Coronavirus (COVID-19) infection control for care providers

What is coronavirus (COVID-19)?

COVID-19 is an infectious disease caused by a newly discovered coronavirus. Whilst most people infected will experience mild to moderate respiratory illness and recover without needing specialist treatment, there are people at higher risk to develop a serious illness, such as older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer.

The most common symptoms are developing a new continuous cough and/or a high fever (above 37.8°C) and now loss/change in your normal sense of smell or taste. Other symptoms that may appear are aches, pains, nasal congestion, sore throat or diarrhoea.

How does coronavirus (COVID-19) spread?

As COVID-19 is a new disease, we are still learning about the effects of the virus and how to best prevent it’s spread. However, we know that COVID-19 is mainly spread through two methods:

• respiratory droplets released when someone sneezes, or coughs and sometimes exhales
• touching surfaces contaminated with respiratory droplets that can then be transferred by touching your eyes, nose or mouth.

The virus has been found in stool samples of people confirmed as suffering from COVID-19. While this is not thought to be the main transmission route, all secretions (excluding sweat) and excretions (such as diarrhoea) from those suffering or suspected to be suffering from COVID-19 should be managed as being possibly infectious.

How to prevent the spread of coronavirus (COVID-19)?

To reduce the spread of COVID-19, the Government has implemented a number of social distancing measures for the general public, which is to only go outside for the following:

• shopping for basic necessities, for example food and medicine, which must be as infrequent as possible
• one form of exercise a day, for example a run, walk, or cycle – alone or with members of your household
• any medical need, or to provide care or to help a vulnerable person
• travelling to and from work, but only where this absolutely cannot be done from home.

On top of this, Public Health England (PHE) has advised the public to:

• always carry tissues and use them to catch a cough or sneeze, then bin the tissue, wash hands, or use a sanitiser gel
• wash your hands more often than usual, for 20 seconds each time with soap and water or hand sanitiser, especially when you:
  • get home or into work
  • blow your nose, sneeze or cough
  • eat or handle food.
• avoid touching your eyes, nose and mouth with unwashed hands
• avoid close contact with people who are unwell.

What can care homes do to stop the spread of coronavirus (COVID-19)

Public Health England (PHE) has advised care homes to stop all visits to residents from friends and family. Medical staff and delivery couriers can still visit, but homes have been asked to leave a hand sanitiser by the entrance and ask them to wash their hands as soon as they enter the building.

• hand washing and hand hygiene
• respiratory and cough hygiene
• personal protective equipment (PPE)
• laundry management
• ventilation
• best practice management of people at high risk or with symptoms of COVID-19.

Handwashing and hand hygiene

Frequent hand washing and good hand hygiene is an essential method to control infection in your setting. All people and staff should decontaminate their hands with alcohol-based rub when moving in and out of areas where care for suspected and conformed cases of COVID-19 is being delivered.

Hand hygiene must be performed before every direct contact with people who use services, or contact that could result in your hands being contaminated such as touching care equipment, PPE or waste.

There are three important stages to cover when talking about suitable hand hygiene: when you need to do it, preparing to wash your hands and the best way to wash your hands.

• When to wash your hands Open

  There are five important moments when you should clean your hands:

  • just before you provide care to a resident
  • as soon as you have finished providing care to a resident
  • straight after you have been exposed to any body fluids
  • straight after touching the person’s surroundings (e.g. chair, door handle) if this may have contaminated your hands
  • as soon as you take off protective gloves.

• Preparing to wash your hands Open

  To prepare for hand hygiene, it is recommended that you:

  • expose your forearms so that they are bare from the elbows down
  • remove all hand and wrist jewellery, a single plain metal finger ring is permitted; however, it should be removed or must be moved during hand hygiene
  • ensure finger nails are clean, short and that artificial nails or nail products are not worn
  • cover all cuts or abrasions with a waterproof dressing.

• Washing your hands Open

  When washing your hands, you should:

  • do so for 20 seconds, or the time it takes to sing ‘Happy Birthday’ twice
  • wet your hands with water and apply enough soap to cover your hands
  • use one hand to rub the back of the other and in between fingers – do the same with the other hand
  • rub hands together and clean between your fingers
  • rub fingers against the back of both your palms
  • rub your thumbs using the other hand – do the same with the other thumb
  • rub the tips of your fingers on the palm of the other hand – do the same with the other hand
  • rinse your hands with water
  • dry your hands with a disposable towel
  • use the disposable towel to turn the tap off.

Where running water and soap are not available, an alcohol-based hand sanitiser should be used instead. Hand sanitiser for staff should be as close to where care is provided, or personal dispensers used. Hand sanitiser should be used for 20-30 seconds to decontaminate the hands.

Where no running water or other hand hygiene is available, such as in a person’s home, staff may use hand wipes followed by hand sanitiser and should wash their hands at the first opportunity.

Health and Care Innovations (HCI) have created a helpful video to guide you on this process.

Respiratory and cough hygiene – ‘Catch it, bin it, kill it’

To minimise transmission of COVID-19 through respiratory droplets, tissues and waste bins should be available to everyone. All staff, residents, users and visitors should:

• use disposable tissues to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose
• dispose of used tissues immediately in the nearest bin
• clean hands after coughing, sneezing, using tissues, after any contact with respiratory droplets or objects contaminated with respiratory droplets
• not touch their eyes, mouth and nose
• help those people who may need help with containing their respiratory droplets such as the elderly
• provide those who are immobile with a bag close by for immediate disposal of tissues
• ensure common areas, or during transportation, that people with symptoms wear a fluid resistant surgical face mask to minimise dispersal of their respiratory droplets or contamination of surfaces
• clean frequently touched surfaces.

Personal protective equipment (PPE) guidelines

The current guidance shown in Recommended PPE for primary, outpatient, community and social care by setting, NHS and independent sector by Public Health England is that when staff and the person receiving care are not showing symptoms or suspected of suffering COVID-19, the use of PPE is not required beyond normal good hygiene practices. However, if they are in the extremely vulnerable group or where a member of the household is within the extremely vulnerable group undergoing shielding, PPE is required.

Whilst providing care to people displaying symptoms, staff should consider the task and assess the risk of exposure between the person with symptoms and themselves. PPE used should provide adequate protection during the task or for the type of care being provided such as facemasks, aprons and gloves, where appropriate.

Note: PPE is only effective when combined with: hand hygiene (cleaning your hands regularly and appropriately); respiratory hygiene and avoiding touching your face with your hands, and following standard infection prevention and control precautions.

Public Health England has released specific guidance for care workers and providers delivering care in the following settings:

• visiting homecare
• extra care housing
• live-in homecare.

• When providing personal care which requires you to be in direct contact with the client(s) (e.g. touching) OR you are within two metres of anyone in the household who is coughing. Open

  • Disposable gloves
  • Disposable plastic apron
  • Fluid-repellent surgical mask
  • Eye protection may be needed with some clients but not all. Please refer to the PHE guidance on page 3

  These principles are also suitable for extra-care housing schemes and live-in homecare. These recommendations assume that care workers are not undertaking aerosol generating procedures (AGPs).

• When your visit does not require you to touch the client but you need to be within two metres of the client Open

  • Dispoable gloves
  • Disposable plastic apron
  • Surgical mask
  • Eye protection

  If practical, household members with respiratory symptoms should remain outside the room or rooms where the care worker is working, they should be encouraged to follow good respiratory hygiene and remain two metres away. If unable to maintain two metre distance from anyone who is coughing (including the client) then follow recommendations in the above drop-down.

For healthcare workers within a metre of a patient with possible or confirmed COVID-19, Public Health England (PHE) recommend:

• Fluid-resistant facemasks Open

  Fluid-resistant facemasks can be used to reduce contact with respiratory droplets by capturing some droplets when you are providing care in close contact. Both the person displaying symptoms and staff providing care should wear facemasks, preferably.

• Aprons Open

  Aprons protect staff uniform from contamination when providing direct care and during environment and equipment decontamination. Fluid-resistant gowns must be worn when disposable aprons cannot provide adequate cover from splashing and body fluids. If non-fluid-resistant gowns are used, a disposable apron should be worn underneath.

• Disposable gloves Open

  Disposable gloves must be worn when providing direct patient care and when exposure to blood or body fluids is likely, as well as during environment and equipment decontamination.

• Eye protection / visor Open

  Eye protection / visor should be worn when there is risk of contamination to the eyes from body fluids. This may be a surgical mask with visor, or polycarbonate safety spectacles or equivalent. Regular vision corrective spectacles are not considered adequate eye protection.

PPE should be:

• compliant with relevant BS/EN standards
• located close to where it will be used
• stored correctly to prevent contamination, and expiry dates adhered to.

When using PPE, you should:

• ensure you have been trained in the proper use and on donning and doffing PPE – videos are available for aerosol generating procedures (AGPs) and non-AGPs
• only use each PPE item once
• change PPE between different care tasks for one person
• change PPE between care tasks for different people
• remove PPE immediately and dispose of used items correctly
• practice hand hygiene and extend to exposed forearms after removing any element of PPE.

Putting on and removing PPE – a guide for care homes (video)

The video from Public Health England will be relevant for the whole social care workforce.

COVID-19: How to work safely in care homes: This updated guidance from Public Health England for PPE has key information that may also be relevant for working in people’s homes.

Laundry and waste management

Do:

• Wash items as appropriate in accordance with the manufacturer’s instructions.
• Dispose items that are heavily soiled with body fluids, such as vomit or diarrhoea, or items that cannot be washed, with the owner’s consent.
• Store personal waste (such as used tissues, continence pads and other items soiled with bodily fluids) and disposable cleaning cloths securely within disposable rubbish bags. Place these bags into another bag, tying securely and keep separate from other waste within the room. This should be put aside for at least 72 hours before being disposed of as normal.

Do not:

• Place dirty laundry on the floor or other surfaces to prevent contamination.
• Shake dirty laundry before washing to minimise the possibility of dispersing virus through the air.

Note: According to Government guidance, you don't need to separate dirty laundry that has been in contact with an ill person from other people’s items.

Staff uniforms and clothing should be protected from contamination by PPE. For staff taking uniform home for laundering, use a plastic bag.

Ventilation

Adequate ventilation can reduce the transmission of infection in health-care settings.

Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections. Therefore, where safe and appropriate, the opening of windows and doors should be considered.

More information can be found on the World Health Organization (WHO) website.

Best practice management of people at high risk or with symptoms of COVID-19

Where it is possible to defer home visits that are not essential or urgent, you may use alternative methods such as telephone or video contact. However, most care and support you provide is likely to involve essential direct contact.

If a member of staff is concerned they have COVID-19 they should follow NHS guidance and PHE self-isolating guidance. They should not visit or care for people until is it safe to do so.

Use the drop-downs below for specific advice.

• People supported by home care services Open

  Showing symptoms:

  Where a person you are providing home care for has symptoms of COVID-19, reduce the risk of transmission by using PPE for close personal contact such as washing and bathing, personal hygiene and contact with bodily fluids.

  If you are providing cleaning for them, household products such as detergent and bleach are effective at getting rid of the virus on surfaces. Clean frequently touched surfaces. If the ill person receiving a support does not have their own washing machine, wait 72 hours after the seven-day isolation period before taking laundry to a public laundromat.

  If someone receiving home care is not ill, but they are part of a household that is isolating, you need to review whether they are able to maintain a safe distance from the ill member of the household. For example, if they have a separate room and bathroom and are keeping two metres away from the household member with symptoms, you can then provide care without extra measures. However, if this separation is not possible then you should use the same procedures as for a person with symptoms of COVID-19 and limit contact with the household member that has symptoms.

  Not showing symptoms:

  If neither the person being supported or the care worker have symptoms, then no PPE is required and normal good hygiene practices should be used, such as hand hygiene. You can also increase cleaning and keep the property ventilated by opening windows when safe and appropriate.

• People living in supported living Open

  Showing symptoms:

  When a person in supported living has symptoms of COVID-19, reduce the risk of transmission by using PPE for close personal contact such as washing and bathing, personal hygiene and contact with bodily fluids.

  If you are providing cleaning for them, household products such as detergent and bleach are effective at getting rid of the virus on surfaces. Clean frequently touched surfaces. If the ill person receiving a support does not have their own washing machine, wait 72 hours after the seven-day isolation period before taking laundry to a public laundromat.

  Public Health England (PHE) Household isolation guidance is recommended for those in supported living. Each case will need to be considered depending on whether there are separate households, or the accommodation is a shared environment with communal areas. You may also need to consider whether underlying health conditions of residents require additional measures.

  Not showing symptoms:

  If neither the person being supported or the care worker have symptoms, then no PPE is required and normal good hygiene practices should be used, such as hand hygiene. You can also increase cleaning and keep the property ventilated by opening windows when safe and appropriate.

• People living in care homes Open

  There has been recent guidance published regarding that highlights how people can be cared for in care homes. If a person does not show COVID-19 symptoms, they can be cared for as usual. Care homes should follow social distancing rules for residents, and, where possible, shielding guidelines for those that are extremely vulnerable to serious illness from COVID-19. Residents need to be monitored twice daily to check for fevers (37.8OC or above) developing, cough or shortness of breath. People who show symptoms should be managed as below and reported to NHS 111.

  If a resident shows symptoms of COVID-19, they should be promptly isolated and separated in a single room with a separate bathroom, where possible, until the required isolation period has passed. Contact the NHS 111 COVID-19 service for advice on assessment and testing. If further clinical assessment is advised, contact their GP. If symptoms worsen during isolation or are no better after seven days, contact their GP for further advice around escalation and to ensure person-centred decision making is followed. For a medical emergency, dial 999.

  Staff should immediately instigate full infection control measures such as cohorting residents and staff, to care for the resident with symptoms, which will prevent the virus spreading to other residents in the care home and stop staff members becoming infected. Testing may be arranged with your health protection team if more than one resident display symptoms. PPE should be worn when working in close contact with residents with possible or confirmed COVID-19.

  Further details are available in the DHSC guidance.

• People at high risk or who require shielding Open

  Public Health England (PHE) have asked that people are considered to be at high risk of severe illness to follow social distancing measures more stringently. These people include those aged 70 or over (regardless of medical conditions) and those under 70 with underlying health conditions (e.g. those ordinarily eligible for the flu jab).

  The NHS has also contacted those considered to be at extremely vulnerable to severe illness and stricter ‘shielding’ measures will be implemented for people in this category. All people that require shielding should have been directly contacted by the NHS.

• People who receive direct payments Open

  Think Local Act Personal (TLAP) have created a page where information and advice for people who receive direct payments including documents about testing PAs/key workers.

  However, there is updated guidance published (21/04/2019) from the the Department of Health and Social Care for individuals who receive care and support through direct payments.

  It states that LAs and CCGs can help direct payment holders get personal protective equipment (PPE) where the fund is not already set up to pay for this, and for people or their families who have COVID-19 their PA is eligible to receive PPE.

  The Q&A provides practical advice for direct payment holders, and may not answer all questions but is intended to by a live document and updated regularly.

  Testing for COVID-19 for PAs

  Additionally, further specific guidance has been issued that invites personal care assistants (PAs) – both health and social care – to register for coronavirus testing where they are self-isolating due to experiencing coronavirus-like symptoms or because a member of their household has symptoms.

  The guidance includes the following practical documents:

  • An invitation for personal care assistant to register for a test if they meet the conditions, to be issued by their employers upon request.
  • A slide pack that contains information and detail on the process for employers and personal care assistants on testing.