Infection prevention and control for COVID-19 in a care

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Infection Control MeasuresCarers

Infection prevention and control for COVID-19in a care home setting

Edited by Francina Hyatt, Senior Lecturer Practitioner, Simulated Learning and Clinical Skills Team, Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, and

Sharon Elliott, Head of Pre-Registration Nursing, University of West London

©2020 Clinical Skills Limited. All rights reserved

COVID-19 is the disease caused by a novel coronavirus, which was first reported in Wuhan, China, on 31 December 2019 (ECDC, 2020a). Since then, COVID-19 has spread rapidly to other parts of the world. The World Health Organization categorised it as a pandemic on 11 March 2020 (WHO, 2020a). A pandemic is said to be occurring when a new disease spreads worldwide (WHO, 2020b).

Most people who catch COVID-19 will experience only a mild flu-like illness, especially if they are young and fit. Others may develop an acute respiratory infection, with sudden onset of cough and/or sore throat and/or shortness of breath, often with a raised temperature and/or severe fatigue and/or loss of or change to sense of smell and taste (NHS, 2020a). In severe cases, the person may develop pneumonia, severe acute respiratory syndrome or multiple organ failure, including kidney failure (Wang et al., 2020), and may die. There is increasing evidence that those who are male, older, from a black and minority ethnic group, and have underlying health problems such as high blood pressure, diabetes, or obesity, are more likely to need hospital treatment and/or die. As of the first half of 2020, the numbers of reported cases and deaths are changing

daily (refer to ECDC [2020b] for the most recent figures). There is also concern that many people may be infected with the virus and show no symptoms, or only very mild ones, but can pass it on to others (WHO, 2020c). Up to a third of people may have minor symptoms but test positive, and may be able to pass the virus on, so it is important to behave as though the virus is present in the care home where you work, even if no staff or residents have been diagnosed with COVID-19 (PHE, 2020a).

COVID-19 is a notifiable disease. If a staff member of a care home finds that one or more residents have symptoms of COVID-19, these residents should be isolated and tested. Staff should seek medical advice if these residents’ symptoms worsen after 7 days (PHE, 2020b).

These pages will cover how the virus that causes COVID-19 spreads, and important infection prevention and control strategies for care homes, taking into account sustained transmission (PHE, 2020c). Following this guidance will help to keep the residents and/or clients that you look after safe, as well as yourself.

Contact with an infected person or their immediate environment, including equipment used during care, is the most common route of transmission. Droplets expelled by an infected person when they cough or sneeze may carry virus to the mouth, nose or eyes of their carer, or may land on surfaces and survive for long periods, depending on the type of surface. Virus from nasal secretions can contaminate someone’s hands and then be transferred onto surfaces. (The virus that causes COVID-19 can also be transmitted by much smaller airborne particles, called aerosols, which can be breathed into the deeper parts of the lungs. Aerosols may be generated by specialised procedures, such as suctioning, and can lead to airborne transmission of the virus. These procedures would not normally take place in a care home; if they do, check local policy on infection control.)

HAND SOAP

Ways in which the COVID-19 virus can be spread

During personal care Contaminated surfaces Direct contact

Infective droplets Contaminated surfaces Poor hygiene

Always take the advice of a properly trained, experienced and competent person, usually your line manager.

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Infection Control Measures

Carers

Infection prevention and control for COVID-19 in a care home setting Page 2

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To limit the spread of COVID-19, the ‘chain of infection’ must be broken

Decontaminate hands Cough into your elbow

Stay at home if you are unwell Perform diagnostic testsIsolate those who show symptoms

Use personal protective equipment correctly, depending on the work you are doing

Keep your hands away from your face at all times, not just when you are at work

Decontaminate single rooms and communal areas at least twice daily (PHE, 2020c)

Every day screen residents for symptoms, even if they say they are well (PHE, 2020b))

Wash your hands more often, with either soap and water or alcohol-based hand sanitiser

Cough into your elbow, instead of covering your mouth with your hand

Look out for residents developing new symptoms, especially if they cannot communicate well

Self-isolate as soon as you notice any symptoms (NHS, 2020b)

As soon as a resident shows symptoms, isolate them, ideally in a single room (PHE, 2020b)

Carry out diagnostic tests for all symptomatic residents (PHE, 2020d)


Add one new pic to each column. On RHS, add a pic under “Avoid touching your face” showing cleaning a door plate on a �re door--it’s enough just to show the hand and the door plate. call it “Decontaminate surfaces regularly”. On LHS, add a pic to illustrate the message, Stay at home if you are unwelleg sta� member on sofa or in bed, caption for this is: Stay at home for at least 7 days from when your symptoms started and follow the PHE guidance (PHE, 2020b).

Sneeze into a tissueWear the right PPE

Avoid touching your face

Screen residents Decontaminate surfaces regularly

Catch sneezes in a tissue and dispose of it immediately in a bin; wash hands immediately

Be alert to new symptoms

She needs to be wearing gloves The virus grows and lives within human

cells. The infected person sheds the virus in mucus from their nose, in sputum when they cough, in saliva, in urine and in faeces. In order to survive, the virus must reach a new host. Preventing this happening means breaking the “chain of infection”.

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Carers


Preventing transmission: (a) Hand hygiene

Washing your hands in the correct way and at the correct times is one of the most important things you can do to reduce transmission of the virus. (See also clinicalskills.net procedure on “Routine hand hygiene”.) Decontaminate your hands immediately before and immediately after each episode of direct contact or care with a resident/client, as well as immediately after having contact with objects or equipment in the person’s immediate environment, which may have contaminated your hands. Wash forearms (PHE, 2020a), when washing your hands. Wash your hands with soap and water, rubbing your hands together vigorously for at least 15 seconds or for 20-30 seconds when using alcohol-based hand sanitiser (HPS, 2020).

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A type I face mask prevents the wearer from spreading the virus to others. It is not considered PPE (PHE, 2020a). Wear this type of mask when working in a care home but always at least 2 metres away from residents. You can wear the mask continuously until you take a break, but change it if it becomes moist, damaged or soiled. Staff who have been providing care to residents, while wearing the PPE shown on the right, and who are taking a break, should remove their PPE, clean their hands and put on a new type I or II face mask.

A type II surgical mask should be worn when working in a care home, within 2 metres of residents but not in a role where you deliver personal care or need to touch them; and where there is no one within 2 metres who has a cough. You can wear the mask continu-ously until you take a break, but change it if it becomes moist, damaged or soiled. If you are already wearing a type IIR surgical mask (see right), you can continue wearing it in this situation. Likewise, if the only masks available are type IIR, you may use these in this situation.

When working in a care home and providing close personal care for residents, such as touching them, or when within 2 metres of any resident who is coughing, you should wear the PPE shown above. (The numbers indicate the order in which you should put the PPE on, where “1” is the first item you put on, etc.) You can wear the FRSM continuously until you take a break, but change it if it becomes moist, damaged or soiled. Carry out a risk assessment to determine whether you need to wear eye protection.


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Examples of when to wear a type I or II surgical mask:• Working in staff-only areas, such as an office, a laundry room, or kitchen• Working as a receptionist or cleaner• Any role where you do not deliver care to residents, and are always 2 metres away from them

Examples of when to wear a type II surgical mask:• Performing medication rounds or prompting residents to take their medication• Cleaning close to residents• Preparing food for residents who can feed themselves without assistance• Working in communal areas such as lounges and corridors

Examples of when to wear a type IIR FRSM:• Whenever working within 2 metres of a resident who is coughing• Assisting residents with getting in or out of bed or with toileting• Caring for residents with unpredictable or challenging behaviour

Type I or II surgical mask. Put this on before or immediately when entering the care home (PHE, 2020a)

Type II surgical mask. This provides a barrier against residents’ respiratory secretions

3. Eye protection, such as goggles (may be worn for the duration of a session of work)

2. Type IIR fluid-repellent surgical mask (FRSM). This protects the wearer from respiratory droplets such as from coughing and sneezing (PHE, 2020a)

1. Disposable plastic apron (single use)

4. Disposable gloves (single use only)

What personal protective equipment (PPE) to wear (PHE, 2020a)


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Put on the FRSM, to protect your mouth and nose from your resident’s/ client’s respiratory secretions. Ensure that it fits snugly around your nose (if it has a metal strip along the top edge, mould this to your nose). Pull it under your chin. Adjust the straps behind your head to achieve a good fit. If the mask has loops for your ears, which are too long, try tying a knot in the loops.

If you are caring for a resident/client who is coughing a lot, or vomiting, or if there is a risk of other body fluids splashing in your eyes, you will need to wear eye protection, such as reusable goggles. If you wear spectacles, you should wear goggles or other eye protection, such as a visor, over these. During care, avoid touching your face or any unnecessary surfaces (inset).


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Putting the PPE on: (a) First perform hand hygiene (b) Put on apron first

(c) Put on an FRSM (d) Put on eye protection

(e) Put on disposable gloves Aprons and gloves are ALWAYS single-use only

Always wash your hands with soap and water, or use alcohol-based hand sanitiser if your hands are visibly clean, before you start caring for a resident/client which will involve touching them, or coming within 2 metres of them if they are coughing (PHE, 2020a).

First put on an apron, to protect your clothes or uniform. Put on the PPE before coming within 2 metres of any resident/client you will be caring for, or before you come within 2 metres of any resident who is coughing (PHE, 2020a). It is a good idea to have a dedicated area for putting on and taking off PPE within the care home (PHE, 2020a).

Gloves protect your hands from becoming contaminated with virus that is on surfaces or on the resident/client. Always use a fresh pair of gloves when starting a new episode of care for a resident/client. You are now ready to provide personal care to the resident/client.

When wearing gloves and aprons as part of your PPE to protect you against transmission of COVID-19, you must continue to discard these after every person you see (PHE, 2020a). Remove gloves first, then apron, then wash your hands (Loveday et al., 2014). If necessary, reapply apron and gloves.

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Pull that glove down towards the fingers, so that it turns inside out. Once you have pulled the glove off, transfer it to your gloved hand.

Now slide your ungloved fingers inside the cuff of the remaining glove, where it covers the back of your wrist.

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Change your face mask if it becomes moist, damaged or soiled during your shift, do NOT allow the mask to dangle.

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Some PPE can be worn for your entire shift Taking off PPE (a) Remove gloves first

Turn the glove inside out Slide your fingers inside the cuff of your gloved hand

Remove the second glove Perform hand hygiene

You can wear a Type IIR FRSM continuously while providing care, from when you start work until you either take a break, or you finish your shift (PHE, 2020a). The same applies to eye protection. Do not touch your face mask apart from when putting it on and taking it off (PHE, 2020a). If eyewear is reusable, you must clean it when you remove it, so that it is clean when you next put it on.

Remove your gloves and apron while still in the resident’s/client’s room (PHE, 2020e) and dispose of them. Remove your gloves first (Loveday et al., 2014) as these are likely to be highly contaminated. To remove your gloves, first take hold of the outside of one glove over the back of your wrist, as shown.

Grasping the glove from the inside, pull it down towards the fingers so that it turns inside out. As this happens, the first glove removed will end up inside this glove. Dispose of the gloves into a clinical waste bin or bag according to local policy. Decontaminate your hands immediately afterwards.

Next, perform hand hygiene by either washing your hands with soap and water, or using alcohol-based hand sanitiser.

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If wearing eye protection, remove this next inside the resident’s room. Holding the arms of the goggles at their tips, move the eye protection forward and off your face. If reusable, clean ready for next use. If not, drop into the clinical waste bag without touching the front surface, which may be heavily contaminated.

Next, perform hand hygiene by either washing your hands with soap and water, or using alcohol-based hand sanitiser. You are now ready to leave the resident’s or client’s room, or the area in which you have come within2 metres of resident(s).

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(b) Remove your apron

(c) Remove eye protection, if wearing Perform hand hygiene

(d) Remove your FRSM (if finishing shift or having break) (e) Glasses

Having performed hand hygiene after removing your gloves, remove your apron inside the resident’s room. First break the neck strap. Use both hands and avoid pulling it against your neck (left). Let the bib of the apron fall downwards in front of you. Next, without touching your clothing, break the apron straps (centre). Grasping the non-contaminated inner side of the apron, and avoiding touching either your clothing or the contaminated outer layer, roll it up into a ball (right) (PHE, 2020f). Dispose of it into the clinical waste bin.

At the exit to the area of exposure, or just outside the resident’s/client’s room, or at least 2 metres away from the resident/client, remove the FRSM (PHE, 2020e). Bend forward slightly. Untie or unloop the mask and allow the PPE to fall away from your face. Dispose of the mask in the clinical waste bin.

If you wear spectacles, but have not worn eye protection on top of these, clean your glasses now using an alcohol lens wipe (PHE, 2020e). Do not put them on again until you have washed your hands.

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CALL

111when it’s less

urgent than 999

Seek medical advice for sick residents

Check residents’ temperatures and, if trained to do so, vital signs such as heart rate, blood pressure, pulse oximetry and new or worsening confusion. A temperature of 37.8 °C or above is outside the normal range. Care home residents may commonly present other symptoms, such as loss of appetitie, reduced oral intake and diarrhoea (BGS, 2020a).

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SPECIAL PRECAUTIONS

STOP

All Staff

Visitors

Use alcohol hand rub / wash hands with soap and water before clinical contact with the patient/environment.

Wash hands with soap and water after contact with the patient/environment, before leaving the isolation

room/bay (even if using gloves).

Wear plastic apron and disposable gloves if having direct contact with the patient, bed linen,

equipment (unnecessary if there is no contact or very limited contact).

Remove apron and gloves, discard as hazardous waste (orange or yellow bag) inside the room/bay, unless transporting soiled equipment, e.g. commode, then

remove apron/gloves after decontaminating equipment.Wash hands with soap and water on completion.

DO NOT ENTER. Please speak to a member of the nursing staff prior to entering the isolation room.

Wash hands or use alcohol hand rub when entering.Apron and gloves are generally unnecessary, unless involved in personal

care of the patient while visiting.Wash hands with soap and water before leaving the room/bay.

For any queries, speak to nursing staff.

Keep the door shut as much as possible.


Carers


Wash your hands with soap and water Removing PPE, when wearing only a face mask

What if there is not enough PPE? Monitor residents for symptoms of COVID-19

Isolate anyone with symptoms

Wash your hands again with soap and water. If you had taken your spectacles off to clean them, replace them now (PHE, 2020e).

First decontaminate your hands by washing with soap and water or using alcohol-based hand sanitiser, before removing the face mask as described earlier. Touch only the straps, not the front of the mask. Dispose of the mask in the clinical waste bin and wash your hands with soap and water.

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Calculate a NEWS2 score and call NHS 111or 999 (if in the UK) as indicated by the score and interpretation (RCP, 2017). (See relevant clinicalskills.net procedures on NEWS2.) If necessary contact their general practitioner. Escalate their medical care as appropriate and according to local policy (PHE, 2020b).

If you notice that stocks of PPE are running low, ensure that the person responsible for ordering supplies in your organisation knows about this. The UK Government is working with local resilience forums (LRFs) to plan local distribution of stock (PHE, 2020g). In addition, there is a National Supply Disruption Response hotline and email address to allow social care organisations to request emergency supplies of PPE (PHE, 2020g).

Isolate any residents showing symptoms immediately, by moving them to a single room (ideally with a separate bathroom) to reduce the risk of spreading the virus to other residents and test them (BGS, 2020a). Staff looking after them should wear the correct PPE as described earlier.

AMBULANC

AMBULANCE

More about Coronavirus

It is very easy to catch Coronavirus.

It is not serious for most people.

But it is serious for olderpeople and people who haveother health problems.

These people may have to gointo hospital.

Dear Sir or Madam,

Thank you for your letter.

We are pleased to say that we

are happy to do the things you

asked us about. We are blah,

blah blah to talk at any

EasyRead

Coronavirus

Accessible Statement

HF mencap

HF Mencap will give you updates

using our facebook page - facebook.com/pg/

HammersmithandfulhamMencap

Our website www.hfmencap.org

And letters home

Please tell a manager if you have been or are going on holiday

or have anyone visiting from other countries to your home.

WWW

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Can the general practitioner visit? Shielding extremely vulnerable residents/clients

Residents/clients with dementia Residents/clients with learning disabilities or autism

Challenging behaviour and mental capacity Residents/clients discharged from hospital

Primary care services should help support care homes during the pandemic: residents identified as needing assessment and care as a priority should have a weekly check by a multidisciplinary team, carried out remotely if appropriate (NHSE&I, 2020a). Use of equipment such as pulse oximeters will make remote monitoring easier (NHSE&I, 2020a), also iPads or similar, as shown.

Depending on the extent of transmission of the virus, some groups of people will be asked to stay at home at all times and avoid any face-to-face contact. This advice will also apply to some people living in long-term care organisations, or those who have visiting carers (PHE, 2020h). When shielding is required, follow local policy for these residents/clients.

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When a person is being discharged from hospital to a care home, the hospital will send the care home the date and results of their test for COVID-19, the date symptoms first appeared, and a care plan for discharging them from isolation (DH, 2020b). If the person is still waiting for their test result, they should be isolated as if they were positive for COVID-19 (DH, 2020b).


Staff will need to be particularly vigilant in determining whether residents with dementia have developed new symptoms of COVID-19 because this group may not be able to convey how they are feeling. Remember that people with dementia may develop delirium if they have an infection (PHE, 2020a; BGS, 2020a).

People with learning disabilities or autism will need specific support in relation to the COVID-19 pandemic (see for example, Mencap, 2020). Be aware of the need for reasonable adjustments and good communication, the use of healthcare passports, and the risks of diagnostic overshadowing—when symptoms of physical ill health are dismissed as due to the person’s learning disability (NHSE&I, 2020b; Kudita & Kupara, 2018).

The British Geriatrics Society have produced useful guidance (BGS, 2020a) to help support care homes where residents have COVID-19, including advice on how to reduce the risk of delirium, which may contribute to wandering, also known as “walking with purpose” (BGS, 2020b). The principles of the Mental Capacity Act continue to apply during the pandemic (DH, 2020a).

If iPads or other video- calling devices are used to call the general practitioner or other primary healthcare professional, ensure they are cleaned afterwards according to the manufacturers’ instructions

All care workers with symptoms can get a nose or throat swab which will be tested to find out if they have COVID-19 (DH, 2020c). You can choose either a drive-through appointment, or a home test kit. Your employer can also refer you for a test if you are self-isolating at home either because you or a member of your family has COVID-19 symptoms. If referred by your employer, you will get a text message telling you how to book your test.

Purell

Hands

Door

Protectiveclothing

Beforeleaving

SPECIAL PRECAUTIONS

STOP

All Staff

Visitors

Use alcohol hand rub / wash hands with soap and water before clinical contact with the patient/environment.

Wash hands with soap and water after contact with the patient/environment, before leaving the isolation

room/bay (even if using gloves).

Wear plastic apron and disposable gloves if having direct contact with the patient, bed linen,

equipment (unnecessary if there is no contact or very limited contact).

Remove apron and gloves, discard as hazardous waste (orange or yellow bag) inside the room/bay, unless transporting soiled equipment, e.g. commode, then

remove apron/gloves after decontaminating equipment.Wash hands with soap and water on completion.

DO NOT ENTER. Please speak to a member of the nursing staff prior to entering the isolation room.

Wash hands or use alcohol hand rub when entering.Apron and gloves are generally unnecessary, unless involved in personal

care of the patient while visiting.Wash hands with soap and water before leaving the room/bay.

For any queries, speak to nursing staff.

Keep the door shut as much as possible.

NHS

Royal Beckham NHS

STAFF

Vicky

co-ordinator

Infection Control

Ben Odrill

This is the wobble room


Carers


Can relatives and friends continue to visit residents? Ensure residents keep in touch with their relatives

What if I get symptoms of COVID-19? Can I get a test to see if I have COVID-19?

Can I get a test to find out if I have already had COVID-19? Taking care of your own mental health

Care homes should discourage unnecessary visits. Guidance alllows restricted numbers of visitors following detailed risk assessment and advice from the public health director on prevalence of local infection rates. Care homes must have a visiting policy with infection control measures such as handwashing, wearing PPE and limiting one visitor per resident (PHE, 2020b).

Homes should also try to use new technology, such as tablets, smartphones and video-calling devices to help residents stay in touch with their family and friends remotely (DH, 2020b). These must be cleaned after each use following the manufacturers’ instructions.

There is a test to detect antibodies to the virus, which would indicate previous infection with the virus that causes COVID-19 (Reuters, 2020). In the UK, these tests are not currently widely available (NHS, 2020c).

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In order to take care of others, you need to take care of yourself first. Seek help if you are struggling. Many organisations have published examples of good practice in relation to supporting staff and where to get help (DH, 2020d; Pearce, 2020; QNI, 2020; RCN, 2020; WHO, 2020d). Some care homes have set up or joined Facebook groups to help staff support each other during the current crisis.

It is very important that if you develop symptoms of COVID-19, such as a high temperature, new continuous cough and/or loss or change to your sense of smell or taste (NHS, 2020a), you should not go to work, as you may spread the virus to residents/clients and/or other staff. You need to stay at home as soon as you notice you have symptoms (NHS, 2020b).

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Infection prevention and control for COVID-19 in a care