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- OFFICIAL SENSITIVE
- OFFICIAL SENSITIVE
- Page 1 of 9
- 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
- england.spocskh@nhs.net
- 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.
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