Influenza Pandemic Plan

Transcription

1 Influenza Pandemic Plan Version 12 May 2015 This plan must be used in conjunction with Infection Control Manual Chapter 36 Influenza pandemic DOCUMENT NUMBER VERSION 12 APPROVING COMMITTEE Risk Management Council DATE APPROVED June 2015 DATE IMPLEMENTED Summer 2015 NEXT REVIEW DATE March 2018 ACCOUNTABLE DIRECTOR Sue Redfern POLICY AUTHOR Jayne Heaney TARGET AUDENCE Entire Trust staff, Medirest and Vinci KEY WORDS Influenza pandemic, infectious disease Note: Quick Guide for Responding Managers: 1. Establish which phase and stage (i.e. DETECT, ASSESS, TREAT, ESCALATE OR RECOVER) the pandemic is at. 2. Check and carry out the actions listed for your ward, department or function (in alphabetical order). Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments. This document is designed to be printed back to back

2 Document History Version 1 March 2009 Version 7 January 2014 Version 2 September 2009 Version 8 February 2014 Version 3 October 2011 Version 9 April 2014 Version 4 January 2012 Version rd April 2014 Version 5 November 2012 Version 11 May 2014 Version 6 December 2012 Version 12 May 2015 Scope This document is a strategic plan for use by all Trust staff and managers in the event of an influenza pandemic from pre emergence of the disease through to catastrophic event that affects all of society. Location of Policy The policy will be kept as a link on the intranet on the Major Incident site and under Policies. Equality assessment The equality assessment and KPIs (approved by the Trust Equality & Diversity Lead) that covers all Major Incident Plans is in the Trust Major Incident Policy. Terminology Major Incident definitions are shown in bold and italic and can be found in the glossary at the back of the document. Amendments A complete re-issue of this handbook will be posted on the intranet every time it is revised and the Emergency Planning Team will replace hard copies in the Major Incident cupboards. Training Training and exercising for all Major Incident plans are shown in the Trust Training Needs Analysis and Training Matrix will be posted on the intranet Ethical framework This plan will be enacted in accordance with: The Cabinet Office/Dept of Health document Responding to Pandemic Influenza, the Ethical Framework for Policy & Planning and General Medical Council, Pandemic Influenza Good Medical Practice - Responsibilities of doctors in a national pandemic, Page 2 of 78 STHK PAN FLU PLAN V11 MAY 2014

3 Mental Health Act The 5 Boroughs Partnership Specialist Mental Health NHS Trust have a Liaison Mental Health Team based in Emergency Department that has a capability to provide cover during office hours and on call out of hours. Indemnity The Trust is a member of the National Health Service Litigation Authority Scheme and as such any members of staff, paid or volunteers will be indemnified for any NHS work undertaken in an NHS establishment on NHS patients. This is providing they operate within their agreed remit and scope of capabilities. Supporting Documents This plan should be read with reference to the following: St Helens & Knowsley Teaching Hospitals NHS Trust (see the Emergency Planning webpage of the STHK Trust internet) Infection Control Manual Chapter 23 Influenza Policy Strategic Business Continuity & Internal Major Incident Plan Major Incident Command Suite Plan and Exec Action Pack Protocol for Human Resources Policies and Procedures - November 2008 Health Work and Wellbeing Service Pandemic Flu - March 2008 Pandemic Influenza Communication Plan February 2009 Compass Group UK & Ireland - Business Continuity Plan Influenza Pandemic Version 2.9 Multi Agency Plans and Memoranda of Understanding (hard copies kept in Major Incident Control Room Cupboards and key officer s files) Merseyside Infectious Diseases Management Plan 2014 Merseyside Mass Fatalities Plan Interim Excess Deaths Protocol NW Critical Care Network Pandemic Influenza: Critical Care Plan 2013 Guidance Guidance during the pandemic can be found by referring to the PHE website: Health and Social Care Influenza Pandemic Preparedness and Response 6/dh_ pdf Pandemic Influenza NHS guidance on the current and future preparedness in support of an outbreak. Operating Framework for Managing the Response to Pandemic Influenza Page 3 of 78 STHK PAN FLU PLAN V11 MAY 2014

4 Pandemic Influenza Guidance on the Management of Death Certification and Cremation Certification 2/ dh-template-guidance-on-management-of-death-certification.pdf Acronyms and abbreviations used in the document 5BP AMU CCGs CM CSU Comms Crit Care DA(E)TER DIPC ED Execs FFP3 FM Services HWWD HPA HR ICU IDT ICT ICAT IPCD KIPS LHRP NHS NHS E NWAS Ops Services Ops Site Mgr PHE PPE The Trust UCAT UK WHO 5 Boroughs Mental Health Partnership Mental Health NHS Trust Acute Medical Unit Clinical Commissioning Groups Cheshire & Merseyside Commissioning Support Unit Communications Critical Care DETECT/ ASSESS (EVALUATE)/ TREATMENT/ TREATMENT/ ESCALATION/ RECOVERY Director of Infection Prevention & Control Emergency Department (formerly known as A&E) Executive Team Face Fitted Protector version 3 disposable respirator Facilities Management (provided by Medirest e.g., cleaning, portering, catering, security, shuttle bus service, reception). Health Work and Wellbeing Dept (formerly Occupational Health) Health Protection Agency now called Public Health England Human Resources Intensive Care Unit (also called Critical Care) Integrated Discharge Team, a combined team of hospital social care workers from Halton, St Helens & Knowsley Councils Integrated Community Health Services formerly Knowsley Integrated Provider Services (KIPS) which is a business unit of 5BP above. Information & computer technology Intermediate care action team Infection Prevention & Control Dept Knowsley Integrated Provider Services now known as ICS@5BP Local Health Resilience Forum, a Merseyside wide strategic level Emergency Planning, Risk & Resilience Forum National Health Service NHS England North West Ambulance Service Operational Services bed managers Operational Site Manager Public Health England (formerly HPA) Personal Protective Equipment (respirators, masks, goggles, visors, gloves, aprons, gowns, etc.) St Helens & Knowsley Teaching Hospitals NHS Trust Urgent Care Action Team (part of CM CSU above) United Kingdom World Health Organisation Page 4 of 78 STHK PAN FLU PLAN V11 MAY 2014

5 Contents Page Introduction 7 Planning Assumptions Aims Impact on the Trust Impact on primary & Community health & social care Emergency of the Pandemic Triggers Emergency response Trust led meetings Emergency response NHS England led meetings Command & control Stand down Mutual aid Finance Communications Critical Care Immunisation Immunisation for Priority/ Risk Groups Out Patients and Hospital at Home Patients Trust On-going Preparation (pre pandemic) 15 Phasing the Response 17 WHO International Phases and UK DA(E)TER Latest UK Approach to the phases of pandemic response. DETECT ASSESS (EVALUATE) TREATMENT ESCALATION RECOVERY Trust s Role Staff Welfare DETECT role of the Trust by function ASSESS (EVALUATE) role of the Trust by function TREATMENT role of the Trust by function ESCALATION role of the Trust by function Escalation Summary RECOVERY role of the Trust by function Trust General Response Business Continuity Staff vaccine Patient vaccine Hospital Pharmacy Arrangements Trust Support to 5 Boroughs Mental Health Partnership (5BP) Patients 5BP Support to the Trust Page 5 of 78 STHK PAN FLU PLAN V11 MAY 2014

6 Contents Page Trust General Response (Cont ) Infection Control & PPE Training Purchasing & Supply Communications Reporting Systems ICU Paediatrics Creating capacity Capacity & Equipment requirements Accelerated Discharge Excess Deaths Recovery References Appendices APPENDIX A Nursing patients with seasonal &/or established Pandemic Influenza APPENDIX B Nursing patients with a new emerging strain of flu APPENDIX C - Putting On and Removing Personal Protective Equipment (PPE) APPENDIX D - Prevention of influenza APPENDIX E Staffing Issues APPENDIX F Other Contingency Measures Page 6 of 78 STHK PAN FLU PLAN V11 MAY 2014

7 Introduction St Helens & Knowsley Teaching Hospitals NHS Trust hereafter referred to as the Trust is required by the Civil Contingencies Act 2004 as a Category One Responder to prepare contingency arrangements in case of a pandemic. An influenza pandemic is an example of a Rising Tide style of event which is difficult to recognise at first and builds slowly over a period of time. Pandemics also come in a series of waves (up to 3 or 4) which may vary in intensity and spread. In most years, seasonal influenza occurs for a 6-8 week period during winter. Influenza A viruses can undergo major changes at unpredictable intervals. When this occurs, the population has no immunity to the new strain and world-wide epidemics (pandemics) of influenza can result. Over the past 100 years there have been 4 pandemics the most recent of which was the Swine Flu Pandemic which started in Mexico in the spring of 2009, the first wave hitting the UK within 2 months but generally appearing to be a very mild disease with few serious cases or deaths in the UK. The UK was hit by the 2 nd wave in the winter of 2010/11 which had a much greater impact and seriously exacerbated the problems of healthcare providers (and this Trust as a case in point) already dealing with outbreaks of Norovirus and very severe weather (snow and record freezing conditions for nearly 3 months). Although there were very few deaths attributed to it in the UK most of the deaths that did occur were not the usual over 65s but younger adults many of whom were pregnant women in their 3 rd trimester or patients with an underlying condition and some children and babies. The psychological effect of these deaths on staff and the public was much greater than perceived in previous seasonal flu outbreaks where most of those who died were elderly people usually with severe respiratory diseases. The expected 3 rd wave never arrived but with the very extensive seasonal flu vaccination campaign in following years (seasonal flu vaccine includes H1N1) it may be that the strived for herd immunity has been achieved for swine flu. When a pandemic occurs, the consequences can be very serious. There can be little warning. Around 25% of the population may be affected and for very harmful strains up to 50,000+ deaths in the UK alone. A pandemic is likely to be of much greater magnitude than even the most severe epidemic influenza winters. More severe illness is likely. Mortality is expected to be higher than that due to normal seasonal influenza. A pandemic can overwhelm health and social care and other services. The overall impact is likely to be even more far-reaching, affecting daily life, business and consequently national and global economies. Disruption is likely to be less if people know what to expect and what to do and have had time to think through the consequences for themselves, their families, communities and organisations. Page 7 of 78 STHK PAN FLU PLAN V11 MAY 2014

8 Planning Assumptions Influenza pandemic planning in the UK has been based on an assessment of the reasonable worst case derived from experience and a mathematical analysis of seasonal influenza and previous pandemics. This suggests that up to 50% of the population could experience symptoms of pandemic influenza during one or more pandemic waves lasting 15 weeks, although the nature and severity of the symptoms would vary from person to person. Analysis of previous influenza pandemics suggests that we should plan for up to 2.5% of those with symptoms dying as a result of influenza, assuming no effective treatment was available. The UK Influenza Pandemic Preparedness Strategy 2011 recognises that the combination of particularly high attack rates and a severe disease is also relatively (but unquantifiably) improbable, and consequently suggests planning for a lower level of population mortality is sensible. Therefore the NHS should ensure plans are flexible and scalable for a range of impacts. While the profile of the next pandemic remains by its very nature unknown, it is prudent to continue to plan and prepare using modelling assumptions based on experiences of previous pandemics. Although all parts of society will be affected by a pandemic, the NHS is likely to be particularly impacted due to an increase in demand for services from patients coupled with a potential reduction in staffing (due to a variety of factors including personal illness and caring responsibilities) and possible supply chain disruptions. Planning at all levels needs to be comprehensive and flexible to address the breadth of possible scenarios. A proportional, graded response that can be adjusted as the threat alters, including cessation or commencement of certain functions, is required. It is essential that NHS England considers all possible impacts due to pandemic influenza and is ready to lead the NHS response in conjunction with relevant partners. Aims The aims of the Trust contingency plans are: To minimise spread of the new virus/ further waves of swine flu. To reduce morbidity and mortality from influenza illness To be able to cope with large numbers of sick and dying people To ensure that essential and critical services are maintained and expanded as needed. To provide timely information at all stages up the regional chain of command to enable multi agency working and correct distribution of resources in the North West To provide for the welfare and protection of staff Page 8 of 78 STHK PAN FLU PLAN V11 MAY 2014

9 Impact on the Trust Increased workload due to the numbers of patients presenting with influenza and complications of influenza, other seasonal outbreaks (e.g. Norovirus) and other factors like extreme weather conditions resulting in higher trauma casualty numbers. Increased requirements for high dependency care and infection control facilities and equipment Increased burden caused by staff anxiety and bereavement Depletion of workforce due to direct and indirect effects of influenza on themselves and their families and burn out. Logistical problems due to interruption of supplies (clinical and non-clinical), utilities and transport as part of the general disruption Delays in dealing with other medical conditions More intense pressure on mortuary facilities Impact on primary & community health & social care Most health (including provision of antiviral treatment and patient vaccination) and social care will have to take place in the community, heavily affecting primary care, community health services and social care providers in local authority and the 3 rd sector. These agencies will be encouraged to employ hospital avoidance measures to relieve pressure on hospital Trusts. Most health and social care, including patient vaccination and provision of antiviral treatment will take place in the community. These agencies will be directed to prioritise hospital attendance and admissions avoidance and to work closely with hospital Trusts to safely accelerate discharges. Emergence of the pandemic Most new influenza viruses have emerged in China or South East Asia. Pandemic strains spread world-wide in 6 months or less. The swine flu pandemic appeared in Mexico and swept the USA. It was brought to the UK by a small number of tourists who had recently visited and its progress was closely monitored by the former Health Protection Agency (HPA now Public Health England) and great effort made by the entire UK health economy to provide contact tracing and containment throughout 2009 until the first proper wave hit in winter 2009/10 so negating the need for such measures (as it could no longer be contained). The duration of the pandemic is expected to last 3-5 months in the UK but successive waves of illness may occur many weeks or months apart. The 2 nd and 3 rd waves could be worse than the first. Page 9 of 78 STHK PAN FLU PLAN V11 MAY 2014

10 TRIGGERS Low Impact Similar number of cases to moderate or severe seasonal influenza outbreaks and mild to moderate clinical features: North West Ambulance Service coping with increased referrals; GPs and Emergency Departments coping with increased pressure; Acute Trusts managing respiratory admissions; Intensive Care Units nearing or at maximum pressure using mutual aid (e.g. network support and paediatrics/adult collaboration); Community pharmacies coping with increased pressures, supplying medicines and providing advice on self-care, and; Potential for increased staff absence due to sickness. Moderate Impact No cases higher than large seasonal epidemic; Young healthy people/ those at-risk groups severely affected and/or more severe illness; GPs cannot continue non-urgent and public health activities (no longer business as usual ); Hospital non-urgent out-patient appointments and admissions no longer possible; Hospitals urgent and emergency activity managed with maximum effort Emergency Departments indicators high; Intensive Care Units at maximum expansion and under severe pressure; Community pharmacies under pressure and difficulty accessing some medicines, and; Community health and social care services prioritising support to those most in need. High Impact Severe pandemic and/or most age groups affected and/or severe, debilitating illness with or without severe or frequent complications; GPs, district nurses and social carers independent sector, pharmacies, residential homes and voluntary organisations fully stretched trying to support essential care in the community with consequential pressure on secondary care; Hospitals can only provide emergency services; Ethical framework implemented for access to critical care;; Transport, schools and shops affected by sickness and family care absences; Pressure on some supplies, and; Numbers of deaths putting pressure on mortuary and undertaker services. Page 10 of 78 STHK PAN FLU PLAN V11 MAY 2014

11 Emergency Response Trust Led Meetings See Trust Strategic & Tactical Business Continuity & Internal Major Incident Plan revised 2013 At various stages of the response the Exec in Charge (normally the Operations Director who may delegate the Chair but not responsibility to an Asst Dtr Ops) may decide to call daily or weekly Multi Agency Emergency Response Meetings in the Major Incident Suite/ Exec Suite and/or teleconferences hosted by the Trust. Meetings must be recorded by a trained Loggist. The attendees to these meetings will change frequently according to need and availability and may consist of representatives from: All relevant Trust depts., wards or functions (key depts. tend to be Ops Services, Infection Control, Pharmacy, DIPC, ED, ICU, AMU, IDT, Theatres, Comms, Purchasing & Supply, Health Work and Wellbeing, HR, Clinical Support Care Group, Emergency Planning, Information Services, IT, mortuaries and wards), Commissioners/ Silver Commanders (local CCGs, UCAT & NHS England) Local community health provider services (mostly ICS (formerly 5BP, Bridgewater Community Health and 5BP Mental Health Partnership) Integrated Discharge Team (combination of social care providers from Knowsley, St Helens and Halton Councils operating from the hospital) Intermediate care (ICAT) NWAS patient transport officer. The object of these meetings is to work in cooperation with all local health providers and commissioners to find dynamic solutions to challenges that arise and those solutions may change according to alterations in flows, capacity, demand etc. Emergency Response NHS England Led Meetings The Trust s accountable officer (Exec Nurse) and/or Operations Director will take part in Merseyside LHRP meetings and teleconferences hosted and led by NHS England at increasing intervals throughout the pandemic as required. The Trust s emergency planning practitioner will attend Health Resilience Group (HRG) meetings hosted by NHSE as required throughout the response. Command & Control At the Treatment phase and beyond, NHS England Area Team (NHSE) may establish an office hours NHS (Gold) Incident Control Centre (ICC) at Regatta House, Liverpool, to manage the Merseyside NHS economy response to the rising tide style incident using the Major Incident Command and Control structure. This ICC would dispense DH demands for information and collate and coordinate situation reports (Sitreps) from all provider organisations and other commissioners and send Merseyside area situation reports to the DH as appropriate. Page 11 of 78 STHK PAN FLU PLAN V11 MAY 2014

12 Stand Down NHS Gold Command will issue the stand down to provider agencies at a point when extreme pressures have decreased to a manageable level and situation reporting and emergency response teleconferences/ meetings are no longer required. Mutual Aid Mutual aid may be coordinated by NHS Gold Command in consultation with commissioners (i.e., NHS England and CCGs) and Public Health England. This may consist of: Activation of the NW Critical Care Network Plan. Excess ICU patients transferred to specialist trusts with respiratory beds (e.g. Liverpool Heart & Chest, Walton Neurological Centre). In a pandemic that targets children hospitals with Paediatric Departments could be asked to support Alder Hey by offering the HDU beds with support from adult ICU or placing older children in adult ICU supported by Paediatric staff. Acute Trusts may deflect minor injuries to Walk-in centres by agreement via NHS Gold Command. Finance Extra emergency supplies and specialist equipment bought or hired to manage the situation should be ordered using an emergency code and cleared with the Exec Team in advance. Communications The Communications Team will work through the NHS Gold Communications Cell as per the Merseyside Press & Media Protocol. Some local messages may be broadcast to local press and media after content is cleared by the Gold Cell. Critical Care As pressure builds in Critical Care the NW Critical Care Network will activate the Escalation Policy for Local Critical Care Capacity Pressures. Actions for trusts to alleviate pressure on critical care beds These include action to: minimise & avoid delayed discharges from critical care, active assessment of elective surgical patients to avoid unplanned admissions to critical care, activation of local (trust) escalation plan postponement of planned, non-urgent major surgery requiring critical care ensure that additional information is added to DOS to reflect trust situation and aid assessment of overall capacity Page 12 of 78 STHK PAN FLU PLAN V11 MAY 2014

13 Immunisation Refer to Trust Infection Control Manual Chapter 23 and Health & Wellbeing Department s staff immunisation policy. Immunisation for Priority/ Risk Groups The need to keep health and other essential services running will mean that, if new vaccine supplies are limited vulnerable groups may need to take precedence for vaccine. Priority aims are as follows (in priority order): Protection of health and social care staff with patient contact. They are at increased risk of acquiring infection from their patients and also passing it on to vulnerable patients Protection of those providing essential services which would be disrupted by excess absenteeism during an outbreak e.g. fire, police, security, communications, utilities, undertakers and the armed forces. Prevention of serious illness in the most vulnerable groups (anticipated or confirmed). Until epidemiological evidences begin to accumulate during a pandemic, it cannot be predicted who those are most likely to be. During the swine flu pandemic in 2009/ 10 these groups emerged as: Patients with chronic or severe respiratory, renal, heart and neurological conditions Immuno-suppressed patients Children under 5 particularly babies under 1 Pregnant women in the third trimester Over 65s Closed communities e.g. residential care homes Those most likely to transmit the virus e.g. children There were very few over 65s who were seriously affected by the last pandemic. They are targeted for vaccination as they are for seasonal flu but nearly all of the deaths resulting from swine flu were under 40 years of age, several of which were pregnant women in the third trimester and young children. Other groups that emerged as at risk were the morbidly obese and, at the other end of the scale, anorexic patients. This may have been because Swine flu is an upper respiratory disease and those with compromised lung space or weakened lungs were badly affected. Out Patients & Hospital at Home Patients Immuno-suppressed Sexual Health patients will be vaccinated directly by the Sexual Health Service. Out-patients with serious conditions and illnesses (e.g. cancer, renal and cardiac conditions) will be directed to their GP for vaccination. But they will Page 13 of 78 STHK PAN FLU PLAN V11 MAY 2014

14 be monitored and may be admitted to hospital if they develop severe flu symptoms. Neurological paediatric patients and their families will be directed to access vaccination by their GP. Maternity patients in their 3 rd trimester are at particular risk of upper respiratory infections like avian or swine flu. Community midwives will encourage maternity patients to take up vaccine from their GP. Maternity patients in their 3 rd trimester who suffer severe flu symptoms may be admitted as a precaution. The families of Paediatric Hospital at Home patients will be informed and encouraged by staff to have the children and the rest of the family immunised. Paediatric Hospital at Home patients will be brought into hospital if they become seriously ill with influenza which exacerbates their underlying condition. Cancer, cardiac, neurological and renal out-patients will be vaccinated by their GP but if they re admitted before this has happened they may be vaccinated by the hospital if they are well enough to receive it. During the swine flu in 2009/10 the Maternity Department offered space and vaccines for community health providers (formerly PCTs) to set up a patient vaccination point within the department and doctors and midwives referred women attending their 20 week clinic appointment. A business plan for maternity patients to be vaccinated by the Trust by midwives appropriately trained to do so with resource and training funded by the CCGs is currently being considered. Page 14 of 78 STHK PAN FLU PLAN V11 MAY 2014

15 Trust Annual On-Going Preparation (pre-pandemic) The Trust s prepares annually for pandemic flu in the following ways: Section/ Department Preparation Acute Medical Unit Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training Burns & Plastics Awareness & planning with Northern Burn Care Network Cancer Services (Lilac Advise and direct patients and their families to GP for Centre) vaccination Communications Monitoring of PHE and other websites and media Critical Care Awareness & planning with North West Critical Care Network Respirator (FFP3) fit test training Monitoring and replacing stocks of PPE for ICU DIPC Monitoring of PHE website and other research Infection Prevention & Train the trainers fit test training for respirators Control Dept Review of Infection control manual 23 and related documents Monitoring and review stocks of PPE in liaison with P&S Emergency Dept Monitoring and replacing stocks of PPE for Emergency Dept Respirator (FFP3) fit test training Emergency Planning Research, awareness and planning in consultation and cooperation with key Trust staff and NHS and other partners Execs Finance (Purchasing & Supply) FM services HR including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development ICT Information Service Integrated Discharge Team (IDT) Labs (Pathology) Monitoring and awareness of strategic issues of pan flu Revision and resupply of PPE Materials Management Team monitoring and restocking PPE in liaison with Infection Prevention & Control Training managers in operational skills to provide resilience. Review and restock of supplies and training for deep cleaning teams. Respirator (FFP3) fit test training Annual staff vaccination programme starting in September. (76%+ achieved in 2013) Training new vaccinators (including anaphylaxis training) Training clinically registered staff in non-clinical roles to support in ICU and ED. Facilitation and maintenance of Immsform and other reporting systems Training in gathering Review of accelerated discharge plans Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. Page 15 of 78 STHK PAN FLU PLAN V11 MAY 2014

16 Section/ Department Maternity Mental Health liaison Mortuary Team Preparation Actively direct and advise pregnant women to their GP for flu vaccination Development of plans/ contract with commissioners to secure resources for potential future vaccination of pregnant women. Year round monitoring of Merseyside Mortuary Capacity Reporting System and operation of Merseyside Excess Deaths Policy as needed. Training pathology staff volunteers to support in the mortuary at times of extra pressure and Major Incidents. Maintaining extra BC body storage places (x 24) in St Helens Hospital. Preparation of winter plans and management of patient flows Advise and direct patient s families to GP for vaccination Operational Services Paediatric Hospital at Home team Paediatric nephrologist Advise and direct patient s families to GP for vaccination Palliative Care Joint N/A at this stage Teams (end of life care) Out Patients Dept Paediatrics Pharmacy Respiratory wards Sexual Health Clinic Theatres Therapy team (actually part of 5BP Community Health but integral to STHK) Wards (General) N/A at this stage Development and review of integrated working with critical care and Alder Hey Children s Hospital Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer Review of business continuity plans re staff shortages and loss of key staff, supplies Identification of potential storage of vaccines and medicines for primary care in extremis if legal restrictions are lifted.. Review and re-supply of vaccines and medicines Review of PPE stocks Respirator (FFP3) fit test training Vaccinate their vulnerable outpatients Training staff to support in ICU as required. Development of major incident plans re support in community to keep patients out of hospital, support in ED to turn patients around faster and wards to prepare patients and care package to accelerate discharge. Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer Review of PPE stocks Respirator (FFP3) fit test training This is additional to the regular review of business continuity plans, training and exercising (see EPRR Training programme 2013/ 14). H:\Emergency Planning WEBSITE\0 STHKTrainingMatrix2013_14.doc Page 16 of 78 STHK PAN FLU PLAN V11 MAY 2014

17 Phasing the Response WHO International Phases & UK DATER Stages International phases Significance for the UK Inter-pandemic period 1 2 No new influenza subtypes detected in humans Animal influenza subtype poses substantial risk UK not affected OR UK has strong trade/travel connections with affected country OR UK affected 3 Human infection(s) with a new sub type, but no new human to human spread to a close contact 4 Small and LAT(s) with limited human to human transmission but spread is still highly localised, suggesting that the virus is not well adapted to humans 5 Large and LAT(s) but human to human spread is still localised, suggesting that the virus is becoming increasingly better adapted to humans Pandemic Alert Period UK not affected OR Pandemic Period UK has strong trade/travel connections with affected country OR UK affected. 6 Increased and sustained transmission in general population UK DATER Response Phases (flexible) Detect, Assess (Evaluate), Treat, Escalate and Recover Post Pandemic Period End of pandemic return to inter-pandemic period Latest UK approach to the phases of pandemic response A new UK approach to the indicators for action in a future pandemic response has been developed. This takes the form of five phases, provisionally named: Detect, Assess (Evaluate), Treat, Escalate and Recover (DATER) and incorporates indicators for moving from one phase to another. The phases are not numbered as they are not linear and it is possible to move back and forth or jump phases. In a severe situation, it may be necessary to activate Detect and Evaluate at the same time, then Treat and Escalate in short order, if not concurrently. Page 17 of 78 STHK PAN FLU PLAN V11 MAY 2014

18 Detect This would commence either on the declaration of the current WHO phase 4 or earlier on the basis of reliable intelligence or if an influenza-related Public Health Emergency of International Concern (a PHEIC ) is declared by the WHO. The focus in this stage would be: Intelligence gathering from countries already affected Enhanced surveillance within the UK The development of diagnostics specific to the new virus Information and communications to the public and professionals. The indicator for moving to the next stage would be the identification of the new influenza virus in patients in the UK. Assess (Evaluate) The focus in this stage would be: The collection of detailed clinical and epidemiological information on early cases on which to base early estimates of impact and severity in the UK. Reducing the spread of the virus within the local community by: a. Actively finding cases b. Self-isolation of cases and suspected cases c. Treatment of cases / suspected cases and use of antiviral prophylaxis for close / vulnerable contacts, based on a risk assessment of the possible impact of the disease. The indicator for moving from this stage would be evidence of sustained community transmission of the virus, i.e. cases not linked to any known or previously identified cases. These two stages together form the initial response. This may be relatively short and the phases may be combined depending on the speed with which the virus spreads, or the severity with which individuals and communities are affected. It will not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so. Treat The focus in this stage would be: Treatment of cases Enhancement of the health response to deal with increasing numbers of cases Consider enhancing public health measures to limit transmission of the virus as appropriate, such as localised school closures based on public health risk assessment. Page 18 of 78 STHK PAN FLU PLAN V11 MAY 2014

19 Arrangements will be activated to ensure that necessary detailed surveillance activity continues in relation to samples of community cases, hospitalised cases and deaths. The indicator to move to the next stage would be when demands for services start to exceed the available capacity available. This decision is likely to be made at a regional or local level as not all parts of the UK will be affected at the same time or to the same degree of intensity. Trust s Role The Trust s role in this phase is likely to be considerable and may necessitate some or all of the measures mentioned in the earlier part of this document and the Strategic Business Continuity Plan (revised 2012), escalating and de-escalating flexibly as determined by dynamic decision making in the daily/weekly Emergency Response Meetings and providing mutual aid as determined by the instruction of the NW Critical Care Network, NHS North of England and DoH. Escalation The focus in this stage would be: Escalation of surge management arrangements in health and other sectors Prioritisation and triage of service delivery Resilience measures. This stage would not necessarily be activated in a mild to moderate pandemic such as that experienced in Recovery The focus in this stage would be: Return to normal service Restoration of business as usual Evaluation Planning and preparation for a resurgence of activity Targeted vaccination, when available The indicator for this phase would be when influenza activity is either significantly reduced compared to the peak or when the activity is considered to be within acceptable parameters. An overview of how services capacities are able to meet demand will also inform this decision. Trust s Role See Trust Strategic Business Continuity Plan, Recovery Section...\Emergency Planning WEBSITE\0 BCM strat Plan revised FINAL 2013 (v12).pdf The Trust s role in this phase is likely to be almost as demanding as dealing with the Pandemic as it will include a planned and phased up-scaling of activity (i.e. providing more out-patients appointments and non-urgent elective surgery out of hours and at Page 19 of 78 STHK PAN FLU PLAN V11 MAY 2014

20 weekends) to account for the back log accrued, loss of business and fulfilment contractual obligations. All this to be achieved together with honouring staff s deferred leave, extra hours worked, dealing with the fall out of burn out and providing extra welfare measures. Also borrowed equipment must be given back, contractors and Trust and bank staff paid, new supplies and replacement equipment must be sourced and DoH supplies returned. It is also likely that new practice and policy may be adopted (as it did after the 2009/10 pandemic). Staff welfare Prophylaxis All Trust staff with patient contact including Paediatric Hospital at Home teams and community midwives can access all prophylactic medicines for their own protection as necessary either through their own GP or as an emergency measure via the Trust. Welfare support Consideration must be given to the care and welfare of staff that may be exhausted and burnt out after a prolonged escalation phase and who may have experienced their own and their loved ones serious illness and bereavement as a result of the pandemic. The Trust has a contract in place with a helpline provider that staff can access any time to obtain advice and help and signposting/referral with a variety of problems ranging from emotional and psychological care to financial and legal assistance. Staff can also be referred by managers or self-refer to Health Work and Wellbeing for care and support. Page 20 of 78 STHK PAN FLU PLAN V11 MAY 2014

21 DETECT role of the Trust by function Section/ Department Acute Medical Unit Burns & Plastics Cancer Services (Lilac Centre) Communications Critical Care (ICU) Director Infection Prevention & Control (DIPC)/ Infection Control Nurse Specialist Emergency Dept (A&E) Emergency Planning Executive team Finance (Purchasing & Supply) FM services HR including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development Actions Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer Awareness & planning with Northern Burn Care Network Advise and direct patients and their families to GP for vaccination Monitoring of PHE and other websites and media. Promotion of the latest flu campaigns; e.g., CHOOSE WELL & CATCH IT BIN IT KILL IT. Awareness & planning with North West Critical Care Network Respirator (FFP3) fit test training by key trainer Microbiologists will be monitoring PHE website. ICNs will be training the trainers and liaising with comms about flu awareness campaign. The IPCT as a whole (i.e. nurses and microbiologists will be reviewing infection control plans). Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer Research, awareness and planning in consultation and cooperation with key Trust staff and NHS and other partners. Monitoring and awareness of strategic issues of pan flu Revision and resupply of PPE Materials Management Team monitoring PPE Training managers in operational skills to provide resilience. Review and restock of supplies and training for deep cleaning teams. Respirator (FFP3) fit test training by key trainer. Latest flu campaign posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas. Annual staff vaccination programme starting in September. Train new vaccinators (including anaphylaxis training) Train staff on how to use the Immsform reporting tool. Train clinically registered staff in non-clinical roles to support in ICU and ED in the escalation stage. Arrange training of ICU staff on Paediatrics and vice versa.

22 Detect continued Section/ Department HR continued ICT (Health informatics) Information Service Integrated Discharge Team (IDT) Combined social care team for Knowsley, St Helens & Halton Labs (Pathology) Maternity Mortuary Team Operational Services Out Patients Dept Palliative/ end of life support Actions Apply for relevant Patient Group Directives (PGD) Work with Comms team to provide staff information. Research and monitor news of the pandemic. Facilitation and maintenance of Immsform (re: staff vaccination reporting) and other reporting systems. Broadcasting of global s for staff information. Hosting of the Merseyside Mortuary Capacity Reporting Tool Training for staff in gathering, producing and sending data for situation reporting to NHS England when required at later stages. Review of accelerated discharge plans and BC plans. Preparation for teleconferences with all NHS and social care partner providers and commissioners at the escalation stage. Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. Actively direct and advise pregnant women to go to their GP for flu vaccination. Development of plans/ contract with commissioners to secure resources for potential future vaccination of pregnant women. Year round monitoring of Merseyside Mortuary Capacity Reporting System and operation/escalation of Merseyside Excess Deaths Policy as needed. Training pathology staff volunteers to support in the mortuary at times of extra pressure and Mass Fatality Major Incidents. Maintaining extra Business Continuity body storage places (x 24) in St Helens Hospital. Preparation of winter plans and management of patient flows. Advance identification of patients in the identified risk categories. Advise and direct patient s families to GP for vaccination and provide information on the disease. Page 22 of 78 STHK PAN FLU PLAN V11 MAY 2014

23 Detect continued Section/ Department Paediatric Hospital at Home team Paediatric nephrologist Paediatrics Pharmacy Respiratory wards Sexual Health Theatres Therapy team (physiotherapy) Wards (General) Actions Advise and direct patient s families to GP for vaccination and provide information on the disease. Advise and direct patient s families to GP for vaccination and provide information on the disease. Development and review of integrated working with ICU and Alder Hey Children s Hospital Review of business continuity plans re staff shortages and loss of key staff, Increase stock of relevant medicines and vaccines. Apply for relevant Patient Group Directives (PGD) Identification of potential storage of vaccines and medicines for primary care in extremis if legal restrictions are lifted. Review and re-supply of vaccines and medicines Review of PPE stocks Respirator (FFP3) fit test training by key trainer Vaccinate their patients and issue specific advice to immuno-compromised patients and families regarding prophylactic medicine. Training staff to support in ICU as required. Development of major incident plans re support in community to keep patients out of hospital, Support in ED to turn patients around faster and wards to prepare patients and care package to accelerate discharge. Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel. Page 23 of 78 STHK PAN FLU PLAN V11 MAY 2014

24 ASSESS (EVALUATE) - role of the Trust by function Dept/ ward/ function Acute Medical Unit Burns & Plastics (Mersey Burn Unit) Communications Critical Care (ICU) Actions Identify isolation and/or cohort areas within the dept for prospective infected patients Swabbing and testing patients and Reporting suspect cases. Isolation of suspected/infected patients. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Awareness and preparation with NBCN. Increase/refresh staff training for ICU support Monitoring of PHE and other websites and media. Working with DIPC, Health Work and Wellbeing and emergency planning to raise staff awareness. Publishing FAQs on intranet and posters for staff areas. Issuing advice to Public from PHE Engage in the national CHOOSE WELL & CATCH IT BIN IT KILL IT campaigns. Work to the Gold Communications Cell at Regatta House, Liverpool (NHS Gold Incident Control Centre for Merseyside). (Merseyside Press & Media Liaison Protocol) Isolating prospective infected patients Isolating prospective infected patients Swabbing and testing patients Reporting suspect cases to infection control and numbers to CSU and NHS E via CMS Isolation of suspected/ infected patients. Issue PPE and brief staff on policies on usage. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Page 24 of 78 STHK PAN FLU PLAN V11 MAY 2014

25 Assess (Evaluate) continued Section/ Department Critical Care (ICU) Emergency Department (A&E) Emergency planning Executive Team FM services ICT (Health Informatics) Infection Control Information Service Actions Engage with the critical care network as per the NW Adult & Paediatric Critical Care Plan. Liaise with paediatric department to prepare to support them with older child patients needing critical care in case Alder Hey ask for mutual aid because of capacity issues in the later stages or if the disease targets children. Identify isolation and/or cohort areas within the dept for prospective infected patients Barrier nurse suspected/ infected patients. Issue PPE and brief staff on policies on usage. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Research, awareness and planning in consultation and cooperation with key Trust staff, the wider NHS and other category 1 and 2, contractors, suppliers and Third Sector partners. Monitoring and awareness. Increase frequency of deep cleaning of areas where suspected infected patients have been. Latest flu campaign posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas. Dissemination of global s and other messages to staff from Health Work and Wellbeing and Infection Control in consultation with comms team. Promotion of PHE website on intranet by link on the ticker tape feed. BC Plan review Promotion and advice to staff re: nursing and special infection control measures for isolated patients via Infection Control leads. Daily situation reporting to NHS England re: confirmed cases via Information team. Providing a daily situation report to NHS England Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit. Page 25 of 78 STHK PAN FLU PLAN V11 MAY 2014

26 Assess (Evaluate) continued Section/ Department Actions HR including Daily situation reporting on staffing absences due to flu like illness to NHS England Staffing Review of BC plans Health Work and Wellbeing Promotion of advice to staff on revised sickness policies, child, care issues due to school Learning & Development closures, etc. Labs Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. Maternity Actively direct and advise pregnant women to go to their GP for flu vaccination. Development of plans/ contract with commissioners to secure resources for potential future vaccination of pregnant women. In consultation with pharmacy providing advice to pregnant women re: vaccination and antiviral treatment options. (Issues around use of Relenza). Mortuary Year round monitoring of Merseyside Mortuary Capacity Reporting System and operation/escalation of Merseyside Excess Deaths Policy as needed. Training pathology staff volunteers to support in the mortuary at times of extra pressure and Major Incidents. Maintaining extra Business Continuity body storage places (x 24) in St Helens Hospital. Operational Services Providing a daily situation report to NHS England Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit via CMS. Out Patients Signposting patients in the risk groups to their GP for vaccination and giving advice re antiviral medicines. Palliative/ end of life support Advise and direct patient s families to GP for vaccination and provide information on the disease. Paediatrics Signposting patients in the risk groups to their GP for vaccination and giving advice re anti - viral medicines. Pharmacy Research and monitoring of situation Provision of advice and work in close consultation with clinical staff re anti-viral and other medicines for different patient groups. Obtaining appropriate PGDs and licences required in advance of later stages. Revise stocks of anti virals, vaccines and consumables and flu symptom relieving medicines. Page 26 of 78 STHK PAN FLU PLAN V11 MAY 2014

27 Assess (Evaluate) continued Section/ Department Pharmacy continued Purchasing & Supply Respiratory Wards Theatres Wards (General) Actions Provide daily situation reports to NHS England via information team on any supply issues. Be prepared to provide support to primary care as directed re receipt and supply of vaccines and consumables and anti virals. Revise, monitor and ensure resilience of supply of stocks of PPE in close consultation with Directorate Managers of respiratory wards, theatres, ICU, ED and AMU and Medirest (FM) Managers and Infection Prevention & Control Team Issue PPE and brief staff on policies on usage. Arrange the isolation of potentially infected patients. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Monitor and reorder stocks of PPE as necessary. Liaise with Comms re latest flu campaigns e.g., CATCH IT BIN IT KILL IT re: posters in public areas as well as wards with tissues, bins & hand gel available Obtain refresher training for theatre staff for critical care support. As above for respiratory wards. Sending staff for training staff to assist in ICU, Emergency Department and other key areas. Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel. Page 27 of 78 STHK PAN FLU PLAN V11 MAY 2014

28 TREAT role of the Trust by function Dept/ ward/ function Acute Medical Unit Burns & Plastics (Mersey Burn Unit) Communications Critical Care (ICU) Actions Cohort flu patients according to capacity increase measures available Fast track patients to cohorted flu areas in respiratory wards/ ICU as appropriate Barrier nurse suspected/infected patients. AMU Specialist Nurse to attend ED to triage medical patients awaiting admission and identified early discharges and speeded up admissions. Liaise with infection control, purchasing and supply, physiotherapy staff, pharmacy, labs, Health Work & Wellbeing, FM services (re: contracting of extra deep cleaning teams). Monitor and reorder stocks of PPE as necessary. Review plans to scale back non-urgent surgery to provide capacity for flu cohort ICU level 2 patients in theatre recovery and trained staff to support ICU and respiratory wards as necessary at escalation stage. Monitoring of PHE and other websites and media. Working with DIPC, Health Work and Wellbeing and emergency planning to raise staff awareness. Publishing FAQs on intranet and posters for staff areas. Issuing advice to Public from NHS England. Placing posters for the public regarding the CHOOSE WELL & CATCH IT BIN IT KILL IT campaigns. Isolate/ cohort suspected flu infected patients Swab and test suspected flu patients Report cases to infection control and numbers to CSU and NHS E via CMS Issue PPE and brief staff on policies on use. Barrier nurse infected acutely ill patients. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, FM services (re: contracting of extra deep cleaning teams). Monitor and reorder stocks of PPE as necessary. Engage with the Critical Care Network as per the NW Adult & Paediatric Critical Care Plan. Work with HR to identify trained staff from other departments to work on ICU in preparation for escalation. Liaise with paediatric department to prepare to support them with older child patients needing critical care in case Alder Hey ask for mutual aid because of capacity issues in the later stages or if the disease targets children. Page 28 of 78 STHK PAN FLU PLAN V11 MAY 2014

29 Treat continued Dept/ ward/ function Emergency Department Emergency planning Executive Team FM services ICT Infection Prevention & Control Team IPCT Information Service HR Staffing Health Work and Wellbeing Actions Isolate and cohort prospective infected patients Issue PPE and brief staff on policies on usage. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, FM services (re: contracting of extra deep cleaning teams). Monitor and reorder stocks of PPE as necessary. Work with HR to identify trained staff from other departments to work on ED in preparation for escalation. Report on numbers of flu presenters on CMS (comments area) Research, awareness and planning in consultation and cooperation with key Trust staff and NHS and other partners. Attendance at Merseyside and partner agency response meetings and teleconferences. Dissemination of DoH demands and situation reporting. Monitoring and awareness. Host weekly teleconferences with key managers and partners to manage the response on a local health economy basis. Situation reporting to NHS E and CM CSU, UCAT. Increase frequency of deep cleaning of areas where suspected infected patients have been. Latest flu campaign posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas. Dissemination of global s and other messages to staff from Health Work and Wellbeing and Infection Control in consultation with comms team. Promotion of PHE website on intranet by link on the ticker tape feed. BC Plan review Promotion and advice to staff re isolation nursing and special infection control measures for isolated patients via Infection Control leads. Daily situation reporting to NHS England re: confirmed cases via Information team. Providing a daily situation report to NHS England and UCAT Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit via CMS and other Sitreps as required. Daily situation reporting on staffing absences due to flu like illness to NHS England. Operation of BC plans Promotion of advice to staff on revised sickness policies, child, care issues due to school closures, etc. Vaccination of staff with any newly developed flu vaccine. Page 29 of 78 STHK PAN FLU PLAN V11 MAY 2014

30 Treat continued Dept/ ward/ function HR Learning & Development Labs Maternity Mortuary Operational Services Out Patients Palliative/ end of life support Paediatrics Actions Training on going of skilled staff for redeployment to key areas at Escalation phase. Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. Actively direct and advise pregnant women to go to their GP for flu vaccination. Development of plans/ contract with commissioners to secure resources for potential future vaccination of pregnant women. In consultation with pharmacy providing advice to pregnant women re: vaccination and anti viral treatment options. (Issues around use of Relenza). Monitor and admit pregnant women in their 3 rd trimester with flu if their symptoms are severe. Year round monitoring of Merseyside Mortuary Capacity Reporting System and operation/escalation of Merseyside Excess Deaths Policy as needed. Training pathology staff volunteers to support in the mortuary at times of extra pressure and Mass Fatality Major Incidents. Maintaining extra Business Continuity body storage places (x 24) in St Helens Hospital. Providing a daily situation report to NHS England Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit and UCAT via CMS. Signposting patients in the risk groups to their GP for vaccination and giving advice re anti-viral medicines. Review BCM plans for joint end of life support teams in consultation with partner agencies. Isolate/ cohort suspected flu infected patients Swab and test suspected flu patients Report cases to infection control and numbers to CSU and NHS E via CMS Barrier nurse cohorted infected patients. Issue PPE and brief staff on policies on use. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, FM services (re: contracting of extra deep cleaning teams). Monitor and reorder stocks of PPE as necessary. Engage with the critical care network as per the NW Adult & Paediatric Critical Care Plan. Page 30 of 78 STHK PAN FLU PLAN V11 MAY 2014

31 Treat continued Dept/ ward/ function Paediatrics continued Pharmacy Purchasing & Supply Respiratory Wards Theatres Wards (General) Actions Work with HR to identify trained staff from other departments to work on paediatrics in preparation for escalation. Liaise with ICU regarding support with older children needing critical care in case Alder Hey ask for mutual aid because of capacity issues in the later stages or if the disease targets children. Liaise closely with Alder Hey, Manchester Children s Hospital and other local Acutes with a paediatric dept. Monitor and admit hospital at home children with flu and underlying conditions as necessary. Research and monitor the situation Provide advice and work in close consultation with clinical staff re anti-viral and other medicines for different in patient and staff groups. Obtain appropriate PGDs and licences required in advance of later stages. Revise stocks of anti virals, vaccines and consumables and flu symptom relieving medicines. Provide daily situation reports to NHS England via information team on any supply issues. Be prepared to provide support to primary care as directed by NHS England re receipt and supply of vaccines, consumables and anti virals. Revise, monitor and ensure resilience of supply of stocks of PPE in close consultation with Directorate Managers of respiratory wards, theatres, ICU, ED and AMU and Medirest (FM) Managers. Issue PPE and brief staff on policies on usage. Arrange the isolation of potentially infected patients. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Monitor and reorder stocks of PPE as necessary. Liaise with Comms re latest flu campaigns e.g., CATCH IT BIN IT KILL IT re: posters in public areas as well as wards with tissues, bins & hand gel available Obtain refresher training for theatre staff for critical care support. As above for respiratory wards. As above for respiratory wards. Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel. Page 31 of 78 STHK PAN FLU PLAN V11 MAY 2014

32 ESCALATE role of the Trust by function Dept/ ward/ function Acute Medical Unit Burns & Plastics (Mersey Burn Unit) Communications Critical Care (ICU) Actions As at Treat plus the following: Cohorting flu patients according to capacity increase measures available Fast tracking patients to cohorted flu areas in respiratory wards. Arrangements with GPs to restrict GP referred admissions. Send the AMU Specialist Nurse to attend ED to triage medical patients awaiting admission and identify early discharges and speed up admissions. As at Treat plus the following: Scale back non-urgent surgery as determined by the Exec Team to provide capacity for flu cohort ICU level 2 patients in theatre recovery Providing trained staff to support ICU and respiratory wards As at Treat plus the following: Monitoring of PHE and other websites and media. Working with DIPC, Microbiologists, Health Work and Wellbeing and emergency planning to raise staff awareness. Publishing FAQs on intranet and posters for staff areas. Issuing advice to Public from NHS England. Placing posters for the public regarding the CHOOSE WELL & CATCH IT BIN IT KILL IT campaigns. As at Treat plus the following: Isolate and cohort suspected flu infected patients Swab and test suspected flu patients Report cases to infection control and numbers to CSU and NHS E via CMS Barrier nurse cohorted infected acutely ill patients. Issue PPE and brief staff on policies on use. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Engage with the critical care network as per the NW Adult & Paediatric Critical Care Plan. Work with HR to identify trained staff from other departments to work on ICU in preparation for escalation. Page 32 of 78 STHK PAN FLU PLAN V11 MAY 2014

33 Escalate continued Dept/ ward/ function Paediatrics continued Emergency Department Emergency planning Executive Team FM services Actions Liaise with paediatric department to prepare to support them with older child patients needing critical care in case Alder Hey ask for mutual aid because of capacity issues in the later stages or if the disease targets children. As at Treat plus the following: Request the AMU Specialist Nurse to attend ED to triage medical patients awaiting admission and identify early discharges and speed up admissions. Isolate and cohort prospective infected patients Issue PPE and brief staff on policies on usage. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Work with HR to identify trained staff from other departments to work on ED in preparation for escalation. Report on numbers of flu presenters on CMS As at Treat plus the following: Research, awareness and planning in consultation and cooperation with key Trust staff and NHS and other partners. Attendance at Merseyside and partner agency response meetings and teleconferences. Dissemination of DoH demands and situation reporting. Attend emergency HRG meetings as necessary. As at Treat plus the following: Monitoring and awareness. Host weekly teleconferences with key managers and partners to manage the response on a local health economy basis. Situation reporting to NHS E and CMCSU UCAT via CMS and specific Sitreps as required. Attend LHRP emergency meetings as necessary. Suspend all non-essential meetings. Increase frequency and operating periods (night teams) of deep cleaning of areas where suspected infected patients have been. Latest flu campaign posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas. Page 33 of 78 STHK PAN FLU PLAN V11 MAY 2014

34 Escalate continued Dept/ ward/ function ICT Infection Control Information Service HR including Staffing Health Work and Wellbeing Learning & Development Labs Maternity Actions Dissemination of global s and other messages to staff from Health Work and Wellbeing and Infection Control in consultation with comms team. Promotion of PHE website and other key websites on the intranet by link on the ticker tape feed. BC Plan actions Promotion and advice to staff re barrier nursing and special infection control measures for isolated patients via Infection Control leads. Daily situation reporting to NHS England re: confirmed cases via Information team. Business continuity plan actions. Providing a daily situation report to NHS England and UCAT Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit via CMS and other Sitreps as required. Daily situation reporting on staffing absences due to flu like illness to NHS England Operation of BC plans Promotion of advice to staff on revised sickness policies, child care issues due to school closures, etc. Vaccination of staff with any newly developed flu vaccine. Suspension of training except for that directly required for redeployed clinical (and admin) staff in support of key departments. Set up a Redeployment Centre in a part of out-patients clinic to strategically redeploy staff to critical areas. Activation of BCM plans for Dept Health & Wellbeing (Health Work and Wellbeing) to account for increased referrals and promotion of PPC support helpline. Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. BC plan actions Actively direct and advise pregnant women to go to their GP for flu vaccination. Develop plans/ contract with commissioners to secure resources for potential future vaccination of pregnant women. In consultation with pharmacy providing advice to pregnant women re: vaccination and anti-viral treatment options. (Issues around use of Relenza). Monitor and admit pregnant women in their 3 rd trimester with flu if their symptoms are severe. Page 34 of 78 STHK PAN FLU PLAN V11 MAY 2014

35 Escalate continued Dept/ ward/ function Mortuary Operational Services Out Patients Palliative/ end of life support Paediatrics Paediatric Dept continued Actions Year round monitoring of Merseyside Mortuary Capacity Reporting System and operation/escalation of Merseyside Excess Deaths Policy as needed. Training pathology staff volunteers to support in the mortuary at times of extra pressure and Major Incidents. Maintain extra Business Continuity body storage places (x 24) in St Helens Hospital. Providing a daily situation report to NHS England Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit and UCAT via CMS. Scale back non urgent outpatients clinics according to the demands of the response. HR may set up a redeployment centre in outpatients dept for staff redeployed to critical depts. Signposting patients in the risk groups to their GP for vaccination and giving advice re anti-virals. Activate BCM plans for joint end of life support teams in consultation with partner agencies. Isolate suspected flu infected patients Swab and test suspected flu patients Report cases to infection control and numbers to CSU and NHS E via CMS Barrier nurse cohorted infected patients. Issue PPE and brief staff on policies on use. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeng, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Engage with the critical care network as per the NW Adult & Paediatric Critical Care Plan. Work with HR to identify trained staff from other departments to work on paediatrics in preparation for escalation. Monitor and admit hospital at home patients with flu and underlying conditions as necessary. Liaise with ICU regarding support with older child patients needing critical care in case Alder Hey ask for mutual aid because of capacity issues in the later stages or if the disease targets children. Liaise closely with Alder Hey, Manchester Children s Hospital and other local Acutes with a paediatric dept. Page 35 of 78 STHK PAN FLU PLAN V11 MAY 2014

36 Escalate continued Dept/ ward/ function Pharmacy continued Purchasing & Supply Respiratory Wards Theatres Wards (General) Actions Research and monitoring of situation Provision of advice and work in close consultation with clinical staff re antiviral and other medicines for different patient groups. Obtaining appropriate PGDs and licences required in advance of later stages. Revise stocks of anti virals, vaccines and consumables and flu symptom relieving medicines, etc. Provide daily situation reports to NHS England via information team on any supply issues. Be prepared to provide support to primary care as directed re receipt and supply of vaccines and consumables and antivirals. Revise, monitor and ensure resilience of supply of stocks of PPE in close consultation with Directorate Managers of respiratory wards, theatres, ICU, ED and AMU and Medirest (FM) Managers. Promote use of National Emergency Purchasing Scheme as appropriate. Issue PPE and brief staff on policies on usage. Arrange the isolation and cohorting of potentially infected patients. Liaise closely with infection control, purchasing and supply, therapy staff, pharmacy, labs, Health Work and Wellbeing, Liaise closely with FM services re: contracting of extra deep cleaning teams. Monitor and reorder stocks of PPE as necessary. Scale back non urgent elective surgery Obtain refresher training for theatre staff for critical care support. As above for respiratory wards. Obtain refresher training for theatre staff for critical care support. As above for respiratory wards. As above for respiratory wards. Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel. Page 36 of 78 STHK PAN FLU PLAN V11 MAY 2014

37 Escalation Summary In the event of escalation the Trust would set up Command & Control as per the Major Incident/ Business continuity Plans. Reporting would be set up via the comments field of the Capacity Management System CMS as often as required by NHS Gold plus regular Situation reports from the Trust s NHS Bronze Command Team as required. A system of isolating patients suspected to have flu-like symptoms would be set up in the Emergency Department and AMU and consideration given to cohorting large numbers when required. Patients would be isolated using airborne precautions and appropriate Personal Protective Equipment with rigorous special infection control measures enacted (as per instructions in Infection Control Manual Chapter 23). Microbiology and infection control depts., the DIPC and Department of Health Work & Wellbeing will monitor the PHE and other websites and provide FAQs on the intranet and posters for operational staff on wards. CATCH BIN IT KILL IT posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas ICU and respiratory wards would follow their escalation plan in line with the North West Critical Care Network Escalation Plan. Non urgent elective surgery may be scaled back and rescheduled to provide capacity in theatre recovery for ICU patients. Non urgent outpatients clinics may be scaled back and rescheduled to provide staffing for critical functions. In extremis the HR Department would set up a Staff Redeployment Centre in part of the Out Patients Dept in Whiston hospital (fracture clinic would continue). HR would provide emergency training sessions for clinically registered staff in non clinical roles to act up as HCAs under the direction of experienced staff in areas under pressure. Non-essential training would be scaled back or stopped and rescheduled. Please note that if the pandemic were to prove severe or other pressures were occurring at the same time (e.g. outbreaks of other diseases like Norovirus, bronchiolitis, etc. and/or severe weather conditions, fuel crisis, industrial action, loss of utilities or a Major Page 37 of 78 STHK PAN FLU PLAN V11 MAY 2014

38 Incident) a full scale response may be required to ensure Business Continuity of critical functions for the duration of the intense pressures. Page 38 of 78 STHK PAN FLU PLAN V11 MAY 2014

39 RECOVERY role of the Trust by function Section/ Department Acute Medical Unit Burns & Plastics Cancer Services (Lilac Centre) Communications Critical Care (ICU) Actions Monitoring and replacing stocks of PPE Phased return to normality re decommissioning of cohorted wards Return of AMU triage nurse to AMU from ED Review of pan flu plans Activation of recovery plan re HR issues Reinstatement of normal GPAU arrangements Activation of recovery plans Review of staffing recovery plans (HR issues) Return to normality re decommissioning of burns beds and staff used in support of ICU and scheduling extra clinics and surgery out of hours to deal with the backlog incurred during the pandemic. Review of pan flu plans and attendance at ICU led joint operational debrief and Trust formal debrief Monitoring and replacing stocks of PPE Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal working. Acceleration of activity to address any backlog. Cascade of stand down and HR recovery FAQs advice to staff Review of pan flu plans Reinstatement of normal operations. Attendance at Merseyside Communications debrief Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations in cooperation with the Critical Care Network re: repatriation of patients transferred from or to other hospitals Acceleration of activity to address any backlog. Attending Critical Care Network debrief Host a joint debrief (meeting or teleconference) with theatres, Mersey Burn Unit and paediatrics and other supporting departments and provide coordinated feedback to the Trust formal debrief. Page 39 of 78 STHK PAN FLU PLAN V11 MAY 2014

40 Recovery continued Section/ Department Director Infection Prevention & Control (DIPC)/ Microbiologist Emergency Dept (A&E) Emergency Planning Executive team Finance (Purchasing & Supply) FM services HR Actions Review of Infection control manual 23 and related documents Activation of staffing recovery plans re HR issues Reinstatement of normal working. Monitoring and replacing stocks of PPE Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Attendance at formal debriefs for the Trust and LHRP groups. Review of pan flu plans. Chief Exec will thank and praise the staff and declare stand down Director of Nursing (accountable officer for EPRR) or Operations Director to host: a) A Trust and partner agency recorded formal debrief and ensure that an action plan is drawn up and flu plans are reviewed and good practice examples are incorporated into normal operations as appropriate. b) A joint local health, contractor, commissioner and partner agency Recovery Team is set up to meet as frequently as required to plan a phased integrated coordinated recovery. And to attend an LHRP debrief Review of pan flu plans Activation of finance recovery plan including payroll issues. Application for DH dispensations Claim for recompense for monies spent on the emergency response Revision and resupply of PPE Materials Management Team monitoring PPE Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Review and restock of supplies and equipment. Review of pan flu plans Activation of HR recovery plans and payroll issues due to leave cancelled/ not taken/ extra hours worked. Page 40 of 78 STHK PAN FLU PLAN V11 MAY 2014

41 Recovery continued Section/ Department HR continued including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development ICT (Health informatics) Information Service Integrated Discharge Team (IDT) Combined social care team for Knowsley, St Helens & Halton Labs (Pathology) Maternity Mortuary Team Operational Services Recovery continued Actions Preparation of staffing FAQs for the intranet and promotion of staff welfare measures Reinstatement of training and scheduling of extra sessions to ensure maintenance of clinical registration and other issues. Planned extra activity for care of staff referred due to issues caused by the pandemic and the response thereto. Review of pan flu plans Reinstatement of planned upgrades and projects. Acceleration of activity to address any backlog. Review of pan flu plans Activation of staffing recovery plans re HR issues Review of joint accelerated discharge plans and BC plans. Activation of staffing recovery plans re HR issues Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog. Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog. Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog. Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Page 41 of 78 STHK PAN FLU PLAN V11 MAY 2014

42 Section/ Department Out Patients Dept Paediatric Dept Paediatric Hospital at Home team Paediatric Nephrologist Pharmacy Respiratory wards Sexual Health Theatres Therapy team (physiotherapy) Actions Review of pan flu plans Activation of staffing recovery plans re HR issues Phased rescheduling of cancelled clinics Acceleration of activity to address any backlog (e.g. scheduling extra clinics out of hours) Review of integrated working with ICU and Alder Hey Children s Hospital and implementing good practice developed during the response. Review of HR issues re: staff holidays, training, overtime hours worked. Attendance at ICU hosted interdepartmental debrief re support to and from ICU during the response Review of integrated working with ICU and Alder Hey Children s Hospital and implementing good practice developed during the response. Review of HR issues re: staff holidays, training, overtime hours worked Return to normality Return to normality Review and reorder of stock of relevant medicines and vaccines. Review of HR issues re: staff holidays, training, overtime hours worked Return to normality. Reordering of supplies as necessary Review of HR issues re: staff holidays, training, overtime hours worked Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Return to normality re use of surgical beds and staff used in support of ICU. Review of HR issues re: staff holidays, training, overtime hours worked Rescheduled elective activity Scheduling out of hours or contracting extra elective activity to deal with the backlog incurred during the pandemic. Attendance at ICU hosted joint dept. debrief re support to ICU during the response. Return to normality. Review of pan flu plans. Activation of recovery plans including recall of staff deployed to respiratory wards and ED. Review of HR issues re: staff holidays, training, overtime hours worked Page 42 of 78 STHK PAN FLU PLAN V11 MAY 2014

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45 Business Continuity General Trust Response The Trust plans recognise that health services should continue to prepare to provide advice and treatment for up to 30% of all symptomatic people in the usual pathways of primary care. Between 1-4% of symptomatic patients could require hospital care, depending on the severity of illness caused by the virus and that of these, up to 25% may require critical care. The Trust can activate this plan to manage the response to a pandemic in conjunction with the Strategic & Tactical Business Continuity & Internal Major Incident Plan, other Major Incident plans and the Adult & Paediatric Critical Care Framework Plan. Staff vaccination The Trust Health Work & Wellbeing Team will strive to vaccinate 80+% of the staff with the seasonal flu vaccine every year. This is to ensure herd immunity. If there is a new strain of flu and a vaccine has been developed and distributed they will immediately plan to vaccinate as many staff as possible starting with frontline staff, e.g., ICU, A&E, AMU, Maternity, Paediatrics, Theatres and all other wards followed by clinics, Clinical Support Services (where staff have patient contact) and then others. Patient vaccination In-patients Longer term in patients in the high risk groups who are not too sick to receive it (i.e., those without infections) will be vaccinated by appropriately trained ward staff. These high risk groups consist of: Long term obstetric/gynaecological patients Long term in-patients suffering from cancer or respiratory conditions, who are well enough to receive vaccination, Patients in stroke rehabilitation Long term paediatric patients GP Discharge Notes Doctors will add advice to GPs discharge notes to read, This patient should have a flu vaccination as soon as possible. Also in the case of 2 stage vaccines a second one and by which date if the first has been administered in hospital.

46 Out Patients & Hospital at Home Patients Immuno-suppressed GUM patients will be vaccinated directly by the GUM service. Out-patients with serious conditions and illnesses (e.g. cancer, renal and cardiac conditions) will be directed to their GP for vaccination. But they will be monitored and may be admitted to hospital if they develop severe flu symptoms. Neurological paediatric patients and their families will be directed to access vaccination by their GP. Maternity patients in their 3 rd trimester are at particular risk of upper respiratory infections like avian or swine flu. Community midwives will encourage maternity patients to take up vaccine from their GP. Maternity patients in their 3 rd trimester who suffer severe flu symptoms may be admitted as a precaution. The families of Paediatric Hospital at Home patients will be informed and encouraged by staff to have the children and the rest of the family immunised. Paediatric Hospital at Home patients will be brought into hospital if they become seriously ill with influenza which exacerbates their underlying condition. During the swine flu in 2009/10 the Maternity Department offered space and vaccines for community health providers (formerly PCTs) to set up a patient vaccination point within the department and doctors and midwives referred women attending their 20 week clinic appointment. A business plan for maternity patients to be vaccinated by the Trust with resource provided by the CCGs is currently being considered. Hospital Pharmacy Arrangements Hospital pharmacies are expected to obtain a store of anti virals for relevant inpatients and staff that they believe will last a number of weeks in a pandemic. Hospital pharmacies will work closely with CCG Medicines Managers, Community Health Providers, community pharmacies and suppliers in the detection phase to build good working relationships, strengthen the lines of communication and ensure local resilience in terms of supply. It may also be an option that Hospital Pharmacies might take delivery of vaccines and anti-virals for distribution to the local communities as required after the legal, security, and receipt and distribution issues have been resolved and guidance issued by the DH. During a pandemic a public information campaign will entreat people to stay at home if they think they may have flu, rather than attending their GP surgery and to only attend hospital if they have severe complications arising from influenza. Page 46 of 78 STHK PAN FLU PLAN V11 MAY 2014

47 Anti viral medicines and vaccines (when available) may be bought at community pharmacies. 5BP will access medicines, antivirals and vaccines for their in-patients from the Trust pharmacy as normal practice. Security During the last pandemic when anti-virals and vaccines were in short supply in the community, extra security had to be arranged for Pharmacy to avoid attempted thefts by organised gangs. The current Pharmacy security measures are likely to deter opportunistic thefts but the risk of criminal activity cannot be underestimated. During the worst of the last wave and the 1 st wave of the swine flu Emergency Department staff suffered aggression from worried patients who had difficulty obtaining antiviral supplies in the community. This can be managed to an extent by a clear and targeted communications campaign. Department of Health stockpiles Antiviral drugs are stockpiled by the Department of Health and will be distributed by the NHS North of England (NHS NoE) via NHS England to local NHS community providers and Trusts during a pandemic, according to need. NHS England Area Team (NHSE) will determine how the receipt and distribution of DH supplies of PPE, antivirals, vaccines and consumables will be received and distributed to NHS providers. This need for more supplies during the treatment and escalation stages will be established according to the exception situation reporting from each NHS trust across the North West that will take place as deemed appropriate by the DH. Arrangements may change during the course of the pandemic as flexibility is the key to emergency response. Accelerated Discharge Pharmacy employed special measures to speed up discharge medicines during the last pandemic which was very effective and would be used again. Pneumococcal vaccine This vaccine can be expected to reduce the incidence of pneumococcal pneumonia following influenza illness. Those for whom it is indicated should have been immunised as part of routine policy. Indications for pneumococcal vaccine are given in the Trust s Infection Control Manual Chapter 23. The 23-valent polysaccharide pneumococcal vaccine has 60% efficacy and protection lasts around 10 years. It is unlikely that the manufacturers would be able to satisfy a sudden increase in demand at the time of a pandemic. Page 47 of 78 STHK PAN FLU PLAN V11 MAY 2014

48 Antiviral drugs Antiviral drugs like Oseltamivir may be effective in shortening the illness, lessening morbidity and reducing hospital admissions if given within 48 hours after the onset of symptoms (it shortens the average illness period by one day). Limited data from epidemic influenza suggests that the treatment has an efficacy of around 50% for the prevention of severe outcomes if administered within 48 hours of symptom onset. Relenza should be given to pregnant women and immuno-suppressed patients. Doses for children - Pharmacy will supply medication with suitably marked oral syringes for parents / carers to measure the dose. Antibiotics There is no evidence that antibiotics have a place in the management of uncomplicated influenza. For the treatment of secondary bacterial pneumonia the Hospital Antibiotic Policy recommends antibiotics which take into account the local antimicrobial sensitivity patterns. Supplies Antiviral medicines To date Pharmacy currently holds stocks of Tamiflu anti-viral medicines, a small stock of Relenza (for maternity patients) and a small stock of antiviral solution for children under one that were enhanced during the last flu pandemic. In a future pandemic they would expect to obtain supplies from manufacturers / DoH contingency stock. There has recently been some adverse publicity in the news relating to the effectiveness of the antivirals. At present the NICE advice would stand i.e. use them if the incidence of flu is above a specified level. Vaccines Pharmacy annually order stock of seasonal flu vaccine sufficient for the Trust s goal of vaccinating 80% of staff and the few long term inpatients who will not have the opportunity of obtaining this from their GP as normal. The Trust anticipates the supply of the latest seasonal flu vaccines for front line staff in September each year. Trust Support to 5 Borough s Partnership NHS Mental Health Trust (5BP) Patients 5BP in-patients who are acutely ill will be cared for in ICU with 5BP Mental Health staff representation as per normal arrangements. Respiratory ward managers and consultants may provide advice and training as agreed at the treatment stage to 5BP staff caring for infected but not acutely ill 5BP in-patients. Page 48 of 78 STHK PAN FLU PLAN V11 MAY 2014

49 Medicines, antivirals and vaccines for 5BP in-patients would be accessed via the Trust pharmacy as per normal practice. 5BP Support to the Trust 5BP will review their business continuity plans for provision of mental health services based in the Trust and be prepared to escalate provision as needed at the Escalation stage. Infection Control and PPE See APPENDIX A Nursing patients with seasonal &/or established pandemic influenza & APPENDIX B Nursing Patients with a new emerging strain of flu (e.g. Avian or Swine Flu) The risk of nosocomial (hospital acquired) infection can be reduced by isolation of cases, cancellation of cold admissions during the epidemic, particularly those with high risk medical conditions, and a policy of, as far as possible, admitting patients with influenza only if they have medical complications and in the early stages cohorting patients with the disease. Public Areas CATCH IT BIN IT KILL IT posters will be put up in waiting areas and the hand gel, tissues and flip top bins will be provided in public areas as well as clinical areas. Training The Infection Control Department purchased a programme of Face Fit Testing Training and other PPE awareness for trainers, delivered at the Learning & Development Centre by an outside contractor. They have now developed and deliver an in-house train the trainers course. The DIPC/microbiologist issues revisions of the Infection Control Manual for Influenza and global s and other notices with the latest news and guidance throughout the response. Staff are trained in: Rigorous hand hygiene isolation nursing Fit testing of FFP3 disposable and 3M reusable respirators Use of PPE. Deep cleaning of isolation rooms and cubicles and equipment. Page 49 of 78 STHK PAN FLU PLAN V11 MAY 2014

50 Infection Control will also dispel myths about the disease and give guidance to all representatives at the daily/weekly Emergency Response Meetings/teleconferences and on FAQs on the intranet as necessary. Health & Wellbeing Dept. training The HWD will identify staff vaccinators and access vaccination training via PHE including anaphylaxis /CPR training. HWD staff will be trained/ refreshed on using the Immsform reporting system. Training clinical staff for redeployment to critical areas during a pandemic It is planned for staff with transferrable skills (e.g. theatre and anaesthetics staff) to spend short periods throughout the year (annually) working in the critical departments e.g., ICU, Emergency Dept., Paediatrics to train and familiarise them with the work of those departments so that they can be effectively redeployed in a crisis after a short refresher course. Purchasing & Supplies Personal Protective Equipment (PPE) There is a substantial stock of Personal Protection Equipment, consumables and cleaning supplies held in the Receipt & Distribution Store on the Whiston Hospital site. There are also satellite stores in key areas across the Trust. All stock is controlled by Purchasing & Supply, Materials Management Team. It is estimated that there are sufficient supplies for a third wave of pandemic influenza. These supplies include: FFP3 respirators 3M reusable respirators in various sizes and filters and carry cases Surgical masks 3M goggles/visors Gloves Disposable theatre gowns Aprons Current numbers of items can be obtained from Purchasing & Supply. For BIPAP, CPAP and other respiratory equipment please see STHK Pan Flu Resilience Plan for Critical Care Capacity (Adults & Paediatrics) Sept 09. Page 50 of 78 STHK PAN FLU PLAN V11 MAY 2014

51 Communications a) A national advertising campaign during the swine flu pandemic (Catch it, Kill it, Bin it) encouraged the public to use paper tissues to catch sneezes and bin them ideally in a foot operated lidded pedal bin and to wash their hands in a vigorous and prescribed manner up to the wrists. Hand gel was provided in all public buildings (not just NHS buildings) and posters displayed everywhere. It is envisaged that similar arrangements would be enacted for any new pandemic regarding the latest flu campaigns. b) During the swine flu pandemic response the Merseyside NHS Gold Communications Cell ran a successful communications campaign using local TV and radio news interviews and newspaper articles and wrap-arounds to reiterate the national campaign and encourage people with flu like symptoms but no complications to stay at home rather than visit GPs, Walk in Centres or A&E. It is anticipated that NHS Gold Command will advise the Strategic Coordinating Group to activate the Merseyside Press & Media Protocol to staff a Gold Communications Cell who may do something similar for any new pandemic. c) The Trust Infection Control Team and Work & Wellbeing Team provided information and FAQ s to staff on a daily basis via global s and posters distributed by the Communications team during the last flu pandemic. It is anticipated that this will be the plan for any new pandemic. d) The Trust intranet ran a tickertape across the top of the intranet screen with a live link to the HPA website for staff to access regular updates. This could be reinstated for a new pandemic response. It is anticipated that Public Health England (formerly HPA) will continue to provide advice and guidance via their website in future pandemics. e) The latest flu campaign (e.g., CATCH BIN IT KILL IT) posters will be provided to managers to display in public areas and promotion of availability of hand gel, tissues and flip top bins in public areas as well as clinical areas. Information Communications will largely be managed by NHS Gold Communications Cell and the Merseyside Press & Media Liaison Plan will be activated. Communication links will be essential at both national and local level. Choose well and respiratory and hand hygiene campaigns will be broadcast and distributed nationally by the DoH. Best practice will be shared between health care organisations. The Communications manager will have a check list briefing sheet identifying lines of communication which will ensure regular liaison with the Command Team and media and allow flexible strategies to be devised. Page 51 of 78 STHK PAN FLU PLAN V11 MAY 2014

52 Regular information will be cascaded to doctors via the Public Health Link and letters. Literature will be widely distributed to the public. Communications will be culturally and linguistically appropriate. Reporting Systems Capacity Management System (CMS)/ UNIFY2 UNIFY2 is updated daily and includes reports on ED pressures, etc. The CMS is updated at least twice daily by Operational Services. NWAS Regional Operational Control Centre (ROCC) and Merseyside NHS Gold Command are updated electronically about the situation in each Trust as frequently as the event changes during the emergency response. Updates about other issues not covered in the sections can be placed in the comments field at the end of the template. Daily (or more frequent) Sitreps A daily Sitrep template will be provided by NHS Gold Command for completion and return before a given time(s) each day. The Trust Information Service will collate data from Operational Services, ED, the ESR, ICU, Infection Control and the mortuary and submitted electronically to the NHS Gold Command before a given time each day. ICU Lessons of the Swine Flu Pandemic During the 2 nd wave of the swine flu pandemic ICU had to increase up to 3 times over the course of the wave. Measures put in place that could be used again were: Non urgent routine elective surgery was stopped freeing up areas of plastics and theatre recovery and some theatre staff who were given a 2 day emergency training course were redeployed to ICU. Staff recently moved to other departments from ICU were seconded back into the department. Staff with nursing registration currently in non clinical roles (mostly managers) were retrained to assist in ICU as healthcare assistants and supervised by the trained ICU staff. Trained ICU staff worked longer shifts and worked through public holidays and leave and non-essential training was cancelled. Burns and theatre recovery staff with respiratory experience were seconded to assist in ICU after non urgent elective surgery was suspended. It was discussed that in future a resilience measure would be for all clinical staff to spend a short secondment in ICU and ED each year to provide extra trained staff as needed and shorten the activation period. This is being developed by HR using the new dynamic enhanced ESR system being trialled currently (as of April 2014). Page 52 of 78 STHK PAN FLU PLAN V11 MAY 2014

53 Paediatrics The response of the paediatric department to the pandemic can be escalated according to the demands of the pandemic. However, the Trust has no PICU and if Alder Hey and other Children s Hospitals were overwhelmed and the Trust had to receive the overspill there are 2 HDU beds in Paediatrics which could be used or in extremis, older children could be admitted to ICU and cared for with support from Paediatric staff. NW Adult & Paediatric Critical Care Contingency Plan (2013) The NW Adult & Paediatric Critical Care Contingency Plan (2013) states: Paediatric patients will be admitted to PICU s for as long as possible, using the national PICU bed stock as a resource. At times of escalation there will be a requirement for an increase in the number of patients requiring inter-hospital transfer to access critical care and the distance travelled. This may occur early depending upon the nature of the escalation scenario as the North West strives to maintain the standard of normal clinical pathways. This is particularly relevant for paediatric patients. Within Cheshire & Mersey, once all available (expanded) critical care capacity at Alder Hey is exhausted, the proposed model will be that older children will stay in local hospitals with in-patient paediatric services including paediatric medicine and paediatric anaesthetic experience on site. These principles should be adhered to whether or not a Major Incident has been declared. Creating capacity Non-urgent admissions, including serious but non-critical surgery will need to be reviewed and may need to be suspended or scaled back on a case by case basis by clinicians to create capacity. Staff rotas will need to be reviewed. The Trust may not be able to meet the obligations of some of its predetermined contracts during the pandemic period. The CSU Urgent Care Action Team and Adult & Paediatric Critical Care Network should issue "yellow" and "red" alerts when the number of admissions is expected to rise to such an extent that all non-critical admissions need to be restricted. This would apply if there was a bed shortage over an area greater than that of a local Trust. Supplies of relevant drugs e.g. antibiotics and equipment e.g. ventilator equipment will need to be secured early in the escalation stage. Page 53 of 78 STHK PAN FLU PLAN V11 MAY 2014

54 Capacity and Equipment Requirements ICU/ respiratory beds More respiratory wards BIPAP beds with-bi Level Positive airway pressure Additional BIPAP on CCU Additional resources for Ventilated patients i.e., Recovery, CCU beds Surgical cubicles identified when isolation required. Staffing of such areas will need to be considered on a Trust wide basis in accordance with the measures outlined in the Trust s HR action Plan in appendix E, this will include: Re-training and redeployment and of suitable staff from areas where activity has been reduced or stopped to key areas like ICU and A&E. Use of re-trained hospital volunteers to support non clinical contractors Emergency Department (ED) During the extreme winter pressures, including the 2 nd wave of Swine flu, there were record numbers of patients with high acuity and trauma injuries flooding into the department every day. Many nursing staff and junior doctors fell sick during the same period despite isolation of suspected swine flu patients in the early stages and many staff having been the first to be vaccinated. Diverts to other Trusts were not an option because other Acutes were in the same position. At times of extreme pressure 16 extra beds were opened up in Zone 3 and special measures put in place with AMU to speed up the processing of such patients. Accelerated discharge planning made space for these admitted patients (see below). Staff were seconded from other departments to assist where possible and trained according to an emergency training programme designed by one of the consultants. Staff worked longer shifts and public holidays and leave and non-essential training was cancelled. AMU Specialist Nurse Triage Support in ED The AMU Specialist Nurse (new post) will attend ED to triage medical patients awaiting admission and identified early discharges and speeded up admissions. Therapy Service support to ED and wards Physiotherapists may be deployed to ED, ICU and respiratory wards on request from the Medical Care Group Tactical Command to provide immediate physiotherapy to accelerate discharge and help avoid admissions. This will be dependent upon their capacity to continue vital community services at the same time. Page 54 of 78 STHK PAN FLU PLAN V11 MAY 2014

55 Accelerated Discharge During the worst of the swine flu 2 nd wave extraordinary measures were employed by Knowsley, Halton and St Helens Social care staff and intermediate care working together with Operational Services to speed up discharges and at one stage were safely discharging more patients than ever known before. This was partly facilitated via the Multi Agency Emergency Response Meetings. As a result of the success of these measures a new Integrated Discharge Team has now been established as part of normal operations in the Trust. Pharmacy employed special measures to speed up discharge medicines. Intermediate care opened up local intermediate care beds. Finance was provided and emergency measures were employed by Operational Services to spot purchase intermediate care beds in the community. Ward rounds were increased and ICAT increased activity on the wards. Social Care and therapy teams provided early assessments and put in place robust early discharge care packages to enable patients to go home and extended working hours to weekends and evenings. Patient Transport Service had more ambulances and drivers to spare for patient discharges because non urgent outpatients clinics were cancelled. The Trust s transport service provided extra minibuses and drivers to deal with discharged patients. Taxi companies were contracted to take patients home. These measures are now a regular planned response at times of intense pressure. Excess Deaths Reporting Mortuary managers across greater Merseyside report daily on capacity via an electronic reporting tool hosted by the Trust and monitored by the mortuary team who then share that capacity matrix with those managers to facilitate mutual aid. The Trust has a new state-of-the-art bereavement centre and mortuary with 96 fridge spaces and some 6 freezer spaces in Nightingale House at Whiston and extra capacity business continuity store of 24 fridge spaces at St Helens hospital. Escalation Should severe pressure across the mortuary network become apparent the Trust mortuary staff will escalate via the Trust Exec in Charge to Merseyside NHS Tactical (Silver) Commander (call via NWAS Health Desk) to activate the Merseyside LRF Extra Deaths Response Plan: 2012/13. Page 55 of 78 STHK PAN FLU PLAN V11 MAY 2014

56 Strategic Coordinating Group (SCG) Gold Command (see Regional Command & Control Structures) will coordinate the multi-agency response from local authority registrars, crematoria and cemeteries, and representatives of local funeral director associations to ease pressure on mortuary storage. This can be further escalated to transportation of bodies to a central emergency body holding facility set up by contractors on retainer to the Merseyside Local Authorities via HM Coroner. An enhanced supply of shrouds, body bags and temporary body storage units will be acquired in advance by the Mortuary Manager when it becomes apparent that there is a potential requirement triggered by severely reduced capacity across the County. If there are a very large number of deceased influenza patients, careful consideration must be given by the Hospital Command Team regarding arrangements for the removal of bodies from the wards etc to the mortuary storage facility. NB: Portering services are likely to be short staffed and may be overwhelmed with other duties (especially if lockdown is required). Funeral Directors normal collection services may be badly hit by the crisis so causing a back log. Knowsley Registrars Service will place a registry clerk within the Trust to register births directly to take pressure off the death certification teams in Prescot Registry Office itself. Death Certification If there are mass deaths across the UK, emergency legislation may be passed relaxing the rules regarding death certification (see Pandemic influenza Guidance on the management of death certification and cremation certification). At this stage mass body storage, cremation and burial will be organised and coordinated by Merseyside Gold Command/ Senior Coordinating Group in accordance with the Merseyside Excess Deaths Plan. Recovery See Trust Strategic Business Continuity Plan Recovery section De-escalation and return to normal business must be carried out in graded manner in consultation with partners and contractors, taking into account a number of factors including: Staff shortages caused by backed up annual leave applications and burn out. Greater pressure on Health Work and Wellbeing services. Delays in replenishment of supplies. Return and cleaning/ restoration/ reordering of equipment. Rescheduling of out-patients appointments and elective surgery out of hours and at weekends to meet targets and deal with the back log. Financial implications of loss of business weighed against greater staff costs. Page 56 of 78 STHK PAN FLU PLAN V11 MAY 2014

57 Debriefs Each Department will hold local debriefs to capture lessons learned and then send a representative to a formal Trust debrief which may be part of the next quarterly Major Incident Planning Committee Meeting. The Trust will then send one or more reps to a Merseyside LHRP formal debrief which in turn will report to the Local Resilience Forum. Staff welfare See HR Pandemic Flu Plan Despite a fairly successful staff vaccination programme before the 2 nd wave of the swine flu pandemic in winter 2010/11 there was a high staff absentee rate due to flu like illness. This was made worse by outbreaks of Norovirus which also affected staff and injuries due to slips and falls because of the sustained severe icy, snowy weather. By December 2009, due to heroic efforts by the Health Work & Wellbeing Team over 80% of all staff had been vaccinated with the new vaccine and cases started to drop off. However, by February absenteeism increased again due to staff burn out (record numbers of acute patients through A&E and ICU had to be increased 3 fold and leave had been cancelled). Many were exhausted and fell prey to minor illnesses or had to claim holidays sacrificed in the emergency response before the end of the financial year. References Pandemic flu: managing demand and capacity in healthcare organisations (surge) et/dh_ pdf Responding to pandemic influenza: The ethical framework for policy and planning s/digitalasset/dh_ pdf Pandemic flu. UK Health departments UK Influenza pandemic contingency plan March Health Protection Agency Influenza Pandemic Contingency plan. Version 7. February Page 57 of 78 STHK PAN FLU PLAN V11 MAY 2014

58 APPENDIX A Nursing patients with seasonal &/or established pandemic influenza Hand hygiene is essential. Isolation Isolate patient in side room. Special ventilation is not necessary. If there are insufficient side rooms, cohort nursing with other influenza patients can be used. PPE An ordinary surgical mask should be worn by staff within 3 feet of patient for protection from droplet spread. Masks must not be touched once on and must be discarded as clinical waste when they become moist (handle only by the ties). Gloves (non-sterile) should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Hands must be washed after removal of gloves. Plastic aprons are advised whenever there is a risk of contamination with blood/body fluids/secretions/excretions or for close contact with the patient e.g. examining the patient. Aerosol-generating procedures e.g. intubation, naso-pharyngeal aspiration, tracheostomy care, chest physiotherapy, bronchoscopy, should be minimised as much as possible. The procedure must be done in a well-ventilated room with the door kept closed. Only those health care workers needed to perform the procedure must be present. A disposable respirator mask (FFP3), gown, gloves and eye protection e.g. visor/spectacles must be worn. N.B. After a review of the evidence, nebulisers have been removed from the World Health Organization s list of potential aerosol-generating procedures Order of donning and removal of PPE o Put on in the following order (wash hands first) Apron/gown first Mask Eye protection Gloves last o Take off in the following order: Gloves first Eye protection Apron/gown Mask last Wash hands Filter masks (FFP3): decontamination issues Disposable masks Discard after each use as clinical waste. Page 58 of 78 STHK PAN FLU PLAN V11 MAY 2014

59 Moving the patient Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplets by giving the patient an ordinary surgical mask to avoid droplet spread. Waste Waste and linen should be managed as standard. Cleaning Crockery & cutlery must be washed in the central dishwasher, not by hand. Disposable crockery & cutlery is not necessary. Clinical areas must be cleaned daily. Frequently touched surfaces e.g. door knobs must be cleaned twice daily with detergent & hot water. Domestic staff cleaning in the vicinity of influenza patients should wear gloves, aprons and a surgical mask. Toys, books, newspapers and magazines should be removed from waiting areas. After patient discharge, the room must be deep cleaned thoroughly and bed curtains should be changed. Nosocomial infection The risk of nosocomial (hospital acquired) infection can be reduced by isolation of cases, cancellation of cold admissions during the epidemic, particularly those with high risk medical conditions, and a policy of, as far as possible, admitting patients with influenza only if they have medical complications and in the early stages cohorting patients with the disease. Patient death including last rites In the event of patient death, last offices should be done using standard infection control precautions. The body should be fully wrapped in a sheet. Transfer to the mortuary should occur as soon as possible after death. If the family wishes to view the body, they may be allowed to do so, again using standard infection control precautions. The mortuary staff should be informed that the deceased had influenza. Standard infection control principles should be followed; there is no further risk of droplet spread. Swabs will be taken and sent for testing during the detect and assessment stages of the pandemic. Funeral directors should be informed of the level of infection risk (that is, a low infection risk). Page 59 of 78 STHK PAN FLU PLAN V11 MAY 2014

60 APPENDIX B Nursing Patients with a new emerging strain of flu New strains of flu like Avian or Swine flu require a much higher level of precautions than seasonal influenza as they tend to: Have a more severe effect on patients have the potential to cause a world-wide pandemic. Guidance and information There are many different strains of avian and swine influenza. Advice may differ slightly according to the strain involved. Specific guidance will be provided by PHE according to the current strain. Refer to website for updated information: Case Definition The case definition for suspected influenza is: Clinical Presentation: Fever ( 38 C) OR history of fever AND flu-like illness (2 or more of the following symptoms: cough, sore throat, rhinorrhoea, limb/joint pain, headache) AND Epidemiological criteria: Close contact (within 1 metre) with sick or dead poultry/pigs OR Close contact (household contact) with a suspected/confirmed human case of avian/swine influenza. General Practice Patients should be assessed by the GP during a home visit, using Personal Protective Equipment (PPE). Samples can be obtained and antiviral treatment commenced, if indicated. Well patients must NOT be sent to the Emergency Department for assessment. Emergency Department If the patient is poorly and requires assessment in the Emergency Department, they should be sent immediately to the Decontamination Room. All staff must wear full PPE (see below) including filter masks. As the number of suspect patients increases they will be cohorted in the department according to a dynamic assessment by the ED Duty Consultant in coordination with the most senior nurse on duty. Page 60 of 78 STHK PAN FLU PLAN V11 MAY 2014

61 Infection control precautions Hand hygiene Pay careful attention to hand hygiene before and after all patient contact or contact with items potentially contaminated with respiratory secretions. Hand hygiene is essential. Alcohol gel can be used for physically clean hands. Isolation Room The patient must be isolated in a room with negative pressure ventilation. Patients with a new strain of influenza must NOT be cared for on an open ward. The door must be kept closed. An AIRBORNE ISOLATION POSTER must be affixed to the outside of the door. Duration of precautions These precautions should be continued for 14 days after onset of symptoms or until either an alternative diagnosis is established or diagnostic test results indicate that the patient is not infected with influenza A virus. Notification Inform the Infection Prevention and Control Team immediately if avian/swine influenza is suspected. The Infection Prevention and Control, Team will immediately contact the CCDC (Consultant in Communicable Disease Control). Specimens for new strain influenza The following specimens should be collected in cases of suspected new strain influenza: Nose AND Throat swabs: dry swabs in viral transport media. Duplicate sets of swabs are required. Place one nose swab (from the back of nasal cavity) and one throat swab into a single vial of viral transport medium and a second nose and throat swab into a second vial. Conjunctival swab (if indicated): dry swab placed in VIRAL TRANSPORT MEDIA. Viral transport medium can be obtained from the Microbiology Department, Whiston Hospital. Use Microbiology request form and mark the form as follows: Clinical Symptoms -? avian/swine influenza Test Required PCR For Influenza A Blood: 10mls clotted blood (2 x 5 mls) Use Microbiology request form and mark the form as follows: Clinical Symptoms -? avian/swine influenza Test Required Serology for influenza The specimens must be sent to the Microbiology Department, Whiston Hospital. Page 61 of 78 STHK PAN FLU PLAN V11 MAY 2014

62 Microbiology Laboratory The specimens must be packaged routinely (according to routine category B transport regulations). The Microbiology Biomedical Scientist (BMS) will telephone Public Health England (PHE) Regional testing laboratory and confirm the arrangements for testing and courier requirements, if advice has not already been given by the PHE. Retrospective diagnosis after admission If new strain influenza has been diagnosed sometime after admission to hospital and full precautions have not been taken, a SERIOUS UNTOWARD INCIDENT will be declared (see Trust Policy on Serious Untoward Incidents) and a meeting (including Medirest and Vinci representatives and those who would normally attend a Major Outbreak meeting) will be convened: Patient pathway Obtain details of the patient pathway e.g. by checking admission and transfer dates & times, details of isolation, interviewing staff and patient as indicated. Contact tracing Contact tracing is to be done for all those with face-to-face contact within 1m who were not wearing full protective clothing, including a filter mask. Don t forget domestics, catering, porters, physiotherapists etc. Remember the duty of patient confidentiality when identifying contacts. Staff contacts can continue to work unless sick. Those with last date of contact more than 7 days ago should be given information leaflets. Other direct contacts (within 7 days of exposure) can be offered oseltamivir (antiviral medicine) prophylaxis plus an information leaflet. Ward managers may need to contact off duty staff. Public Health England (PHE) will contact patients who have been discharged home. The PHE CCDC will be responsible for managing contacts outside the hospital e.g. household contacts. If staff have cared for a patient with avian or swine influenza, without wearing full PPE, the Cheshire and Merseyside Public Health Unit will advise on antiviral prophylaxis. Staff who have been in contact with avian/swine/seasonal/pandemic influenza who show no symptoms can work normally. No isolation or exclusion is necessary. Sick Leave All contacts, whether treated or not, must report flu-like symptoms/conjunctivitis. They must go off sick immediately. Cases not requiring hospitalization should be Page 62 of 78 STHK PAN FLU PLAN V11 MAY 2014

63 advised to remain at home until they are symptom-free and treated as advised by the local Health Protection Unit. Hospitalized cases must be isolated as above. Aerosol generating procedures Aerosol-generating procedures e.g. intubation, naso-pharyngeal aspiration, tracheostomy care, chest physiotherapy, bronchoscopy, should be minimised as much as possible. PPE Gloves (non-sterile) should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Hands must be washed after removal of gloves. Plastic aprons are advised whenever there is a risk of contamination with blood/body fluids/secretions/excretions or for close contact with the patient e.g. examining the patient. A disposable respirator mask (FFP3), gown, gloves and eye protection e.g. visor/spectacles must be worn by staff working closer than 3 feet and/or performing aerosol-generating procedures e.g. intubation, naso-pharyngeal aspiration, tracheostomy care, chest physiotherapy, bronchoscopy. The procedure must be done in a well-ventilated room with the door kept closed. Only those health care workers needed to perform the procedure must be present. Use dedicated equipment such as stethoscopes, disposable blood pressure cuffs, disposable thermometers etc. N.B. After a review of the evidence, nebulisers have been removed from the World Health Organization s list of potential aerosol-generating procedures Order of donning and removal of PPE o Put on in the following order (wash hands first) Apron/gown first Mask Eye protection Gloves last o Take off in the following order: Gloves first Eye protection Apron/gown Mask last Wash hands Transfer to other departments Transfers must be kept to the essential minimum. The department must be prewarned so that they can ensure that staff have suitable PPE and that contact with other patients e.g. in waiting areas will be avoided. Page 63 of 78 STHK PAN FLU PLAN V11 MAY 2014

64 Personal protective equipment (PPE) when transferring patients: Full protective clothing must be worn by all staff with contact with the patient (within 1 metre), including porters i.e. Gown Fit-tested respirator (FFP3 filter mask). Eye protection (i.e. eye visors or face shields). Gloves The patient must also be given an FFP3 mask to minimise droplet spread. Filter masks (FFP3): decontamination issues Discard disposable masks after each use as clinical waste. Reusable filter respirators There is a contingency store of these masks in ED, ICU and respiratory wards. They will only be issued if there are supply issues with disposable respirators to staff working on cohort wards who have to wear PPE for long periods. One advantage of reusable masks is that face fitting can be achieved immediately by covering the filters and breathing in when the mask is in place. Another is the reduction of clinical waste. Reusable masks are allocated to individual staff. They must not be shared between staff. They must be stored in the bag (after cleaning) when not in use. The bag and mask must be labelled with the name of the staff member. They must not be taken home. Decontamination of reusable respirator After each use, remove the white filter boxes and head straps. Wipe both the interior and exterior surfaces of the face-piece and the outer surface of the filter box carefully with Chlorclean, or other proprietary hard surface disinfectant wipes. Re-attach the filter box. Wash hands. Daily decontamination of reusable respirators Reusable respirators must be disassembled daily. The respirator must be disinfected by washing in sodium hypochlorite (Chlorclean) solution. Rinse in fresh, warm water and air dry in a non-contaminated atmosphere. Attach new filters before use. Full disassembly/assembly instructions and maintenance instructions are contained in the booklet supplied with your respirator. DO NOT TAKE THE RESPIRATOR HOME. If damaged or malfunctioning, the respirator must be discarded as clinical waste and replaced. (Note: The filter boxes can be used for up to 3 months). Page 64 of 78 STHK PAN FLU PLAN V11 MAY 2014

65 Oseltamivir (antiviral medicine) Where necessary, the hospital pharmacy will provide antiviral medicine (e.g. oseltamivir) and patient leaflets. The latter will include advice specific to the strain involved. Pharmacy and Health Work and Wellbeing will receive, distribute and control supplies of antiviral medicines for staff and patients during the outbreak. Antiviral Treatment For individuals who fulfil the case definition for suspected new strain influenza: Adults (& children over 13*): 75mg capsule of oseltamivir (Tamiflu) bd (twice daily) for 5 days. Prophylaxis An individual who is well but has been in close contact (face-to-face contact within 1m) with a suspected case of avian influenza (24 hours before and 8 days after onset of illness): Adults (& children over 13*): Oseltamivir 75mg once daily for 10 days *For dose regimes for younger children, please refer to the British National Formulary for Children. Nosocomial infection The risk of nosocomial (hospital acquired) infection can be reduced by isolation of cases, cancellation of cold admissions during the epidemic, particularly those with high risk medical conditions, and a policy of, as far as possible, admitting patients with influenza only if they have medical complications and in the early stages cohorting patients with the disease. Page 65 of 78 STHK PAN FLU PLAN V11 MAY 2014

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67 APPENDIX C - Putting On and Removing Personal Protective Equipment (PPE) Putting on PPE Healthcare workers should put on PPE before they enter a single room or cohorted area. The order given here for putting on PPE is practical, but the order for putting on is less critical than the order of removal. Gown or apron (illustrated) if it is NOT an aerosol-generating procedure) Fully cover the torso from the neck to knees and the arms to the end of the wrist, and wrap around the back. Fully cover the torso from the neck to knees and the arms to the end of the wrists, and wrap around the back. Fasten at back of neck and waist. Surgical mask (or FFP3 respirator if it IS an aerosol-generating procedure) Secure the ties or elastic bands at middle of head and neck. Fit flexible band to nose-bridge. Fit snug to face and below chin. Fit check the respirator. Goggles or face shield (in aerosol-generating procedures and as appropriate after risk assessment) Place over face and eyes and adjust to fit. Disposable gloves Extend to cover wrist of gown if a gown is worn. Page 67 of 78 STHK PAN FLU PLAN V11 MAY 2014

68 Removing PPE Healthcare workers should remove PPE upon leaving the room or cohorted area in an order that minimises the potential for cross-contamination. If a single room has been used for an aerosol-generating procedure, those involved in the procedure should, before leaving the room, remove their gloves, gown and eye goggles (in that order) and dispose of them as clinical waste. After they leave the room they can remove the respirator and dispose of it as clinical waste. Hand hygiene should be performed after all PPE has been removed. The order for removing PPE is important to reduce cross-contamination. The order outlined as follows always applies, even if not all items of PPE have been used. Gloves (Assume that the outside of the glove is contaminated). Grasp the outside of the glove with the opposite gloved hand; peel off. Hold the removed glove in gloved hand. Slide the fingers of the un-gloved hand under the remaining glove at the wrist. Peel off second glove over first glove. Discard appropriately. Gown or apron (Assume that the front and sleeves of the gown or apron are contaminated) Unfasten or break the ties. Pull the gown or apron away from the neck and shoulders, touching the inside of the gown only. Turn the gown inside out. Fold or roll it into a bundle and discard appropriately. Goggles or face shield (Assume that the outside of the goggles or face shield is contaminated) To remove, handle by head band or ear pieces. Page 68 of 78 STHK PAN FLU PLAN V11 MAY 2014

69 Discard appropriately or follow decontamination protocol for non-disposable and goggles. Respirator or surgical mask (Assume that the front of the respirator or surgical mask is contaminated) Untie or break the bottom ties, followed by the top ties or elastic, and remove the respirator or mask by handling the ties only. Discard appropriately or follow decontamination protocol for non-disposable FFP3 masks. Perform hand hygiene immediately after removing all PPE. FFP3 Reusable Respirator Cleaning and Disinfection FFP3 re-useable mask are for single person, they will be issued and fitted to individuals, they should be cleaned between uses, they can NOT be cleaned and used by another person. Respirators once issued are the responsibility of the individual they have been issued to. Equipment Needed: CHLORCLEAN Procedure: This procedure is for single person re-useable masks. Remove Cartridges from respirator. Wipe cartridges with CHLORCLEAN. Wash mask with CHLORCLEAN detergent and hot water ensuring all areas are cleaned inside and out. Rinse with clean hot running water. Dry AND CLEAN WITH CHLORCLEAN Re assemble mask with cartridges. Leave in ventilated area (away from any contaminated area) to completely air dry. Store in dry area (Not in plastic bag), labelled with users name. Checks: Respirators should be checked after each wash to ensure they are fully operational, If there are any defects then a new one should be requested. Cartridges in use with respirators should be checked that they are still in date, they should be changed monthly. Page 69 of 78 STHK PAN FLU PLAN V11 MAY 2014