This toolkit aims to recognise risks when providing close proximity care for patients known or suspected to have a respiratory infection, and the increasing evidence base supporting this risk in enclosed spaces which can be applied to homes and health and care environments more generally. Given that for many people with respiratory symptoms the specific virus responsible will not be known it is recommended that a risk-based approach is adopted that takes into account a number of elements including the prevalence of respiratory infections in the wider local community, potential infection following foreign travel and current outbreaks of infection in the workplace.

Links to surveillance data on circulating respiratory infections can be found below. Whilst infections are more prevalent in the winter period they are present all year round and vary according to multiple factors.

• Scotland Public Health Scotland
• England UKHSA
• Wales
• Northern Ireland Public Health Agency Northern Ireland

This toolkit is intended to support health and care workers in all settings, employers and managers to navigate existing guidance, local policies and procedures to enable risk assessment in their workplace and to reduce the transmission of infection. The principles included within this toolkit can be applied to any respiratory infection, capable of causing harm to health.

The toolkit recognises that health and care workers in contact with patients/clients who have or who may have a respiratory infection which could cause harm to health should be adequately protected under the legal duties placed on their employers under the Control of Substances Hazardous to Health (COSHH) Regulations 2002. In Northern Ireland this includes the Management of Health and Safety at Work Regulations (Northern Ireland) 2000 and The Control of Substances Hazardous to Health Regulations (Northern Ireland) 2003. This represents a shift from mandated pandemic requirements in previous national guidance documents to the need to risk assess the use of respiratory protective equipment. (see Risk Assessment Tool section).

Regulation 6 of the COSHH Regulations and Regulation 3 of the Management of Health and Safety at Work Regulations 1999 place a legal duty on employers to make a suitable and sufficient assessment of the risk of exposure to a substance hazardous to health and identify the steps that need to be taken to control the risk. If the risk of exposure cannot be prevented, adequate controls, in line with the principles of protection (outlined in Schedule 2A of COSHH) must be in place. Principle (e) in Schedule 2A requires the employer to provide employees with suitable personal protective equipment (PPE), e.g. respiratory protective equipment (RPE), in addition to all other control measures if the combination of those measures fails to achieve adequate control of exposure.

The employer must also provide employees who undertake work liable to expose them to respiratory infections which could cause significant harm to their health with suitable and sufficient information, instruction and training provided in a manner appropriate to the level, type and duration of exposure identified by the risk assessment.

We know that in the face of continuing pressures caused by all respiratory infections, our members want to deliver the best and safest care they can and deserve adequate and appropriate protection whilst working. Therefore, in collaboration with CAPA (COVID Airborne Protection Alliance group) and the British Occupational Hygiene Society (BOHS) the RCN has developed a risk assessment toolkit to support members working in all health and care settings.

It is the legal duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees. The COVID-19 pandemic has shone a light on the risks faced by health professionals in all care settings and the need for rigorous and detailed health and safety procedures.

This toolkit aims to bring together all relevant duties, including Infection Prevention and Control (IPC) guidance (UK, national or local), health and safety legislation and employment law duties in a way that ensures that they work together in a complementary way from a health and safety perspective.

The toolkit aims to support relevant staff to solve practical problems and thinking through the considerations that employers and managers are legally obligated to consider when arriving at decisions which will determine the health of health care workers.

It should be highlighted that some of the information and detail in this toolkit might be new to health care workers who have not had to consider respiratory protection against biological hazards previously in their roles as employers, managers or individual workers. For more information on health and safety, see the Health and Safety Executive Northern Ireland and Health and Safety Executive Great Britain websites.

Why a toolkit, rather than a single tool?

It is recognised that risk assessments can be poorly understood, complex, and duties outlined in legislation/regulation are sometimes difficult to navigate. At different employee and managerial levels within health and care organisations, the challenges in decision-making manifest themselves in different ways and hinge on different sets of duties and perspectives.

It is for this reason therefore that, working across a range of professional and scientific organisations, we have developed a toolkit that seeks to clarify the primary obligations of decision-makers at different levels across the health care sector to enable a consistent and systematic consideration of health and safety responsibilities in the context of COVID-19.

The COVID-19 pandemic has led to a greater understanding of how respiratory infections can be spread between individuals in closed physical environments such as homes, prisons, schools, public spaces (e.g. theatres and restaurants) and health and care environments. Learning based on growing international evidence is challenging the historical dogma of respiratory infections spread via droplets or airborne transmission and the impact of this categorisation on the application of health and safety legislation aligned to this.  It is now widely accepted that both infectious droplets and smaller aerosols can be produced by people with a respiratory infection as part of activities of daily living (talking, breathing, coughing) in addition to care procedures such as induction of sputum, endoscopy and dental procedures as described in local of employer policies on aerosol generating procedures. This has resulted in a renewed focus on the role of air and ‘airborne transmission’ and its impact on the prevention of infection. International consensus concludes that a number of measures such as adequate ventilation, use of respiratory protective equipment, physical distancing, air filtering/cleaning technologies or reduced density of people in indoor environments may be required.

It is important to note that individual staff who work whilst symptomatic with an acute respiratory infection are at risk of transmitting this to others in the workplace wherever that is. National guidance outlines actions for health and care staff to take including when to stay at home if not well enough to work. Local policies should support this in additional to national guidance such as ‘promoting health and wellbeing and attendance at work’ (NHS Employers).  Managers should support staff to stay at home if they are unwell and staff should not feel pressured to work until well enough to do so. RCN members can contact RCN Direct for support if required. 

Evidence has highlighted that healthcare workers are at an increased risk of acquiring COVID-19 and other respiratory infections compared to the general population (Mutambudzi et al 2021, UKHSA 2022 and Toren 2023).  As a result of the pandemic, there is now increased awareness and scrutiny of the impact of respiratory infections acquired as a result of spread within the health and care workplace affecting staff and patients.  The Health and Safety Executive Approved List of biological agents set by the Advisory Committee on Dangerous Pathogens (HSE 2023) is a useful reference for supporting risk assessment and management of risk in the workplace. Those that can cause respiratory illness and potential harm fall in to Hazard groups 2 and 3. They all require risk assessment and controls to be in place under Control of Substances Hazardous to Health Regulations (COSHH).   

Table 1 - Health and Safety Executive Approved List of biological agents hazard group definitions, Advisory Committee on Dangerous Pathogens (HSE 2023)

A number of pathogens that cause respiratory infection are classified as potentially causing severe infection in humans includes Mycobacterium tuberculosis (TB), some influenza viruses, measles, disseminated herpes zoster, Middle East respiratory syndrome-related coronavirus (MERS), Severe acute respiratory syndrome-related coronavirus 1 (SARS-CoV-1) and Severe-acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) the cause of COVID. 

The evolution of SARS-CoV-2 variants of concern (VoC) associated with increased transmission of the virus and rapid rise in healthcare worker infections and sickness absence has raised many questions regarding the route and risk of transmission of the virus.  The key consideration is transmission through the air and quality of ventilation to mitigate this where health and care is delivered, for example, in care homes, patients own homes, prisons, and primary care/acute settings.

Taking such evidence into account the RCN and partners have developed this online risk assessment toolkit. The toolkit has been developed to provide guidance to mitigate the airborne route of transmission which is recognised as posing a significant risk to healthcare workers when working within 2m of a person known or suspected to have COVID-19 and other respiratory infections. 

Risk assessment is fundamental to the provision of a safe and effective workplace – in healthcare this supports the protection of staff, patients, and visitors. Risk assessment, as a core component of health and safety legislation, is already embedded in healthcare with examples including the control of hazardous substances (chemicals, asbestos, biological agents) and the prevention of musculoskeletal injuries when moving and handling and sharps injuries. The toolkit may be of benefit to employers, managers, healthcare professionals and trade union health and safety representatives. It recognises that toolkit readers needs may vary. Readers may wish to read all elements of the toolkit or go directly to sections applicable to their needs at the time. The left-hand toolbar can be used to navigate sections of the toolkit according to need 

Note: Infection prevention and control national and local guidance should inform local risk assessment carried out under relevant health and safety law. This toolkit does not replace national or local policies/guidance, and should be used in conjunction with these to support employers to meet their legal obligations.  

Specific roles and responsibilities for applying health and safety legislation will be different depending on the roles and positions within your own organisation. Health and safety legislation and regulations apply to all workplaces. This includes health and care settings wherever care is provided such as people’s own homes, prisons, and ambulances. For more information on health and safety, see the Health and Safety Executive Northern Ireland and Health and Safety Executive Great Britain websites.

The toolkit acknowledges the learning that has occurred as a result of the COVID-19 pandemic and recognition that airborne transmission is now a significant factor in the spread of respiratory infections and therefore a key aspect of health and safety risk assessment for health and care worker protection.

Risk assessment supports local decision making, on whether and what level of actions are required to protect staff, patients, and visitors. Action to support risk assessment is the responsibility of many people and some are described in the toolkit.

Health care workers providing close physical care (within 2 m) are at greater risk of acquiring an infection spread via the respiratory route, especially in poorly ventilated environments (e.g. wards, single rooms, ambulances, patient homes).

Evidence currently demonstrates that the highest concentration of infective respiratory particles (droplets or aerosols) occurs when a health care worker is close to the patient.

Ventilation or air cleansing technologies alone do not protect health care workers in close proximity to patients with a known or suspected infection that may cause harm to health.

A risk assessment which considers all relevant controls to reduce the likelihood of exposure is still required. 

Fluid resistant surgical face masks (FRSM) are not classified as PPE and should not be provided as protection against infections spread via the airborne route.

Examples to support practical implementation of risk assessment: 

As our experience of undertaking risk assessment for respiratory infections grows, there are examples that we can learn from a range of organisations. The tools and resources below can be used to support the risk assessment toolkit.

• Royal College of Speech and Language Therapists 6P’s for covid-19 risk assessment
• British Occupational Hygiene Society Summary (BOHS)

You have a duty to protect yourself and your colleagues from work activities that can lead to harm to health or death. You must cooperate with your employer and follow any safety instructions or safe operating procedures that the employer puts in place to protect you from harm.

You should not be required by your employer to put yourself in harm's way. Your employer or manager must conduct a suitable and sufficient risk assessment that highlights risks to you and, if adequate protection is not available, you should be made aware of this. Refer to the risk assessment process in Risk Assessment Tool section.

Remember to report via incident reporting processes if/where controls in place fail, for example, incidental exposure occurs causing infection in a member of staff.

Based on the above it is recommended that:

• You should raise any concerns to your manager in a timely way and document these.
• You should continue to raise any outstanding concerns with your trade union and/or representatives or professional organisation if you need further advice or support.
• Health and care staff should feel able to raise concerns without detriment and should receive timely feedback on their concerns.

For RCN members, if your concerns remain unresolved, refer to our raising concerns guidance and speak to your line manager. RCN members can also contact RCN Direct for advice.

Other professionals should consult their relevant professional organisation. For Speech and Language Therapists, email info@rcslt.org to escalate concerns.

There are many health and safety requirements for employers to meet. We have listed some of these below to help employers as well as managers who have been delegated to support them and individual employees understand the breath of responsibilities.

The Health and Safety at Work etc Act 1974 and the Health and Safety at Work (Northern Ireland) Order 1978 state that the employer has a legal duty to ensure, so far as is reasonably practicable, the health safety and welfare at work of all their employees. 

In simple terms, "so far as is reasonably practicable" may be interpreted as what is reasonably able to be done to protect employees' health and safety, taking into account and weighing up all relevant matters including: the likelihood or frequency of contact with the hazard (i.e., a respiratory virus including influenza or SARS CoV-2 the cause of COVID-19), the severity of harm resulting from exposure and weighing this up against the time, effort and cost needed to control it.

Vaccination is recognised as a key component in protecting staff as detailed in Chapter 12 of the green book and the specific disease chapters. The immunisation of staff can not however be used as a rationale for determining that all reasonable and practical measures are in place. Influenza and COVID-19 vaccines have had a significant impact on reducing the severity of disease, but vaccination alone will not prevent all infection or stop people transmitting infection. Other measures are needed. This duty extends to people not employed by you, but who may be affected by your work (for example, patients, visitors, contractors etc.)

You must not substitute infection prevention and control guidelines for documented proper and systematic risk assessment needed to protect workers from respiratory infection exposures. Infection prevention guidance or local polices help inform the application of health and safety legislation including risk assessment but cannot supersede this.

To assist you as an employer in carrying out your legal duties, you should appoint one or more competent persons, who have sufficient training, experience and/or knowledge in health and safety as described in the Management of Health and Safety at Work Regulations 1999/ Management of Health and Safety at Work Regulations (Northern Ireland) 2000, Regulation 7(1). You must also ensure that the competent person has sufficient time and resources to fulfil their role.

The law states you should ensure every worker is protected from death and illness, and the risk of infection by a respiratory pathogen/virus is controlled so far as is reasonably practicable, for each and all employees/workers.

As an employer, you are entitled to restrict activities and services in order to protect the lives and health of healthcare workers.

In addition to the responsibilities outlined above, you should separately and directly address the question of how to protect your workforce from exposure to COVID-19 and other respiratory illnesses, especially in the context of loss of life, long-term or serious injury. This should be clearly reasoned, governed and should be auditable.

What is an acceptable risk

The law states you should consider that an acceptable risk is one where the risks of harmful infection in a workplace environment are no greater than the risk of harmful infection that may be experienced by a person in normal day-to-day life. For example, would a normal person be expected to spend long periods of time in enclosed spaces and have close contact (within 1m) with multiple people with known or suspected infection?

Factors you may wish to consider when assessing risk

Any risks that are harmful to health and arise purely because of the nature of the work or the workplace that are different from everyday risks need to be controlled so far as is as reasonably practicable. For example, health and care workers may undertake swallowing assessments, chest physiotherapy, support patients with eating or drinking or perform suctioning which could induce a cough or other procedures which generate large amounts of respiratory particles capable of transmitting infection.

Patient assessment

The evolving evidence on transmission of respiratory infections but specifically COVID-19 highlights factors to consider which may include but are not limited to:

• The infection status of the patient (known, suspected or previously exposed to COVID-19 or other respiratory infections)
• Current prevalence and transmission of infections within the local population and international alerts/advice based on emerging variants of SARS-CoV-2 or emerging/novel infections
• Immunosuppressed status of patient
• Patients that are coughing/spluttering or sneezing
• Patients with impaired cognitive ability
• Patients who are unable to tolerate a face mask/covering
• Environmental assessment
• The presence of carers or family who may have symptoms of respiratory infection

The evolving evidence on transmission of COVID-19 highlights factors to consider may include but are not limited to:

• Healthcare workers working in small, enclosed spaces
• Ventilation – is this considered adequate/inadequate? Refer to Ventilation in the workplace and Covid-19 Guidance: Ventilation (v5) (Chartered Institution of Building Services Engineers (CIBSE). Note ventilation or air cleansing technologies alone do not protect HCWs when working in close proximity to patients with a respiratory infection.
• The ability to open windows/the ambient external temperature
• The provision of technology, for example, air filtering machines. The NHS Estates Technical Bulletin (NETB 2023/01A): application of HEPA filter devices for air cleaning in healthcare spaces: guidance and standards may be helpful to consider

Reasonably practicable means doing what is reasonably able to be done to control the risk, considering, the likelihood and severity of the hazard or the risk concerned occurring weighed against the time, cost and trouble of controlling the risk.

To meet health and safety legal requirements you should make decisions affecting the health of your workforce in a legal, rational and procedurally proper way. This means:

You should ensure that a suitable and sufficient risk assessment is undertaken at organisational level, in consultation with healthcare workers and/or their representatives, e.g. safety representative. You should also ensure that any risk assessment is done systematically and comprehensively and should consider practice 'at the shop floor' (e.g. in the patient's own home, prison, custody suite, accident and emergency dept, ambulance). There should also be a management arrangement which outlines roles and responsibilities and the organisations approach to managing biological agents which is then considered as part of the risk assessments.

This should take into account proactive consideration of risks faced by your employees in different scenarios and settings, for example paramedics entering a person's own home, speech and language therapists undertaking assessments in community settings/homes, community nurse delivering care overnight. This will ensure that exposure to COVID-19 infection (or other biological agents that are harmful to health), is reduced so far as is reasonably practicable. This is separate to an individual employee's dynamic risk assessment undertaken when assessing risks to them at specific moments in time.

COSHH Regulation 6 states you must identify how to control potential sources of infection entering the workplace, the means by which pathways to infection can be interrupted and how workers can be prevented from being exposed to infected persons or the virus in the environment.

Therefore taking into account this legal duty you must:

• Keep evidence under review and reassess risks in the light of changing evidence/science associated with respiratory infections. Your local IPC provider or health protection teams can advise on this.
• Identify the best means of controlling these infection risks and failsafe methods to manage any risks arising from the failure of these controls. For example, call handlers may advise the opening of windows prior to the arrival of paramedics or community staff.
• Have other controls in place as well as PPE, which may include RPE, because PPE failure or improper use will always result in uncontrolled exposure to infection. Suitable and sufficient PPE must always be available in the case of a control failure which may lead to a risk of direct exposure to an infected person or a contaminated environment. This is the same principle that applies for example to the availability of gloves in case of exposure to blood/body fluids.
• Let workers know if you assess that the controls that you are able to put in place fall short of being able to adequately protect them from exposure (for example ventilation) and of any deficits in failsafe measures for controls which might result in exposure, should primary controls fail – e.g. the lack of availability of PPE.
• Reassess risk periodically or when there is a change in process or nature of infection (for example as a result of emerging surveillance of disease internationally)

You should ensure that you have a culture of openness, dialogue, and challenge within the context of controlling risks and that workers are not penalised for exercising their right not to expose themselves to health risks, to ask to be consulted about decisions and to raise issues of concern or poor practice within and, where necessary, beyond the organisation. Employers should encourage staff/employees to report via incident reporting processes if/where controls in place fail – for example incidental exposure occurs causing infection in a member of staff, respiratory protective equipment does not meet the right standard, fit testing not provided etc.

If, having undertaken a suitable and sufficient risk assessment, you are unable to offer the protection that workers need, you should stop the worker from undertaking the unsafe activity and escalate the issue to senior management. Follow your employer's local policies for escalating concerns and document these.

There is a legal duty under the Safety Representatives and Safety Committees Regulations 1977 to consult with trade union health and safety representatives on matters affecting the health and safety of their members. Your reps should be consulted on risk assessments and policies and procedures to protect staff.

Health and care staff should feel able to raise concerns and report incidents without detriment and should receive timely feedback on their concerns. For RCN members, if your concerns remain unresolved, refer to our raising concerns guidance and speak to your line manager. You can also contact RCN Direct or your local RCN/Trade Union representative for advice.

As a health and safety representatives you should be consulted on the development of risk assessments and subsequent proposed control measures, action plans and safe working procedures. Additionally, you should support and represent relevant members with matters of health and safety, including investigating health and safety concerns identified by members and raising these with your employer either directly or through the local Health and Safety Committee or your regional officer.

You are also able to conduct workplace inspections and investigate accidents/ incidents and dangerous occurrences in the workplace.

You should also be able to provide information, advice and guidance on health and safety matters to members and work inclusively and proactively to address health and safety inequalities in the workplace.

You can find more information on RCN health and safety representatives on our RCN reps page.

If you are a member of another Union, you should contact them to find out more.

Duty: Competency

Task: Ensure you (the employer) have the competency to carry out a suitable and sufficient risk assessment

What might this mean? - You may wish to consider the following:

• Do you have the knowledge and experience to understand how healthcare workers in your organisation, department or area could be exposed to biological agents?
• Do you have the relevant knowledge, skills, training and experience to make sound decisions about the level of risk to employees and others and the control measures needed to prevent exposure?
• Do you have the ability and the authority of the employer to collate all the necessary, relevant information?

More information can be found on the Health and Safety Executive website.

Duty: Risk assessment

Task: Carry out a suitable and sufficient risk assessment of the risk to health from the biological agent(s) to your employees and others in consultation with employee representatives such as a trade union health and safety representative.

What does this mean?

Determine the hazard grouping and properties of the biological agent. For example SARS-CoV-2 and Mycobacterium tuberculosis are classed as a group 3 hazard and exposure could lead to serious illness. Other viral examples currently include dengue viruses (types 1-4), Middle East respiratory syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).

In their guidance on compliance with the COSHH regulations the Health and Safety Executive state that Immunisation should be seen only as a useful supplement to reinforce physical and procedural control measures, not as the sole protective (control) measure.

Note: despite the positive impact of vaccination on reducing the severity of severe illness in those that have received it, vaccination cannot be used as a rationale for determining that all ‘reasonable and practical’ measures are in place (refer to the ‘As an employer’ section). Vaccination does not prevent infection in all cases and those with COVID-19, even if vaccinated, can still pass the infection to others.

Consider:

The route of exposure e.g., inhalation of infectious respiratory particles/aerosols:

• The route of exposure e.g., inhalation of infectious respiratory particles/aerosols.
• How exposure may occur
• Where, how often (frequency) and how long people may be exposed to the biological agent. For example, some staff may have frequent but short term exposure in an Accident and Emergency dept., speech and language therapy assessments, or community nurses who may remain with patients overnight in confined rooms with an infected patient.
• Which workers could be exposed and who may be affected?
• The ways in which, and the extent to which, other groups of people (ward clerk, porter, visitors, contractors etc) could be exposed; for example, increased risks due to multiple exposures over a period of time as in A/E.
• Employees who may be at increased risk, e.g., Black, Asian and minority ethnic healthcare workers, workers who are pregnant, workers with a disability and any employees known to be susceptible to certain illnesses such as asthma etc should have an individual assessment of vulnerability to severe COVID-19, undertaken. Staff whose immune system response may have been affected as a result of long Covid, could be more at risk of and from re-infection.
• You may also wish to consider any employee carer responsibilities in their personal life and the vulnerability of those they care for.
• How likely the foreseeable risk of ill health is (e.g. whether the risk is probable, possible, remote or nil/negligible)
• The severity and consequence of ill health, if it occurs, for example:
• serious health effects – permanent, progressive, irreversible,
• significant health effects – non-permanent, reversible and non-progressive conditions e.g. long-COVID
• minor health effects – such as respiratory irritation.
• Any foreseeable deterioration, or failure, of any control measure provided.
• What existing control measures are in place to manage the risks
• What further action needs to be taken to control the risks
• Who needs to carry out the action
• When the action is needed by

Record: If your organisation has 5 or more employees, you must record the significant findings of the risk assessment.

Review: The risk assessment should be reviewed (and documented if required) at set periods and/or where a significant change may (for example preceding expected seasonal changes) or has occurred or if it is no longer valid.

If you are unsure of any aspects of the above and require more information, please go to the Health and Safety Executive or Health and Safety Executive Northern Ireland websites for more information or seek the advice of your ‘competent person.’

Task: Prevent or Adequately Control Exposure so far as is reasonably practicable (Reminder: what it is that is reasonably able to be done to ensure health and safety, considering and weighing up all relevant matters including: the likelihood of the hazard or the risk concerned occurring).

You may find Health and Safety Executive guidance on ‘How to carry out a COSHH risk assessment’ helpful to refer to.

The following should be considered as examples to support the risk assessment but are not limited to:

• Can exposure to the biological agent be eliminated or prevented? This is often challenging in health and care situations unless virtual options are available.
• How are health and care processes carried out and can they be modified to reduce potential exposure?
• Can engineering controls be applied to reduce or remove the risk such as mechanical ventilation? Note ventilation is unlikely to be effective in removing the risk of COVID-19 transmission where care is provided when in close contact (within 2m) of a patient. The use of carbon dioxide monitors should be considered as an aid to the assessment of quality of ventilation in closed environments in addition to the use of air filtering/cleaning devices.
• Can ways of working be adapted to minimise exposure, for example reducing the number of potentially infected patients and visitors?
• Whether employees require Personal Protective Equipment/Respiratory Protective Equipment (see Worker Respiratory Infection Tool).
• The frequency and cumulative exposure of staff contact with known or suspected patients with COVID-19infection regardless of vaccination status and/or the wearing of masks by patients/carers.

Personal Protective Equipment/Respiratory Protective Equipment

If adequate control of exposure cannot be achieved by other means, suitable and sufficient Respiratory Protective Equipment (RPE), in addition to the other identified control measures should be provided (note a fluid repellent surgical mask (FRSM) would not be considered suitable in this instance).

Where tight fitting respiratory protection is selected as a control measure, the wearer must be face fit tested by a person competent to do so. It must not be worn continuously for longer than one hour at a time. Note: The British Safety Industry Federation (BSIF) has introduced a fit2fit scheme for fit testers to support identification of competent testers. If re-usable masks are provided, adequate appropriate training must also be provided to support storage and cleaning of these items.

Duty: Use of control measures

Task: Ensure control measures are properly used

Responsibilities:

These include:

• Your employees should be fully aware of the risk assessments and any control measures to be implemented.
• Develop safe working procedures and practice based on the control measures in the risk assessment for staff to follow.
• The employer should take steps to ensure that where a control measure has been provided that it is properly used and maintained. Staff should be informed of decisions regarding control measures and how to apply these.
• Your employees should make full and proper use of any control measure provided and;
• Your employees should report any defects with any control measures to you immediately. 

Duty: Information, instruction and training

Task: Provide suitable and sufficient information, instruction and training to employees/persons who may be exposed.

Provide information on:

• What the biological agent is and what the risk to health is;
• How and when to use control measures;
• How to use PPE, and especially RPE – where face fit testing must take place if using tightfitting masks are worn, e.g., disposable half mask respirator (FFP3) or a reusable half mask respirator;
• The cleaning, storage and disposal procedures your employees should follow, why they are required and when they are to be carried out. Reusable respiratory protective equipment will also require a planned schedule of maintenance.
• The procedure to follow in an emergency situation for example in a patient/visitor cardiac or respiratory arrest, or in situations where physical restraint is required.

In addition:

• Where appropriate, display notices outlining safe operating procedures; e.g. , in accident and emergency or urgent care facilities where harmful infections are suspected
• Adapt the information you provide to ensure it is relevant according to the work being carried out:
• Provide the information in a manner appropriate to the level, type and duration of exposure identified by the risk assessment and offer opportunities for staff to ask questions/seek reassurance.

Record: Keep a record to show the training provided to individual employees or specific groups of named employees.

Can infected patients/patients whose COVID-19 or other respiratory infection status is unknown be excluded from treatment by workers in the local context being assessed?

Yes: Consider implications of exclusion and plans to provide alternative support

No: Consider other controls below

Note: This is “Elimination” which is the most effective protection of workers, but unlikely to be an option for the health and care services.

Can patients be treated virtually or supported through telephone or signposted to information?

Yes: Consider long-term risks to the patient, increased health inequalities and service demand implications

No: Consider other controls below

Note: This is “Substitution” and is an effective control, but may not be an option for many treatments or on a regular basis.

Can engineered solutions sufficiently reduce the risk to health and care workers as per the risk assessment (e.g. ventilation?)

Yes: Consider factors which may effect the effectiveness and maintenance of engineering controls.

No: Consider other controls below

Note: These are “Engineering Controls” and ventilation is not going to be effective in preventing close range transmission of airborne and short range infections (less than 1m) required during direct patient/client care.

Can effective distancing (e.g. through space management), combined with managed exposure durations, reduce exposure to infectious transmission risks?

Yes: Consider factors which may impact the continued effectiveness of space management.

No: Apply RPE Use Checklist assessment and deploy – urgently highlight the need to improve any higher level controls to management.

Note: This is Personal Protective Equipment, including respiratory protective equipment (RPE), which does not include FRSM (used for source control). Note that RPE failure will result in exposure. There are no further controls.

Can RPE be adequately managed having applied the RPE use checklist?

Yes: Ensure that there is an RPE step-down plan through the application of other better controls where possible.

No: Exposing workers to this would amount to an illegal and dangerous risk. Seek urgent management support to enable compliance with Health and Safety duties.

Note: IPC guidance does not override the duties required under the Health and safety at Work Act. If a local risk assessment determines RPE is required, then suitable and sufficient RPE must be made readily available by the employer.

Further information on SARS-CoV-2

The pandemic has highlighted limitations of traditional microbiological views of droplet, fomite, and airborne transmission of infection. A range of publications are summarized to support additional reading to inform local risk assessments.

Transmission of SARS-CoV-2

1. Airborne transmission of respiratory viruses.https://www.science.org/doi/10.1126/science.abd9149. This publication examines recent advances in understanding the role of airborne transmission of respiratory infections via aerosols as opposed to the traditional view of larger droplets. 

2. Ten Scientific reasons in support of airborne transmission of SARS-CoV-2/COVID-19. The Lancet 2021;397(10285):1603-1605 DOI: https://doi.org/10.1016/S0140-6736(21)00869-2. Ten streams of evidence are presented that collectively support the hypothesis that SARS-CoV-2 is transmitted primarily by the airborne route. 

3. Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) Wang et al (2021) DOI: https://doi.org/10.1016/j.jhin.2020.12.022

4. Airborne protection for staff is associated with reduced hospital-acquired COVID-19 in English NHS Trusts. https://www.journalofhospitalinfection.com/article/S0195-6701(21)00427-8/fulltext

5. The effect of respiratory activity, non-invasive respiratory support and facemasks on aerosol generation and its relevance to COVID-19 - https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/anae.15475

6. Chapter 14A of the ‘Green Book’; paragraph 4 https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

7. Reducing transmission of SARS-CoV-2 https://www.science.org/doi/full/10.1126/science.abc6197

8. Transmission of SARS-CoV-2: implications for infection prevention precautions (WHO) https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. Notes the scientific evidence points clearly to risk of infection being greatest within 1-2m of an infected person and that ventilation and other control measures are relatively ineffective at this range when dealing with patients with known or suspected COVID-19.

9. SAGE S1169 - https://www.gov.uk/government/publications/emg-masks-for-healthcare-workers-to-mitigate-airborne-transmission-of-sars-cov-2-25-march-2021

10. SAGE 98 minutes: Coronavirus (COVID-19) response, 7 December 2021 https://www.gov.uk/government/publications/sage-98-minutes-coronavirus-covid-19-response-7-december-2021/sage-98-minutes-coronavirus-covid-19-response-7-december-2021

11. Protection from COVID-19 at work: health and safety law is fit for purpose. Agius et al (2021) https://www.bmj.com/content/375/bmj.n3087

The importance of ventilation

• Stop COVID-19 hanging around' UK Government campaign (November 2021) https://www.gov.uk/government/news/new-campaign-to-stop-covid-19-hanging-around
• Indoor Air Changes and Potential Implications for SARS-CoV-2 Transmission https://jamanetwork.com/journals/jama/article-abstract/2779062
• Improving Ventilation in Your Home (CDC) https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/Improving-Ventilation-Home.html

Organisation positions/resources

• Royal College of Nursing Position on personal protective equipment https://www.rcn.org.uk/covid-19/rcn-position/ppe-position-statement
• Royal College of Nursing COVID-19 resources https://www.rcn.org.uk/covid-19/
• British Medical Association https://www.bma.org.uk/advice-and-support/covid-19
• Royal College Speech and Language Therapists https://www.rcslt.org/learning/covid-19/
• Royal College of Podiatrists COVID-19  resources https://rcpod.org.uk/news-and-features/covid-19
• College of Paramedics https://www.collegeofparamedics.co.uk/COP/COP/News/Covid-19/Covid19_Information.aspx

Guidance

• COVID-19: infection prevention and control (IPC) guidance. UKHSA (updated 21st December 2021) https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

Mutambudzi, M., Niedwiedz, C., Macdonald, E.B., Leyland, A., Mair, F., Anderson, J., Celis-Morales, C., Cleland, J., Forbes, J., Gill, J., Hastie, C., Ho, F., Jani, B., Mackay, D.F., Nicholl, B., O’Donnell, C., Sattar, N., Welsh, P., Pell, J.P., Katikireddi, S.V., Demou, E., 2020. Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants. Occup Environ Med oemed-2020-106731. https://doi.org/10.1136/oemed-2020-106731

SAGE 98 minutes: Coronavirus (COVID-19) response, 7 December 2021 https://www.gov.uk/government/publications/sage-98-minutes-coronavirus-covid-19-response-7-december-2021/sage-98-minutes-coronavirus-covid-19-response-7-december-2021

Martin et al (2021) Predictors of SARS-CoV-2 infection in a multi-ethnic cohort of United
Kingdom healthcare workers: a prospective nationwide cohort study (UKREACH) https://www.medrxiv.org/content/10.1101/2021.12.16.21267934v1.full.pdf

This toolkit contains information, advice and guidance. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this toolkit has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used.