Influenza Pandemic Plan - STHK Trust Website Home Plan 2015.pdf · Page 2 of 78 STHK PAN FLU PLAN...

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

Influenza Pandemic Plan

Version 12 – May 2015 This plan must be used in conjunction with Infection Control Manual Chapter 36 Influenza pandemic

of 78 STHK PAN FLU PLAN V11 MAY 2014

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 10 23rd 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” http://www.scotland.gov.uk/Resource/Doc/924/0054555.pdf and

General Medical Council, Pandemic Influenza Good Medical Practice - Responsibilities of doctors in a national pandemic,

http://www.gmc-uk.org/GMP_in_pandemic_draft_23Oct09.pdf_27941326.pdf

http://www.scotland.gov.uk/Resource/Doc/924/0054555.pdf

http://www.gmc-uk.org/GMP_in_pandemic_draft_23Oct09.pdf_27941326.pdf


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: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Influenza/ Health and Social Care Influenza Pandemic Preparedness and Response https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213696/dh_133656.pdf Pandemic Influenza NHS guidance on the current and future preparedness in support of an outbreak. http://www.england.nhs.uk/wp-content/uploads/2014/04/pand-flu-guid-overview.pdf Operating Framework for Managing the Response to Pandemic Influenza http://www.england.nhs.uk/wp-content/uploads/2013/12/framework-pandemic-flu.pdf

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Influenza/

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213696/dh_133656.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213696/dh_133656.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/04/pand-flu-guid-overview.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/framework-pandemic-flu.pdf


Pandemic Influenza Guidance on the Management of Death Certification and Cremation Certification https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216822/2012-06-21dh-template-guidance-on-management-of-death-certification.pdf

Acronyms and abbreviations used in the document

5BP 5 Boroughs Mental Health Partnership Mental Health NHS Trust

AMU Acute Medical Unit

CCGs Clinical Commissioning Groups

CM CSU Cheshire & Merseyside Commissioning Support Unit

Comms Communications

Crit Care Critical Care

DA(E)TER DETECT/ ASSESS (EVALUATE)/ TREATMENT/ TREATMENT/ ESCALATION/ RECOVERY

DIPC Director of Infection Prevention & Control

ED Emergency Department (formerly known as A&E)

Execs Executive Team

FFP3 Face Fitted Protector version 3 – disposable respirator

FM Services Facilities Management (provided by Medirest e.g., cleaning, portering, catering, security, shuttle bus service, reception).

HWWD Health Work and Wellbeing Dept (formerly Occupational Health)

HPA Health Protection Agency now called Public Health England

HR Human Resources

ICU Intensive Care Unit (also called Critical Care)

IDT Integrated Discharge Team, a combined team of hospital social care workers from Halton, St Helens & Knowsley Councils

ICS@5BP Integrated Community Health Services formerly Knowsley Integrated Provider Services (KIPS) which is a business unit of 5BP above.

ICT Information & computer technology

ICAT Intermediate care action team

IPCD Infection Prevention & Control Dept

KIPS Knowsley Integrated Provider Services now known as ICS@5BP

LHRP Local Health Resilience Forum, a Merseyside wide strategic level Emergency Planning, Risk & Resilience Forum

NHS National Health Service

NHS E NHS England

NWAS North West Ambulance Service

Ops Services Operational Services – bed managers

Ops Site Mgr Operational Site Manager

PHE Public Health England (formerly HPA)

PPE Personal Protective Equipment (respirators, masks, goggles, visors, gloves, aprons, gowns, etc.)

The Trust St Helens & Knowsley Teaching Hospitals NHS Trust

UCAT Urgent Care Action Team (part of CM CSU above)

UK United Kingdom

WHO World Health Organisation

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216822/2012-06-21dh-template-guidance-on-management-of-death-certification.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216822/2012-06-21dh-template-guidance-on-management-of-death-certification.pdf


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

8

8

9 9 9 10 11 11 11 12 12 12 12 12 13 13 13

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

17 17 18 18 18 19 19 19 20 21 24 28 32 37 39

Trust General Response 44

Business Continuity Staff vaccine Patient vaccine Hospital Pharmacy Arrangements Trust Support to 5 Boroughs Mental Health Partnership (5BP) Patients 5BP Support to the Trust

44 44 44 46 48 49


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

49 49 50 51 52 52 53 53 54 55 55 56 57

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

58

60 67

71 73 77


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 2nd 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 3rd 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 3rd 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.


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


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 3rd 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 2nd and 3rd waves could be worse than the first.


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.


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 KIPS) @ 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.


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


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


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 3rd 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 3rd 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.


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 Centre)

Advise and direct patients and their families to GP for 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 Infection Prevention & Control Dept

Monitoring of PHE website and other research Train the trainers fit test training for respirators 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 Monitoring and awareness of strategic issues of pan flu

Finance (Purchasing & Supply)

Revision and resupply of PPE Materials Management Team monitoring and restocking PPE in liaison with Infection Prevention & Control

FM services Training managers in operational skills to provide resilience. Review and restock of supplies and training for deep cleaning teams. Respirator (FFP3) fit test training

HR including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development

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.

ICT Facilitation and maintenance of Immsform and other reporting systems

Information Service Training in gathering

Integrated Discharge Team (IDT)

Review of accelerated discharge plans

Labs (Pathology) Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use.


Section/ Department Preparation

Maternity 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.

Mental Health liaison

Mortuary Team 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.

Operational Services Preparation of winter plans and management of patient flows

Paediatric Hospital at Home team

Advise and direct patient’s families to GP for vaccination

Paediatric nephrologist Advise and direct patient’s families to GP for vaccination

Palliative Care Joint Teams (end of life care)

N/A at this stage

Out Patients Dept N/A at this stage

Paediatrics 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

Pharmacy 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

Respiratory wards Review of PPE stocks Respirator (FFP3) fit test training

Sexual Health Clinic Vaccinate their vulnerable outpatients

Theatres Training staff to support in ICU as required.

Therapy team (actually part of 5BP Community Health but integral to STHK)

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

Wards (General) 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


Phasing the Response

WHO International Phases & UK ‘DATER’ Stages

International phases Significance for the UK

Inter-pandemic period

1 No new influenza subtypes detected in humans

UK not affected OR UK has strong trade/travel connections with affected country OR UK affected

2 Animal influenza subtype poses substantial risk

Pandemic Alert Period

3 Human infection(s) with a new sub type, but no new human to human spread to a close contact

UK not affected OR

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

UK has strong trade/travel connections with affected country OR

5 Large and LAT(s) but human to human spread is still localised, suggesting that the virus is becoming increasingly better adapted to humans

UK affected.

Pandemic Period

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.


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


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.


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


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 2009.

Recovery


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


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.

DETECT – role of the Trust by function

Section/ Department Actions

Acute Medical Unit Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer

Burns & Plastics Awareness & planning with Northern Burn Care Network

Cancer Services (Lilac Centre) Advise and direct patients and their families to GP for vaccination

Communications Monitoring of PHE and other websites and media. Promotion of the latest flu campaigns; e.g., CHOOSE WELL & CATCH IT BIN IT KILL IT.

Critical Care (ICU) Awareness & planning with North West Critical Care Network Respirator (FFP3) fit test training by key trainer

Director Infection Prevention & Control (DIPC)/ Infection Control Nurse Specialist

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).

Emergency Dept (A&E) Monitoring and replacing stocks of PPE Respirator (FFP3) fit test training by key trainer

Emergency Planning Research, awareness and planning in consultation and cooperation with key Trust staff and NHS and other partners.

Executive team Monitoring and awareness of strategic issues of pan flu


Revision and resupply of PPE Materials Management Team monitoring PPE

FM services 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.

HR including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development

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.


Detect continued


HR continued Apply for relevant Patient Group Directives (PGD) Work with Comms team to provide staff information. Research and monitor news of the pandemic.

ICT (Health informatics) Facilitation and maintenance of Immsform (re: staff vaccination reporting) and other reporting systems. Broadcasting of global emails for staff information. Hosting of the Merseyside Mortuary Capacity Reporting Tool

Information Service Training for staff in gathering, producing and sending data for situation reporting to NHS England when required at later stages.

Integrated Discharge Team (IDT) Combined social care team for Knowsley, St Helens & Halton

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.

Labs (Pathology) 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.

Mortuary Team 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.

Operational Services Preparation of winter plans and management of patient flows.

Out Patients Dept Advance identification of patients in the identified risk categories.

Palliative/ end of life support Advise and direct patient’s families to GP for vaccination and provide information on the disease.


Detect continued



Advise and direct patient’s families to GP for vaccination and provide information on the disease.

Paediatric nephrologist Advise and direct patient’s families to GP for vaccination and provide information on the disease.

Paediatrics Development and review of integrated working with ICU and Alder Hey Children’s Hospital

Pharmacy 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

Respiratory wards Review of PPE stocks Respirator (FFP3) fit test training by key trainer

Sexual Health Vaccinate their patients and issue specific advice to immuno-compromised patients and families regarding prophylactic medicine.

Theatres Training staff to support in ICU as required.

Therapy team (physiotherapy) 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

Wards (General) 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.


ASSESS (EVALUATE) - role of the Trust by function

Dept/ ward/ function Actions

Acute Medical Unit 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.

Burns & Plastics (Mersey Burn Unit)

Awareness and preparation with NBCN. Increase/refresh staff training for ICU support

Communications 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)

Critical Care (ICU) 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.


Assess (Evaluate) continued


Critical Care (ICU) 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.

Emergency Department (A&E) 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.

Emergency planning 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.

Executive Team Monitoring and awareness.

FM services 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.

ICT (Health Informatics) Dissemination of global emails 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

Infection Control 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.

Information Service Providing a daily situation report to NHS England Merseyside Area Team NHS Gold Command or PHE Cheshire & Mersey Unit.




HR including Staffing Health Work and Wellbeing Learning & Development

Daily situation reporting on staffing absences due to flu like illness to NHS England Review of BC plans Promotion of advice to staff on revised sickness policies, child, care issues due to school 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 anti-viral 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 anti-viral 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.




Pharmacy continued 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.

Purchasing & Supply 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

Respiratory Wards 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.


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

Theatres Obtain refresher training for theatre staff for critical care support. As above for respiratory wards.

Wards (General) 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.


TREAT – role of the Trust by function


Acute Medical Unit 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.

Communications 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.

Critical Care (ICU) 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.


Treat continued


Emergency Department

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)

Emergency planning 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.

Executive Team 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.

FM services 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.

ICT Dissemination of global emails 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

Infection Prevention & Control Team IPCT

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.

Information Service 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.

HR Staffing Health Work and Wellbeing

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.


Treat continued


HR Learning & Development

Training on going of skilled staff for redeployment to key areas at Escalation phase.

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 anti viral treatment options. (Issues around use of Relenza). Monitor and admit pregnant women in their 3rd trimester with flu if their symptoms are severe.

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 Mass Fatality 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 and UCAT via CMS.

Out Patients Signposting patients in the risk groups to their GP for vaccination and giving advice re anti-viral medicines.

Palliative/ end of life support

Review BCM plans for joint end of life support teams in consultation with partner agencies.

Paediatrics 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.


Treat continued


Paediatrics continued 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.

Pharmacy 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.

Purchasing & Supply 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.


Arrange the isolation of potentially infected patients.





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

Theatres Obtain refresher training for theatre staff for critical care support. As above for respiratory wards.

Wards (General) As above for respiratory wards. Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel.


ESCALATE – role of the Trust by function


Acute Medical Unit 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

Communications 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.

Critical Care (ICU) 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.


Escalate continued


Paediatrics continued 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.

Emergency Department 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

Emergency planning 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.

Executive Team 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.

FM services 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.


Escalate continued


ICT Dissemination of global emails 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

Infection Control 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.

Information Service 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.

HR including Staffing Health Work and Wellbeing Learning & Development

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.

Labs Ensure appropriate testing facilities are available to obtain results in a timely manner. Train staff in their use. BC plan actions

Maternity 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 3rd trimester with flu if their symptoms are severe.


Escalate continued


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. Maintain 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 and UCAT via CMS.

Out Patients 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.

Palliative/ end of life support

Activate BCM plans for joint end of life support teams in consultation with partner agencies.

Paediatrics 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.

Paediatric Dept continued

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.


Escalate continued


Pharmacy continued 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.

Purchasing & Supply 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.


Arrange the isolation and cohorting of potentially infected patients.




Theatres 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.

Wards (General) As above for respiratory wards. Ensure items of stocks available of latest flu campaign posters, tissues, bins & hand gel.


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


Incident) a full scale response may be required to ensure Business Continuity of critical functions for the duration of the intense pressures.


RECOVERY – role of the Trust by function


Acute Medical Unit 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

Burns & Plastics 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

Cancer Services (Lilac Centre) 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.

Communications 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

Critical Care (ICU) 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.


Recovery continued


Director Infection Prevention & Control (DIPC)/ Microbiologist

Review of Infection control manual 23 and related documents Activation of staffing recovery plans re HR issues Reinstatement of normal working.

Emergency Dept (A&E) Monitoring and replacing stocks of PPE Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations.

Emergency Planning Attendance at formal debriefs for the Trust and LHRP groups. Review of pan flu plans.

Executive team 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

FM services Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Review and restock of supplies and equipment.

HR Review of pan flu plans Activation of HR recovery plans and payroll issues due to leave cancelled/ not taken/ extra hours worked.


Recovery continued


HR continued including Workforce planning Health Work Wellbeing (Health Work and Wellbeing Learning & Development

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.

ICT (Health informatics) Review of pan flu plans Reinstatement of planned upgrades and projects. Acceleration of activity to address any backlog.

Information Service Review of pan flu plans Activation of staffing recovery plans re HR issues

Integrated Discharge Team (IDT) Combined social care team for Knowsley, St Helens & Halton

Review of joint accelerated discharge plans and BC plans. Activation of staffing recovery plans re HR issues

Labs (Pathology) Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog.

Maternity Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog.

Mortuary Team Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations. Acceleration of activity to address any backlog.

Operational Services Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations.

Recovery continued



Out Patients Dept 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)

Paediatric Dept 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

Paediatric Nephrologist Return to normality

Pharmacy Return to normality Review and reorder of stock of relevant medicines and vaccines. Review of HR issues re: staff holidays, training, overtime hours worked

Respiratory wards Return to normality. Reordering of supplies as necessary Review of HR issues re: staff holidays, training, overtime hours worked

Sexual Health Review of pan flu plans Activation of staffing recovery plans re HR issues Reinstatement of normal operations.

Theatres 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.

Therapy team (physiotherapy) 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


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General Trust Response

Business Continuity

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.


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 3rd 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 3rd 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 in-patients 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.


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 1st 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.


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.


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 emails 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.


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.


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 emails 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 .


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 2nd 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).


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.


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 2nd 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.


Accelerated Discharge

During the worst of the swine flu 2nd 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.


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.


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 2nd 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) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098750.pdf Responding to pandemic influenza: The ethical framework for policy and planning http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080729.pdf Pandemic flu. UK Health departments UK Influenza pandemic contingency plan March 2005. http://www.dh.gov.uk/PolicyAndGuidance/EmergencyPlanning/PandemicFlu/fs/en Health Protection Agency Influenza Pandemic Contingency plan. Version 7. February 2005. http://www.hpa.org.uk/infections/topics_az/influenza/pdfs/HPAPandemicplan.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098750.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098750.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080729.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080729.pdf

http://www.dh.gov.uk/PolicyAndGuidance/EmergencyPlanning/PandemicFlu/fs/en

http://www.hpa.org.uk/infections/topics_az/influenza/pdfs/HPAPandemicplan.pdf


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.


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


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).


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: http://www.hpa.org.uk/NewsCentre/

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.


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.

http://www.hpa.org.uk/NewsCentre/


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.


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


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 pre-warned so that they can ensure that staff have suitable PPE and that contact with other patients e.g. in waiting areas will be avoided.


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).


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.




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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.


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.


● 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.


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APPENDIX D - Prevention of influenza

Vaccination

The normal annual influenza vaccine will give no protection against the pandemic strain. Once the pandemic strain is identified, it will take at least 4-6 months for production of a specific vaccine. During a pandemic, there will be 3 stages in the public health strategy: 1. No vaccine available. 2. Vaccine in limited supply. 3. Vaccine widely available. Even when vaccine against the pandemic strain is produced, protection will not be 100%. More than one dose, or a larger dose may be required. Nonetheless, the vaccine can be expected to reduce the impact of pandemic influenza by reducing complications, hospitalisations and deaths. A tiered approach to immunisation is planned, targeting the highest risk groups first.

Priority groups for immunisation

The need to keep health and other essential services running will mean that, if vaccine supplies are limited these groups may need to take precedence for vaccine. Priority aims are as follows (in priority order) 1. Protection of health care staff with patient contact. They are at increased risk of acquiring infection from their patients and also passing it on to vulnerable patients. 2. Protection of those providing essential services which would be disrupted by excess absenteeism during an outbreak e.g. fire, police, security, communications, utilities, undertakers, armed forces 3. Prevention of serious illness in the most vulnerable groups (anticipated or confirmed). Until epidemiological evidence begins to accumulate during a pandemic, it cannot be predicted who those are most likely to be. 4. Reduction of spread in closed communities e.g. residential care homes 5. Reduction of spread by immunising those most likely to transmit the virus e.g. children 6. Prevention of illness in the general population. Final decisions on priority groups will be made by the UK National Influenza Pandemic Committee. Vaccine distribution will be organised centrally to ensure equity.

Health Work and Wellbeing

Special clinics will be necessary to ensure distribution of vaccine to all health care staff in the Trust.

Antiviral drugs

Antiviral drugs e.g. oseltamivir have been stockpiled by the Department of Health but are also likely to be in short supply. Doctors will be advised of national policy for their use (as a supplement or alternative to vaccine for short-term protection as well as


their role in treatment) in light of knowledge of the pandemic and the availability of the drugs. (See Appendix 3 for further details).

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 Appendix 4. 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.

Slowing the spread of infection

Apart from vaccination and antiviral drugs, other measures may help to limit or slow the spread of influenza e.g. hand washing, limitation of non-essential travel and mass gatherings and by encouraging people suffering from the disease to stay at home. The risk of nosocomial (hospital-acquired) infection may 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.

Use of 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.




APPENDIX E – Staffing Issues

See HR Pandemic Influenza Plan

As large numbers of patients and staff may develop influenza, contingency plans for the operational management of the Trust are in place. These are covered in detail in the Business Continuity Plans for Trust HR and partner agencies in New Hospitals 1.e., Medirest and Vinci.

Exec Team

The Executive Team will review cancellation of services, training and some meetings to ensure appropriate staffing levels etc., on a daily basis.

All staff

During an influenza pandemic, trust staff may be required to undertake tasks different from their normal duties. Health care workers at high risk e.g. pregnant women or immune-compromised workers should not provide care for influenza patients for the duration of the pandemic or until vaccinated.

Managers will consider nurse staffing availability and admin staffing (receptionists, booking in clerks, those operating key electronic systems or dealing with the public)

Clinical staff from surgical wards/departments may be allocated to medical wards.

Annual and study leave may need to be cancelled.

More flexible shift arrangements may be required, including home working / teleconferencing, where appropriate/possible.

Utilise any nursing staff currently in non-shift role to boost ward staffing levels if necessary.

Staff rosters must allow for adequate break and leave periods to ensure a sustainable response of several weeks/months. Transfer of staff from influenza affected wards to unaffected wards must be avoided in order to minimise spread of infection

Medical staffing availability

Staff from surgical wards/departments may be allocated to medical wards

Annual and study leave may need to be cancelled.

Non-urgent clinic appointments may be cancelled/ scaled back so that medical staff time is freed up.

Staff rosters must allow for adequate break and leave periods to ensure a sustainable response of several weeks/months.


Other staffing availability

Consider other staffing availability e.g. pharmacy etc.

Curtail non-urgent services if necessary.

Staff volunteers

Ensure a system for vetting and training additional staff, including volunteers.

If volunteers are to be taken on, consider issues of Health Work and Wellbeing, police checks, skills re-training, indemnity, and supervision (see Major Incident Plan).

Departments must consider increased demand for staff welfare services in the business continuity plans.

Transport services

Staff drivers may be required to drive minibuses to allow prompt discharge of patients if ambulance services are disrupted. If public transport is disrupted, they may also be required to bring staff into work. Recording of staff sickness & return to work

Staff will report sickness (including the nature of their illness) to their line manager who will pass the information on to Health Work and Wellbeing.

Health Work and Wellbeing will collate the information and report to the Executive Team.

Health Work and Wellbeing will advise if there are any queries about staff returning to work.

Accommodation

The strategic team will consider accommodation for staff to rest between shifts when transport home may be difficult or disrupted. There is an emergency stock of sleeping bags, camp beds and inflatable mattresses (known to staff as the ‘snow beds’ after they were used in severe weather events) which can be distributed and retrieved by security to (and from) staff for use in pre-assessed seminar rooms and offices during such an event. Local hotels could also be used.

Child care

Closure of day care facilities for children and schools may be advised in order to reduce spread of infection which can cause further staffing problems. See Trust HR Guidance to managers and staff in this case.


Cancelled/ reduced activity

Non-essential meetings will be cancelled.

Non-essential business travel will be cancelled.

Some training will be cancelled

In areas of high pressure essential activity like ED and ICU leave may be cancelled.

Recovery - Staff welfare

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 the Dept of Health & Wellbeing (Health Work and Wellbeing) for care and support.


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APPENDIX F – Other Contingency Measures

Bed availability

Clinical Directors and Operational Services will consider bed availability. The NW Critical Care Framework escalation policy will be used regarding Critical Care.


Signs must be displayed in Emergency Department instructing patients with respiratory symptoms to inform reception immediately on their arrival. Triage

Triage of patients i.e. quickly assess their needs and ensure that they are directed to the appropriate care, transferring to a segregated waiting area (to be determined according to the situation).

AMU Specialist Nurse Triage Support in ED

The AMU Specialist Nurse (new post) will attend ED to triage medical patients awaiting admission and identify early discharges and speed 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.

Capacity Management

Routine non urgent surgical admissions may need to be cancelled (not only to release beds but to prevent patients from contracting hospital-acquired influenza).

Routine medical admissions may need to be cancelled, particularly those patients with high-risk medical conditions (to avoid hospital-acquired influenza).

Non-essential outpatient visits may be cancelled.

Early discharge of patients as soon as well enough.

Admit patients with influenza only if they have medical complications.

ICU may need to access Intensive Care bed bureau for identified ICU beds for patient transfer. If none available, the Burns Unit/Theatres may be utilised for additional ICU beds.

Supplies

Ensure that adequate supplies of protective equipment e.g. gloves, plastic aprons are available.

ICU staff to ensure adequate supplies of ventilator accessories etc.


Information sheets taken from Department of Health documents to be made available to staff, patients and relatives.

Consider the logistics of maintaining supplies of equipment and pharmaceuticals, including the blood supply (transport and other services will be affected by the pandemic).

Activate the National Emergency Purchasing Scheme as required.

Anti- viral use

Decide on antiviral use (if available) according to national policy at this time.

Mortuary capacity and arrangements

The Trust hosts the Merseyside Mortuary electronic capacity reporting tool on the internet.

The Mortuary manager or deputy populates this for the Trust’s capacity every day at 11.00.

All mortuary managers monitor the capacity across all Merseyside mortuaries daily and the storage of bodies is managed across the County with the agreement of HM Coroner.

Should a lack of capacity across the County be a concern then the Mortuary Manager will escalate via the Major Incident Command structure so that the Merseyside Excess Deaths Plan may be activated to manage the situation at a Merseyside Resilience Forum level involving special contingency arrangements by not only mortuaries but also Local Authorities’ registrars, crematoria and cemeteries in close liaison with funeral directors.

Body bags are not required. Portering staff may be required to assist mortuary staff in the receipt and release of the deceased bodies and in dealing with telephone enquiries (sickness levels permitting). Microbiology laboratory to report on bacterial pathogens and antibiotic sensitivity associated with severe/ fatal infections.

Visitors

Strict visiting times will apply to all areas. Only one visitor will be permitted at any one time for all patients. Visitors will be advised against making unnecessary visits and visits should be confined to immediate family only.

Influenza Pandemic Plan - STHK Trust Website Home Plan 2015.pdf · Page 2 of 78 STHK PAN FLU PLAN...

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