COVID -19 Positive Cohort Ward - Standard Operating Procedures

Publication: 17/04/2020  --
Last review: 01/01/1900  
Next review: 27/08/2020  
Standard Operating Procedure
ID: 6374 
Approved By: Clinical Advisory Group (CAG) 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Standard Operating Procedures: COVID-19 Positive Cohort Ward

General Infection Control measures

The virus that causes COVID-19 is mainly transmitted through droplets generated when an infected person breathes, speaks, coughs or sneezes. Large droplets are too heavy to hang in the air so they quickly fall on floors or surfaces. Small droplets may hang around for longer but opening windows helps to remove them from a room.

You can be infected by breathing in the virus if you are close to a person who has COVID-19 or if you enter a bay/side room where COVID-19 patients are being looked after. You can also be infected by touching a contaminated surface and then touching your eyes, nose or mouth before washing your hands. The virus can survive on inanimate objects (e.g. tables, beds, toilets) for several hours. Therefore secretions and excretions from suspected/confirmed COVID-19 patients should be considered potentially infectious.

Based on what we know about this virus, ‘contact and droplet precautions’ are required for normal ward-based care and ‘airborne precautions’ are required for care during aerosol generating procedures (AGPs) or in high risk areas where AGPs regularly take place.

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Recommended Personal Protective Equipment (PPE)

Public Health England (PHE) published updated PPE guidance on 2nd April 2020 after working with representative bodies from the healthcare professions1. The World Health Organisation (WHO) has confirmed that the new PPE guidance is in line with its own2.

According to WHO ‘PPE effectiveness depends strongly on adequate and regular supplies, adequate staff training, appropriate hand hygiene, and appropriate human behaviour.’2

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On entering a COVID-19 cohort ward

All staff must wash their hands and put on a fluid resistant surgical facemask on entering the ward, whether or not they are involved in direct patient care.

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PPE during usual ward care

In addition to a surgical mask further PPE should be worn whenever a member of staff is within 2 metres of a patient (e.g. in a bay/side room, helping them mobilise or transfer). The recommended PPE is:

  • Gloves, apron, fluid repellent surgical mask and eye protection
  • Gloves and apron are single use and must be changed between patients
  • Masks and eye protection are recommended for a ‘session’ of work* (i.e. doing a ward round, doing an observation round in a clinical area)
  • A long sleeved gown or coverall can be worn when a risk of splashing bodily fluids is anticipated – this should be changed between patients in non-AGP areas
  • If wearing an apron, hand washing should include the forearms (not just the wrists). Forearms should be washed first and then the wrists/hands.

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Exiting a side room or bay

Bins are placed next to the sink. Gloves and apron should be removed in the correct way at the sink (see Appendix one) followed by handwashing.

In a side room, the sink should be at least 1 metre away from the patient.

Hands should be cleaned with soap and water again (or hand sanitiser if wash basin not nearby) after exiting a side room because you are likely to have touched a door handle.


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Undertaking a “session of care”:

PHE defines a ‘session’ of care as: ‘A period of time where a healthcare worker is undertaking duties in a clinical care setting/exposure environment e.g. ward round, or doing obs on a set of patients on a cohort ward. A session ends when the healthcare worker leaves the clinical care setting/exposure environment.’ PHE does not define how long a ‘session’ is – it could be going to see one patient in a side room, or seeing a bay of patients, or doing an entire ward/obs round1.

Staff can move between bays/side rooms during a session of care wearing their mask/eye protection. Do not handle your eye protection during a session. If a mask or disposable eye wear is touched or removed from the face during a session of care it should be discarded and replaced. Reusable eye protection should be cleaned after each session; as well as after removing a mask, after touching, or after any splashes.

Sessional use of masks and visors may have the added benefit of reducing the risk associated with having to handle and replace masks frequently as long as the PPE is not damaged, soiled or compromised.

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Completing a “session of care”

Once you have finished a session of care, remove all your PPE (i.e. gloves and apron before exiting the bay/side room; eye protection and facemask outside the bay/side room). Wash your hands. At this point, eye protection is not required if you are not within 2 metres of a patient and you judge there is no risk to you from contaminated splashes or body fluids. Put on a clean fluid repellent surgical mask whilst remaining in the ward area. If you are outside the bay/side room and working for a prolonged period at the Nurses’ Station, you only need to wear a clean facemask. All surfaces need to be wiped down regularly.

Government guidance in place from the 15th of June 2020 states that a fluid repellent surgical mask will need to be worn everywhere while you are in hospital. So fluid repellent surgical masks MUST be worn in staff rooms, offices that are shared and in any area where appropriate social distancing cannot be followed.

You can wear a cloth reusable face covering on your way to and from work and outside of the trust.

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Aerosol Generating Procedures (AGPs)

The PPE for AGPs has not changed: FFP3 mask, long sleeved gown, gloves and eye protection.

AGP PPE is required for entering a high risk clinical area (e.g. ICU) and when delivering AGPs in any setting. Resuscitation rooms in ED and wards in which NIV/CPAP is performed are now defined as high risk clinical areas.

The AGPs that could take place in a ward area are:

  • Cardio- pulmonary resuscitation (CPR)
  • Tracheal intubation (highest risk)
  • Open suctioning/induction of sputum
  • Non-invasive ventilation (NIV) or CPAP – including home NIV/CPAP
  • HFNOT (‘Airvo’)

Nebulisers, standard oxygen therapy, chest physiotherapy (not involving induction of sputum or suctioning) and taking throat swabs are not AGPs. During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Systematic reviews of the literature during the SARS pandemic showed that nebulisers in non-ICU settings are not aerosol inducing. Staff should use droplet precaution PPE (waterproof surgical mask, gloves and apron) and appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.

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Cardio-pulmonary resuscitation (CPR)

All patients should have ceiling of care decisions made at the time of their initial assessment and by the first senior review at the latest. Cardiac arrest in hospital is usually preceded by a rising NEWS2 score or increasing oxygen requirements and these should be escalated without delay.

Staff should follow the UK Resuscitation Council guidance and the adult ALS for COVID-19 algorithm.

  • If a member of staff finds a patient unresponsive or witnesses a collapse, they should shake and shout the patient whilst wearing their usual PPE. Do not look, listen and feel for breathing and do not start CPR.
  • Pull the emergency buzzer and go to the entrance of the bay/side room to inform arriving colleagues that the patient is suspected/confirmed COVID-19.
  • If the crash team is called, you must state ‘COVID-19’.
  • Limit the number of people entering the area to essential personnel only, with runners outside.
  • Staff should attach a defibrillator to the patient whilst wearing their usual PPE.
  • If there is a shockable rhythm, deliver 3 successive shocks without CPR in between (the team should know how to use the manual override function if using an AED).
  • If there is a non-shockable rhythm and the team leader decides that chest compressions and airway manoeuvres should commence, staff should stop and put on the correct PPE before proceeding.

Any re-usable equipment (e.g. AED) must be cleaned afterwards. The adult ALS algorithm for COVID-19 is in Appendix Two.

The bay or side room that the patient was in when they received CPR is considered to be contaminated for 1 hour after CPR and no member of staff should enter during this time unless they are wearing AGP PPE. After one hour the room can be accessed by clinical and cleaning staff wearing PPE (surgical mask, gloves and apron) for removal of equipment, a thorough terminal clean or to attend to other patients in the bay. The curtains should be changed. Following this, the room is ready to be used again.

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Tracheal intubation

In the event that an anaesthetist decides to intubate a patient prior to transfer to ICU, all staff in the room must wear the correct PPE (FFP3 mask, gloves, long sleeved gown, eye protection) and the door must remain shut.

The ICU team will transport the patient to ICU after the procedure. When the patient is ready to exit the room, the co-ordinator must clear the corridor of all staff and visitors (mainly to get people out of the way – the patient is now intubated and is not generating an aerosol). Lifts do not need to be cleaned afterwards. Staff already inside the room wearing AGP PPE should tidy up the room before exiting – but should not start handing things to colleagues outside. Removing PPE for AGPs involves removing your gloves, gown and visor inside the room but your FFP3 mask outside the room.

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Open suctioning/induction of sputum, NIV and CPAP

These should only be performed in side rooms as they are AGPs and staff should enter wearing the correct PPE (FFP3 mask, gloves, long sleeved gown, eye protection). This includes patients who are using home NIV or CPAP. Ideally, NIV/CPAP should be performed in a negative pressure room. If no negative pressure rooms are available in the hospital, then this should be performed in designated side rooms with windows that can be opened if possible.

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Summary of PPE recommendations

  • All staff must wash their hands and put on a fluid resistant surgical facemask on entering the ward whether or not they are involved in direct patient care.
  • ‘Contact and droplet precautions’ apply when you are in a clinical care/exposure environment:
    • In a bay or a side room with patients
    • Within 2 metres of a patient (e.g. during transfer)
    • In an empty bay or a side room that has not been cleaned yet
  • You should wash your hands thoroughly whenever you remove any PPE
  • Gloves and apron are single use and must be changed between patients and before exciting the side room/bay
  • When completing a “session of care” eye protection and masks should be removed at the PPE station outside the room/bay
  • Wipe down surfaces regularly.


Visitors should be taught how to put on and remove the same PPE that staff wear when close to a patient.

Porters, cleaners, and housekeepers should follow the same guidance.


Layout of clinical environment

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Cohorted Bays

Inside each bay there should be:

  • dedicated obs machine (wipe clean between patient use )
  • disposable stethoscopes available for each patient
  • sharps bin
  • further supply of disposable aprons and gloves (to change between each patient care)

Posters demonstrating correct handwashing technique ( see appendix 3) and “Taking off PPE’ (see appendix 1 ) should be displayed next to every hand washing basin

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Side rooms

Inside each side room there should be:

  • dedicated obs machine
  • disposable stethoscope
  • sharps bin

In a side room, the sink should be at least 1 metre away from the patient.

Posters demonstrating correct handwashing technique (see appendix 3) and “Taking off PPE’ (see appendix 1) should be displayed next to every hand washing basin

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General Principles:

Bins, obs machines and linen skips (bays only) must remain inside bays/side rooms.

Patients must remain inside their bay or side room at all times except for transfer or to visit a bathroom (where there is none in the bay). If leaving the bay or side room the patient should wear a face mask and ideally not touch the corridor handrails. If a patient needs assistance to mobilise, a staff member will provide this, wearing PPE (gloves, apron, mask, eye protection). If a patient has touched handrails, they should be wiped clean afterwards.

  • All re-usable equipment that has come in to contact with patients must be cleaned afterwards with disinfectant wipes (e.g. BP cuffs, ECG cables).
  • ‘‘Clean’ objects which must remain in the corridor/staff station areas include: medical/nursing notes and computers-on-wheels (COWs).
  • All patients in transit should wear a mask (surgical mask if not requiring  oxygen mask)
  • Staff who are not transporting patients should ensure they move at least 2 metres away from the patient.

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Linen skips are not required in side rooms. Used linen skips/bags should not be left on the ‘clean’ corridor. A clean red and white linen bag should be brought to the side room as needed. Linen from any suspected/proven COVID-19 case should be placed in a red bag then sealed. Staff inside the side room will hand the sealed bags to a colleague outside wearing gloves, apron and surgical mask who will transport it to the nearest waste disposal room. Colleagues inside the room can then remove their PPE in the correct way

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Bed-side procedures:

Staff who have performed a procedure (e.g. administering IV antibiotics, inserting a cannula or taking an arterial blood gas sample) will be inside a ‘contaminated’ area with a used procedures tray. In these instances staff should buddy with a colleague who is outside the bay/side room and pass the ‘contaminated’ tray to their colleague who remains outside the bay/side room and is wearing gloves, apron and surgical face mask. The staff member inside the “contaminated” area should dispose of all sharps in the sharps bin in bay/side room before passing the tray to their colleague outside. The colleague should be someone trained to dispose of the contents of the tray correctly. Any samples (e.g blood) taken inside the room should be labelled before entering, checked on obtaining, and rechecked prior to sealing in the first bag inside clinical area and placed straight into second “double” bag that your buddy has available. Then the staff member inside the bay/side room can remove their PPE correctly and exit.

Drug rounds will be performed using a ‘buddy’ system: a ‘buddy’ nurse will remain outside the bay with the COW while the ‘administrating’ nurse will administer medication to patients. The ‘buddy’ nurse does not have to change their apron and gloves between patients if they are only placing medication pots on tables and not touching any surfaces or providing patient care.

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Correct removal of PPE

See Appendix 1 for a poster demonstrating how to correctly remove PPE. Even non-AGP PPE needs to be removed in the correct way. Staff should read the ‘Taking off PPE’ posters displayed next to every sink.

PHE has produced videos that demonstrate correct putting on and removal of PPE1. These can be found at:

Staff should immediately report empty soap/hand towels, full bins or broken bin lids, absent hand sanitiser etc. to housekeeping, domestic staff or the nurse in charge.

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Daily checks

The following brief checks should be carried out by the nurse in charge at the start of every shift

  • Team members should know each other by name
  • All ‘dirty’ and ‘clean’ objects are in the correct place
  • There is an adequate PPE supply
  • There are no concerns re oxygen flow at each patient’s bedside
  • All staff working in that area for the duration of the shift know how to put on and remove PPE correctly, and how to remove ‘contaminated’ items from the room.

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It is recommended that key clinical members of staff have twice daily huddles on each ward. This allows team members on the ward to:

  • Know who they are working with by name and their role
  • Update on unwell patients/ share concerns about patients they are worried about
  • Share organisational updates/ change in procedures
  • Flag any PPE issues
  • Check on staff wellbeing.
  • Flag patients for discharge
  • Review patient issues such as falls risk, skin and nutrition

Clinical handovers

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Medical staff

Medical handover should be limited to key staff to avoid overcrowding in offices. If the handover covers patients on multiple wards, each ward should have a maximum of one representative. The duty manager/nurse co-ordinator will provide a situation report at the start of handover. Handover should focus on sick patients/those with high NEWS2 scores, urgent jobs and flagging up patients who could go home. Any other members of staff who are in the office but not part of handover should temporarily vacate the room. During clinical handovers, staff should wipe clean any computer keyboards and surfaces in clinical stations and staff rooms. Fluid repellent surgical Masks will be need to worn at all times in these situations.

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SPACES- Sharing Patient Assessments Cuts Exposure for Staff

It is important to reduce the variation in individual ward/service/organisational practices and try as much as possible to adopt a shared, safe standard for staff looking after ward patients.

SPACES is a standardised approach to the management of ward care. It is based on the principles of "Maximum patient contact - minimum staff exposure".

Clerking new patients

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Medical clerking

Divide doctors into COVID and non-COVID teams to minimise the number of people going in and out of COVID areas. Minimise the number of people who have to see patients by ensuring tasks are performed by the same person seeing the patient at any one time (e.g. clerk in + cannulate).

Doctors should reduce unnecessary repetition of clerkings by utilising the focused COVID assessment tool on PPM+. Ensure the diagnosis and treatment plan is based on all the available information and test results. Current vital signs and results should be noted, and treatment prescribed. Ceiling of care decisions should be made and then communicated to the relevant nursing staff and ensure that the RESPCT form is completed. Patients do not necessarily require a repeat physical examination on arrival to ward if they are well.

Medical notes are ‘clean’ and should not be taken in to ‘bays/side rooms.

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Nursing clerking

Nursing paperwork is ‘clean’ and should not be taken in to ‘dirty’ bays/side rooms.

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Ward rounds

Only the minimum number of people required should enter a bay/side room for a ward round. The notes should remain outside. Clinicians should use the disposable stethoscopes provided inside the bay/side room. Correct PPE procedures must be followed at all times.

Ward rounds should check that ceiling of care decisions have been made for all patients. Ensure all patients discharged with suspected or proven COVID-19 are given advice to self-isolate (see appendix 4), and safety netted to return to hospital if they develop problems breathing.

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Transfer of patients (including procedures for porters)

When transporting all COVID-19 patients, PPE (surgical mask, gloves, apron) should be worn by porters and accompanying nurses as they will be within 2m of the patient. The nurse is responsible for assessing whether eye protection needs to be worn by themselves and the porters. Risk assessment on the use of eye protection, for example, should consider risk of droplet transmission to eye mucosa such as with a coughing patient during the transfer and any need for direct patient contact during transfer. The patient should wear a mask for transport, unless they are wearing an oxygen mask.

On arrival, the porter(s) and any accompanying nurse should place the patient in the bay/side room and remove their PPE (gloves and apron) correctly inside the bay/side room before exiting, removing mask and washing hands. The receiving nursing team should have cleaned and moved the existing bed out of the way, ready for exchange. Porters should not touch the ‘clean’ empty bed whilst wearing their PPE.

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Transfer of any patient with AGP e.g ventilated patients

Porters and nursing staff should not enter clinical high risk areas such as ICU unless they are wearing PPE designed for a high risk area (FFP3 mask, long sleeved gown, gloves, eye protection). The nurse in charge should ensure the portering staff are taken through the PPE procedures.

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Cleaning clinical areas

The new PHE guidance states that: ‘Patient isolation rooms, cohort areas and clinical rooms must be decontaminated at least daily, and that bed spaces or side rooms must have a terminal clean immediately following discharge or transfer (this includes removal and laundering of all curtains and bed screens)1.

During the pandemic, PHE advice is that cleaners should pay particular attention to:

  • Frequently touched surfaces such as medical equipment, door/toilet handles and locker tops,patient call bells, bed tables and bed rails. These should be cleaned at least twice daily and also when known to be contaminated with secretions, excretions or body fluids1.
  • Bathrooms1.

Ideally cleaning staff should be allocated to specific area(s) and not move between COVID and non-COVID areas. They should be trained in what PPE they need to wear and correct methods for putting on, removing and disposing of PPE. As detailed above (see Recommended Personal Protective Equipment).

Avoiding close contact with others (unless wearing PPE), frequent handwashing and regular cleaning of surfaces are important.

After a patient has left a bay/side room, there should be a terminal clean of the area immediately. Cleaners should pay particular attention to wiping surfaces such as tables, lockers, door handles, and anything the patient may have touched. Bathrooms should also be cleaned. Facemask, gloves and an apron should be worn and the gloves and apron should be disposed of in the correct way, along with careful handwashing, before exiting the side room.

The procedure for cleaning is different if an AGP has just taken place in the bay/side room. Cleaners should check with the nurse in charge before entering. After an AGP a terminal clean should take place at least 1hr after the procedure has finished, while wearing a waterproof surgical mask, gloves and apron.

Procedures for deceased patients

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Certifying death

Staff should consider wearing the same PPE they use for seeing patients when certifying death.

‘COVID-19’ is an acceptable cause of death on a death certificate and is not on its own a reason to notify the Coroner. All deaths certificates should be discussed with the consultant in charge.

The cause of death on a death certificate is to the ‘best knowledge and belief’ of the doctor who attended the deceased during their last illness. If a patient had clear clinical features of COVID-19 then you do not need a positive test result to be able to write this as the cause of death.

When attending bereavement to complete a Medical Certificate of Cause of Death (MCCD) please ensure that you are familiar enough with the patient’s medical history to complete the certificate without access to paper notes. Electronic patient records on PPM will be available via computers dedicated for medical staffs’ use in each of the Bereavement Suites.

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Care After Death Proforma

The Bereavement Offices at SJUH and LGI are not accepting patient notes into the department, therefore:

  • When a patient has died ensure that the first page (both sides) of the Care After Death Proforma (CAD) is completed and includes: date and time of death; verifying doctor’s name and GMC No; and, contact details for the patient’s preferred contact
  • Once the CAD has been checked for completeness, scan the two sides of the first page of the CAD and send to

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Preparing the deceased body

The European Centre for Disease Prevention and Control (ECDC) has published guidance on the safe handling of bodies of deceased persons with suspected/proven COVID-19. Staff responsible for wrapping bodies before transport should wear appropriate PPE to minimise exposure to infected bodily fluids, contaminated objects and surfaces.

The recommended PPE for preparing a body for transport to the mortuary is:

  • Long-sleeved water-resistant gown
  • Gloves
  • Fluid repellent surgical mask
  • Eye protection

The following procedures should be followed by nursing staff wearing the appropriate PPE:

  • Remove all catheters, lines and other tubes
  • Keep the movement and handling of the body to a minimum
  • Remove all valuables and clean with disinfectant wipes, then place them in a tray
  • Wrap the body in a shroud but do not tie it at the wrists
  • Place an ID band on each wrist and ensure they are visible and legible
  • Place the body in a zipped cadaver bag (zip opener at head end), expel any air from the bag, zip it fully up
  • Remove gloves, wash hands, put a new pair of gloves on (do not exit the bay/room)
  • Place dry valuables in a biohazard bag
  • Wipe the outside of the cadaver bag with green Clinell® wipes
  • When the cadaver bag is dry, wrap the body in a white hospital sheet
  • The Notice of Death must be attached to the sheet using the minimum amount of tape
  • Any patient property/clothing (non-valuables) should be placed in a red linen bag then sealed. The red bag should then be placed in a white bag and removed by staff as described on p6.
  • Once the body is enclosed then porters can remove the body
  • Nursing staff should correctly remove their PPE

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Use of Body bags

Please ensure ALL deceased patients who have tested positive and those who are suspected of being positive for COVID-19 are placed in a single body bag on the ward.

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Patient Identification

Please complete and send two body cards attached to the outside of the body bag before transfer to the mortuary. In addition please attach one of the patient's ID bracelets to the outside of the body bag as this will ensure patient identification and registration can take place in the mortuary without the need to open the body bag.

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Mortuary location

All positive and suspected positive patients should be transferred to Beckett Wing facility if on the SJUH site and to the usual mortuary at the LGI.

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Transfer to mortuary

Porters transporting a body in a sealed body bag need only to wear gloves, a surgical mask, and an apron, and wash their hands afterwards.

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Patient belongings

If a patient has died of suspected/proven COVID-19 then their property/clothing are considered to be contaminated and their relatives should be advised of this. If there was a relative present at the time of death staff should request their assistance with taking property home or ask for permission to dispose of the property on the ward.

The property should be handled with gloves and cleaned with a detergent followed by disinfection with a solution of at least 70% ethanol or 0.1% (1000 ppm) bleach. It should be sealed in a standard white property bag (a clinical waste bag could cause distress to families) with the instruction not to open for 5 days. Then advise relatives that clothing and other fabric belonging to the deceased should be machine washed with warm water at 60−90°C and laundry detergent.

Valuables should be double-bagged using standard valuables bags available on wards and delivered to Patient Affairs. Patient Affairs will ensure the belongings are held for five days until being delivered to the bereavement office for return to relatives.

Relatives can also pick up belongings via the ‘drive through’ pick up service at the St James’s site. This will be co-ordinated by the bereavement office from Tuesday 7 April 2020. Where relatives are unable to collect the belongings the property will be delivered to their address wherever possible.

If there is a build-up of property on your ward/department email: with ‘Property - Ward no x’ in the subject header to arrange collection. In all cases, property must be kept on the ward/department for 5 days before being moved. Once the backlog of property has been collected, wards and departments should return to previous practice of bringing patient property to the Bereavement Office, whilst maintaining the five day rule.

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Catering procedures

Catering staff should wear the same PPE as clinical staff when working in clinical areas. That is: surgical mask, gloves and apron in the bays/side rooms. Eye protection is not required if you are at least 2 metres away from patients and there is no ‘splash risk’. Surgical masks should be worn outside the bays and side rooms. Nursing staff should prepare patients in bays/side rooms before mealtimes (e.g. repositioning patients in bed).

The recommended procedure for giving out meals is:

  • Catering staff should wear a mask, apron and gloves to hand meal trays to a member of nursing staff wearing PPE in the bay who will place the tray on patients’ tables
  • The nurse need not change their gloves and apron between patients (same as for medication rounds) during the distribution of trays – as long as surfaces have not been touched and care has not been provided
  • A similar procedure will operate for collection of trays.
  • If there are no nurses available to take meals in then housekeepers should wear gloves, apron and a fluid repellent surgical mask to enter the bay or side room. Gloves and apron must be removed before exiting. Hostesses should know the correct methods for putting on, removing and disposing of PPE.

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Uniform policy

Staff in close contact with patients on COVID-19 ward areas should not work in their own clothes (for example doctors). Staff who have a uniform should continue to wear this, for staff who do not have a uniform scrubs are provided. If a patient touches your clothing you should immediately change into a new uniform or if this is not available scrubs. At the end of their shift, staff should change out of their scrubs or uniform. Staff should leave their shift wearing their own clothes. Scrubs can be placed in the linen skip. ‘Dirty’ scrubs must not be left in any other place apart from the linen skip in the changing room. Staff in uniform or their own scrubs should place them in a laundry bag and they should be washed after every shift (60°C with detergent).

Uniforms/own scrubs should be laundered:

  • Separately from other household linen
  • In a load not more than half the machine capacity
  • At the maximum temperature that the fabric can tolerate, then ironed or tumble dried.

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How to troubleshoot and escalate problems

Any problem, no matter how small, that impairs a staff member’s ability to comply with the procedures in this document should be escalated immediately to the co-ordinator, who can escalate to their matron and/or bronze command if needed.

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Appendix 1 : PHE. Donning and Duffing.

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Appendix 2 : COVID-19 Resuscitation Algorithm

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Appendix 3: Handwashing

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Appendix 4: Self Isolation Advice

Appendix 5


Record: 6374

This Standard Operating Procedures (SOP) document sets out the procedures to be followed by all staff working on Covid-19 positive cohort wards. These procedures are designed to keep us safe, and to provide clarity and reassurance for all staff.

All of us have a responsibility to follow these procedures and inform other staff who may be less familiar with a Covid-19 cohort ward environment

Clinical condition:


Target patient group:
Target professional group(s): Secondary Care Nurses
Allied Health Professionals
Registered Nurses Working in Critical Care
Secondary Care Doctors
Tertiary care teams
Adapted from:

Evidence base

  1. European Centre for Disease Prevention and Control. Considerations related to the safe handling of bodies of deceased persons with suspected or confirmed COVID-19. Stockholm: ECDC; 2020.
  2. World Health Organization. Infection Prevention and Control for the safe management of a dead body in the context of COVID-19. Interim guidance 24 March 2020.

Approved By

Clinical Advisory Group (CAG)

Document history

LHP version 1.1

Related information

Who this document is for:

  • Medical staff (all grades, from any department)
  • Nursing staff (all grades, from any department)
  • Health Care Assistants
  • Clinical Support Workers
  • Allied Health Professionals
  • Housekeepers
  • Porters
  • Domestic Staff
  • Catering Staff
  • Security Staff

If any procedure cannot be carried out properly due to lack of kit, this must be reported immediately.

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.