7. Visitors
Visitors should be restricted to essential visitors only, such as parents of pediatric patients or an affected patient’s main carer. This should be subject to a local risk assessment having been performed.
PPE must be made available to visitors, including instruction and supervision of correct usage and donning and doffing.
The hospital should be mindful of its responsibilities to persons who are not employees, under The Control of Substances Hazardous to Health Regulations 2002 and The Management of Health and Safety at Work Regulations 1999.
8. Personal Protective Equipment (PPE)
The following PPE is to be worn by all persons entering the room where a patient is being isolated (either before definitive assessment, or once assessed as a possible case):
• long sleeved, fluid-repellent disposable gown – wearing scrubs underneath obviates problems with laundering of uniforms and other clothing
• gloves with long tight-fitting cuffs
• FFP3 respirator conforming to EN149 must be worn by all personnel in the room. Fit testing must be undertaken before using this equipment and a respirator should be fit-checked every time it is used
• eye protection, such as single use googles or full-face visors, must be worn (note prescription glasses do not provide adequate protection)
The PPE described above must be worn at all times when in the patient’s room (see putting on and removing personal protective equipment)
9. Hand hygiene
This is essential before and after all patient contact, removal of protective clothing and decontamination of the environment.
Use soap and water to wash hands or an alcohol hand rub if hands are visibly clean.
Rings (other than a plain smooth band), wrist watches and wrist jewellery must not be worn by staff.
10. Aerosol generating procedures
Procedures that produce aerosols of respiratory secretions, for example bronchoscopy, induced sputum, positive-pressure ventilation via a face mask, intubation and extubation, and airway suctioning carry an increased risk of transmission. Where these procedures are medically necessary, they should be undertaken in a negative-pressure room, if available, or in a single room with the door closed.
Only the minimum number of required staff should be present, and they must all wear PPE as described above. Entry and exit from the room should be minimised during the procedure.
If aerosol generating procedures are undertaken in the patient’s own room, the room should be decontaminated 20 minutes after the procedure has ended.
If a different room is used for a procedure it should be left for 20 minutes, then cleaned and disinfected before being put back into use.
Clearance of any aerosols is dependent on the ventilation of the room. In hospitals, rooms commonly have 12-15 air changes per hour, and so after about 20 minutes there would be less than 1 per cent of the starting level (assuming cessation of aerosol generation).
If it is known locally that the design or construction of a room may not be typical for a clinical space, or that there are fewer air changes per hour, then the local IPCT would advise on how long to leave a room before decontamination.
11. Equipment
• re-useable equipment should be avoided if possible; if used, it should be decontaminated according to the manufacturer’s instructions before removal from the room
• use dedicated equipment in the isolation room. Avoid storing any extraneous equipment in the patient’s room
• dispose of single use equipment as per clinical waste policy inside room
• ventilators should be protected with a high efficiency filter, such as BS EN 13328-1
• closed system suction should be used
• disposable crockery and cutlery may be used in the patient’s room as far as possible to minimise the numbers of items which need to be decontaminated
12. Environmental decontamination
There is evidence for other coronaviruses of the potential for widespread contamination of patient rooms or environments, so effective cleaning and decontamination is vital.
Cleaning and decontamination should only be performed by staff trained in the use of the appropriate PPE; in some instances, this may need to be trained clinical staff rather than domestic staff.
After cleaning with neutral detergent, a chlorine-based disinfectant should be used, in the form of a solution at a minimum strength of 1,000ppm available chlorine.
The main patient isolation room should be cleaned at least once a day, and following aerosol generating procedures or other potential contamination.
There should be more frequent cleaning of commonly used hand-touched surfaces and of anteroom or lobby areas (at least twice per day).
To ensure appropriate use of PPE and that an adequate level of cleaning is undertaken which is consistent with the recommendations in this document, it is strongly recommended that cleaning of the isolation area is undertaken separate to the cleaning of other clinical areas.
Dedicated or disposable equipment must be used for environmental decontamination. Reusable equipment must be decontaminated after use with a chlorine-based disinfectant as described above.

Coronavirus (COVID 19) infection prevention and control guidance part 2

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