New Government guidance on infection prevention and control

26 August 2020

A new, UK-wide guidance document entitled: COVID-19: Guidance for the remobilisation of services within health and care settings has been published, superseding guidance released on 18 June 2020. This commentary highlights some of the changes that can be found in the new guidance and provides comments on these changes. The new guidance is particularly relevant to planned care and perioperative settings, but we recommend that it be read in conjunction with recently published critical care guidance, as the two are aligned, and the latter is also relevant to perioperative care.

Changes in the new guidance

The guidance describes three patient care pathways, which we summarise as:

High Risk

Patients who have or are likely to have SARS-CoV-2 infection or COVID-19 and patients who have not been triaged.

Medium Risk

Asymptomatic patients awaiting a SARS-CoV-2 PCR test result.

Low Risk

Asymptomatic patients with a negative PCR test within 72 hours who have self-isolated in accordance with NICE guidance*; those who have recovered from COVID-19, have been asymptomatic for >72 hours and have a negative PCR; patients who are tested regularly and have a negative PCR.

*For most patients, this is “since a PCR test”, i.e. ≤72 hrs. For those in vulnerable, very vulnerable or other high-risk groups, isolation may have been longer.

The new guidance clarifies the use of personal protective equipment (PPE) and limits the sessional use of PPE to facemasks.

The list of aerosol-generating procedures (AGPs) that create a higher risk of respiratory infection transmission is unchanged from previous guidance.

The concept of the “time required for clearance of aerosols” by operating theatre ventilation systems is replaced by the terms “theatre downtime” and “fallow period”.

The guidance confirms that there is a very low infection risk from air that leaves operating theatres through doors or ventilation channels, as any aerosol particles “will be highly diluted and not considered a risk”. This supports our advice that there is no need to wait for aerosol clearance after an AGP at the end of a procedure before taking the patient out of the operating theatre.

The main change signalled by the new guidance is that healthcare workers (HCWs) should use standard infection control precautions (SICPs) in place of transmission-based precautions (TBPs) for patients in low risk pathways, even if AGPs are being performed. In the context of the delivery of anaesthesia and critical care, when contact with blood and body fluids is frequent, these are:

  • Disposable gloves - single use.

  • Apron (gown if risk of splashing/spraying) – single use.

  • Type IIR fluid-resistant surgical mask - sessional use possible*.

  • Eye/face protection if possibility of contact with blood or body fluids.

*Type II masks are often provided for HCWs to wear in hospital but, as these are not fluid-resistant, they are not appropriate for direct patient care.

Double gloving is not recommended for any pathway.

General anaesthesia can be given in anaesthetic rooms to low-risk pathway patients. Anaesthetic rooms can be used for patients undergoing local, neuraxial regional anaesthesia alone in all three pathways. The guidance states that patients in the medium and high-risk pathways should be “anaesthetised and recovered in the operating theatre” if an AGP such as those associated with general anaesthesia is performed. We interpret ‘recovery’ in this context to mean removal of an invasive airway used solely for anaesthesia, and completion of all AGPs. At this time patients in the medium and high risk-pathways can be transferred to a Post-Anaesthesia Care Unit (Recovery Room).

The document gives no guidance on the use of supraglottic airways (SGAs) in these patients. Guidance published recently on this website gives updated advice on the use of SGAs during the endemic phase of COVID-19.

For patients in medium-risk and high-risk pathways, droplet-precaution PPE should be used, with airborne precautions being used when AGPs are performed.

There is no clear indication as to which pathway asymptomatic in-patients should be routinely allocated if they require surgery. The guidance includes in its list of examples of medium risk pathway patients and facilities: “Facilities where individuals are cared (for), for example in-patients; adult and children, Mental health, Maternity, Critical Care Units”. However, a passage later in the guidance states that: “Transmission based precautions should only be discontinued in consultation with clinicians and should take into consideration the individual’s test results and clinical symptoms. If test results are not available (for example the patient declines), TBPs can be discontinued after 14 days (inpatients) depending on contact exposure and providing the patient/individual remains symptom free”. From these comments, and from the guidance that individuals who are regularly tested and have a negative PCR should be in low-risk pathways, our interpretation is that asymptomatic inpatients who are in hospital areas that do not care for high-risk patients, and who have had regular negative results from PCR testing, can be treated as low-risk patients with clinician approval.

Critical Care Considerations

If numbers of COVID-19 cases decline such that suspected or confirmed COVID-19 cases can be cared for in single rooms or isolation rooms, ICU areas need no longer be classified as an AGP “hot spot” or “high risk area”. This should be confirmed locally based on prevalence data and the security of pathway processes. This negates the requirement for the routine wearing of airborne PPE provided the only patients admitted to an ICU area are in a low risk COVID-19 pathway.

For medium-risk and high-risk patients, droplet precautions apply as a minimum. However, consideration may need to be given to the use of airborne precautions where the number of patients suspected or confirmed to have COVID-19 who require AGPs increases and patients cannot be managed in single or isolation rooms.

Comments

This updated guidance is welcome for its clarity with regard to the categorisation of patients into risk-stratified pathways and the PPE to be used for each pathway in varying circumstances, and for its alignment with recent critical care guidance.

We support changes to healthcare processes that increase timely access to NHS care, maintain the safety of patients and protect HCWs from harm while improving working conditions. The changes in infection control precautions outlined in the guidance document are predicated on a low community prevalence of COVID-19 that may not be geographically uniform or constant. These local variations, in combination with recent changes to guidance on preoperative isolation for patients undergoing planned procedures, should lead hospitals to involve local experts in infection prevention and control in determining the use of SICPs and TBPs in critical care areas and operating theatres. This approach is supported by the new guidance document, which states that: “providers of planned services should be responsive to local and national prevalence data and adapt processes so that services can be stepped-up or down”. Further, as outlined in our document on managing theatres processes, there may be a role for individual variation after risk assessment and involvement of Occupational Health: “in some settings, it may be logical for individuals at higher risk to alter their work behaviour, e.g. location of work and/or level of PPE used”. This approach is emphasised in our document on higher-risk and shielding doctors in anaesthesia and intensive care medicine.

ENDS