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FAO:
Chief Executives of NHS Trusts
Chief Executives of NHS Foundation Trusts
NHS Medical Directors
STP /ICS leads
CCG clinical leads
CCG accountable officers
NHS England and NHS Improvement Regional Directors
Regional EPRR leads (please cascade to emergency
planning leads in trusts and CCGs)
Regional Heads of Nursing (please cascade to all
directors of nursing)
Regional Heads of Primary Care and Regional Heads of
Public Health – (for information)
Health and Justice leads (Secure and detained estate):
Emergency Preparedness
Resilience and Response
Skipton House
80 London Road
London
SE1 6LH
[email protected]
Publications reference number: 001559
2 March 2020
Dear colleague
COVID-19 NHS preparedness and response
As you will be aware, the current outbreak of a novel coronavirus is resulting in
national and international preparations to be stepped up.
In declaring a level 4 incident, NHS England and NHS Improvement have
established an Incident Management Team (National) (IMT- N) with an operational
Incident Coordination Centre established 7 days a week, working closely with the
Department of Health and Social Care (DHSC), Public Health England (PHE) and
other government departments.
All NHS Regions have also been asked to establish an operational COVID-19
Incident Coordination Centre to the same hours working with the national team and
their NHS local organisations, CCGs, other health care providers and LRFs.
Health providers and commissioners are working together with Local Resilience
Forum (LRF) partners to ensure that they are ready to respond to any outbreaks,
including social care for supporting discharge and home care arrangements.
NHS England and NHS Improvement
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This letter covers what is required of NHS organisations and includes annexes
detailing a new requirement to establish case detection for intensive care
admissions, and guidance on the decontamination of an NHS 111 coronavirus pod.
We have also separately asked NHS laboratories to commence working up the PHE
approved protocol test to further increase the available testing capacity for COVID19.
To date COVID-19 has been managed as a high consequence infectious disease
through our specialist centres so we could learn as much as possible about the virus
and course of the illness. It is now appropriate to begin to manage some patients
within wider infectious disease units and, in due course if the number of cases
continues to grow, we will need to use all acute units, for example through the
cohorting of patients.
Therefore, in light of the continued spread of the virus in multiple countries and the
impact on health and social care we are asking all NHS organisations, following Joint
Emergency Services Interoperability Principles (JESIP), to establish a COVID-19
Incident Management Team led by your Accountable Emergency Officer (AEO).
For all NHS organisations the AEO should:
• Establish an Incident Management Team functioning 7 days a week
• Have a single point of contact available 24/7 for liaison and coordination
for all COVID-19 patient management, alerts, referrals and tracking. This is
particularly important for receiving and acting on COVID-19 test results
and should be available to NHSE/I regional teams, PHE, CCGs and local
providers.
• Ensure the organisation has processes in place to ensure timely returns of
any information needed nationally including situation reporting (SitReps).
Ensure appropriate senior representation is available to join any NHS
England and NHS Improvement regional teleconferences that may be
called to brief on the situation.
• Ensure that all arrangements for the management of infectious disease
patients, specifically those with COVID-19 are known and understood
throughout the organisation (including fit testing training, Personal
Protective Equipment (PPE) refresher training, and hand wash
training/refresher).
• Ensure that any guidance issued by PHE and NHS England and NHS
Improvement is cascaded to all your relevant staff recognising the evolving
incident and frequent changes (in and out of hours arrangements should
be in place). Engage with staff side organisations to support changes in
working practices, risk management and staff information and safety.
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• Ensure that your procurement and materials management teams have
processes in place for the close monitoring and control of PPE, medical
devices and other clinical consumables required to support your response,
and that staff are aware of processes for ordering additional product and
identifying suitable alternatives where necessary.
• Ensure local stock levels are maintained at levels proportionate to
anticipated short term demand, underpinned by regular replenishment
from normal supply routes and NHS Supply Chain. Medicines, medical
devices and clinical consumables should not be stockpiled by
organisations or patients as this may put a strain on the supply chain and
exacerbate any potential shortages. These stocks are being monitored
daily, with additional stock being ordered where necessary.
• Review business continuity arrangements to ensure that you can maintain
business critical services.
• Ensure that you cooperate with the Local Resilience Forum (LRF) and
Local Health Resilience Partnerships (LHRPs) to review and align
arrangements within the area.
• With your LRF, review your organisation's plans against the infectious
disease reasonable worst-case scenario.
• Engage with your social care partners and ensure that they are ready to
locally manage their residents that may be impacted and that they have
infection prevention control measures in place, and their staff are aware of
how to maintain these measures.
• Review mutual aid agreements with other care providers including
specialist, private and voluntary agency providers.
• Ensure that any member of staff, including bank staff and sub-contractors,
who has to be physically present at an NHS facility to carry out their duties,
receives full pay for any period in which they are required to self-isolate as
a result of public health advice.
• Notify your local NHS England and NHS Improvement Emergency
Preparedness Resilience and Response (EPRR) lead of any current or
scheduled works or operational changes currently affecting service
delivery within your organisation.
• Refresh business continuity plans for the maintenance of essential
services.
Acute care providers are also asked to:
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• Review all pathways, specifically those in ‘medicine’ that support those with
respiratory illness and consider the impact that a possible surge in medical
patients might have on services and stocks.
• Clearly identify how your organisation will implement the sequence of
segregation of clinical areas (in Emergency Departments (ED), wards, critical
care) and diagnostic and intervention suites to support the continued
response in the event of a significant escalation in COVID-19 cases.
• Assume that they will need to look after COVID-19 cases in due course so will
need to ensure support services are in place to facilitate this and identified
areas are, or can be modified to, provide a cohorting model of infectious
disease care.
• Review your critical care and high dependency capacity and consider how
you could increase capacity and the impact of doing so.
• Where possible, consider implementing alternative models such as remote
consultations for those patients who can be supported at home and review
arrangements to support vulnerable individuals in alternative settings,
including in the community.
• All Intensive Care Units and Severe Respiratory Failure (ECMO) centres
should commence case detection (please see Annex A).
Ambulance trusts are also asked to:
• Ensure resilient arrangements are in place to support the safe transfer of
COVID-19 positive patients to designated facilities 24/7.
• Implement arrangements to support/deliver the case transfer framework.
Community and mental health providers are also asked to:
• Review arrangements for the management of patients that are ill within the
community and ensure that all staff have appropriate awareness of infection
prevention control measures in community settings.
• Ensure plans are in place to support the medium and long term psychosocial
support required by individuals, communities and staff.
• Where possible, consider implementing alternative models such as remote
consultations for those patients who can be supported at home and review
arrangements to support vulnerable individuals in alternative settings,
including in the community.
Secure and detained estate are asked to:
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• Ensure they follow approved PHE guidelines for healthcare staff in secure and
detained premises.
• Review current infection control practice to ensure they have achieved a state
of preparedness in the event of COVID-19 infection outbreak.
• Adhere to wider PHE guidance in relation to staff presenting in work as unwell
and ensure all staff are aware and adhere to said guidance.
• Ensure engagement with the estate managers (Governors and Directors) to
support and secure immediate isolation procedures as appropriate in and
across establishments.
Sustainability and Transformation Partnerships/Integrated Care Systems,
Clinical Commissioning Groups and Commissioning Support Units are required
to:
• Undertake and support the implementation of incident response structures
within your areas and that a central coordinating function is established.
• Review appropriate local cascades to all of Primary Care within your
commissioning area, both in and out of hours.
• Undertake a coronavirus exercise which aims to review arrangements in place
across the NHS in your area.
Thank you for your leadership at this time. If you have any queries, please discuss
them with your Regional Incident Management Team in the first instance.
Kind regards,
Professor Keith Willett
NHS Strategic Incident Director
NHS England and NHS Improvement
Stephen Groves
Incident Director
NHS England and NHS Improvement
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Annex A: COVID-19 case detection for intensive care admissions
In recent days, new COVID-19 infections have been diagnosed in intensive care
units in a number of European countries, without any epidemiological links to high
risk areas. Nosocomial transmission has occurred in these units affecting other
patients and staff. It is essential that we detect cases admitted to intensive care at
the earliest opportunity.
We are requesting that all Intensive Care Units and Severe Respiratory Failure
(ECMO) centres commence case detection.
Those trusts which have already begun case detection early, as part of the SCOVER
system, should continue.
Case detection
The case detection process does not apply to any patients that meet the current
COVID-19 case definition. These patients should be isolated and tested as usual,
according to the PHE guidance.
General and paediatric intensive care units are asked to test all patients that
meet the following criteria:
- Admitted to intensive care AND
- Presenting condition is an acute community acquired respiratory infection of
any kind, regardless of known or suspected causative pathogen and clinical
features.
Severe Respiratory Failure (ECMO) centres are asked to test all patients admitted
through the SRF referral pathway, regardless of level of respiratory support required.
Sampling
The samples sent for testing should be nose and throat swabs in viral or universal
transport medium and lower respiratory tract samples (e.g. BAL, ETA, or sputum) if
available.
Residual samples from the samples used for clinical testing on admission (e.g. for
routine influenza testing) can be used; if no residual sample is available, repeat nose
and throat swabs in viral or universal transport medium as required, and lower
respiratory specimens should also be sent if available.
As these samples are being submitted for early case detection there is no need to
isolate these patients or take any other special measures outside normal care.
Staff should wear PPE as they would for managing severe influenza in ICU (e.g.
gloves, aprons and fluid repellent mask) and should also follow their local PPE
protocols for aerosol generating procedures, incorporating FFP3 respirator, eye
protection, gown and gloves.
Please discuss this with your local microbiology/ virology department who will assist
you in sending the samples to a PHE laboratory. The turnaround time for the test is
24 to 48 hours; the samples need to be received in the PHE laboratory before 8am
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to allow testing on that day. Results will be reported to your microbiology laboratory
and positive results notified to the clinician rapidly for immediate management with
the support of the NHS High Consequence Infectious Diseases Network.
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Annex B: Decontamination of the NHS 111 coronavirus pod
General principles
The NHS 111 coronavirus pod (‘the pod’) will need full decontamination, with
appropriate Personal Protective Equipment (PPE), following use by any individuals
who are deemed to require diagnostic sampling following assessment by NHS 111.
Any associated designated waiting areas must also be decontaminated in line with
this guidance and any staff performing decontamination must be fully trained in these
protocols, and the appropriate donning and doffing of PPE.
If NHS 111 has determined that the suspected case does not require diagnostic
sampling, then decontamination of the facility is not required and, if visibly clean, is
deemed ready for the next individual.
Cleaning the pod once the patient has left the pod
Preparation
Once a suspected case has left the pod, the pod should not be used. The door
should remain shut, if possible with windows opened and any air conditioning
switched off, until it has been cleaned with detergent and disinfectant. Once this
process has been completed, the pod can be put back in use immediately.
The responsible person undertaking the cleaning with detergent and disinfectant
should be familiar with these processes and procedures and should collect all
cleaning equipment and clinical waste bags before entering the room.
Personal Protective Equipment (PPE)
Before entering the pod, perform hand hygiene then put on a disposable plastic
apron and gloves. An FFP3 respirator does not need to be worn. If there is any
reason to suspect a patient presents a higher risk, due to the length of time spent in
the pod or their clinical symptoms, then a risk assessment of the need for additional
PPE should be undertaken in conjunction with the trust infection prevention and
control team.
On entering the pod to undertake cleaning and disinfection
• keep the door closed with windows open to improve airflow and ventilation
whilst using detergent and disinfection products
• bag all items that have been used for the care of the patient as infectious
clinical waste
• ideally no linen should need to be used in the pod. If deemed essential (ie a
blanket for warmth) then this should be bagged inside the pod in accordance
with procedures for infectious linen.
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Cleaning process
Communal cleaning trollies should not enter the pod. Use disposable cloths, paper
roll or disposable mop heads to clean and disinfect all horizontal surfaces, chairs,
sanitary fittings, door handles and floor in the pod, following one of the two options
below:
1. use either a combined detergent disinfectant solution at a dilution of 1000
parts per million (ppm) available chlorine (av.cl.)
2. or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.)
o follow manufacturer’s instructions for dilution, application and contact
times for all detergents and disinfectants
o any cloths and mop heads used must be disposed of as single use
items
Cleaning and disinfection of reusable equipment
• clean and disinfect any reusable non-invasive care equipment that are in the
pod prior to their removal
• clean all reusable equipment systematically from the top or furthest away
point
On leaving the pod
• discard detergent or disinfectant solutions safely at disposal point
• all waste from suspected contaminated areas should be removed from the
pod and disposed of as category B clinical waste
• disinfect, clean, dry and store re-usable parts of cleaning equipment, such as
mop handles
• remove and discard PPE as clinical waste
• perform hand hygiene
Cleaning of waiting areas
If a suspected case spent time in a waiting area or toilet facilities, then these areas
should be cleaned with detergent and disinfectant (as above) as soon as practicably
possible, unless there has been a blood or body fluid spill which should be dealt with
immediately. Once cleaning and disinfection have been completed, the area can be
put back in use.