Mapping of Govt guidance for IPC for COVID-19 in care homes - BushProof
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Mapping of Govt guidance for IPC for COVID-19 in care homes
Version: 14 May 2020
Purpose of this document:
1. To map the current guidance on infection prevention and control (IPC) in care homes from the UK
Government and Public Health England
2. To understand the strengths and gaps – so we can advocate to get the gaps and weaknesses responded
to
3. To inform our interim practical, in-one-place, guidance for use by Care Home Managers (see below), as
a tool, building on the existing UK Govt and PHE guidance, while it is still scattered and in some cases,
contradictory
Authors of this document:
This is a ‘living’ document that will be updated as Guidance is updated. It has been prepared by:
• Dr Sarah House, BEng, DIS, MSc, D.Litt, CEng, MICE, C.WEM, FCIWEM, Water Sanitation & Hygiene
(WASH) Consultant / Public Health Engineer, Leicester, UK
• Eric Fewster, MSc, C.WEM, MCIWEM, CEnv, Independent Water & Environmental Manager, Salford, UK
A range of other reviewers contributed to the strategy on which the recommendations made in this
mapping document are based:
Care Homes Strategy for Infection Prevention & Control of Covid-19 Based on Clear
Delineation of Risk Zones - This strategy document has been prepared with inputs from a range of
experts who collectively have a mix of experience from medicine/health, care homes,
water/sanitation/hygiene, outbreak infection prevention & control (specifically from Ebola, SARS, cholera
and Lassa Haemorrhagic Fever outbreaks) and emergency response.
This can be found at: https://www.bushproof.com/care-homes-strategy-for-infection-prevention-control-
of-covid-19-based-on-clear-delineation-of-risk-zones/; or https://ltccovid.org/2020/05/01/resource-care-
homes-strategy-for-infection-prevention-control-of-covid-19-based-on-clear-delineation-of-risk-zones-
update/
Meaning of font colour and style within this document:
• Red text = gaps in guidance, contradictory points, questionable aspects
• Black bold = highlights certain useful points
1Contents
KEY DOCUMENTS UTILISED IN THIS MAPPING ANALYSIS ......................................................................... 3
1. OUR CARE HOMES IPC STRATEGY DOCUMENT ................................................................................................................ 3
2. THE UK GOVT GUIDANCE REFERRED TO (BY LETTER) IN THE COMPARISON TABLE .................................................................. 3
UK GOVERNMENT GUIDANCE VS OUR STRATEGY FOR IPC IN CARE HOMES ............................................. 7
3. CRITICAL ELEMENTS OF IPC ......................................................................................................................................... 7
3.1 - Zoning / clarification of risks / risk areas ........................................................................................................................... 7
3.2 - Encourages understanding of infection routes and how to prevent transmission ........................................................... 10
3.3 - Symptomatic vs asymptomatic or pre-symptomatic transmission .................................................................................. 13
3.4 - Discharge of COVID+ patients into a care home .............................................................................................................. 15
3.5 - Acknowledgement of different geriatric symptoms to COVID-19 .................................................................................... 17
3.6 - Allocation of staff responsibilities within the home ......................................................................................................... 17
3.7 - Isolation vs communal sitting........................................................................................................................................... 18
4. PPE ...................................................................................................................................................................... 20
4.1 – Donning and doffing areas .............................................................................................................................................. 20
4.2 - Donning and doffing processes ........................................................................................................................................ 21
4.3 - PPE - Use of gloves, handwashing and handwashing with gloves ................................................................................... 21
4.4 – PPE – Use of aprons ......................................................................................................................................................... 23
4.5 - PPE - Use of face masks .................................................................................................................................................... 24
4.6 - PPE - Use of goggles / visors ............................................................................................................................................ 27
4.7 - PPE – Use of gowns or lab coats ...................................................................................................................................... 28
4.8 - PPE for aerosol generating procedures ............................................................................................................................ 29
4.9 - Re-use of PPE .................................................................................................................................................................... 29
5. DISINFECTION, LAUNDRY, WASTES .............................................................................................................................. 31
5.1 - Disinfection protocols ....................................................................................................................................................... 31
5.2 - Cleaning routines and de-contamination ......................................................................................................................... 32
5.3 - Laundry............................................................................................................................................................................. 34
5.4 - Solid waste disposal ......................................................................................................................................................... 36
5.5 - Management of incontinence pads, faeces and urine ..................................................................................................... 37
5.6 - Management of bodies of the deceased .......................................................................................................................... 37
6. STAFF, TRAINING, TESTING, VISITORS........................................................................................................................... 38
6.1 - Staff health/sickness ........................................................................................................................................................ 38
6.2 - Staff training, hygiene and well-being ............................................................................................................................. 39
6.3 - Testing of residents and staff ........................................................................................................................................... 40
6.4 - Visitors .............................................................................................................................................................................. 41
7. VULNERABILITY, PEOPLE WITH MENTAL HEALTH CONDITIONS, AGPS ................................................................................ 42
7.1 - Working with people who are hard of hearing or who have learning difficulties, autism or dementia........................... 42
7.2 - Who is considered most vulnerable and requirements for each ...................................................................................... 43
7.3 - Use of nebulisers and chest compressions ....................................................................................................................... 44
8. OTHER REFERENCES ................................................................................................................................................. 46
8.1 Other UK Govt references............................................................................................................................................ 46
8.2 Other guidance for care homes ................................................................................................................................... 46
8.3 Zoning / traffic control bundling ................................................................................................................................. 47
8.4 Other PPE guidance ..................................................................................................................................................... 47
8.5 A-symptomatic and pre-symptomatic infection and transmission risks for COVID-19 ............................................... 47
2Key documents utilised in this mapping analysis
1. Our care homes IPC strategy document
Core document Date Link Notes
1 Our practical April 18 – https://www.bushproof.co Focusses on providing simple
recommend- updated m/care-homes-strategy-for- practical guidance in one place. Focus
ations on IPC regularly infection-prevention- on zoning and hand-washing at
strategy for care control-of-covid-19-based- critical times to improve IPC through
homes on-clear-delineation-of-risk- nudges. Incorporates responses to
document zones/; or asymptomatic / pre-symptomatic
transmission. Understands that
https://ltccovid.org/2020/0
symptoms for older people are not
5/01/resource-care-homes-
the same as for younger people.
strategy-for-infection-
prevention-control-of-
covid-19-based-on-clear-
delineation-of-risk-zones-
update/
2 Webinar on our https://youtu.be/QNN9iTnn Provides an overview on the strategy
care homes IPC RH0 above, including explaining the issue
document of asymptomatic and pre-
symptomatic transmission and
introducing key elements of the
document
2. The UK Govt guidance referred to (by letter) in the comparison table
Core Date Link Notes
document
A Department 2 April https://assets.publishing.s This guidance focuses only on
of Health & 2020 ervice.gov.uk/government symptom-based screening, not taking into
Social Care / /uploads/system/uploads/ account asymptomatic / pre-symptomatic
PHE / CQC / attachment_data/file/878 cases. It also says you can give ‘care as
NHS - 099/Admission_and_Care_ normal’ for someone who does not have
‘Admission of_Residents_during_COVI symptoms (presumably without PPE).
and Care of D- It also recommends people with COVID+
Residents 19_Incident_in_a_Care_H tests can be returned to the home. It does
during Covid- ome.pdf not focus much on IPC.
19 Incident in
a Care Home’ Says it is in the process of being updated.
guidance
3B PHE 17 April https://www.gov.uk/gover Says it is drawn from ‘C’ below for
Guidance for updated nment/publications/covid- application in care homes and it is a guide
working 27 April 19-how-to-work-safely-in- (but where there is conflict with legislation
safely in care care-homes then the legislation prevails – so they leave
homes the responsibility to the care homes to
investigate and interpret).
Some improvements on the A doc above
with clearer bits on PPE and when to use.
Brief mentions of possible asymptomatic
transmission + need for more than just PPE
– but does not say how to respond to
these issues.
C UK Gov – 24 April https://assets.publishing.s This is the Govt’s main IPC document
PHE, NHS, updated ervice.gov.uk/government across hospitals, health centres, care
PHS, PHA, 27 April /uploads/system/uploads/ homes etc, from which document B has
PHW, HPS - attachment_data/file/881 drawn. This document has a range of
COVID-19: 489/COVID- useful information in it and less incorrect
infection 19_Infection_prevention_ information than in A – but it’s quite hard
prevention and_control_guidance_co to locate the key information for use in the
and control mplete.pdf case home setting.
(IPC)
guidance
D Table 2 - PHE 8 April Table 2: Tables which indicate the PPE that it is
guidance on 2020 advised that care-workers use in care-
https://assets.publishing.s
PPE in homes, and for when assessing someone
ervice.gov.uk/government
community who may have COVID-19.
/uploads/system/uploads/
care settings 9 April
attachment_data/file/877 Eye wear protection is just recommended
2020
Table 4 - 599/T2_Recommended_P based on risk assessment and based on
Additional PE_for_primary_outpatien sessional use. We are recommending they
consideration t_and_community_care_b should be used at all times when in contact
s, in addition y_setting_poster.pdf with residents.
to standard Table 4:
infection and
prevention https://assets.publishing.s
control ervice.gov.uk/government
precautions /uploads/system/uploads/
attachment_data/file/879
111/T4_poster_Recomme
nded_PPE_additional_con
siderations_of_COVID-
19.pdf
4E Donning and 8 April Donning: This is OK - except it misses a hand-
doffing washing step after taking off an apron and
https://assets.publishing.s
guidance before taking of the mask when doffing.
ervice.gov.uk/government
Risks infecting face.
/uploads/system/uploads/
attachment_data/file/878 Note that our document follows CDC
677/PHE_11606_Putting_ advice, advocating an additional hand
on_PPE_062_revised_8_A hygiene between steps 3 and 4 during
pril.pdf doffing (i.e. after removing apron, and
before putting hands near face).
Doffing:
https://assets.publishing.s
ervice.gov.uk/government
/uploads/system/uploads/
attachment_data/file/878
678/PHE_11606_Taking_o
ff_PPE_064_revised_8_Ap
ril.pdf
F DH&SC - 15 April https://assets.publishing.s Mentions that people who are COVID+ can
COVID-19: 2020 ervice.gov.uk/government be sent back to care homes while still
Our Action (V1) /uploads/system/uploads/ positive to free up critical care beds in
Plan for Adult attachment_data/file/879 hospitals.
Social Care 639/covid-19-adult-social- But also, that where the care home is not
care-action-plan.pdf able to isolate / cohort them, that they can
be taken elsewhere for quarantine and
that the Govt has provided funding to
support discharge from hospital.
G Gov.UK – 3 May https://www.gov.uk/gover Based on the WHO advice on re-use (6
Management 2020 nment/publications/wuha April).
of shortages n-novel-coronavirus- Discusses the need for face fit for FFP2
in PPE infection-prevention-and- respirators + that they are user specific.
control/managing-
shortages-in-personal- Notes where acute shortages of PPE it
protective-equipment-ppe allows the sessional use and reuse of PPE.
H HM May https://assets.publishing.s This new document has a section on
Government 2020 ervice.gov.uk/government protecting care homes (Section 5.2 – page
– Our plan to /uploads/system/uploads/ 34). For the first time it has a specific focus
CP 239
rebuild: The attachment_data/file/884 on IPC - as well as testing, workforce,
UK (11 May) 760/Our_plan_to_rebuild_ clinical support, guidance and local
Government’ The_UK_Government_s_C authority role.
s COVID-19 OVID- IPC section says:
recovery 19_recovery_strategy.pdf
strategy • Govt stepping in the support PPE to
care homes, hospices, residential
rehabs and community care orgs.
• “It is supporting care homes with
extensive guidance, both online and by
phone, on how to prevent and control
5COVID-19 outbreaks. This includes
detailed instructions on how to deep
clean effectively after outbreaks and
how to enhance regular cleaning
practices”.
• “The NHS has committed to providing a
named contact to help ‘train the
trainers’ for every care home that
wants it by 15 May”.
• “The Government expects all care
homes to restrict all routine and non-
essential healthcare visits and reduce
staff movement between homes, in
order to limit the risk of further
infection”.
For other Govt and wider references for evidence which support the recommendations in the comparison
table (which follows) – see the end of the document.
6UK Government guidance vs our strategy for IPC in care homes
Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
3. Critical elements of IPC
3.1 - Zoning / The following recommendations have some useful 5 7 28 (1 & 2) Recommendation for
clarification of aspects of zoning or consideration of relative risk 10 zoning / TCB is based
Our
risks / risk areas areas incorporated in them: on learning from SARS
11 recommendations
in Taiwan, Ebola and
• (A) “Any resident presenting with symptoms of are based around
cholera - to provide
COVID-19 should be promptly isolated (see Annex the concept of
nudges for staff to
C for further detail), and separated in a single ‘zoning’ / ‘traffic
remember particular
room with a separate bathroom, where possible”. control bundling’
transmission risks and
“Staff should immediately instigate full infection (TCB) based on
reduce risks. It also
control measures to care for the resident with green/amber/red
considers/responds to
symptoms, which will avoid the virus spreading to zones
the asymptomatic
other residents in the care home and stop staff Plus, when to do transmission.
members becoming infected”. hand hygiene +
In some places PHE
• (A) Resident contacts are defined as residents change PPE +
guidance seems to
that: a) Live in the same unit / floor as the separate staff
focus only on isolating
infectious case (e.g. share the same communal groups + keep
and caring for the
areas), or b) Have spent more than 15 minutes cleaning
symptomatic residents
within 2 metres of an infectious case. [not sure equipment
only and seems to
where this 15 min has come from, we understand separate etc.
assume this on its own
from experiences in Vancouver that transmission
will prevent infection
has happened even with short contact in their
to the other residents.
care homes?]
7Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
• (A) “Symptomatic residents should ideally be It also talks of
isolated in single occupancy rooms. Where this is cohorting people with
not practical, cohort symptomatic residents symptoms together if
together in multi-occupancy rooms. Residents single occupancy
with suspected COVID-19 should be cohorted only rooms are not
with other residents with suspected COVID-19. available.
Residents with suspected COVID-19 should not be But in other places it
cohorted with residents with confirmed COVID-19. also recommends
Do not cohort suspected or confirmed patients isolating contacts as
next to immunocompromised residents”. well.
• (A) Clearly sign the rooms by placing IPC signs, Scattered throughout
indicating droplet and contact precautions, at the the various documents
entrance of the room. there are some points
• (A – Annex C) Re what to do with contacts: states that suggest some
to isolate contacts for 14 days ideally in single form or degree or
rooms or in groups together. Extremely zoning - but they are
vulnerable residents should be in a single room time-consuming and
and only one bathroom. not simple to find to
understand the whole
• (A – Annex C) It is also recommended that
concept and not clear
residents who have not had any exposure to the
in presentation.
symptomatic case can be cohorted separately in
another unit within the home away from the However, instituting
cases and exposed contacts. the zoning or TCB
approach would
• (A – Annex E) Notes that signage should be used support a range of the
to prevent unnecessary entry to the isolation PHE guidance.
room, but then also says confidentiality must be
8Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
maintained [we agree on the need for signage –
but this risks being contradictory – how can you
maintain confidentiality if a sign is placed?].
• (B) “You and or your manager may want to
monitor your residents for symptoms. If any of
your residents develop symptoms, become
suddenly unwell with a cough and or temperature
or you are concerned about any of them you must
inform your manager immediately. Whilst you will
wear PPE for all patients as per
recommendations, when you know someone has
symptoms it may be appropriate to visit those
individuals at the end of rounds (where safe to do
so) and discuss with your manager ways you
might be able to minimise direct contact where
practical, to further reduce risk to yourself”.
[doesn’t go into IPC requirements – seems to
over simplify the situation – just leaving them
until the end of the rounds]
• (C) “A single session refers to a period of time
where a health and social care worker is
undertaking duties in a specific clinical care
setting or exposure environment… A session ends
when the health and social care worker leaves the
clinical care setting or exposure environment.
Once the PPE has been removed it should be
disposed of safely. The duration of a single session
9Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
will vary depending on the clinical activity being
undertaken”. [“The clinical care setting or
exposure environment” – is effectively saying
going between zones]
• (C) “The following important factors would safely
reduce gown usage over a session but
organisations should develop an implementation
and action plan suitable to their organisation: a)
Label all higher risk area bays, single rooms,
corridors, treatment rooms and nurses’ stations
as ‘clinical’ areas within a specific hospital area.
Limit ‘non-clinical’ areas to staff kitchen/rest
areas and changing room. b) Once gown or
coverall is donned, the gown/coverall should
remain on the staff member until their next break.
Plastic aprons and gloves should be changed
between patients (with the notes from aprons
highlighted below). C) Staff should doff the gown
or coverall only when going from the clinical to
nonclinical area of the ward, or if they are leaving
the ward for a break”. [This paragraph is
effectively zoning]
3.2 - Encourages These statements which are scattered through the 11 3 13 (1, 2 and whole The consideration of
understanding of documents, highlight some elements of the PHE and 4 document) the possible routes for
infection routes UK Govt understanding of infection routes: 5 Our document has transmission including
and how to from asymptomatic
the understanding
and pre-symptomatic
of transmission
10Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
prevent • (A) States that “when transferring symptomatic routes - at the core patients has been the
transmission residents between rooms, the resident should of its logic - and the biggest weakness in
wear a surgical face mask” [but does not state recommended the PHE guidance.
other PPE for staff or IPC procedures]. strategies are We have stricter
produced on this
• (B) Notes: “PPE is only effective when combined recommendations for
basis (such as
with: hand hygiene (cleaning your hands regularly PPE, recommending
zoning and
and appropriately); respiratory hygiene that full PPE must be
understanding
https://coronavirusresources.phe.gov.uk/hand- used when in contact
asymptomatic and
hygiene and avoiding touching your face with with any residents at
pre-symptomatic
your hands, and following standard infection all times. And also
spread).
prevention and control precautions. stressing the
www.nice.org.uk/guidance/cg139” [good that it Our guidance also importance of
says you need to follow standard IPC precautions recognises the risk changing PPE between
- but does not give specific guidance – it won’t be from care workers zones.
easy for all care homes to pull out the relevant to the residents as PHE has recognised
guidance needed from the NICE document link well as vice versa. some risks for
provided]. transmission such as
• (B) It talks about gloves being to protect you from through sharing
body fluids and secretions [but does not talk mobility devises,
about the virus on solid materials]. It also electronic gadgets etc.
mentions the mask being to protect the carer,
[but not highlighting that it also protects the
resident, as the carer can also be asymptomatic].
• (B) Recommends only to use a mask but no other
PPE needed if within 2m of patients but not
touching them, including in communal areas.
Does not think that eye protection, plastic apron
11Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
or gloves are needed. [we think this is not
adequate and full PPE should be worn when with
residents at all times – for example, if a staff
member is asymptomatic and does not wear a
mask for example, they can infect surfaces that
then can be touched by a resident or other staff
member; and a resident may be asymptomatic
and cough when not expected, leading to
droplets into the eyes, or breathe on a staff
member]
• (A) Mentioned dedicating specific medical
equipment to residents of possible or confirmed
cases.
• (A) Restricts sharing of personal devices.
• (C) A precautionary approach is recommended
and close contact has been defined as within 2
metres (approximately 6 feet) of a patient due to
general opinion that droplets tend to not reach
further than this distance.
• (C) “Survival on environmental surfaces is also
dependent on the surface type. 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 up to 8 hours on copper”.
• (C) “Contact precautions - Used to prevent and
control infection transmission via direct contact or
12Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
indirectly from the immediate care environment
(including care equipment). This is the most
common route of infection transmission”.
3.3 - Symptomatic The following points identify the PHE and UK Govt 5 3 11 (1 & 19) We believe that any
vs asymptomatic understanding of the transmission routes of COVID- 6 PHE guidance that
Our document is
or pre- 19: does not acknowledge
based on evidence
symptomatic the pre-and
• (A) Care home providers should follow social that spread is likely
transmission asymptomatic
distancing measures for everyone in the care to be
transmission is not fit
home, wherever possible, and the shielding asymptomatic /
for purpose, will give a
guidance for the extremely vulnerable group. pre-symptomatic /
false sense of security
and symptomatic –
• (B) Gives guidance on PPE when touching any to staff and will not
as per evidence
resident (with or without symptoms) or when prevent infection.
from Singapore,
within 2m of someone coughing [includes full PPE
USA, Canada, There is a brief
including eye protection – but only said is needed
Germany etc. [see mention in B and C but
for some residents]. Also gives guidance when
references at end does not give
more than 2m away / not touching / and in
of this document] recommendations for
communal areas.
how to respond.
• (B) In the Q&As it recognises that 1/3 of people
C was updated 27 April
who test positive may not have symptoms and
- but there have been
the risk between resident and staff and vice
papers published in
versa. [good to see this acknowledged
April on evidence from
somewhere – although it contradicts the doc C]
a number of countries
• (C) “Infection control advice is based on the in the asymptomatic
reasonable assumption that the transmission nature of the virus
characteristics of COVID-19 are similar to those of while having the
the 2003 SARS-CoV outbreak”. [this is not condition for large
13Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
reasonable based on the evidence on proportions of infected
asymptomatic and pre-symptomatic positive cases in care homes
cases] and homeless shelters.
• (C) “The incubation period is from 1 to 14 days
(median 5 days). Assessment of the clinical and
epidemiological characteristics of COVID-19 cases
suggests that, similar to SARS, most patients will
not be infectious until the onset of symptoms. In
most cases, individuals are usually considered
infectious while they have symptoms; how
infectious individuals are, depends on the severity
of their symptoms and stage of their illness”. [this
is not reasonable based on the evidence on
asymptomatic and pre-symptomatic positive
cases]
• (C) “The median time from symptom onset to
clinical recovery for mild cases is approximately 2
weeks and is 3 to 6 weeks for severe or critical
cases. There have been case reports that suggest
possible infectivity prior to the onset of
symptoms, with detection of SARS-CoV-2 RNA in
some individuals before the onset of symptoms”.
[good that it is acknowledged – but they don’t
suggest what to do about it]
• (C) “Further study is required to determine the
frequency, importance and impact of
asymptomatic and pre-symptomatic infection, in
14Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
terms of transmission risks. From international
data, the balance of evidence is that most people
will have sufficiently reduced infectivity 7 days
after the onset of symptoms”. [they have ignored
the people who are asymptomatic and pre-
symptomatic]
3.4 - Discharge of • (A) “As part of the national effort, the care sector 4 (1) We strongly
COVID+ patients also plays a vital role in accepting patients as they recommend that it is
We do not think safer for the
into a care home are discharged from hospital – both because that due to the government to always
recuperation is better in non-acute settings, and infection risks for
because hospitals need to have enough beds to provide alternative
many vulnerable quarantine
treat acutely sick patients. Residents may also be residents, that any accommodation for
admitted to a care home from a home setting. patient who has
Some of these patients may have COVID-19, people who have been
COVID+ and has discharged from
whether symptomatic or asymptomatic. All of not had a negative hospital still positive
these patients can be safely cared for in a care test, should be
home if this guidance is followed”. [but their with COVID to free up
entered into a care acute care beds, rather
guidance is not strong enough to prevent spread] home until that than sending them
• (A) “If an individual has no COVID-19 symptoms negative test is into care homes,
or has tested positive for COVID-19 but is no obtained. where they risk
longer showing symptoms and has completed The DHSC plan for infecting staff and
their isolation period, then care should be COVID-19 says that residents. But we
provided as normal”. [so, what about people who if effective understand that some
are asymptomatic and pre-symptomatic?] isolation/ cohorting care homes have been
• (A) Negative tests are not required prior to cannot be done threatened with losing
transfers / admissions into the care home. then alternative funding if they do not
quarantine take in residents who
15Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
• (A – Annex D) – If someone is discharged from accommodation. have not been tested
hospital with no symptoms of COVID-19 then should be made or are positive:
they should provide ‘care as normal’. If they have available. https://news.sky.com/
tested positive from COVID and are no longer story/coronavirus-
Being in a hospital
showing symptoms and have not yet completed care-homes-faced-
increases a
their 14-day isolation, then they should remain in funding-cut-if-they-
person’s risk of
room for the rest of the 14 days and staff should didnt-take-in-covid-19-
catching COVID-19,
wear PPE. patients-11986578
so we think any
new resident being It is also concerning
discharged from that they recommend
hospital or in (A) that if a person is
otherwise should discharged from
be isolated for the hospital to a care
first 14 days on home without
arrival. symptoms they should
be provided with ‘care
as normal’.
Being in a hospital
increases a person’s
risk of catching COVID-
19, so we think any
new resident should
be isolated for the first
14 days on arrival.
16Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
3.5 - • (A) “Care homes should implement daily 5 (2) PHE does not seem to
Acknowledgement monitoring of COVID-19 symptoms amongst recognise the
We have listed a
of different residents and care home staff, as residents with differences in
range of symptoms
geriatric symptoms COVID-19 may present with a new continuous symptoms for older
that include less
to COVID-19 cough and/or high temperature. Assess each people and younger
obvious ones that
resident twice daily for the development of a fever people – older people
have been noted
(≥37.8°C), cough or shortness of breath. do not tend to get a
for older people.
Immediately report residents with fever or cough or fever.
respiratory symptoms to NHS 111, as outlined in
the section below”. [This ignores that symptoms
for older people tend to be different to younger
people]
3.6 - Allocation of These are all positive recommendations in alignment 11 13 (4) The PHE makes some
staff with a zoning strategy – but the points are a bit occasional
Recommends staff
responsibilities scattered and not emphasised in the (B) document: recommendations
are allocated to
within the home about allocation of
• (A) “Staff caring for symptomatic patients should either green,
staff to different areas
also be cohorted away from other care home amber or red areas
with symptomatic /
residents and other staff, where (or green and
non symptomatic
possible/practical. If possible, staff should only amber + red) to
residents.
work with either symptomatic or asymptomatic reduce risk of
residents. Where possible, staff who have had transmission. So, our
confirmed COVID-19 and recovered should care And to not mix with recommendation is
for COVID-19 patients. Such staff must continue similar, but just stated
staff from other
to follow the infection control precautions, more clearly.
zones during
including PPE as outlined in this document”. breaks.
17Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
• (C) “Assigning a dedicated team of staff to care
for patients in isolation/cohort rooms/areas is an
additional infection control measure. This should
be implemented whenever there are sufficient
levels of staff available (so as not to have a
negative impact on nonaffected patients’ care)”.
• (C) “Staff who have had confirmed COVID-19 and
recovered, should continue to follow the infection
control precautions, including personal protective
equipment (PPE)”.
• (C) “Domestic/cleaning staff performing
environmental decontamination should: a) ideally
be allocated to specific area(s) and not be moved
between COVID-19 and non-COVID-19 care areas;
and b) be trained in which personal protective
equipment (PPE) to use and the correct methods
of wearing, removing and disposing of PPE”.
3.7 - Isolation vs Presuming this means when there is a specific 21 (7) Once there is a first
communal sitting outbreak: case, then we strongly
We recommend:
recommend that no
• (A – Annex H) Notes that all gatherings should be • That at the first communal activities
cancelled and alternative arrangements to be case within a should be permitted
made for communal activities which incorporate care home, that for the period of the
social distancing. all communal outbreak.
sitting and
Even when there are
activities should
no people with
be prohibited
18Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
for 2 weeks symptoms, it is still
minimum - or possible that people
longer until are pre or
everyone tests asymptomatic, and so
negative. in reality the best
situation would be for
• That at all
everyone to be
times, whether
isolated in their rooms
there is a case
all the time, as the
or otherwise,
general population has
staff should
been in their houses
have no contact
(although the general
with anyone
public has been
(resident or
allowed out for
staff member)
exercise).
without
wearing a mask However, for long-
as a minimum, term well-being (in the
and a higher coming 12 months)
PPE level when there needs to be
in contact with strategies for safe
any resident in socialising /
all zones. interaction, so we have
agreed that some form
• If no outbreak,
of contact would be
then for the
beneficial, but it has to
longer-term,
be with strict
ways to be
distancing.
found for
19Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
communal
sitting and
activities – but
with strict 2m
social
distancing and
use of windows
or perplex
sheets between
people to
reduce risk of
transmission.
4. PPE
4.1 – Donning and • (B) When removing and replacing PPE, ensure 8 (9) We are recommending
doffing areas you are 2 metres away from residents and other 9 systematising the
We have
staff – see Donning and Doffing of PPE video process and awareness
recommended a
www.gov.uk/government/publications/covid-19- moving from one zone
dedicated area (or
how-to-work-safely-in-carehomes/covid-19- to another + correct
areas in a big
putting-on-and-removing-ppe-a-guide-for-care- putting on/taking off
home) to
homes-video of PPE and to reduce
systematise
risk of contamination
• (B) Your manager and yourself will need to decide process + have
of clean PPE and/or
the best place to do this in the care home e.g. posters to follow
multiple other surface
have dedicated area for putting on and taking off for how to don and
or receptacles for used
PPE. doff + have a tap
PPE.
and sink and
20Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
containers for
waste and used
PPE.
4.2 - Donning and • (B) When removing and replacing PPE ensure you 8 (16) To prevent risk of
doffing processes are 2 metres away from residents and other staff contamination on face
Same as PHE
– see Donning and Doffing of PPE video when removing mask
guidance except to
www.gov.uk/government/publications/covid-19- and goggles/visor.
add in additional
how-to-work-safely-in-carehomes/covid-19- hand-washing step Note that with the
putting-on-and-removing-ppe-a-guide-for-care- before removing recommendation to
homes-video goggles/visor. Ours only remove apron
aligns with the and gloves (and not
CDC’s. mask and eye
protection) between
each resident who you
have direct contact
with (in scenario
where not enough
PPE), there is a need to
keep on your mask and
eye protection, and
this complicates the
doffing procedures.
4.3 - PPE - Use of • (A) States washing hands with soap and water 17 6 T2 3 (3) Gloves on hand-
gloves, needed after contact with resident, removal of T4 We are stressing washing is a lesson
handwashing and PPE and cleaning if equipment and the from successes in the
the need for
environment SARS outbreak and
alcohol gel to be
21Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
handwashing with • (A) It states alcohol-based hand rub should be in throughout the based on basic
gloves prominent places ‘where possible’ [this is not care home understanding of
enough] including both transmission risks. We
sides of every are concerned that the
• (B) States that gloves should be single use and
residents’ room PHE guidance that
thrown away after completion of a procedure or
door. does not focus on this
task and after each resident. Plus, to care not to
gives staff a false sense
touch the mouth or eyes when wearing gloves. We have
of security when
emphasised the
• (B) Mentions that handwashing must be wearing PPE,
need for more
performed immediately before every episode of particularly gloves and
handwashing /
care and after any activity or contact that feel they can touch
hand gelling while
potentially results in your hands being anything they like and
gloves are on in
contaminated. This includes removal of PPE, be safe/not transmit
between touching
equipment decontamination and waste handling. the virus.
objects, as well as
• (C) “If wearing an apron rather than a gown (bare when gloves are The recommendation
below the elbows), and it is known or possible off. This is not for re-use of rubber
that forearms have been exposed to respiratory mentioned in PHE gloves for cleaners is
secretions (for example cough droplets) or other guidance. to enable the nitrile
body fluids, hand washing should be extended to gloves to be available
We are
include both forearms. Wash the forearms first for the care staff. We
recommending
and then wash the hands”. did the same for Ebola.
that they should be
• (G) States that gloves cannot be re-used. changed between
people who you
• (G) Further work is being done on validating
have had direct
methods to safely reprocess masks and fluid
contact with. Plus,
repellent gowns is under way and future updates
that the standard
will be circulated when available.
disposable gloves
22Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
should not be re-
used. This is the
same as PHE
guidance.
We are though
recommending
that cleaners can
use rubber gloves
to minimise use of
the nitrile gloves,
and that the rubber
gloves can be re-
used after soaking
in chlorine. This is
not in PHE
guidance.
4.4 – PPE – Use of • (B) States that aprons should be single use and 6 T2 3 (9) Use of rubber gloves
aprons thrown away after completion of a procedure or T4 to minimise use of the
We are
task and after each resident. Plus, to care not to nitrile gloves where
recommending
touch the mouth or eyes when wearing gloves. stocks are low, and
that aprons should
that the rubber gloves
• (G) States that gowns cannot be re-used. be changed
can be re-used if
between people
• (A) and (C) – also has similar recommendations disinfected in chlorine
who you have had
on aprons not to be re-used (as we did for Ebola).
direct contact with.
Plus, that
disposable aprons
23Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
should not be re-
used. This is the
same as PHE
guidance.
We are however
recommending
that heavy duty
aprons can be
reused if
disinfected by
soaking in chlorine
solution as noted.
4.5 - PPE - Use of The guidance on use of masks is a bit mixed: 6 32 T2 5 (9) It is better to change
face masks 7 37 T4 6 the mask between
• (B) It recognises that surgical masks and fluid We are
each resident when in
repellent surgical masks (FRSM) are to protect 8 recommending
contact with them,
both the staff and the resident. that ideally masks
wherever possible, as
should be changed,
• (B) States that the mask can be used continuously you do not know if
after you have had
while providing care between patients, until you they have COVID or
direct contact with
take a break in duties or at the end of your shift. otherwise.
a resident.
• (B) “There is no evidence to suggest that However, the mask
But that they can
replacing face masks and eye protection between itself does not touch
be used for a
each resident would reduce risk of infection to the resident and hence
session in the same
you. In fact, there may be more risk to you by it does not pose as
zone, if stocks are
repeatedly changing your face mask or eye much risk for the next
too low for new
resident, as gloves or
apron. So, we agree
24Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
protection as this may involve touching your face ones between each with the PHE that use
unnecessarily”. resident. for sessions within
zones should be
• (B) “You can wear the same face mask between If PPE stocks are
permissible.
residents whether or not they have symptoms of very low, we are
COVID-19”. [this should depend on the order in recommending It is however more
which you see them – it would not be good to that FFP2/N95 kind difficult to change an
wear any PPE after seeing a person with COVID of masks can be re- apron if a mask and
and then to a person without it – but the other used but have visor or goggles remain
way around does not pose so much risk]. given a link to the on, so this adds a
CDC complication.
• (B) Also remove and replace if damaged, soiled,
recommendation
damp, uncomfortable, difficult to breathe For re-use at a later
for how they
through time, then this only
should be re-used. applies for FFP2/N95
• (B) Do not dangle around your neck or put in a
masks and not the
surface for later use
surgical or FRSM
• (B and G): The Health and Safety Executive masks.
recommends that where face masks are to be re-
We also feel that the
used (ones with elastic ear hooks) you should do
CDC guidance for re-
the following: a) carefully fold your face mask so
using masks is better
the outside surface is folded inward and against
than the HSE guidance.
itself to reduce likelihood of contact with the
outer surface during storage; b) store the folded
mask between uses in a clean sealable bag/ box
which is marked with your name and stored in a
well-defined place; c) practice good hand hygiene
before and after removal. [it is acknowledged
that the availability of PPE is challenging and
25Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
hence why the re-use of masks is being
promoted, but one challenge with this method is
that the mask may be wet / damp and hence risks
not drying when in a sealed bag or box. There are
also risks that the virus still remains on it, so
there is some risk of contamination when
handling. The CDC guidance of having a number
of masks that mean they are left for the natural
virus die off responds to this issue before re-use].
• (C) “A fluid resistant (Type IIR) surgical facemask
(FRSM) should be worn whenever a health and
social care worker enters or is present inpatient
area (for example, ward) containing possible or
confirmed COVID-19 cases, whether or not
involved in direct patient care. For undertaking
any direct patient care, disposable gloves, aprons
and eye protection should be worn”.
• (C.) “FRSMs are for single use or single session use
(section 5.6) and then must be discarded. The
FRSM should be discarded and replaced and NOT
be subject to continued use in any of the
circumstances outlined for respirators”.
[contradicts the statement above from the HSE]
• (G) There is insufficient evidence to consider
homemade masks or cloth masks in health and
care settings.
26Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
4.6 - PPE - Use of • (B) [Bit confusing re continued use or re-use as it 7 35 (9) We also re-used
goggles / visors states you can use the eye protection 8 goggles / visors after
We are
continuously while providing care, until you need disinfection during the
recommending
to take a break between duties. But then it says it Ebola response.
that ideally,
must be decontaminated between uses]. goggles/visors
• (B) Also remove and replace if damaged, soiled, should be changed
damp, uncomfortable, difficult to breathe between residents
through after you have had
direct contact with
• (B) Do not dangle around your neck or put in a
a resident. But can
surface for later use
be used for a
• (C) “For direct care of possible or confirmed cases session in the same
in facilities such as care homes, mental health zone if stocks are
inpatient units, learning disability and autism too low for
residential units, hospices, prisons and other multiple use.
overnight care units, plastic aprons, FRSMs and
We are
gloves should be used. Need for eye protection is
recommending
subject to risk assessment (section 5.7) meaning
goggles and visors
dependent on whether the nature of care and
can be washed,
whether the individual symptoms present risk of
disinfected and
droplet transmission. For further information,
dried throughout
refer to guidance on residential care provision”.
the day for re-use.
But that this should
be done by a
separate staff
member, rather
than the person
27Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
themselves taking
them off, cleaning
and disinfecting
them and putting
them down and
back on later.
4.7 - PPE – Use of • (G) Further work is being done on validating 3 (9) Adds another layer of
gowns or lab coats methods to safely reprocess masks and fluid protection to cover the
We have
repellent gowns and future updates will be recommended that scrubs or uniforms,
circulated when available. long-sleeved gowns particularly when
handling / touching an
• (G) Says that alternatives to gowns are reusable or washable lab
infected or suspected
gowns, reusable washable laboratory coats, coats would be
resident, as the aprons
reusable washable patient gowns or reusable useful where
do not cover all areas
coveralls. possible, with
of the staff members
laundry in house,
clothes.
as part of PPE to
protect scrubs or Particularly important
uniforms when when being near and
handling patients. touching a COVID+
resident.
PHE have also
made this Logically most useful if
suggestion in their these coats get
working safely in changed when PPE is
case homes changed.
document (B).
28Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
4.8 - PPE for • (C) This is noted for staff in operating theatres [so 18 (9)
aerosol generating not related to care homes – but interesting point We have included
procedures raised] - “Staff should wear protective clothing the PHE T2 on PPE
(see table 1) but only those within 2 metres of an requirements for
aerosol generating procedure, such as performing AGPs.
intubation, need to wear FFP3 respirators,
disposable fluid repellent coveralls or long sleeved
gowns, gloves and eye protection”. – [noted here
out of interest that even with an aerosol
generating procedure they are saying only those
within 2m of the procedure where you need the
better PPE. Whereas it is understood that
aerosols hang around in the air for quite a while –
so this comment does not seem reasonable?]
4.9 - Re-use of PPE • (B) “Advice approved by the Health and Safety 9 5 (9 & 11) Some is the same
Executive on strategies for optimising the use of 7 We have suggested recommendation as
PPE and consideration for the re-use of PPE when 8 that goggles, visors, the PHE.
in short supply may be found here: lab coats/coveralls, Differences:
https://www.gov.uk/government/publications/w heavy-duty
uhan-novel-coronavirus-infection-prevention- • You can re-use
waterproof re-
and-control/managing-shortages-in-personal- heavy-duty rubber
usable aprons and
protective-equipment-ppe” gloves + a strong
heavy-duty rubber
waterproof apron
• (G) States that goggles and visors can be re-used, gloves for cleaners
as long as they are
but not aprons and gloves. can be re-used
disinfected
after suitable
• (G) FRSM and FFP2/3 masks can be used for between residents
disinfection
sessional use “in one work area”.
29Issue Govt guidance – UK Govt / PHE / NICE etc A B C D E F G Our guidance Rationale for our
recommendations
(some of which is contradictory)
(“Until you need to take a break” = “a session”) Page number (Section number)
• (G) Further work is being done on validating process for the PPE – we re-used them
methods to safely reprocess masks and fluid in question. for Ebola
repellent gowns is under way and future updates We have also said • We don’t think you
will be circulated when available. that the should be
• (G) Says that various items can be re-used in googles/visors and commonly re-using
these exceptional circumstances but then says … masks can be used masks in care
but you should consider the conditions of each by session if not settings – although
individual place of work and comply with all enough. agree they can be
applicable legislation including the Health and Strong waterproof used for sessional
Safety at Work Act, 1974 [a get out of re-usable aprons use if not taken off
responsibility clause for the UK Govt?] must be changed and not damaged
as per PHE
• (G) Says that single use PPE should not be re- between residents
if you have handled guidance.
used/reprocessed and that reusable PPE should
be reprocessed in accordance with the a resident in the • We have suggested
manufacturer’s instructions amber or red if there is no
zones, but can be option as PPE is
disinfected. very low, that CDC
We have logic-based
recommended not guidance on re-use
re-using fluid- of the higher-grade
repellent surgical FFP2/N95 type
masks (FRSM/Type masks is probably
IIR). But we have the better option.
suggested that This is where
masks for AGPs (i.e. masks are
FFP2/N95) can be allocated to staff
re-used based on and stored
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