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  1. OFFICIAL SENSITIVE
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  4. FAO:
  5. Chief Executives of NHS Trusts
  6. Chief Executives of NHS Foundation Trusts
  7. NHS Medical Directors
  8. STP /ICS leads
  9. CCG clinical leads
  10. CCG accountable officers
  11. NHS England and NHS Improvement Regional Directors
  12. Regional EPRR leads (please cascade to emergency
  13. planning leads in trusts and CCGs)
  14. Regional Heads of Nursing (please cascade to all
  15. directors of nursing)
  16. Regional Heads of Primary Care and Regional Heads of
  17. Public Health – (for information)
  18. Health and Justice leads (Secure and detained estate):
  19. Emergency Preparedness
  20. Resilience and Response
  21. Skipton House
  22. 80 London Road
  23. London
  24. SE1 6LH
  25. england.spocskh@nhs.net
  26. Publications reference number: 001559
  27. 2 March 2020
  28. Dear colleague
  29. COVID-19 NHS preparedness and response
  30. As you will be aware, the current outbreak of a novel coronavirus is resulting in
  31. national and international preparations to be stepped up.
  32. In declaring a level 4 incident, NHS England and NHS Improvement have
  33. established an Incident Management Team (National) (IMT- N) with an operational
  34. Incident Coordination Centre established 7 days a week, working closely with the
  35. Department of Health and Social Care (DHSC), Public Health England (PHE) and
  36. other government departments.
  37. All NHS Regions have also been asked to establish an operational COVID-19
  38. Incident Coordination Centre to the same hours working with the national team and
  39. their NHS local organisations, CCGs, other health care providers and LRFs.
  40. Health providers and commissioners are working together with Local Resilience
  41. Forum (LRF) partners to ensure that they are ready to respond to any outbreaks,
  42. including social care for supporting discharge and home care arrangements.
  43. NHS England and NHS Improvement
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  47. This letter covers what is required of NHS organisations and includes annexes
  48. detailing a new requirement to establish case detection for intensive care
  49. admissions, and guidance on the decontamination of an NHS 111 coronavirus pod.
  50. We have also separately asked NHS laboratories to commence working up the PHE
  51. approved protocol test to further increase the available testing capacity for COVID19.
  52. To date COVID-19 has been managed as a high consequence infectious disease
  53. through our specialist centres so we could learn as much as possible about the virus
  54. and course of the illness. It is now appropriate to begin to manage some patients
  55. within wider infectious disease units and, in due course if the number of cases
  56. continues to grow, we will need to use all acute units, for example through the
  57. cohorting of patients.
  58. Therefore, in light of the continued spread of the virus in multiple countries and the
  59. impact on health and social care we are asking all NHS organisations, following Joint
  60. Emergency Services Interoperability Principles (JESIP), to establish a COVID-19
  61. Incident Management Team led by your Accountable Emergency Officer (AEO).
  62. For all NHS organisations the AEO should:
  63. • Establish an Incident Management Team functioning 7 days a week
  64. • Have a single point of contact available 24/7 for liaison and coordination
  65. for all COVID-19 patient management, alerts, referrals and tracking. This is
  66. particularly important for receiving and acting on COVID-19 test results
  67. and should be available to NHSE/I regional teams, PHE, CCGs and local
  68. providers.
  69. • Ensure the organisation has processes in place to ensure timely returns of
  70. any information needed nationally including situation reporting (SitReps).
  71. Ensure appropriate senior representation is available to join any NHS
  72. England and NHS Improvement regional teleconferences that may be
  73. called to brief on the situation.
  74. • Ensure that all arrangements for the management of infectious disease
  75. patients, specifically those with COVID-19 are known and understood
  76. throughout the organisation (including fit testing training, Personal
  77. Protective Equipment (PPE) refresher training, and hand wash
  78. training/refresher).
  79. • Ensure that any guidance issued by PHE and NHS England and NHS
  80. Improvement is cascaded to all your relevant staff recognising the evolving
  81. incident and frequent changes (in and out of hours arrangements should
  82. be in place). Engage with staff side organisations to support changes in
  83. working practices, risk management and staff information and safety.
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  87. • Ensure that your procurement and materials management teams have
  88. processes in place for the close monitoring and control of PPE, medical
  89. devices and other clinical consumables required to support your response,
  90. and that staff are aware of processes for ordering additional product and
  91. identifying suitable alternatives where necessary.
  92. • Ensure local stock levels are maintained at levels proportionate to
  93. anticipated short term demand, underpinned by regular replenishment
  94. from normal supply routes and NHS Supply Chain. Medicines, medical
  95. devices and clinical consumables should not be stockpiled by
  96. organisations or patients as this may put a strain on the supply chain and
  97. exacerbate any potential shortages. These stocks are being monitored
  98. daily, with additional stock being ordered where necessary.
  99. • Review business continuity arrangements to ensure that you can maintain
  100. business critical services.
  101. • Ensure that you cooperate with the Local Resilience Forum (LRF) and
  102. Local Health Resilience Partnerships (LHRPs) to review and align
  103. arrangements within the area.
  104. • With your LRF, review your organisation's plans against the infectious
  105. disease reasonable worst-case scenario.
  106. • Engage with your social care partners and ensure that they are ready to
  107. locally manage their residents that may be impacted and that they have
  108. infection prevention control measures in place, and their staff are aware of
  109. how to maintain these measures.
  110. • Review mutual aid agreements with other care providers including
  111. specialist, private and voluntary agency providers.
  112. • Ensure that any member of staff, including bank staff and sub-contractors,
  113. who has to be physically present at an NHS facility to carry out their duties,
  114. receives full pay for any period in which they are required to self-isolate as
  115. a result of public health advice.
  116. • Notify your local NHS England and NHS Improvement Emergency
  117. Preparedness Resilience and Response (EPRR) lead of any current or
  118. scheduled works or operational changes currently affecting service
  119. delivery within your organisation.
  120. • Refresh business continuity plans for the maintenance of essential
  121. services.
  122. Acute care providers are also asked to:
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  126. • Review all pathways, specifically those in ‘medicine’ that support those with
  127. respiratory illness and consider the impact that a possible surge in medical
  128. patients might have on services and stocks.
  129. • Clearly identify how your organisation will implement the sequence of
  130. segregation of clinical areas (in Emergency Departments (ED), wards, critical
  131. care) and diagnostic and intervention suites to support the continued
  132. response in the event of a significant escalation in COVID-19 cases.
  133. • Assume that they will need to look after COVID-19 cases in due course so will
  134. need to ensure support services are in place to facilitate this and identified
  135. areas are, or can be modified to, provide a cohorting model of infectious
  136. disease care.
  137. • Review your critical care and high dependency capacity and consider how
  138. you could increase capacity and the impact of doing so.
  139. • Where possible, consider implementing alternative models such as remote
  140. consultations for those patients who can be supported at home and review
  141. arrangements to support vulnerable individuals in alternative settings,
  142. including in the community.
  143. • All Intensive Care Units and Severe Respiratory Failure (ECMO) centres
  144. should commence case detection (please see Annex A).
  145. Ambulance trusts are also asked to:
  146. • Ensure resilient arrangements are in place to support the safe transfer of
  147. COVID-19 positive patients to designated facilities 24/7.
  148. • Implement arrangements to support/deliver the case transfer framework.
  149. Community and mental health providers are also asked to:
  150. • Review arrangements for the management of patients that are ill within the
  151. community and ensure that all staff have appropriate awareness of infection
  152. prevention control measures in community settings.
  153. • Ensure plans are in place to support the medium and long term psychosocial
  154. support required by individuals, communities and staff.
  155. • Where possible, consider implementing alternative models such as remote
  156. consultations for those patients who can be supported at home and review
  157. arrangements to support vulnerable individuals in alternative settings,
  158. including in the community.
  159. Secure and detained estate are asked to:
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  163. • Ensure they follow approved PHE guidelines for healthcare staff in secure and
  164. detained premises.
  165. • Review current infection control practice to ensure they have achieved a state
  166. of preparedness in the event of COVID-19 infection outbreak.
  167. • Adhere to wider PHE guidance in relation to staff presenting in work as unwell
  168. and ensure all staff are aware and adhere to said guidance.
  169. • Ensure engagement with the estate managers (Governors and Directors) to
  170. support and secure immediate isolation procedures as appropriate in and
  171. across establishments.
  172. Sustainability and Transformation Partnerships/Integrated Care Systems,
  173. Clinical Commissioning Groups and Commissioning Support Units are required
  174. to:
  175. • Undertake and support the implementation of incident response structures
  176. within your areas and that a central coordinating function is established.
  177. • Review appropriate local cascades to all of Primary Care within your
  178. commissioning area, both in and out of hours.
  179. • Undertake a coronavirus exercise which aims to review arrangements in place
  180. across the NHS in your area.
  181. Thank you for your leadership at this time. If you have any queries, please discuss
  182. them with your Regional Incident Management Team in the first instance.
  183. Kind regards,
  184. Professor Keith Willett
  185. NHS Strategic Incident Director
  186. NHS England and NHS Improvement
  187. Stephen Groves
  188. Incident Director
  189. NHS England and NHS Improvement
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  193. Annex A: COVID-19 case detection for intensive care admissions
  194. In recent days, new COVID-19 infections have been diagnosed in intensive care
  195. units in a number of European countries, without any epidemiological links to high
  196. risk areas. Nosocomial transmission has occurred in these units affecting other
  197. patients and staff. It is essential that we detect cases admitted to intensive care at
  198. the earliest opportunity.
  199. We are requesting that all Intensive Care Units and Severe Respiratory Failure
  200. (ECMO) centres commence case detection.
  201. Those trusts which have already begun case detection early, as part of the SCOVER
  202. system, should continue.
  203. Case detection
  204. The case detection process does not apply to any patients that meet the current
  205. COVID-19 case definition. These patients should be isolated and tested as usual,
  206. according to the PHE guidance.
  207. General and paediatric intensive care units are asked to test all patients that
  208. meet the following criteria:
  209. - Admitted to intensive care AND
  210. - Presenting condition is an acute community acquired respiratory infection of
  211. any kind, regardless of known or suspected causative pathogen and clinical
  212. features.
  213. Severe Respiratory Failure (ECMO) centres are asked to test all patients admitted
  214. through the SRF referral pathway, regardless of level of respiratory support required.
  215. Sampling
  216. The samples sent for testing should be nose and throat swabs in viral or universal
  217. transport medium and lower respiratory tract samples (e.g. BAL, ETA, or sputum) if
  218. available.
  219. Residual samples from the samples used for clinical testing on admission (e.g. for
  220. routine influenza testing) can be used; if no residual sample is available, repeat nose
  221. and throat swabs in viral or universal transport medium as required, and lower
  222. respiratory specimens should also be sent if available.
  223. As these samples are being submitted for early case detection there is no need to
  224. isolate these patients or take any other special measures outside normal care.
  225. Staff should wear PPE as they would for managing severe influenza in ICU (e.g.
  226. gloves, aprons and fluid repellent mask) and should also follow their local PPE
  227. protocols for aerosol generating procedures, incorporating FFP3 respirator, eye
  228. protection, gown and gloves.
  229. Please discuss this with your local microbiology/ virology department who will assist
  230. you in sending the samples to a PHE laboratory. The turnaround time for the test is
  231. 24 to 48 hours; the samples need to be received in the PHE laboratory before 8am
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  235. to allow testing on that day. Results will be reported to your microbiology laboratory
  236. and positive results notified to the clinician rapidly for immediate management with
  237. the support of the NHS High Consequence Infectious Diseases Network.
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  241. Annex B: Decontamination of the NHS 111 coronavirus pod
  242. General principles
  243. The NHS 111 coronavirus pod (‘the pod’) will need full decontamination, with
  244. appropriate Personal Protective Equipment (PPE), following use by any individuals
  245. who are deemed to require diagnostic sampling following assessment by NHS 111.
  246. Any associated designated waiting areas must also be decontaminated in line with
  247. this guidance and any staff performing decontamination must be fully trained in these
  248. protocols, and the appropriate donning and doffing of PPE.
  249. If NHS 111 has determined that the suspected case does not require diagnostic
  250. sampling, then decontamination of the facility is not required and, if visibly clean, is
  251. deemed ready for the next individual.
  252. Cleaning the pod once the patient has left the pod
  253. Preparation
  254. Once a suspected case has left the pod, the pod should not be used. The door
  255. should remain shut, if possible with windows opened and any air conditioning
  256. switched off, until it has been cleaned with detergent and disinfectant. Once this
  257. process has been completed, the pod can be put back in use immediately.
  258. The responsible person undertaking the cleaning with detergent and disinfectant
  259. should be familiar with these processes and procedures and should collect all
  260. cleaning equipment and clinical waste bags before entering the room.
  261. Personal Protective Equipment (PPE)
  262. Before entering the pod, perform hand hygiene then put on a disposable plastic
  263. apron and gloves. An FFP3 respirator does not need to be worn. If there is any
  264. reason to suspect a patient presents a higher risk, due to the length of time spent in
  265. the pod or their clinical symptoms, then a risk assessment of the need for additional
  266. PPE should be undertaken in conjunction with the trust infection prevention and
  267. control team.
  268. On entering the pod to undertake cleaning and disinfection
  269. • keep the door closed with windows open to improve airflow and ventilation
  270. whilst using detergent and disinfection products
  271. • bag all items that have been used for the care of the patient as infectious
  272. clinical waste
  273. • ideally no linen should need to be used in the pod. If deemed essential (ie a
  274. blanket for warmth) then this should be bagged inside the pod in accordance
  275. with procedures for infectious linen.
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  279. Cleaning process
  280. Communal cleaning trollies should not enter the pod. Use disposable cloths, paper
  281. roll or disposable mop heads to clean and disinfect all horizontal surfaces, chairs,
  282. sanitary fittings, door handles and floor in the pod, following one of the two options
  283. below:
  284. 1. use either a combined detergent disinfectant solution at a dilution of 1000
  285. parts per million (ppm) available chlorine (av.cl.)
  286. 2. or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.)
  287. o follow manufacturer’s instructions for dilution, application and contact
  288. times for all detergents and disinfectants
  289. o any cloths and mop heads used must be disposed of as single use
  290. items
  291. Cleaning and disinfection of reusable equipment
  292. • clean and disinfect any reusable non-invasive care equipment that are in the
  293. pod prior to their removal
  294. • clean all reusable equipment systematically from the top or furthest away
  295. point
  296. On leaving the pod
  297. • discard detergent or disinfectant solutions safely at disposal point
  298. • all waste from suspected contaminated areas should be removed from the
  299. pod and disposed of as category B clinical waste
  300. • disinfect, clean, dry and store re-usable parts of cleaning equipment, such as
  301. mop handles
  302. • remove and discard PPE as clinical waste
  303. • perform hand hygiene
  304. Cleaning of waiting areas
  305. If a suspected case spent time in a waiting area or toilet facilities, then these areas
  306. should be cleaned with detergent and disinfectant (as above) as soon as practicably
  307. possible, unless there has been a blood or body fluid spill which should be dealt with
  308. immediately. Once cleaning and disinfection have been completed, the area can be
  309. put back in use.
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