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