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COVID-19 workplace risk assessment toolkit

Introduction

Image of nurse wearing a mask The aim of this toolkit is to support healthcare professionals consider and manage risks associated with the transmission of respiratory infections, specifically COVID-19, and aid local decision making on the level of personal protective equipment (PPE) required to protect them whilst at work.

The toolkit may be of benefit to employers, managers, healthcare professionals and safety representatives.

Toolkit readers needs may vary. The toolkit aims to support users by highlighting the role and duties of those in specific roles (for example employers or managers) as well as providing information on risk assessment actions to support the identification and management of risks wherever health professional’s work. 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: This toolkit does not replace national or local policies/guidance and should be used in conjunction with these.

Employers have legal duties and responsibilities to ensure they provide a safe and healthy workplace so far as is reasonably practicable.

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.

Healthcare workers are at an increased risk of acquiring COVID-19 compared to the general population (Mutambudzi et al 2021). Martin et al (2021) highlight predictors of SARS-CoV-2 infection in HCWs and state these include: working in nursing or midwifery roles, occupational exposure to increasing numbers of patients with COVID-19, lack of access to PPE, cohabiting with another key worker and working in hospital inpatient or ambulance settings.

Taking such evidence into account the RCN and partners have developed this online Infection Prevention and Control (IPC) 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.

It is considered that there is a need to fully acknowledge this key route of transmission, and the increasing international evidence and consensus demonstrating that it may be detrimental to managing the risk of infection in the workplace and subsequent provision of suitable respiratory protective equipment in situations where that risk of transmission is high. See the Respiratory Protective Equipment (RPE) section and further resources for more detail.

The Scientific Advisory Group for Emergencies (SAGE) published a situation update as a result of the Omicron variant increase in cases 8th December 2021. SAGE confirm recent outbreaks suggest a greater role for airborne transmission than has previously been the case. They conclude that measures to reduce airborne spread such as ventilation, well-fitting masks and distancing or reduced density of people in indoor environments may be even more important and the risk of nosocomial transmission is likely to be increased.

This toolkit has been produced collaboratively in association with the other professional organisations and associations as set out in the acknowledgement section.

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 booklet 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.

Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this toolkit.

This toolkit aims to recognise risks when providing close proximity care for patients known or suspected to have COVID-19, and the increasing evidence base supporting this risk in enclosed spaces which can be applied to homes and health and care environments more generally. The UKHSA has confirmed the following regarding transmission of SARS-CoV-2, the virus that causes COVID-19:

  • SARS-CoV-2 is primarily transmitted between people through respiratory particles (droplet and aerosol) and indirect contact through fomite transmission (contact with contaminated surfaces).
  • When someone with COVID-19 breathes, speaks, coughs or sneezes, they release droplet or aerosol particles containing SARS-CoV-2.
  • Aerosol particles can also be released when certain procedures or support treatments are performed in health and care settings.
  • A person can be infected when these particles are inhaled, or come into contact with the eyes, nose or mouth.
  • Transmission risk is highest where people are in close proximity (particularly within 2 metres) and/or in poorly ventilated indoor spaces, particularly if individuals are in the same room or ambulance together for an extended period of time”.

Source: New campaign to 'Stop COVID-19 hanging around' - GOV.UK

The information included within this toolkit does not represent alternative guidance to existing health and safety legislation, infection prevention and control guidance and employment law. It is intended to support health and care workers in all settings and managers to navigate existing guidance and support risk assessment in their workplace to reduce the transmission of infection. The principles included within this toolkit can be applied to respiratory infections other than COVID-19 if they represent a hazard to health.

Healthcare workers are at greater risk of being exposed to COVID-19, compared with the general working population, due to the undertaking of their duties whilst at work.

The SARS Cov-2 virus has been classified by the Advisory Committee on Dangerous Pathogens (ACDP) as a Hazard Group 3 biological agent. A group 3 biological agent is a substance which is hazardous to health. 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 through the air and quality of ventilation to mitigate this where health and care is delivered for example care homes, patients own homes, prisons, and primary care/acute settings.

The toolkit recognises that health and care workers  in contact with patients/clients who have or who may have the virus 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.

COSHH Regulation 6 and Regulation 3 of the Management of Health and Safety at Work Regulations 1999 places 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 COVID 19 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 this continuing crisis, 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 current 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.

It is recognised that risk assessments can be complex, and duties outlined in legislation/regulation are sometimes difficult to navigate.  At different 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 healthcare sector to enable a consistent and systematic consideration of health and safety responsibilities in the context of COVID-19.

This toolkit aims to bring together all relevant duties, including 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 healthcare workers.

It should be highlighted that some of the information and detail in this toolkit might be new to healthcare 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.

This toolkit should not be used in place of national or local guidance.  It is designed to complement existing guidance as outlined in the introduction.

Toolkit users should select the appropriate section relevant to their role to review. You may also find it informative to review the roles and responsibilities of others to support your understanding of the management of risk where you work.

The risk assessment process identified within the Risk Assessment Tool section is designed as a guide to help identify potential risks for the transmission of infection where you work.

Also within this section is a guide to identifying potential control measures including the correct level of respiratory protection that may be required.

Advice for employers / health and care leaders

Image of man reading contract Assessing risks facing healthcare workers in the COVID-19 context

Employers and managers have legal duties to protect workers.

Your legal responsibilities:

 

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 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 Order (Northern Ireland) 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 it is that is reasonably able to be done to ensure health and safety, taking into account and weighing up all relevant matters including: the likelihood or frequency of contact with the hazard (i.e., COVID-19).

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. 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.

As an employer, you have a legal duty to ensure, so far as is reasonably practicable, that people not employed by you, but who may be affected by your work (for example, patients, visitors, contractors etc.) are not exposed to risks to their health or safety.

You must not substitute infection prevention and control guidelines for proper and systematic risk assessment needed to protect workers from COVID-19 exposures.

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, 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 infection such as COVID-19 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, 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 COVID-19 highlights factors to consider may include but are not limited to:

  • The infection status of the patient (known, suspected or previously exposed to COVID-19)
  • Current prevalence and transmission of COVID-19 in the local population
  • 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 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
  • The ability to open windows/the ambient external temperature
  • The provision of technology filtering air

Reasonably practicable means doing what 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.

To meet health and safety legal requirements you should make decisions affecting the health of your workforce in a legal, rationale 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).

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.
  • 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. However 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.
  • let workers know if you determine 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.

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.

Advice for managers

Image of person signing contract Assessing risks facing healthcare workers in the COVID-19 context

As a manager you will support the employer to meet their legal and regulatory requirements.

Your legal responsibilities:

As a manager your role will include the need to support your employer to meet their legal and regulatory requirements.

You have a legal duty to ensure that workers you manage are not subjected to death and disease  therefore you should not force workers into situations they have reason to believe are unsafe and should listen to any concerns raised by your employees and act on these in a timely way. We recommend that concerns should be documented together with the outcome/decision of action taken.

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.

Consult your trade union representatives 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. You can also contact RCN Direct for advice.

Advice for healthcare workers

Image of healthcare worker in front on an amublance Assessing risks facing healthcare workers in the COVID-19 context

You have a duty to protect yourself and your colleagues from work activities that can lead to harm to health or death.

Your legal responsibilities:

Nurses, midwives and nursing associates should be aware of and comply with the NMC Code. Other health professionals should consult their relevant codes of practice for more information.

You have a duty to protect yourself and your colleagues from work activities that can lead to harm to health or death.

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.

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 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.

Advice for safety representatives

Image of health and safety reps talking Assessing risks facing healthcare workers in the COVID-19 context

You should support and represent your members with matters of health and safety.

Your legal responsibilities:

Employers have a duty to consult with their employees, or their representatives, on health and safety matters.  The Health and Safety Executive guidance, Consulting employees on health and safety: A brief guide to the law, describes how employees must be consulted in different situations and the different choices employers have to make. It confirms that in workplaces where the employer recognises trade unions and trade unions  are recognised for collective bargaining purposes, the Safety Representatives and Safety Committees Regulations 1977 (as amended) will apply.

The RCN and some other unions support the provision of safety representatives.

In principle safety representatives should support and represent relevant members with matters of health and safety, investigating health and safety concerns identified by members and raising these with the employer either directly or through the local Health and Safety Committee or your regional health and safety officer.

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

You can find more information on RCN safety representatives here.

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

 

Risk Assessment Tool

Images of question marks Risk Assessment Tool for Respirable Biological Exposures (COVID-19) in line with the Control of Substances Hazardous to Health Regulations 2002

Employers have a legal duty to ensure the health, safety and welfare of their employees whilst they are at work. The Management of Health and Safety at Work Regulations 1999 state that employers should appoint one or more competent persons to assist them in carrying out their legal duties.

This tool aims to highlight responsibilities and actions of employers to assess and manage risks to employees in relation to COVID-19. Employees may find it helpful to be aware of these responsibilities. Employees have the right to request to see local and organisational risk assessments.  If a risk assessment has not been performed you have the right to ask that one is undertaken.  Contact your local representative if you need support.

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 to understand how healthcare workers in your organisation/department/area could be exposed?
  • Do you have the relevant knowledge, skills, training, and experience to make sound decisions about the level of risk and the 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 to your employees in consultation with employee representative.

What does this mean?

  • The hazard grouping and properties of the biological agent, for example COVID-19 is classed as a group 3 hazard, and exposure could lead to serious illness. Other viral examples include dengue viruses (types 1-4), Middle East respiratory syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). Group 3 bacterial pathogens include Mycobacterium tuberculosis (HSE 2021)
  • 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 droplets and/or airborne particles:

  • How, where, and how often (frequency) the biological agent could  be transmitted For example some staff may have frequent but short term exposure as in an Accident and Emergency dept., community nurses may remain with patients overnight in confirmed 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. 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.

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 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’.

Duty: Control

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).

The following should be considered but are not limited to:

  • Can exposure to the biological agent be eliminated or prevented?
  • 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 fixed screens, or 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.
  • 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-19 regardless of vaccination status and/or the wearing of masks by patients/carers.

NB: 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).

NB: Where tight fitting respiratory protection has been provided, the user must be face fit tested by a person competent to do so and must not be worn continuously for longer than one hour at a time. Where re-usable masks are provided adequate appropriate training must also be provided.

Duty: Use of control measures

Task: Ensure control measures are properly used

Responsibilities:

These include:

  • You should take steps to ensure that where a control measure has been provided that it is properly used and maintained
  • 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, eg FFP3 respirator;
  • The cleaning, storage and disposal procedures your employees should follow, why they are required and when they are to be carried out.
  • The procedure to follow in an emergency situation for example cardiac or respiratory arrest, fitting, situations where physical restraint is required

In addition:

  • Where appropriate, display notices outlining safe operating procedures; e.g. dedicated covid areas, accident and emergency or urgent care facilities
  • 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.

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

Worker Respiratory Infection Safety Tool

Image of masked nurse talking to patient The purpose of this tool is to guide the healthcare worker or manager through a series of questions to consider how the transmission of infection can be considered and controlled as part of the risk assessment process.

This aligns to a framework called the hierarchy of controls referred to in a variety of Health and Safety and IPC guidance documents in the UK and abroad.

Note: this does not replace the risk assessment process as outlined in the risk assessment tool section.

You can view the tool here.

Error in point 4 engineered solutions.  The current wording states (less than 1m).  Please note this should state less than 2m.   

Respiratory Protective Equipment (RPE)

RPE is a form of personal protective equipment (PPE) that protects the individual worker from specific hazards that may cause harm if inhaled. In the case of COVID-19 it protects the wearer from breathing in airborne substances hazardous to health such as SARS-CoV-2. See the Health and Safety Executive website for more information on RPE.

A risk assessment should identify if/where RPE is required. Figure 1 in the Respiratory Infection Equipment document (link below) helps to illustrate the different types of RPE available. HSE guidance (HSG53) requires RPE to be both adequate and suitable in line with health and safety guidance.

Read our document on Respiratory Protective Equipment (RPE) here

Further information

Airborne - A variety of terms are used in UK and international literature to describe a range of particles that can carry viruses such as SARS-CoV-2 in the air.   Aerosols and droplets are most frequently referred used in scientific literature and guidance documents.  For the purposes of this toolkit ‘airborne’ is used to describe the movement through the air of aerosols produced via the respiratory tract.  An illustration of this can be found in Tang et al (2021) in the Respiratory Protective Equipment document.

Droplet – a particle produced via the respiratory tract that is typically larger than aerosols at >100-μm diameter. As larger particles these fall to the floor as a result of gravity within 2 m of the source person. FRSM’s will help protect the wearer from exposure of the nose/mouth to droplets and potential infection via this route.

FRSM – Fluid resistant surgical face mask.  These can also be referred to as Type IIR surgical masks and provide a physical barrier protecting the wearer against respiratory droplets reaching the mucosa of the mouth and nose.

Respiratory Protective equipment (RPE) - RPE is a form of personal protective equipment (PPE) that protects the individual worker from breathing in substances hazardous to health.  In the context of this toolkit that includes the SARS-CoV-2 virus and other airborne infections such as pulmonary tuberculosis.

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/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-precautionsNotes 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

Organisation positions/resources

Guidance

 

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

 

Acknowledgements

This resource has been developed by the RCN in association with other professional bodies, organisations and individuals as listed below:

Members of the Covid Airborne Protection Alliance (CAPA)

BAPEN

BAPEN logo

BDA

BDA


BIASP

BIASP logo


BSG

BSG logo


College of Paramedics 

College of Paramedics logo


Fresh Air NHS

Fresh Air NHS logo


GMB Union

GMB union logo


HCSA

HSCA logo


National Nurses Nutrition Group (NNNG)

NNNG logo


Queen's Nursing Institute

QNI logo


Royal College of Speech and Language Therapists (RCSLT)

RCSLT logo


Unite the Union

Unite logo


British Occupational Hygiene Society (BOHS)

BOHS logo


Feedback

As a new resource the RCN acknowledges that it will evolve over time as evidence and learning from the pandemic increases. The ongoing development of the toolkit will be an iterative process and will take into account feedback from users.

If you have any questions or feedback, please get in touch with us at IPC@rcn.org.uk.

Page last updated - 23/12/2021