Name of Policy: Management of a patient with suspected V iral · healthcare setting, have a high...

VHF / MERS Policy v1

Policy No: IC39

Version: 1.0

Name of Policy: Management of a patient with suspected Viral

Haemorrhagic Fever (VHF) or Middle East

Respiratory Syndrome Coronavirus (MERS-CoV)

Effective From: 23/08/2017

Date Ratified 20/07/2017

Ratified IPCC

Review Date 01/07/2019

Sponsor Director of Infection Prevention and Control

Expiry Date 19/07/2020

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues

VHF / MERS Policy v1 2

Version Control

Version Release Author/Reviewer

Ratified

by/Authorised

by

Date Changes

(Please identify page no.)

1.0

23/08/2017 Dr J S Moore

Daniel Stevens

Angela Craddock

Dr G M Horne

IPCC 24/07/2017


Contents

Section Page

1 Introduction: ................................................................................................................................ 5

1.1 Key messages. .................................................................................................................... 5

1.2 Overview ............................................................................................................................ 5

1.2.1 Viral haemorrhagic fever (VHF .............................................................................. 5

1.2.2 Middle East respiratory syndrome coronavirus (MERS-CoV ................................. 6

1.2.3 Avian Influenza ...................................................................................................... 7

1.2.4 Severe acute respiratory syndrome (SARS) coronavirus ...................................... 7

2. Policy scope .................................................................................................................................. 7

3. Aim of policy ................................................................................................................................. 7

4 Duties (Roles and responsibilities) ............................................................................................... 7

5 Definitions / Case Definitions ....................................................................................................... 8

6 Assessment and Management of patients with suspected VHF or MERS-CoV ............................ 8

6.1 Quick reference guide flow chart for the management of suspected VHF ..................... 9

6.2 Quick reference guide flow chart for the management of suspected MERS-CoV…..…….10

6.3 Communication chain (internal communications) ………………………..……………………………..11

6.4 Identifying at risk patients (patient referral and acceptance) ......................................... 12

6.5 Patient risk assessment algorithms ................................................................................. 12

6.6 Initial risk assessment in A&E .......................................................................................... 13

6.7 Risk assessment process .................................................................................................. 13

6.8 Management of a patient categorised as “low possibility of VHF/MERS-CoV” .............. 15

6.9 Initial management and transfer of a patient categorised as “high possibility of VHF” . 16

6.10 Investigations for a patient categorised as “high possibility of VHF” .............................. 17

6.11 VHF screen and further management ............................................................................. 18

6.12 Transfer of a patient categorised as “high possibility of VHF” to SSU room 2 ................ 19

6.13 Decontamination of a side room following use by a patient categorised as

“high possibility of VHF” .................................................................................................. 21

6.14 Management of a patient with a negative VHF Screen ................................................... 21

6.15 Management of a patient with confirmed VHF ............................................................... 22

6.16 Initial management of a patient categorised as “high possibility of MERS-CoV”……..….22

6.17 Investigations for a patient categorised as “high possibility of MERS-CoV”…………………23

6.18 Transfer of a patient categorised as “high possibility of MERS-CoV ............................... 24

6.19 After death care with respect to VHF and MERS-CoV ..................................................... 24

6.20 Decontamination of spillages of blood or body fluids and clinical waste in VHF ............ 25

6.21 Decontamination of persons accidentally exposed to spillages of blood

or body fluids associated with VHF risk ........................................................................... 26

6.22 Decontamination in the context of MERS-CoV…………………………………….……………………….26

6.23 VHF/MERS-CoV/Avian Influenza personal protective equipment (PPE) ......................... 26

6.24 Public Relations (external communications)...……………………………………………………………..28

6.25 Staff support and surveillance ......................................................................................... 28

7. Training ......................................................................................................................................... 28


8. Equality and diversity ................................................................................................................... 28

9. Monitoring compliance with the policy ....................................................................................... 28

10. Consultation and review .............................................................................................................. 29

11 Implementation of policy (including raising awareness) ............................................................. 29

12 References .................................................................................................................................... 29

13 Associated documentation (policies) ........................................................................................... 29

Appendices

Appendix 1 Contact Details ................................................................................................................. 30

Appendix 2 Collection of blood samples from patients categorised as ‘High Possiblility of VHF’ or

Patients awaiting VHF assessment .................................................................................. 31

Appendix 3 VHF Personal Protective Equipment (PPE) donning and removal ................................... 33

Appendix 4 Diagrams of the Emergency Care Centre ground floor and areas around

A&E room E4 and room 2 on the Short Stay Unit (SSU) .................................................. 45

Appendix 5 Preparing rooms E4 in A&E, room 2 on the SSU and room 1 on the assessment

suite for the arrival of a patient with possible VHF or MERSCoV .................................... 48

Appendix 6 Location and Contents of the ‘VHF/MERS Box’ .............................................................. 49

Appendix 7 Flow of staff through the red, amber and green areas ................................................... 50

Appendix 8 Designated locations for nursing patients with possible VHF/MERS-CoV along with

characteristics of these rooms and advice regarding surrounding locations .................. 51

Appendix 9 Incident Control Team………….………………………………………………….………..…………………………52


Management of a patient with suspected viral haemorrhagic fever (VHF) or Middle

East respiratory syndrome coronavirus (MERS-CoV)

1.1 Introduction: Key messages

• Patients returning from, or who have recently travelled to, certain parts of the world are at

risk of contracting a number of severe life threatening viral infections such as viral

haemorrhagic fever (VHF) or Middle East respiratory syndrome coronavirus (MERS-CoV).

• These infections are highly contagious. Therefore, prompt recognition and early isolation,

together with great attention to best infection control practice, are essential to minimise

the risk of cross transmission to other patients, members of staff and the wider public.

• All staff should be aware of these guidelines and be able to promptly recognise patients at

risk of VHF and MERS-CoV. These guidelines are designed to help staff recognise patients at

risk of such infections and direct initial clinical and infection control management.

• It is imperative that the duty Medical Microbiologist, Infection Control nursing team and

Infectious Diseases Team at the RVI are contacted immediately should a patient with

suspected VHF or MERS-CoV be identified to assist with management of the case.

1.2 Introduction: Overview

In recent years, globally there have been outbreaks of VHF (such as Ebola) as well as a number of

other serious respiratory viral infections such as MERS-CoV and avian influenza outwith of the UK.

With increasing international air travel, there is a risk that returning travellers might import such

infections to the UK and to our hospital. Given the life threatening and extremely contagious nature

of these infections, it is vital that the trust has mechanisms in place to identify returning travellers

at risk of such infections and that appropriate infection prevention control measures are instigated

early, with notification of appropriate individuals completed in a timely fashion.

An overview is provided here of currently circulating and possible threats. It must be recognised

that the situation is constantly changing. Therefore, links to the Public Health England and World

Health Organisation websites are provided to detail the most up to date case definitions and the

latest geographical distribution of these viruses.

1.2.1: Viral haemorrhagic fevers (VHFs)

Viral haemorrhagic fevers (VHFs) are severe, life threatening diseases caused by a range of viruses

classified as Hazard Group 4 pathogens. Most are endemic in Africa, parts of South America and

some rural parts of Asia, the Middle East and Eastern Europe. The number of patients diagnosed

with VHF in the UK is very low (1-2 cases every two years). All recorded cases of VHF in the UK have

been acquired abroad, with the exception of one case transmitted through a needle-stick injury.

VHFs are of particular public health importance because they can spread easily including within the

healthcare setting, have a high case fatality rate and at present there is no effective treatment.

VHFs are transmitted through direct contact with blood or body fluids of an infected person

through broken skin, mucous membranes, inoculation injury and/or indirect contact with

environmental contamination.


Clinically, VHFs present as severe acute viral illnesses often characterised by sudden onset fever,

intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, loose

stools, rash, impaired renal and liver function and in some cases, both internal and external

bleeding. Pancytopenia is a common finding. The incubation period is anywhere between 2 to 21

days. Patients remain infectious as long as their blood and secretions contain the virus.

VIRAL HAEMORRHAGIC FEVER VIRUSES

ARENAVIRIDAE

BUNYAVIRIDAE

Lassa, Lujo, Chapare, Guanarito, Junin

Crimean-Congo Haemorrhagic Fever

Machupo and Sabia

FLAVIVIRIDAE

FILOVIRIDAE

Kyasanur Forest Disease

Ebola and Marburg

Alkhurma Haemorrhagic Fever

Omsk Haemorrhagic Fever

The key to successful management of VHF or potential VHF cases is risk assessment of patients at

presentation to hospital who may have risk factors for infection. Patients meeting the following

criteria must be identified:

• Fever ≥37.5ºC or history of fever in the previous 24 hours AND

• Has returned from an area where VHF is endemic within 21 days OR

• Has cared for/come into contact with a person or body fluids of/ or handled clinical specimens

from an individual or animal known or strongly suspected to have VHF within 21 days of

becoming unwell.

In the UK, only persons meeting the above criteria are considered to be at risk of VHF infection.

Latest information about VHF and case definitions can be found on the Public Health England

website at: https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-and-

guidance-on-management-of-patients

Links to maps showing the latest geographical locations of endemic areas are included:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/558888/VHF_Afri

ca_2016_960_640.png. Areas with outbreaks of Lassa, Crimean-Congo Haemorrhagic Fever, and

Ebola and Marburg are shown. ProMED-mail can be used to view locations of current outbreaks.

1.2.2: Middle East respiratory syndrome coronavirus (MERS-CoV)

MERS-CoV is a severe life threatening respiratory viral disease first identified in 2012. Since then,

over 2,040 cases have been reported to the WHO (http://www.who.int/emergencies/mers-

cov/en/) with over 714 related deaths. Most cases to date have been reported from the Arabian

Peninsula particularly the Kingdom of Saudi Arabia. A single imported case into South Korea in 2015

resulted in 186 cases and 36 deaths linked to delayed identification and hospital-related

transmissions.

For an up to date case definition and list of countries affected refer to the following link:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543560/MERS-

CoV_case_algorithm.pdf

Symptoms include fever, breathlessness and cough that can progress to severe pneumonia. The

case fatality rate is around 36%. Dromedary camels are an identified host, and the likely source of

primary infection in some cases, however, most cases are due to human-human transmission.


Large outbreaks linked to healthcare facilities have occurred. The incubation period is up to 14

days. No vaccine or specific treatment is available.

1.2.3: Avian Influenza (H5N1 and H7N9)

Most avian influenza viruses do not infect humans; however some, such as A(H5N1) and A(H7N9),

have caused serious infections in people. So far there is no convincing evidence of sustained person

to person spread. Infection is associated with close contact with living or dead infected poultry.

Symptoms include a flu-like illness and upper and lower respiratory tract infections.

Influenza A (H5N1) is endemic in several countries with over 800 confirmed human cases and over

400 deaths, with the majority of human cases seen in Egypt and Indonesia. Influenza A (H7N9) is

endemic in China. Over 500 human cases and 200 deaths have been reported.

For up to date case definitions and a list of countries affected use the following link:

https://www.gov.uk/government/publications/avian-influenza-guidance-and-algorithms-for-

managing-human-cases . There are separate documents for H5N1 and H7N9.

For further information refer to the WHO fact sheet on Avian influenza found at:

http://www.who.int/mediacentre/factsheets/avian_influenza/en/

1.2.4: Severe acute respiratory syndrome coronavirus (SARS)

SARS is a severe respiratory disease caused by SARS coronavirus. It was first recognised in

Guangdong Province in China in November 2002, and spread worldwide before being contained,

with the last case identified in 2004.

Over 8000 individuals were affected in over 30 countries. There is an animal reservoir in civets and

some bats in China. The possibility of SARS re-emergence remains and there is a need for

continuing vigilance.

2 Policy scope

This policy is applicable to all trust staff involved in the risk assessment and management of

patients with suspected VHF, MERS-CoV or Avian Influenza in hospital and the community.

3 Aim of policy

The aim of this policy is to provide operational guidance for all staff in the correct management

(clinical and infection prevention control) of patients with suspected VHF, MERS-CoV or Avian

Influenza and therefore to prevent exposure of Hazard Group 4 pathogens to all HCW, patients and

visitors within the trust.

4 Duties (roles and responsibilities)

The Executive Director of Nursing & Director of Infection Prevention and Control and Medical

Directors (DIPCs) on behalf of the Chief Executive will ensure that Assistant Directors and Heads of

Service take clinical ownership of the policy.

The Assistant Directors, Heads of Service and Service line Managers will:

• Ensure that all health care workers comply with this policy

• Ensure that all healthcare workers attend mandatory infection prevention and control training


The Infection Prevention and Control Team will:

• Act as a resource for information and support

• Monitor the implementation of this policy within clinical areas

• Regularly review and update the policy

• Alert the waste manager regarding potential cases of VHF or other infections requiring specific

attention.

The waste manager will:

• Organise and coordinate the safe removal of waste for disposal in such cases.

All trust staff including all clinicians will:

• Comply with this policy to promptly identify and manage suspected cases or VHF, MERS-CoV or

Avian Influenza.

• Inform the Infection Prevention and Control Team of any issues or concerns relating to this

policy.

5 Definitions / Case definitions

Case definitions are frequently updated in line with changes in viral circulation or new knowledge

relating to transmission, incubation period and symptoms. For this reason, case definitions are not

detailed here; instead links to the current case definitions for currently circulating viruses have

been included in sections 1.2 and 6.5.

6 Assessment and management of patients with suspected VHF or MERS-CoV

Section 6 describes how patients with suspected VHF or MERS-CoV should be managed in hospital.

Patients presenting with potential novel respiratory viruses should be managed following the

guidance set out for potential MERS-CoV patients. A summary flow chart is included in sections 6.1

and 6.2.

Primary care assessment of patients with suspected VHF or MERS-CoV

Physicians and nurse practitioners working in primary care should be aware of VHF and MERS-CoV

and be familiar with the contents of section 1 and the guidance contained in section 6.5.

Primary care practitioners can use the screening questions detailed in sections 6.4 and 6.7 to make

an initial risk assessment and classify the patient according to the guidance in section 6.5. If

possible, it would be preferable to perform this risk assessment over the telephone rather than

face to face with the patient (thus negating the need for the patient to attend the surgery or walk

in center).

If the risk assessment is done in person, the practitioner should wear appropriate PPE (e.g. for

MERS-CoV an FFP 3 mask as well as a gown and gloves). As soon as the possibility of risk is

established, the practitioner should promptly leave the room and contact either the Newcastle

Infectious Diseases Consultant on call (Appendix 1) or a Consultant Medical Microbiologist for

advice. They will direct on how best to manage the patient from that point on.


6.1 QUICK REFERENCE GUIDE FLOW CHART FOR THE MANAGEMENT OF VHF

All patients attending A&E should be screened

at the time of booking in to identify those at

risk of VHF/MERS-CoV (Section 6.4)

Initial triage: A&E room E4 – more detailed questioning (Section 6.5 and 6.6) wearing as a minimum

gloves, apron and FFP3 mask or Enhanced PPE if high risk already established or suspected

Initiate the communication chain to inform necessary staff (Section 6.3)

Risk Assessment: A&E room E4. Use ‘VHF Box’ for written guidance and equipment

Consultant assessment (follow Sections 6.5, 6.6 and 6.7) wearing enhanced PPE (section 6.23)

Nurse in charge closes surrounding corridor and creates a contact list

Discuss the case with the ID team (RVI) and Consultant Medical Microbiologist to arrange urgent

transfer to the RVI (Section 6.9) or to UCL high level isolation unit (Appendix 1).

In the meantime, follow the general instructions described in Section 6.7.

Update the communication chain (Section 6.3)

If (blood) testing for VHF is advised by the Newcastle ID team refer to Section 6.10 & Appendix 2

Decontamination of the side room once vacated (Section 6.13)

In the unlikely event that transfer to the RVI is not possible and patient assessed as high risk of VHF:

Patient will be moved to room 2 on the SSU (Sections 6.11 and 6.12)

Other useful sections for quick reference:

Background: Section 1

Decontamination of spillages and clinical waste: Section 6.20

Decontamination of persons accidently exposed to blood or bodily fluids: Section 6.21

PPE: Section 6.23 and appendix 3

After death care: Section 6.19.1

High risk of VHF established

All GP referrals should be screened (Section

6.4 and 6.5) and if risk established -> referral

should be re-directed to the Newcastle ID

team (Section 6.4, Appendix 1)

If ID advise admission to the QE

Section 6.4

Low possibility or VHF

felt to be unlikely

See section

6.8


6.2 QUICK REFERENCE GUIDE FLOWCHART FOR THE MANAGEMENT OF MERS-CoV

All patients attending A&E should be screened

at the time of booking in to identify those at

risk of VHF or MERS-CoV (Section 6.4)

Initial triage: A&E room E4 – more detailed questioning (Section 6.5 and 6.6) wearing as a minimum

gloves, apron and FFP3 mask or Enhanced PPE if high risk already established or suspected

Initiate the communication chain to inform necessary staff (Section 6.3)

Risk Assessment: A&E room E4. Use ‘VHF Box’ for written guidance and equipment

Consultant assessment (follow Section 6.5, 6.6 and 6.7) wearing enhanced PPE (section 6.23)

Nurse in charge closes surrounding corridor and starts contact list

Discuss the case with the ID team (RVI) and Consultant Medical Microbiologist to arrange urgent

transfer to the RVI (Section 6.18) or to UCL high level isolation unit (Appendix 1).

In the meantime, follow the general instructions described in Section 6.7 and 6.16.

Update the communication chain (Section 6.3)

If (respiratory / blood) testing for MERS-CoV is advised by the Newcastle ID team, refer to Section

6.17 which also describes what to do with regards to CXR, ECG etc.

Decontamination of the side room once vacated (Section 6.13)

In the unlikely event that transfer to the RVI is not possible and patient assessed as high risk of MERS-

CoV:

Patient will be moved to room 2 on the SSU (Sections 6.11 and 6.12)

Other useful sections for quick reference:

Background: Section 1

Decontamination of spillages and clinical waste: Section 6.22 for MERS-CoV

PPE: Section 6.23 and appendix 3

After death care: Section 6.19.2

High risk of MERS-CoV established

All GP referrals should be screened (Section

6.4, 6.5) and if risk established -> referral

should be re-directed to the Newcastle ID

team (Section 6.4) and appendix 1

If ID advise admission to the QE

Section 6.4

Low possibility /or

MERS-CoV unlikely

See section

6.8


6.3 Communication Chain

Timely and accurate communication is essential when dealing with possible cases of VHF or MERS-

CoV to ensure that all relevant staff are aware of the situation promptly. The following section lists

which members of staff need to be informed should a suspected case of VHF or MERS-CoV attend

A&E or be admitted and outlines a cascade communication plan.

a. A&E Receptionist (booking in) or clinician accepting GP referrals MUST inform the

following staff:

� Duty triage nurse

� Nurse in-charge of A&E

b. Nurse in charge of A&E (for 999 ambulance admissions) MUST inform the following staff:

� The Duty A&E Consultant (overnight the on call Consultant should be informed)

� Senior Nurse (Bp 3039) / Clinical Bed Manager. Overnight: Bp 1200.

� The Infection Prevention Control nursing team (Monday to Friday between 0800-

1700) or the duty Consultant Medical Microbiologist (1700-0900) via switchboard.

� The Waste manager (0900-1700 Mon-Fri: Sustainability, PAM and waste manager (Ext

2456). Out of hours: Inform the above contact first thing the next morning.

c. The Duty A&E Consultant MUST inform the following staff:

� Consultant Medical Microbiologist (0900-1700: Bp 2092; 1700-0900 via switch).

� ID Consultant on call at Newcastle Hospitals (via Newcastle hospitals switch – 0191

233 6161).

� The Duty Medical Consultant on the Short Stay Unit (0900-1700) or the on call medical

consultant (1700-0900)

d. The Senior nurse MUST inform the following staff:

� On Call senior manager (SLM)

e. The Consultant Medical Microbiologist MUST inform:

� Senior biomedical scientist in the laboratory (Ext 6649) to arrange for category A

transport and processing of laboratory samples as specified by laboratory SOP.

� Duty Consultant Virologist at Newcastle Hospitals (0900-1700: 0191 28 then 21104,

21102 or 21105; 1700-0900: Via Newcastle switch – 0191 233 6161).

� Public Health England /Health Protection Unit. (0900-1700: 0300 303 8596: Ask for

‘The Consultant in the office’ or 1700-0900: 0191 269 7714 – ‘Consultant on call’).

� The Infection Prevention Control Nursing Team (Monday to Friday 0800-1700).

f. The Consultant Virologist will inform:

� Imported Fever Service 0844 7788990 to arrange testing.

g. The Infection Prevention Control Nursing Team MUST inform:

� The Waste manager (contact details in part b).

h. The on call senior manager MUST inform the following staff:

� On call Director – via switchboard

� Medical Director / Director of Infection Prevention and Control


� The Chief Executive’s office.

6.4 Identifying at risk patients

• All patients who self-refer to A&E should be assessed for risk of VHF, MERS-CoV and

Avian Influenza promptly.

• On arrival in A&E, patients should be asked if they have travelled or worked outside

of Europe, Australia / New Zealand or North America in the last 21 days. If they have,

a formal assessment should be conducted by the triage nurse as soon as possible as

per sections 6.5 and 6.6.

• Posters will be displayed in A&E advising patients meeting the above criteria to

inform a member of staff to initiate a prompt assessment.

• Any member of clinical staff (nursing or medical) receiving a referral for admission of

a patient with a history of fever and foreign travel should enquire about risk factors

for VHF, MERS-CoV or Avian Influenza (see section 6.5). If significant risk factors are

identified, the referral should be redirected to the Infectious Diseases Unit at the

Royal Victoria Infirmary Hospital (RVI), Newcastle (Appendix 1). Patient referrals risk

assessed as “High Possibility of VHF, MERS-CoV or Avian Influenza” should always

be re-diverted to the RVI (after discussion with the Infectious Disease team).

• If a patient is referred who is considered at risk of VHF, MERS-CoV or Avian Influenza

and must attend Gateshead Health NHS Foundation Trust (GHNHSFT) for further

assessment, the communication chain must be initiated immediately (section 6.3)

and the appropriate room and surrounding area prepared (Appendix 5).

• On arrival, patients should enter A&E through the ambulance entrance (Appendix 4).

They must be met at the entrance by staff wearing PPE (sections 6.23) and escorted

directly to either room E4 in A&E (for initial assessment) or room 2 on the Short Stay

Unit (the latter is preferable for cases considered to be higher risk).

• Conduct the initial assessment as set out in sections 6.5, 6.6 and 6.7.

• A risk assessment should also be performed for accompanying visitors.

6.5 Patient Risk Assessment Algorithm

Use the following links to locate the most up to date risk assessment algorithms to assess

the risk of VHF, MERS-CoV and Avian Influenza:

VHF:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/478115/

VHF_Algo.pdf

MERS-CoV:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543560/

MERS-CoV_case_algorithm.pdf

Avian Influenza - H7N9 (China)

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/35867

3/Investigation_and_management_of_possible_human_cases_of_avian_influenza_A_H7

N9__flow_diagram_July_new.pdf

Avian Influenza – H5N1

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/35867

5/Case_management_of_suspected_human_case.pdf


6.6 Initial risk assessment in A&E

Patients (including children) identified whilst booking into the department at A&E reception

as being at risk of VHF, MERS-CoV or Avian Influenza should ideally be escorted directly and

immediately to A&E room E4 (Appendix 4) which should be prepared (as outlined in

Appendix 5). The initial formal risk assessment will be carried out by senior staff wearing

appropriate PPE (section 6.23).

If room E4 is occupied, the patient in room E4 should immediately be moved to any

available alternative room or location and the room prepared (Appendix 5). In the

meantime, the patient should be taken to any vacant single room and kept apart from

other patients, relatives and members of staff. Any room used as a transit location must be

taken out of use once vacated until the risk assessment is completed and appropriate

cleaning carried out. All staff having contact with the patient should wear appropriate PPE.

All necessary equipment and crib sheets for the management of a possible case of

VHF/MERS-CoV in A&E can be found in the ‘VHF/MERS box’ which is located behind the

main nursing hub in A&E or in the Majax store room (Appendix 6).

Whilst the initial assessment is conducted, the connecting corridor should be closed off to

through traffic (as shown in Appendix 4). Room E3 should be vacated. Appendix 7 shows

the location at which staff members should don and doff PPE in the corridor outside the

room utilising the ‘red, amber and green’ areas appropriately. Posters on the wall here

demonstrate the process and lines marked on the floor show the designated areas.

A summary of the locations designated for nursing patients with possible VHF/MERS-CoV is

listed in Appendix 8 along with some key characteristics of these rooms and advice

regarding surrounding locations.

Initial Contacts: The nurse in charge must make a list of all staff, patients and the public

who had contact with the possible case. This should be given to the infection control team

who will then liaise with PHE/HPU regarding follow-up / required public health actions. Any

ambulance used to transport the patient to A&E must be appropriately decontaminated.

6.7 Risk Assessment Process

Staff performing the initial risk assessment should as an absolute minimum put on gloves

and a plastic apron (plus an FFP 3 mask if MERS-CoV or Avian Influenza is suspected) before

escorting the patient to the side room or entering the room to question the patient.

If risk has already been established (e.g. GP referral or information deemed from booking

process) then nursing and medical staff conducting the initial risk assessment process MUST

don enhanced PPE (section 6.23). This is particularly important if the patient has respiratory

symptoms, D&V, bleeding or bruising or if there is any other concern that there may be

inadvertent contact with the patient’s body fluids. Similarly, if the patient will require

assistance (e.g. to transfer) enhanced PPE should be worn from the outset.

Staff should familiarise themselves with this document and print the appropriate risk

assessment algorithm (section 6.5) identifying key incubation periods and geographical

distribution of salient viral infections (section 1.2).

Initial questioning should ascertain the likelihood that the patient may have VHF, MERS-CoV

or Avian Influenza. Direct physical contact should be avoided if at all possible until the


patient has been questioned and their risk category established. Key points to ascertain

from the history are:

� Exact locations visited (including dates of visit).

� Exact timings of travel.

� A brief surmise of symptoms (notably establishing if patient has had a fever in the

last 24 hours, bleeding or respiratory symptoms).

� Any contacts with patients suffering from VHF or MERS-CoV.

� Any poultry / animal contacts (Avian Influenza).

Following initial questioning, if it is possible that the patient will be categorised in the “High

Possibility of VHF/MERS-CoV or Avian Influenza” group, enhanced PPE should be worn (see

section 6.23) before measuring the patient’s temperature. Further observations (e.g. blood

pressure, oxygen saturation) and clinical examination should be deferred unless deemed

absolutely essential for immediate patient management. Finger prick blood glucose

monitoring and urine dipstick testing should not be performed.

• Paperwork and IT devices including ipads for Vitalpac observations should not be

taken into the patient’s room unless it can be left inside.

• Relatives or friends who have accompanied the patient should be asked if they have

also had symptoms of fever in the past 24 hours. If they report symptoms of fever

they should be escorted to the side room with the patient for a risk assessment. If

they do not report a history of fever in the previous 24 hours they should be either

sent home by the nearest exit or be allowed to wait in the adjacent closed rooms

(e.g. Room E3 in A&E or room 1 on the short stay unit).

• Areas that the patient has passed through and spent minimal time in (e.g. the waiting

room and the corridor) but which are not visibly contaminated with body fluids do

not need to be specially cleaned and disinfected in the event of VHF risk. For MERS-

CoV, any area where the patient has been coughing should be decontaminated

(section 6.22, 6.13).

• If contamination of the environment with the patient’s body fluids occurs outside of

the side room, it should be decontaminated using the methods specified in section

6.13 by staff wearing appropriate PPE.

Cases must be discussed at the earliest possible opportunity with the duty Medical

Microbiologist (0900-1700: bleep 2902, 1700-0900: Via Switchboard), Infection Control

Nursing Team (Monday to Friday 0800-1700) and the duty Infectious Diseases doctor at

the RVI, Newcastle (via Switchboard).

The duty Medical Microbiologist will inform the Health Protection Unit about the case.

Together with the on call Medical Microbiologist and/or Infectious Diseases Team, an

assessment should be made following the algorithms (section 6.5) to establish the

likelihood of VHF, MERS-CoV and/or Avian Influenza.

Cases with HIGH possibility of VHF/MERS-CoV/Avian Influenza

Should be discussed immediately with the Regional Infectious Diseases unit at the RVI

and where possible transferred there without further investigation (see section 6.9).

Cases with LOW possibility of VHF/MERS-CoV/Avian Influenza

Refer to section 6.8.


Cases where VHF/MERS-CoV/Avian Influenza are excluded

If the patient does not meet the case definitions for VHF/MERS-CoV or Avian influenza, they

should be managed as clinically appropriate without additional precautions and can be

transferred to the Assessment Suite for further assessment. Standard cleaning of the

location of the initial assessment should be carried out by domestic services.

6.8 Management of a Patient Categorised as “Low Possibility of VHF/MERS-CoV/Avian

Influenza”

In these patients, a risk assessment will be conducted by the duty Medical microbiologist,

responsible consultant (+/- Infectious Diseases team). The key questions that will be:

� What level of risk is present?

� What investigations are required (e.g. Is VHF or MERS-CoV testing

indicated? If so, follow the guidance in section 6.10, 6.17 / Appendix 2).

What other investigations are required to look for other travel related

illnesses e.g. malaria etc)?

� What form of isolation and infection control precautions are required

pending the results of these investigations?

• If, in spite of the ‘low possibility of VHF/MERS-CoV/Avian Flu’, this is still considered

to be on the list of differentials, it may be decided that the safest way to proceed is

to follow the pathway for patient’s at higher risk. If this is the case, the patient should

be moved to room 2 on SSU and you should follow the ‘high possibility’ pathways

pending the results of investigations. Enhanced precautions (e.g. vacating rooms 1

and 3) and sealing the room 1-3 annex on SSU may not be deemed necessary in such

circumstances but this will be decided by the duty Microbiologist and SSU Consultant.

• If within the case definition of ‘low possibility of VHF/MERS-CoV/Avian Influenza’,

this diagnosis is felt to be extremely unlikely, after a thorough risk assessment, the

duty microbiologist, responsible consultant and infection control team may decide

that it would be safe to manage the patient in a standard side room on the

Assessment Suite (with an en-suite toilet). If this is the case:

• Standard contact precautions apply: hand hygiene, disposable gloves and a plastic

apron. Eye protection and fluid repellent surgical facemask should be worn for splash

inducing procedures. An FFP3 respirator mask should be worn for aerosol generating

procedures (e.g. endotracheal intubation or airway suctioning) and if MERS-CoV or

Avian Influenza is considered possible.

• Patient observations, including temperature, blood pressure and oxygen saturation,

should be measured as normal. Finger prick blood glucose and urine dipstick testing

may be performed if indicated.

• Investigations can proceed following standard precautions. Malaria testing should be

performed and blood cultures taken, with additional investigations requested as

appropriate. A haematology laboratory staff member must be informed that these

samples are being sent and that the patient has been risk assessed and categorised

as “Low Possibility of VHF”. Samples from suspected cases of VHF must be double-

bagged, and clearly labelled “Low Possibility of VHF”. The haematology staff member

will then liaise with biochemistry and microbiology laboratory staff and pathology

reception as necessary. The patient can attend the radiology department for a chest

x-ray unless otherwise inappropriate (e.g. diarrhoea and vomiting).


• The patient should be managed clinically pending further results, with treatment (e.g.

fluids, oxygen, antibiotics) given as deemed appropriate. Once the malaria test and

blood results are available further management may be discussed with the regional

Infectious Diseases unit at the Royal Victoria Infirmary if required.

• The communication chain (Section 6.3) should be updated and case discussed with

the duty Consultant physician on the assessment suite.

6.9 Initial management and transfer of a patient categorised as “high possibility of VHF”

The doctor who makes or confirms a risk assessment categorisation of “high possibility of

VHF” should personally contact the on call Infectious Diseases doctor at the Royal Victoria

Infirmary to request immediate patient transfer. They will require the patient’s full travel

history, details of any risk activities and their clinical presentation and symptom onset date.

The infectious diseases unit will arrange transport and will advise on further patient

management, including any further examination, investigation or treatment necessary

whilst awaiting transfer. The patient should REMAIN in Room E4 in A&E until transfer with

the door kept CLOSED. Further direct patient contact, including observations and clinical

examination, should only be performed if essential for patient management. A commode,

disposable bedpan and/or urine bottles should be provided.

Dedicated transfer will be arranged by the Infectious Diseases Team in conjunction with the

North East Ambulance Service via specialised ambulance crewed by staff wearing enhanced

PPE. Prior to transfer to the ambulance the route to the Ambulance entrance should be

cleared of patients and staff prior to patient being escorted by staff wearing enhanced PPE.

Transfer is dependent on capacity at the regional Infectious Diseases unit, and in

exceptional circumstances a patient may need to remain at Gateshead Health NHS

Foundation Trust until the diagnosis is confirmed. In such circumstances, the patient

should be transferred to room 2 on the Short Stay Unit (SSU) (See section 6.12 for further

details). Prior to transfer, the bed manager should be asked to clear any patients in rooms

1, 2 and 3 immediately to enable the room to be vacated, cleaned and prepared for the

new patient (Appendix 5). Refer to the bed escalation protocol.

• All staff entering the room should wear enhanced VHF PPE – see section 6.23.

• The number of staff in contact with the patient should be restricted and a contact list

maintained (forms for this are kept in the VHF box in A&E). If further medical

assessment is necessary, this should be performed by a senior member of the team

familiar with the use of VHF PPE to minimise the need for multiple assessments.

• If clinical examination is necessary, disposable equipment should be used along with

a dedicated stethoscope. Any equipment taken in must be left in the room after use,

including the thermometer, blood pressure monitor and pulse oximeter used for

patient observations. Finger prick blood glucose monitoring and urine dipstick testing

should not be performed. Equipment used for venepuncture or cannulation should

remain in the room - only the blood sample bottles collected should be removed

(appendix 2).

• Disposable crockery and cutlery should be used where possible. Non-disposable

items must not be removed from the room.


• Clinical waste, including vomit, faeces and urine, should remain in the side room with

the patient. Fluid waste should not be poured down the sink - any clinical waste (e.g.

bed pan or vomit bowl contents) should first be solidified with high-absorbency

granules before being sealed in a yellow clinical waste bag. This should then be

double-bagged in a second yellow clinical waste bag, sealed and left in the room.

Waste will be removed every 24 hours under the supervision of the waste manager.

• Patients must use a bed pan/commode for toileting. The contents of the bedpan or

commode must be solidified with high-absorbency granules before being sealed in a

yellow waste bag and then double bagged.

• Water used for washing the patient should be placed in a bowl and absorbed using

high-absorbency granules before being sealed in a yellow waste bag and the double

bagged.

• The patient should be managed clinically pending transfer, with treatment (e.g.

fluids, oxygen, antibiotics) given as appropriate, as advised by the infectious diseases

unit. If blood transfusion is required O negative blood should be used as the

laboratory will be unable to perform blood grouping.

• Patient communications and family support/liaison: Patients and their relatives will

be informed of the possible diagnosis, treatment plans and reasons for the enhanced

infection control precautions.

• Visitors: will NOT be able to have physical contact whilst the patient remains

infectious. Staff will make all efforts to enable the patient in isolation to

communicate with relatives via mobile telephones, patient line or other electronic

devices (e.g. iPads) where possible.

6.10 Investigations for a Patient Categorised as “High Possibility of VHF”

If blood testing prior to transfer is advised by the regional infectious diseases unit, the

GHNHSFT doctor who assessed the patient should personally contact the duty Medical

Microbiologist (bleep 2092 0900-1700 or via switchboard 1700-0900) to arrange for the

blood tests to be processed using special precautions.

The duty Medical Microbiologist will liaise with the laboratory but medical staff must also

contact a haematology laboratory staff member when the samples are ready to be

transported so they can be met at specimen reception.

Blood samples should not be transported to the laboratory before speaking to the duty

Medical Microbiologist.

• Blood should be collected for FBC, malaria, clotting, U&Es, LFTs, CRP, glucose and

blood cultures (appendix 2). Biochemistry will routinely perform additional assays

including bicarbonate and lactate to prevent the need for add on tests. A 7.5 mL red

top EDTA blood sample and a 7.5 mL brown top serum sample should also be

collected for a VHF screen. Paediatric equivalent blood bottles may be used when

essential. Note that 0.5 mL serum is the minimum sample for VHF testing but a full

imported infections screen may not be possible with this amount and a larger volume

is preferable.


• Any visible blood on the outside of each sample bottle should be wiped off with a

chlorhexidine / alcohol wipe. The samples should then be double-bagged in specimen

bags which are sealed inside the patient’s room. These should then be dropped into a

rigid transport container held by an assistant standing outside the room wearing PPE

(see appendix 2 and 3). Blood samples should be carried to the laboratory in the

transport container and must not be sent through the pneumatic transport pod

system. Samples should be transported by a member of the medical or nursing team

(not a porter). The sample should be taken directly to the main pathology reception

of the QE pathology laboratory. As the sample is safely contained within the

transport container, there is no need for this member of the team to wear PPE.

Laboratory staff members (haematology and microbiology) should be informed

when the samples are ready to be transported to the laboratory so they can be met

at reception in pathology.

• Blood bottles should be labelled before entering the room and yellow “Danger of

Infection” stickers should be applied to each bottle and to each request form. The

request forms should be labelled “High Possibility of VHF”. Forms should not be

taken into the patient’s room. Request forms must not be placed in the sample bags

with the blood bottles or put in the container used to transport them – they should

be carried outside of the container.

• Standard procedures should be followed when collecting blood samples, including

the use of aseptic non-touch technique (ANTT).

• Arterial blood gas sampling should not be performed, as the samples cannot be

safely processed. Finger prick glucose testing should also not be performed.

• Laboratory staff will meet the staff member transporting the sample to pathology in

pathology main reception. They will then follow the laboratory SOP ‘MC-RIS-FOR-

005.QE’ for handling such samples.

• Subsequent blood tests should be kept to a minimum and only taken at the request

of an ID Consultant or responsible Consultant if deemed essential for management.

• Urine dipstick testing should not be performed.

• A chest x-ray should only be performed in exceptional circumstances if it is essential

for immediate patient management. In most cases a chest x-ray can be deferred until

the results of the VHF screen are available. If required a portable film should be

obtained in the side room. The radiographer must wear VHF PPE as detailed in

section 6.23. The x-ray cassette must be protected from direct contact with the

patient using a yellow clinical waste bag, which should then be removed and

disposed of during removal of the VHF PPE. Once used the portable x-ray machine

should remain in the patient’s room until the results of the VHF screen are available.

• An ECG should only be performed in exceptional circumstances if it is essential for

immediate patient management. If required the ECG machine should remain in the

patient’s room until the results of the VHF screen are available.

6.11 VHF Screen and Further Management

• Once the malaria screen and other blood results are available the need for processing

the VHF screen should be assessed. Patients who have tested positive for malaria

may not require screening. This decision should be made on an individual patient


basis. Patients who have reported contact with a known or strongly suspected case

of VHF, handled clinical specimens from such a case or have visited a current VHF

outbreak area should be screened regardless of a positive malaria result. If a

patient is strongly suspected to have VHF clinically it may be appropriate to begin

arranging the VHF screen before the malaria result is available.

• If indicated, the duty Medical Microbiologist will make arrangements for the

laboratory to send the VHF screen to the Rare and Imported Pathogens Laboratory

(RIPL) in Porton Down, Salisbury for testing. This requires liaison with the Imported

Fever Service, who will make the final decision on whether testing will proceed. A

result should normally be available within 24 hours. RIPL will normally test in parallel

for other agents likely to cause similar presentations that occur in the country of

origin e.g. dengue, rickettsial infections, leptospirosis.

• A patient who is strongly suspected to have VHF based on their contact history and

clinical picture (i.e. haemorrhagic features) should be discussed with the High Level

Isolation Unit (HLIU) at the Royal Free hospital, London without waiting for the

results of the VHF screen (see appendix 1 for contact details).

• The duty Medical Microbiologist will inform the local Health Protection Unit (Public

Health) and the Infection Prevention and Control Team (duty Matron out of hours)

that screening is being undertaken.

• Patients who require screening for VHF and require medical admission should

remain in room 2 on the SSU until the results of the VHF screen are available

(unless transferring to the regional Infectious Diseases unit at the Royal Victoria

Infirmary or UCL). Infection control precautions, including the use of VHF PPE,

should be maintained.

• If further blood testing is essential before VHF screen results are available, the

procedure in appendix 2 should be followed. See section 6.10 for permitted

investigations.

• If a patient requires VHF screening but is judged not to require admission then

provided they can isolate themselves at home and they have their own means of

private transport they may be allowed to leave the hospital. This should first be

discussed and agreed with the local Health Protection Unit. Contact details must be

taken so the results of the VHF screen can be communicated and further

management arranged as appropriate, with daily review by telephone in the interim.

Patients should exit A&E through a side door out of the building.

• If a patient’s risk categorisation is stepped down as the result of a positive malaria

film and VHF screening is not required please refer to section 6.8. A risk assessment

regarding onward care and infection control requirements needs to be made.

6.12 Transfer of a Patient Categorised as “High Possibility of VHF” to room 2 on the Short Stay

Unit (SSU)

• Patients categorised as “High Possibility of VHF” should always ideally be

transferred to the regional Infectious Diseases unit at the Royal Victoria Infirmary

(RVI) Hospital after discussion with the on call Infectious Diseases Consultant at the

RVI. These patients should remain in room E4 in A&E until dedicated transfer can

occur via specialised ambulance crewed by staff wearing enhanced PPE (section 6.9).


• In exceptional circumstances, if insufficient capacity exists to transfer the patient, a

decision may be taken to manage the patient at QE pending the result of the VHF

screen (which may take up to 24 hours). In such cases, the patient will need to be

transferred to a room with facilities to accommodate them for this time period.

• In such circumstances, the patient should be moved to room 2 on the SSU. This room

has been chosen as it offers side room accommodation and surrounding facilities for

staff to don and doff PPE whilst minimising disruption to the rest of the unit. The

room has negative pressure ventilation and the area can be sealed off.

• Prior to transfer from room E4 in A&E, this room needs to be fully prepared with the

surrounding area cleared (Appendix 5). Patients in the rooms 1,2 and 3 will need to

be re-located immediately (as per the bed escalation protocol) and the rooms

cleaned. Portable curtains should be put into place at the head of the corridor to

rooms 1,2 and 3 to restrict through traffic through this area to essential personnel

caring for the patient only.

• When the room is ready for the patient, the pre-defined route should be cleared of

members of the public, patients and other staff members in preparation for transfer.

The pre-defined route is shown in Appendix 4 along the back corridor and using the

lifts to the rear of the emergency care centre. All patients on the SSU should be asked

to remain in their rooms with doors closed whilst the index case and escorting staff

move from the lift area to room 2 (turning right out of the lift then right in the SSU

and left towards room 2).

• The patient will be transferred by nursing and/or medical staff wearing enhanced

VHF PPE (section 6.23). If they are sufficiently mobile the patient should walk

unaided. If a chair or trolley is required for the transfer it should remain with the

patient in their new room in case subsequent transfers are required.

• Having transferred the patient into room 2 on the SSU, accompanying staff should

remove their PPE in the gowning area as described in appendix 4 and 7 following the

procedure set out in appendix 3.

• Areas that the patient has passed through and spent minimal time in (such as

corridors) but which are not visibly contaminated with body fluid do not need to be

specially cleaned and disinfected.

• If contamination of the environment with the patient’s body fluid occurs during the

transfer it should be decontaminated using the methods specified in section 6.13 by

staff wearing VHF PPE.

• Any non-disposable equipment used (e.g. blood pressure monitor, thermometer,

pulse oximeter) should either transfer with the patient or remain in the A&E side

room for decontamination.

• In room 2 on the SSU, the patient should not use the en-suite facilities for toileting

but instead use a commode. Fluid waste should not be poured down the sink. Any

clinical waste (e.g. bed pan, commode or vomit bowl contents) should first be

solidified with high-absorbency granules before being sealed in a yellow clinical

waste bag. This should then be double-bagged in a second yellow clinical waste bag,

sealed and left in the room.


• Appendix 7 outlines the utilisation of red, amber and green zones in the area outside

room 2 on the SSU and illustrates the flow of staff through these areas.

• Follow the guidance laid out in Section 6.9 regarding waste, visitors and general

infection control principles. Waste will be removed every 24 hours under the

supervision and direction of the waste manager.

6.13 Decontamination of a side room following use by a patient categorised as “High

possibility of VHF”

If a patient remains categorised as “High Possibility of VHF” (i.e. the diagnosis has not been

confirmed or excluded) the side room must be decontaminated before being reused by

staff wearing enhanced PPE (section 6.23). This process will be supervised by the infection

control team and waste manager. Full decontamination involves utilising hydrogen

peroxide fogging equipment (which is not currently available locally so will have to be hired

in). In the meantime, the contaminated room MUST be kept sealed and out of use.

• Any clinical waste (e.g. bed pan or vomit bowl contents) should first be solidified with

high-absorbency granules before being sealed in a yellow clinical waste bag. This

should then be double-bagged in a second yellow clinical waste bag and sealed.

• Laundry and any other waste (e.g. food containers) should be bagged in this manner.

The sharps bin should be closed. Staff should wear VHF PPE when handling any waste

or laundry. Waste bags should not be removed from the room until hydrogen

peroxide fogging has occurred; this includes any room used for waste overspill.

• If there is no visible contamination of the side room with the patient’s body fluids,

then the room surfaces should first be cleaned with freshly prepared hypochlorite

solution containing 1,000ppm available chlorine. Following cleaning the room should

be fogged with hydrogen peroxide (isolating fire alarms first).

• If visible contamination of the side room with the patient’s body fluids has occurred

the spillages must be terminally cleaned with 10,000ppm available chlorine solution

prior to being fogged with hydrogen peroxide.

• Any commode used should be disinfected with hypochlorite solution containing

10,000ppm available chlorine prior to removal from room.

• Once the room has been decontaminated, yellow clinical waste bags and the sharps

bin must be put into a yellow griff bin (drum) with a yellow lid, sealed and clearly

labelled by the end user. The griff bins (drums) are to be put into a designated yellow

clinical waste cart which is to be locked and clearly labelled by the end users. Contact

the waste manager for necessary transportation arrangements for disposal or refer

to the waste policy regarding VHF treatment of waste.

6.14 Management of a Patient with a Negative VHF Screen

Ongoing management decisions should be made in conjunction with the regional Infectious

Diseases team at the RVI. The communication chain should be updated (Section 6.3).

• The duty microbiologist will inform the local Health Protection Unit and the Infection

Prevention and Control Team of the negative VHF result.


• If no other diagnosis has been confirmed and the patient continues to be febrile the

same level of infection control precautions may need to be maintained initially.

• If an alternative diagnosis has been confirmed and/or the patient has remained

afebrile for 24 hours then infection control precautions may be stepped down.

Standard contact precautions should still be applied: hand hygiene, disposable gloves

and a plastic apron. The patient should continue to be managed in a side room but

may be transferred to another ward. The vacated side room should be cleaned

following standard inpatient protocol before being re-used.

6.15 Management of a Patient with Confirmed VHF

Patients confirmed to have VHF on testing should be transferred to the High Level Isolation

Unit (HLIU) at the UCH, London. The transfer will be arranged by HLIU staff.

• The duty Medical Microbiologist will inform the local Health Protection Unit (Public

Health) and the Infection Control Team of the positive VHF result.

• An Incident Control Team should be convened (Appendix 9), including Public Health

and Trust representatives. If the patient was transferred to the regional Infectious

Diseases unit prior to confirmation the team should involve both Trusts.

• Pending transfer, staff members should continue to wear enhanced VHF PPE. The

number of staff in contact with the patient should continue to be restricted.

• A list of all staff that have been in direct contact with the patient should be compiled.

Contacts will be managed in accordance with the recommendations of the Incident

Control Team.

• Following a VHF positive patient discharge, the room used to house the patient will

need to be decontaminated via fumigation by staff wearing full PPE. Procedures for

decontamination will be established in consultation with HLIU staff. The equipment

required to fumigate the room will have to be hired in. In the meantime, the room

should be locked and kept out of use (section 6.13).

6.16 Initial Management of a Patient categorised as High possibility of MERS-CoV or Avian

Influenza

• Only essential staff should enter the room. All staff entering the room should wear

enhanced respiratory PPE including fit tested FFP 3 masks – see section 6.23.

The doctor who makes or confirms a risk assessment categorisation of “High

Possibility of MERS-CoV or Avian Influenza” should personally contact the on call

Infectious Diseases doctor at the Royal Victoria Infirmary to request immediate

patient transfer. They will require the patient’s full travel history, details of any risk

activities and their clinical presentation and symptom onset date. The infectious

diseases unit will arrange transport and will advise on further patient management,

including any further examination, investigation or treatment necessary whilst

awaiting transfer. The patient should REMAIN in A&E room E4 until transfer with

the door kept CLOSED (so long as transfer can be arranged within 1 hour). Further

direct patient contact, including observations and clinical examination, should only

be performed if essential for patient management. A commode / disposable

bedpans and/or urine bottles should be provided.

Dedicated transfer will be arranged by the Infectious Diseases Team in conjunction

with the North East Ambulance Service via specialised ambulance crewed by staff

wearing enhanced PPE. Prior to transfer to the ambulance, the route to the

ambulance entrance should be cleared of patients and staff prior to patient being

escorted by staff wearing enhanced PPE.


Transfer is dependent on capacity at the regional Infectious Diseases unit, and in

exceptional circumstances a patient may need to remain at Gateshead Health NHS

Foundation Trust until the diagnosis is confirmed. In such circumstances, the

patient should be transferred to room 2 on the SSU (see section 6.12).

Prior to transfer, the bed manager should be asked to clear any patients in beds 1, 2

and 3 on the SSU immediately to enable the room to be vacated, cleaned and

prepared for the new patient.

• The number of staff in contact with the patient should be restricted and a contact list

maintained (forms for this are kept in the VHF box in A&E). This list should be kept

outside the room. If further medical assessment is necessary this should be

performed by a senior member of the team who is familiar with the use of PPE and

has been ‘fit tested’ to minimise the need for multiple assessments.

• If clinical examination is necessary, disposable equipment and a dedicated

stethoscope should be used. Any equipment taken in must be left in the room after

use, including the thermometer, blood pressure monitor and pulse oximeter used for

patient observations. Equipment used for venepuncture or cannulation should

remain in the room - only the blood sample bottles collected should be removed

(appendix 2). Use of equipment that re-circulates air (e.g. fans) should NOT be used.

6.17 Investigations for a patient categorised as “High possibility of MERS-CoV”

A chest X-ray is needed as part of the diagnostic procedure. This should be obtained in

the side room using portable x-ray equipment. To undertake this test the following

should be followed:

- Inform the on call radiographer.

- The radiographer must wear PPE (section 6.23) and have been ‘fit tested’ for their

FFP3 mask.

- The x-ray cassette must be protected from direct contact with the patient using a

yellow clinical waste bag, which should then be removed and disposed of during

removal of the PPE.

- The x-ray equipment must be cleaned with 1,000 ppm Chlor clean solution after

use.

A FBC, U&E, LFT, Clotting, CRP, Lactate and blood cultures +/- malaria film should also be

sent with all samples labelled as ‘biohazard’.

Diagnostic viral testing should be discussed with the duty Medical Microbiologist who will

in turn discuss with the on call virologist in Newcastle +/- the reference laboratory. Lower

respiratory tract samples (e.g. sputum or BAL) offer the most accurate results. If it is not

possible to obtain such a sample, then an upper respiratory tract sample should be sent

(e.g. nose and throat swab) using a standard viral swab (such as that used for Influenza

testing). A serum (yellow top bottle) blood sample should also be sent for testing. At

present, the samples are sent to the Manchester PHE reference laboratory.

Samples should be labelled on the ward as a ‘biohazard’ and double bagged as outlined in

section 6.10. The clinician or nursing staff should then phone the microbiology laboratory

prior to delivery so that a biomedical scientist can be waiting in pathology reception to take

delivery of the sample. On arrival at the Microbiology laboratory samples will be

appropriately packaged and couriered to the reference laboratory according to the

laboratory SOP ‘MC-RIS-FOR-005.QE’.


6.18 Transfer of a patient categorised as “High possibility of MERS-CoV”

• Patients categorised as “High Possibility of MERS-CoV” should always ideally be

transferred to the regional Infectious Diseases unit at the Royal Victoria Infirmary

(RVI) Hospital after discussion with the on call Infectious Diseases Consultant.

These patients should remain in A&E room E4 until dedicated transfer can occur via

specialised ambulance crewed by staff wearing enhanced PPE (see section 6.9).

• In exceptional circumstances, if insufficient capacity exists to transfer the patient, a

decision may be taken to manage the patient at QE pending the result of the MERS-

CoV screen (which may take up to 24 hours). In such cases, the patient will need to

be transferred to a room with facilities to accommodate them for this time period.

• In such circumstances, the patient should be moved to room 2 on the SSU. This room

has been chosen as it offers side room accommodation with en-suite toilet facilities

and surrounding facilities for staff to don and doff PPE whilst minimising disruption to

the rest of the unit. The room has negative pressure ventilation and the area can be

sealed off.

• Prior to transfer from room E4 in A&E, this room needs to be fully prepared

(Appendix 5) with the surrounding area cleared. Ideally, the corridor concerned

should contain doors that can be sealed (if required). Through traffic through this

area should be minimised to essential personnel caring for the patient only.

• When the room is ready for the patient, the pre-defined route should be cleared of

members of the public, patients and other staff members before and during the

transfer process in preparation for transfer. The pre-defined route is shown in the

diagram in Appendix 4 and described in section 6.12.

• The patient will be transferred by nursing and/or medical staff wearing enhanced PPE

including a FFP3 mask (section 6.23). If they are sufficiently mobile the patient should

walk unaided whilst wearing a surgical mask. If a chair or trolley is required for the

transfer it should remain with the patient in their new room in case subsequent

transfers are required.

6.19.1 After Death Care of a patient with VHF

If a patient dies who is confirmed or suspected to have VHF (either categorised as “High

Possibility of VHF” or incompletely risk assessed before their death) then it is essential to

inform the following people of the death and ensure that additional precautions are taken

when dealing with the body:

• The death should be discussed with HM Coroner, Public Health England, the

mortuary and funeral director.

• Staff wearing VHF PPE (section 6.23 and appendix 3) should place the body in a leak

proof body bag, which should then be placed in a second body bag. Absorbent

material should be placed between each bag (e.g. absorbent pads), and the bag

sealed and disinfected with 1000 ppm available chlorine solution. Once the outer bag

is dry the body should be transported to the mortuary by medical or nursing staff

using a clean trolley. Staff placing the body within the body bags should change their

VHF PPE before transporting the body to the mortuary. Body bags labelled as high

risk and absorbent pads are kept in the mortuary.


• The mortuary should be alerted before transporting the body, and the risk of VHF

explained so that mortuary staff can take appropriate precautions.

• An infection control notification sheet should be completed in readiness for the

funeral directors who will also need to be informed in due course of the risk of VHF.

This section applies when patients are categorised as “High Possibility of VHF” or have been

confirmed to have VHF. Standard procedures should be followed for decontamination

issues related to patients categorised as “Low Possibility of VHF”, including the treatment

of laundry.

6.19.2 After death care of a patient with MERS-CoV

• Staff must wear enhanced PPE including an FFP3 mask as described in section 6.23

when preparing the body. Once in the hospital mortuary it is acceptable to open the

body bag in order to view the body.

• Washing or preparing the body is acceptable if those carrying out the task wear

appropriate PPE. To ensure adequate staff safety the PPE recommended is;

disposable long sleeved fluid repellent gown, FFP3 mask, visor and gloves.

• Mortuary staff and funeral directors must be advised of the biohazard risk.

• Embalming is not recommended because of the potential presence of virus in blood.

• If a post mortem is required then it needs to be undertaken using safe working

techniques (e.g. manual rather than power tools) and wearing enhanced PPE

including a ‘fit tested’ FFP3 mask (see section 6.23).

6.20 Decontamination of spillages of blood or body fluids and clinical waste in cases of VHF

• Staff must wear VHF PPE (section 6.23) whilst undertaking these decontamination

procedures. Spillages should be mopped up with absorbent material (e.g. disposable

paper towels).

• The area should then be disinfected with freshly prepared hypochlorite solution (Haz

Tabs) containing 10,000ppm available chlorine ensuring a contact time of two

minutes before wiping up with disposable paper towels.

• The surface should then be washed with Chlor Clean (1000 ppm available chlorine

solution).

• Contained clinical waste (e.g. bed pan or vomit bowl contents) should be solidified

with high-absorbency gel then double bagged in yellow waste bags.

• Linen should be treated as clinical waste and must not be returned to the laundry.

• All waste, including paper towels, should be sealed in a yellow clinical waste bag. This

should then be double-bagged in a second yellow clinical waste bag, sealed and left

in the room with the patient pending the results of the VHF screen.

• For confirmed VHF cases, the mattress should be treated as per other waste, double

bagged in yellow clinical mattress bags and clearly labelled as hazardous. These are

to be taken away with other waste as advised by the waste manager.


6.21 Decontamination of persons accidentally exposed to spillages of blood or body fluids

Accidental exposures that need to be dealt with promptly are:

• Percutaneous injury e.g. needle stick injuries

Immediately wash the affected part with soap and water. Encourage bleeding via

squeezing.

• Contact skin (broken or unbroken)

Wipe with an alcohol/ sanitising wipe in the first instance then immediately wash the

affected part with an anti-septic solution (e.g. Hibiscrub).

• Contact with mucous membranes (eyes, nose, or mouth)

Immediately irrigate the area with emergency wash bottles / sterile water for 5

minutes. This must be undertaken by another staff member ideally wearing PPE

(appropriate to where the incident occurs). If in the mouth; rinse for 5 minutes with

water, spitting out each mouth full.

Following this immediate management, exposed staff should shower and clean

themselves with soap and water (following removal of VHF PPE if applicable – see

appendix 3). Change into clean clothes and dispose of clothing into waste as detailed

in section 6.13.

In all cases, the incident must be reported immediately to the duty microbiologist.

The individual should be referred to Occupational health. The risk of exposure to a

blood borne virus (hepatitis B and C and HIV) must be assessed (see Prevention and

Management of Potential Exposure to Blood Borne Viruses Including Needlestick and

Sharps Injuries policy).

In the event that VHF infection is confirmed in the source patient, the exposed

individual must be followed up as a Category 3 contact and monitored for 21 days.

This will be arranged by the Incident Control Team.

6.22 Decontamination in the context of MERS-CoV

It is possible that the virus can survive in the environment for at least 48 hours, so

environmental decontamination is vital.

Domestic staff must wear PPE (section 6.23) and be trained in the use of this.

Follow procedures outlined for VHF in section 6.13 and 6.20.

6.23 VHF/MERS-CoV/Avian Influenza Personal Protective Equipment (PPE)

Only ESSENTIAL staff should enter rooms where a patient deemed to be at risk of VHF or

MERS-CoV/Avian Influenza is being nursed. Staff looking after such patients must have

been trained in how to don and doff PPE and have been deemed competent in this skill (see

training / section 7). They must wear:

Enhanced VHF PPE

Staff should wear enhanced VHF PPE when in contact with a patient categorised as “High

Possibility of VHF” or a confirmed VHF case, or when dealing with spillages of their blood or

body fluids.


Enhanced VHF PPE consists of:

1 Surgical scrubs

2 Fluid repellent suit/gown (White)

3 Plastic over apron

4 Two pairs of surgical gloves

5 Hood (head cover)

6 FFP3 mask

7 Disposable visor

8 Wellington boots

VHF PPE equipment is contained in the VHF boxes in A&E.

An assistant must be used to ensure safe donning, wear and removal of PPE. See appendix

3 for the sequence to follow when donning and removing VHF PPE. All staff members

should be trained and assessed as competent in using this PPE BEFORE using the PPE in

practice.

MERS-CoV/ Avian influenza

All staff entering the room should wear:

• Long sleeved, fluid-repellent disposable suit/gown

• Non-sterile surgical gloves.

• An FFP3 respirator mask (conforming to EN149:2001). Fit testing must be

undertaken before using this equipment and a respirator should be fit-checked

every time it is used.

• Visor or disposable goggles (prescription glasses do not provide adequate protection

against droplets, sprays and splashes).

• Disposable aprons should also be worn as for standard precautions when

undertaking patient care

It is vital that the protective clothing described above is worn for all airway

management, including intubation.

PPE must be removed in the following way:

1. Apron, if worn for patient care

2. Gown (crossing arms to pull and roll away from the shoulders and body)

3. Gloves, ensuring hands are not contaminated during removal

4. Wash hands

5. Remove visor from strap at the back of the head

6. Wash hands

7. Remove mask from straps at the back of the head

8. Wash hands in green area

All staff should be vigilant for any respiratory symptoms in the 14 days following last exposure to a

case of MERS-CoV and should not come to work if they have a fever or cough. They should seek

advice from their IPCT or Occupational Health Service. If symptomatic, staff should avoid close

contact with people both in the hospital and in the general community.


6.24 Public Relations (external communications)

All communications with the media MUST go through the Chief Executive’s office /

Communications Team and in conjunction with the outbreak control team.

All staff are reminded of their duty NOT to discuss confidential information in public areas or on

social media platforms. Similarly, reference to possible cases of VHF or MERS-CoV should NOT be

made anywhere where any member of the public or patients may be able to hear or on any form

of social media as this can lead to unnecessary panic, fear and negative publicity.

6.25 Staff Support and Surveillance

Support will be given to all HCW by the Occupational Health Service throughout the time they are

involved in the care of a patient with VHF or MERS-CoV. All HCWs who have had contact with

patients with VHF or MERS-CoV will be followed-up on a daily basis for a period of 21 and 14 days

respectively.

7 Training

Infection prevention and control training is covered under the Mandatory Training Policy. All staff

working on Trust premises, including Trust employed staff; agency and locum staff are responsible

for accessing IPC policies in order to assist in the management of their patients. It is the

responsibility of the relevant departmental leads to ensure that staff are aware of this policy.

Nursing and medical staff triaging patients in Accident and Emergency as well as staff accepting

referrals should be familiar with this policy and the need to undertake the initial screen. A suitable

number of senior staff in Accident and Emergency and SSU will be identified and trained annually in

how to manage patients at risk of VHF/MERS-CoV and be trained and competency assessed for the

donning and doffing of PPE and ‘fit tested’ for FFP3 masks. A number of radiographers and

domestic staff will also undergo this training.

8 Equality and diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide

services to the public and the way we treat our staff reflects their individual needs and does not

discriminate against individuals or groups on the grounds or any protected characteristics (Equality

Act 2010).

9 Monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Lead Tool Frequency Reporting

Arrangement

All patients will be risk assessed

prior to admission to the Trust

All patients with a suspected

VHF will have a completed

interhealth care transfer form

ECC Matron

Matrons/IPCT

Audit

Audit

Monthly

Every case

IPC Operational Group

IPC Operational Group

Immediate Isolation Matrons/IPCT Audit Every case IPC Operational Group

Practice ‘dry run’ exercise IPCT/ECC

Matron/ A&E

medical team

Exercise Annual IPC Operational Group


10 Consultation and review

This policy is reviewed on an annual basis to ensure that it continues to provide a comprehensive

and workable framework. When the policy was first produced in 2017 it was done so after

consultation with relevant parties and extensive planning. The initial working group included input

from Consultant Medical Microbiologists, Acute Medical and A&E Consultants, the matron for ECC

and senior nursing staff, the infection control team and waste manager. Consultation with the

critical care and paediatric teams was also undertaken.

11 Implementation of policy (including raising awareness)

A run through exercise will be conducted with key staff and the Emergency Care Centre to raise

awareness ensure training needs are being met with regard to the use of PPE.

12 References

Department of Health. Viral haemorrhagic fever: ACDP algorithm and guidance on management of

patients. November 2015. https://www.gov.uk/government/publications/viral-haemorrhagic-fever-

algorithm-and-guidance-on-management-of-patients

Public Health England. The Coordination and management of the health sector response to a case

of Viral Haemorrhagic Fever in the North East. June 2016.

13 Associated documentation

IC 2 PPE Policy

IC 6 Isolation Policy

IC 15 Cleaning and Disinfection Policy


Appendix 1

Contact details

Regional Infectious Disease Unit

Ward 19, New Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne NHS FT Hospitals.

Telephone: 0191 233 6161 (Ask to be connected to the on call Infectious Diseases Consultant / SpR)

High Security Infectious Disease Unit (HSIDU)

Royal Free Hampstead NHS Trust, London www.royalfree.nhs.uk

Telephone: 020 7794 0500 or 0844 8480700. Ask for Infectious Diseases consultant on call (24 hour).

Imported Fever Service

0844 778 8990 (24 hour)

Public Health England – Newcastle Health Protection Unit

Telephone: 0300 3038596 option 1

Out of hours contact the Public Health on-call via QEH switch board

Reference Laboratories – for VHF Screen

Rare and Imported Pathogens Laboratory (RIPL)

PHE Porton Manor Farm Road

Porton Down, Wiltshire

SP4 0JG

Telephone: 01980 612100 (24 hour)

The Imported Fever Service will usually direct the referring laboratory to send samples to RIPL as above. In

unusual circumstances, where the RIPL lab is not available, samples may be directed to Colindale at the

address below.

Microbiology Services Division – Colindale, 61 Colindale Avenue, Colindale, London, NW9 5HT

Telephone: 0208 200 4400 or 0208 200 6868 (24 hour)

Waste Manager, QE Facilities Estates Department

Queen Elizabeth Hospital, Queen Elizabeth Avenue

Sheriff Hill, Gateshead, NE9 6SX

Telephone– 0191 4452456 or 07950972114


Appendix 2

Collection of Blood Samples from Patients Categorised as

“High Possibility of VHF” or Patients Awaiting VHF Assessment

Before Entering the Patient’s Room

1. Prepare blood bottles and sample request forms:

1 × 3.4 mL purple top EDTA FBC, malaria testing

1 × 2.9 mL light blue top citrate Clotting screen

1 × 7.5 mL yellow/gold top serum gel U&Es, LFTs, CRP

1 × 5.5 mL grey top fluoride oxalate Glucose

1 × 7.5 mL yellow/gold top serum gel and VHF

screen 1 × 7.5 mL purple top EDTA (or 2 × 3.4 mL EDTA)

1 × set of blood cultures

2. Label blood bottles with patient details.

3. Apply a yellow “Danger of Infection” sticker to each bottle and to each form.

4. Do not take request forms into the patient’s room – leave them outside.

5. Gather equipment for venepuncture and place in a disposable tray.

6. Gather 8 specimen bags.

7. Put on VHF PPE (see appendix 3)

Use paediatric equivalent blood bottles where necessary

(adult bottles are preferred if feasible)

0.5 mL serum is the minimum sample for VHF testing

Inside the Patient’s Room

• Collect blood samples using standard ANTT technique.

• Wipe off any visible blood on each bottle with a chlorhexidine and alcohol wipe.

• Place haematology, biochemistry, VHF screen and blood culture samples into separate

specimen bags.

• Seal each bag and double-bag each one in a further specimen bag.

• Open the room door and drop the bags into a rigid transport container held by an assistant

standing outside the room wearing PPE. Do not touch the container.

• Leave all of the equipment, including the tourniquet and sharps box, inside the room when

exiting.

• Any spillages of blood should be dealt with following the procedure in section 6.20.


Following Collection of the Samples

• If not already done, the doctor should personally contact the duty microbiologist if the

patient has been assessed as “High Possibility of VHF” (Bp 2902 or through switchboard

out-of-hours) to arrange for the blood tests to be processed using special precautions.

• Write “High Possibility of VHF” on the request forms.

• Keep the request forms separate to the blood samples – do not place the forms in the

transport container.

• Inform a haematology laboratory staff member when the samples are ready to be

transported to the laboratory so they can be met at specimen reception.

• Carry the transport container and request forms directly to pathology specimen

reception. Do NOT use the pneumatic transport pod system.

Patient’s categorised as “Low Possibility of VHF”

• Blood samples can be collected and transported to the laboratory using standard

precautions.

• A haematology laboratory staff member should be informed that the samples are being sent

and that the patient has been risk assessed and categorised as “Low Possibility of VHF”.

• Write “Low Possibility of VHF” on the request forms.


Appendix 3

VHF Personal Protective Equipment (PPE) donning and removal

*NOTE – This appendix is intended as a general guide. Equipment available may differ from that shown in

these photographs. The steps required however will be the same as those shown here with the exception

of steps 5 and 6 (donning) and step 3 (doffing) which we have agreed locally are not necessary.


Appendix 4i: Diagram of Emergency Care Centre ground floor and location of A&E room E4 and access

and transfer routes:

Lift

A

A

A

P

X

E

R

M

M

E See

Map

2 E4

Toilets

Toilets

Waiting

area

Front desk

Main A&E

Entrance

A&E ambulance

reception area

Key:

(1) ‘At risk’ patient presenting via self-referral.

(2) ’At risk patient presenting via GP referral/ambulance.

(3) Route for patients identified as ‘at risk of VHF/MERS-CO-V’ to room E4 A&E

(4) Route for at risk patient from room E4 to room 2 on SSU.


Appendix 4ii: Diagram of A&E room E4 and E pod and SSU room 2

A

(B)

E5

E6

E7

E8

(6 )

Back door

(D) (2)

(3)

(4)

(5)

E4

E3

E2

E1

Green

area

Amber

area

Red

area

(C)

(1) (A)

R

WHEN ROOM E4 IS IN USE WITH PATIENT AT RISK OF VHF/MERS.CO.V;

Doors (1), (2), (3), (4), (5), (6) must ALL be locked to prevent access or manned by staff to monitor access.

Secure perimeter must be established preventing access of patients, visitors and unnecessary staff at points

A (locked door/manned entrance) B, C (curtain) and D (locked door).

Room E3 as a MINIMUM must be vacated and left empty.

If High Risk ENTIRE E pod should be vacated

WC

Cupboard


SHORT STAY UNIT (SSU) room 2 and Zones

SHORT

STAY

UNIT

Dirty utility

(Rest of ward)

SSU

Room 2

lobby

SSU

Room 2

(RED AREA)

En suite

En suite

WARD ONE

SR

(A) (GREEN AMBER

AREA) AREA)

Swipe acces Ward

doors (B) one

Nurses

station

En suite

SSU Room 3

(GREEN

AREA) (C)

En suite

(d)

SSU Room 1 Domestic

room

(GREEN (AMBER

AREA) AREA)

(A) Insert temporary screen/roller blind

(A) / (B) Secure perimeter needs to be established preventing access of patients, visitors and unnecessary

staff at points A and B.

(C) PPE storage and donning area.

(d) Close off whilst high risk VHF patient nursed in SSU room 2


Appendix 5: Preparing rooms E4 in A&E, room 2 on the SSU and room 1 on the assessment suite for

the arrival of a patient with possible VHF or MERS-CoV:

• Empty the room of all unnecessary equipment and any existing waste.

• For room E4 in A&E and room 1 Assessment suite, ensure that the ‘back door entrance’ to the

room is locked.

• For room 2 on SSU and room 1 on the assessment suite please check that the pressure designation

for the room is set to negative and that the negative pressure system is working and not alarming.

• Clear the surrounding areas and secure the area as shown in appendix 4 to prevent other patients

or visitors inadvertently having contact with the index case.

• All the required equipment (which should be found in the VHF/MERS-CoV box) should be gathered

outside the room.

• Put the VHF/MERS-CoV box onto a trolley outside the room.

• Place a 60 litre yellow rigid container (waste ‘griff’ drum) with double yellow waste bags either

inside the room or outside the room in the ‘red designated area’.

• A further 60 litre yellow rigid container with double waste bags should be placed in the red area for

used PPE.

• The yellow rigid container must have absorbency gel put at the bottom before inserting the first

yellow waste bag and a gel pad at the bottom of the 1st

yellow waste bag before inserting the

second yellow waste bag to absorb any loose liquid.

• Remove all other waste bins from the rooms.

• Place a disposable sharps bin in the isolation room (remove any re-usable sharps bins).

• For room E4 in A&E: ensure that the surrounding corridors are cleared of patients and relatives

(including any patient waiting on trolleys in this area). Room E3 should also be vacated.

• For room 2 on SSU: ensure that patients residing in rooms 1,2 and 3 are relocated immediately

(referring to the bed escalation policy for further details). Room 2 should then be rapidly cleaned

and prepared as above.

• If a patient considered to be at high risk of VHF or MERS-CoV is moved to bed 1 on the assessment

suite, the other 7 beds in the pods should be relocated as soon as possible (refer to bed escalation

policy).


Appendix 6: Location and Contents of the ‘VHF/MERS Box’:

Location: The VHF/MERS-CoV box is currently located behind the nursing hub (by the ambulance entrance

to A&E). Wellington boots and larger equipment can be found in the *MAJEX room at the front of A&E –

entrance outside A&E in ambulance bay. The access code for this room is available from the nurse in charge

in A&E.

Contents of VHF/MERS-CoV box:

• A copy of this policy (Management of a patient with suspected VHF or MERS-CoV)

• Action checklist: Dressing the clinical worker

• Action checklist: Undressing the clinical worker

• Fluid repellent suit/gown (White)

• Plastic over apron – (Green)

• 2 pairs surgical gloves

• Hood (head cover)

• FFP3 masks

• Disposable visor

• Permanent marker pens

• Wellington boots (located in the MAJAX Room*)


Appendix 7: Flow of staff through the green, red and amber areas

Green, Red and amber areas are designated in order to ensure appropriate flow of staff whilst ensuring

strict isolation remains unbroken.

1. Green Area; PPE Storage and Donning Area:

This is a designated clean area outside the patient room (marked side corridor area outside E4/majors pod,

SSU (ward 2) RM3 and corridor outside SSU RM 3/ Rm 2 lobby) where clean PPE is stored and PPE is donned

prior to entering the contaminated area/patient’s room. No contaminated equipment/PPE should enter or

be left or used within this area.

2. Red Area; Patient Room/direct contact area:

This is the contaminated clinical area containing the patient and where clinical tasks are performed (Room

E4 in A&E or SSU RM 2). All contaminated waste to be stored in this area to reduce cross contamination as

per section 6.9 with the exception of PPE (Also area directly outside E4).

3. Amber Area; PPE Doffing Area:

Designated area near the patient’s room (corridor area outside E4, corridor outside SSU RM 2 and half of

SSU RM 1) where PPE is doffed and discarded, and also designated initial decontamination, as per

Appendix 3.

Area should include area to disinfect PPE and perform hand hygiene. Areas should be designated around

the perimeter of the doffing room where each piece of PPE will be removed, moving from areas of greater

contamination to less contaminated areas of the room as PPE is doffed.

The en suite in SSU RM1 will also provide showering facilities, allowing full decontamination before

re-entering into clean environment/green area.


Appendix 8: Designated locations for nursing patients with possible VHF/MERS-CoV along with

characteristics of these rooms and advice regarding surrounding locations.

Location Role Location Characteristics Surrounding locations

A&E room E4 Immediate assessment.

(first 30 mins-1 hour)

Readily available for

swift access in A&E

However, room is NOT

pressurised – therefore:

only suitable for initial

assessment (<1 hour).

Back door must be

locked.

Requires considerable

effort to safely manage

area concerned as listed.

Will disrupt department

activity.

If E4 is used for VHF/MERS

assessment: Rooms E3 (+/- E2

and E1) must be closed. Security

must lock (or man) back corridor

doors by red area and E1-E8

corridor (both sides). Entrance to

corridor servicing E4 must also

be blocked off and manned to

prevent patients, visitors or press

accessing at risk area.

SSU room 2 Desired location for any

patient likely to be in the

hospital for > 1 hour.

Negative pressure room.

Wide corridor space

outside for staff to don

and doff PPE.

Adjacent rooms suitable

for storing PPE/kit and

waste.

Area can be potentially

walled off / quarantined.

If Rm 2 used for VHF/MERS

assessment and management,

rooms 1 and 3 must be vacated.

Domestics will be unable to

access their store room via Ward

1 entrance.

Assessment

Suite room 1

Safe location for initial

assessment and short to

medium term

management for 1-24

hours (in the event that

room on SSU not

available)

Negative pressure room.

Pod can be easily and

safely sealed off.

Back door entrances

must be locked.

All other rooms in the pod (i.e. 7

rooms) will have to be vacated.

Limited area for staff to don and

doff PPE.


Appendix 9: Incident control team

In the event that a case of VHF or MERS-CoV is confirmed an Incident Control Team (ICT) will need to be

convened. This team should include representatives from all involved parties, including the local public

health body and the hospital Trust(s) involved. The chair for this group and membership will depend on the

particular situation and be established ahead of the first meeting.

The incident control team should include:

From the trust:

- Joint Director of Infection Prevention and Control

- Head of Infection Prevention and Control

- Infection prevention and control doctor and/or Consultant Microbiologist(s)

- Responsible clinician (A&E, Medical and/or ITU consultant)

- Infection prevention and control nursing team

- Bed manager

- Chief Matron

- Waste manager

- Domestic Services manager

- Estates representation

- Occupational Health Team

- Security manager

- Laboratory manager or senior biomedical scientist representation

- Director of communications and PR officer

From external organisations:

- Consultant in Health Protection (Public Health England)

- Senior Health Protection Nurse (Public Health England)

- Consultant Virologist

- Consultant in Infectious diseases (Newcastle Hospitals NHSFT)

- Other representation from Newcastle Hospitals NHSFT or University College Hospitals

London or Public Health England

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