NHS Gateshead€¦ · suspected VHF or MERS-CoV be identified to assist with management of the...

Policy Title

Management of a patient with suspected Viral Haemorrhagic Fever (VHF), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Wuhan Novel Coronavirus (WN-CoV)

Policy Number

IC39

Version Number

3.0

Ratified By

Infection Prevention and Control Committee

Date Ratified

21/01/2020

Effective From

24/01/2020

Author(s) (name and designation)

Jonathan Moore, Consultant Medical Microbiologist

Sponsor

Andrew Beeby, Medical Director

Expiry Date

01/01/2023

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues

VHF / MERS / WN-CoV Policy 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

2.0

01/09/2017 Dr J S Moore IPCC 23/08/17 Updated hyperlinks (P 6) to expanded case definitions for MERS-CoV Updated statistics (P 6)

3.0

24/01/2020 Dr J S Moore IPCC 21/01/20 A&E replaced by ED (entire document) All hyperlinks and statistics checked and updated (entire document) Information on Wuhan Novel Coronavirus added (entire document notably: P7, P13) Slight modifications to summary flow charts (P 9 and 10) and testing arrangements (P 17,18,23) Monitoring criteria modified (P28)

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 1.2.5 Wuhan Novel Coronavirus (WN-CoV)………………………………………………………………….7

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

3. Aim of policy ................................................................................................................................. 8

4 Duties (Roles and responsibilities) ............................................................................................... 8

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 .................. 10 6.2 Quick reference guide flow chart for the management of suspected MERS-CoV…..….11 6.3 Communication chain (internal communications) ………………………..……………………………..12 6.4 Identifying at risk patients (patient referral and acceptance) ......................................... 13 6.5 Patient risk assessment algorithms ................................................................................. 13 6.6 Initial risk assessment in the ED ...................................................................................... 14 6.7 Risk assessment process .................................................................................................. 14 6.8 Management of a patient categorised as “low possibility of VHF/MERS-CoV” .............. 16 6.9 Initial management and transfer of a patient categorised as “high possibility of VHF” . 17 6.10 Investigations for a patient categorised as “high possibility of VHF” .............................. 18

6.11 VHF screen and further management ............................................................................. 20 6.12 Transfer of a patient categorised as “high possibility of VHF” to SSU room 2 ................ 21 6.13 Decontamination of a side room following use by a patient categorised as

“high possibility of VHF” .................................................................................................. 22 6.14 Management of a patient with a negative VHF Screen ................................................... 23 6.15 Management of a patient with confirmed VHF ............................................................... 23 6.16 Initial management of a patient categorised as “high possibility of MERS-CoV”……..….23 6.17 Investigations for a patient categorised as “high possibility of MERS-CoV”…………………24 6.18 Transfer of a patient categorised as “high possibility of MERS-CoV ............................... 25 6.19 After death care with respect to VHF and MERS-CoV ..................................................... 26 6.20 Decontamination of spillages of blood or body fluids and clinical waste in VHF ............ 26 6.21 Decontamination of persons accidentally exposed to spillages of blood

or body fluids associated with VHF risk ........................................................................... 27 6.22 Decontamination in the context of MERS-CoV…………………………………….……………………….28

6.23 VHF/MERS-CoV/Avian Influenza personal protective equipment (PPE) ......................... 28 6.24 Public Relations (external communications)...……………………………………………………………..29 6.25 Staff support and surveillance ......................................................................................... 29

7. Training ......................................................................................................................................... 30 8. Equality and diversity ................................................................................................................... 30 9. Monitoring compliance with the policy ....................................................................................... 30 10. Consultation and review .............................................................................................................. 30


11 Implementation of policy (including raising awareness) ............................................................. 30 12 References .................................................................................................................................... 31 13 Associated documentation (policies) ........................................................................................... 31

Appendices Appendix 1 Contact Details ................................................................................................................. 32 Appendix 2 Collection of blood samples from patients categorised as ‘High Possiblility of VHF’ or Patients awaiting VHF assessment .................................................................................. 33 Appendix 3 VHF Personal Protective Equipment (PPE) donning and removal ................................... 35 Appendix 4 Diagrams of the Emergency Care Centre ground floor and areas around ED room E4 and room 2 on the Short Stay Unit (SSU) ..................................................... 47 Appendix 5 Preparing rooms E4 in the ED, room 2 on the SSU and room 1 on the assessment suite for the arrival of a patient with possible VHF or MERSCoV .................................... 50 Appendix 6 Location and Contents of the ‘VHF/MERS Box’ .............................................................. 51 Appendix 7 Flow of staff through the red, amber and green areas ................................................... 52 Appendix 8 Designated locations for nursing patients with possible VHF/MERS-CoV along with characteristics of these rooms and advice regarding surrounding locations .................. 53

Appendix 9 Incident control team……………………………………………………………………………………………………54

Management of a patient with suspected Viral Haemorrhagic Fever (VHF), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) or Wuhan Novel Coronavirus

(WN-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 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_Africa_2016_960_640.png. Areas with outbreaks of 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 2,494 cases have been reported to the WHO (http://www.who.int/emergencies/mers-cov/en/) with over 858 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

https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-and-guidance-on-management-of-patients


https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/558888/VHF_Africa_2016_960_640.png

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/558888/VHF_Africa_2016_960_640.png

http://www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_20080918.png?ua=1

https://www.gov.uk/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations

https://www.gov.uk/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations

http://www.promedmail.org/

http://www.who.int/emergencies/mers-cov/en/

http://www.who.int/emergencies/mers-cov/en/

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



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 .

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. 1.2.5: Wuhan Novel Coronavirus (WN-CoV) On the 31st December 2019, the World Health Organization (WHO) was informed of a cluster of cases of pneumonia of unknown cause detected in Wuhan City, Hubei Province, China. On 12 January 2020 it was announced that a novel coronavirus had been identified in samples obtained from cases. This novel virus is, at the time of writing, being referred to as Wuhan Novel Coronavirus (WN-CoV). Early indications are that this virus can be transmitted from person to person most likely via large respiratory droplets and direct or indirect contact with infected secretions. For up to date information regarding WN-CoV including the latest case definition, epidemiology and incidence along with public health advice can be found at: https://www.gov.uk/government/collections/wuhan-novel-coronavirus Until further information is available, the main principle would be that any potential case of WN-CoV should be managed as per any potential case of MERS-CoV following this policy. Where available, specific links for WN-CoV have been added.

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, Avian Influenza and WN-CoV 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, Avian Influenza or WN-CoV and therefore to prevent exposure of Hazard Group 4 pathogens to all HCW, patients and visitors within the trust.

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

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

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

https://www.gov.uk/government/collections/wuhan-novel-coronavirus


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, Avian Influenza or WN-CoV.

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, MERS-CoV or WN-CoV

Section 6 describes how patients with suspected VHF or MERS-CoV should be managed in hospital. Patients presenting with potential novel respiratory viruses (such as WN-CoV) 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 (including the Blaydon walk in centre) should be aware of VHF, MERS-CoV and WN-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 or WN-CoV an FFP 3 mask as well as a gown and gloves +/- eye protection). 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

Patients attending the ED at risk of VHF must be promptly identified and triaged. Posters are

displayed in the ED to ask patients to immediately volunteer travel history (Section 6.4)

Initial triage: ED 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: ED 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 or WN-CoV

Patients attending the ED at risk of MERS-CoV or WN-CoV must be promptly identified and

triaged. Posters are displayed in the ED to ask patients to immediately volunteer travel history

to at risk countries (Section 6.4)

Initial triage: ED 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: ED 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 testing for MERS-CoV or WN-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 or WN-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 or WN-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 / WN-CoV unlikely

See section 6.8


6.3 Communication Chain Timely and accurate communication is essential when dealing with possible cases of VHF, MERS-CoV or WN-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, MERS-CoV or WN-CoV attend the ED or be admitted and outlines a cascade communication plan. a. ED Receptionist (booking in) or clinician accepting GP referrals MUST inform the

following staff via Vocera:

Duty triage nurse

Nurse in-charge of the ED

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

The Duty ED Consultant (overnight the on call Consultant should be informed)

Senior Nurse (Bp 3039/Vocera) / Patient Flow (Vocera). Overnight: Bp 1200.

The Infection Prevention Control nursing team (Monday to Friday between 0800- 1800) or the duty Consultant Medical Microbiologist (1800-0900) 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 ED 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 appropriate transport and processing of laboratory samples as specified by laboratory SOP.

Imported Fever Service AND/OR reference laboratory to arrange testing.

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 0800-1800).

The Consultant Virologist on call may be consulted for additional advice if necessary.

f. The Infection Prevention Control Nursing Team MUST inform:

The Waste manager (contact details in part b).

g. 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 the ED should be assessed for risk of VHF, MERS-CoV, Avian Influenza and WN-CoV promptly.

Posters are displayed in ED advising patients who have either travelled to or worked outside of Europe, Australia / New Zealand or North America in the last 21 days to inform a member of staff immediately to initiate a prompt assessment.

A formal assessment should be conducted by the triage nurse as soon as possible as per sections 6.5 and 6.6.

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, Avian Influenza or WN-CoV (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, Avian Influenza or WN-CoV” 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, Avian Influenza or WN-CoV 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 the ED 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 the ED (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, Avian Influenza and WN-CoV: 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 – including H7N9, H9N2, H5N1, H5N6: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/806505/Avian_flu_human_cases_guidance_June2019.pdf

Wuhan Novel Coronavirus (WN-CoV): (see section 2) https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection

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

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



https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/806505/Avian_flu_human_cases_guidance_June2019.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/806505/Avian_flu_human_cases_guidance_June2019.pdf

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection




6.6 Initial risk assessment in the Emergency Department

Patients (including children) identified whilst booking into the department at the ED reception as being at risk of VHF, MERS-CoV, Avian Influenza or WN-CoV should ideally be escorted directly and immediately to ED 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, visitors 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/WN-CoV in ED can be found in the ‘VHF/MERS box’ which is located behind the main nursing hub in ED 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 4ii). 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 the ED 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, Avian Influenza OR wn-CoV is suspected) before escorting the patient to the side room or entering the room to question the patient. If VHF 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, Avian Influenza or WN-CoV. 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, MERS-CoV or WN-CoV. Any poultry / animal contacts (Avian Influenza and WN-CoV). Following initial questioning, if it is possible that the patient will be categorised in the “High Possibility of VHF/MERS-CoV, Avian Influenza or WN-CoV” 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 electronic 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 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 an adjacent closed room (e.g. Room E3 in ED 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 and WN-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, Avian Influenza and/or WN-CoV. Cases with HIGH possibility of VHF/MERS-CoV/Avian Influenza/WN-CoV 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/WN-CoV are excluded If the patient does not meet the case definitions for VHF/MERS-CoV, Avian influenza or WN-CoV, they should be managed as clinically appropriate without additional precautions and can be transferred to the Assessment Unit 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/WN-CoV”

In these patients, a risk assessment will be conducted by the duty Medical microbiologist, responsible consultant (+/- Infectious Diseases team). The key questions will be:

What level of risk is present? What investigations are required (e.g. Is VHF, MERS-CoV or WN-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/WN-CoV’, 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 (VHF: Section 6.9; MERS-CoV / WN-CoV: Section 6.16) 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/WN-CoV’, 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 Unit (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, Avian Influenza or WN-CoV 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 unit.

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 the ED 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 ED). 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 yellow 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.

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.

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.

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-MAN-RIS-005.QE’ and ‘MC-SER-FOR-014.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 ED 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) after discussion with acute physicians and duty Medical Microbiologist.


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 ED 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 the ED, 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 ED 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, Avian Influenza or WN-CoV

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, Avian Influenza, WN-CoV” should personally contact the on call Infectious Diseases doctor at the Royal Victoria Infirmary to discuss 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 ED 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 the ED). 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 or WN-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 reference laboratory carrying out the test +/- the on call virologist in Newcastle. 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). At present, MERS-CoV samples are sent to the Manchester Public Health Laboratory. WN-CoV samples are sent to PHE Colindale, London. For both MERS-CoV and WN-CoV testing TWO respiratory samples should be collected as one sample will


also be sent to Newcastle for conventional viral PCR testing. For WN-CoV an EDTA blood and serum blood sample should also be collected for testing.

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-MAN-RIS-005.QE and ‘MC-SER-FOR-014.QE’.

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

Patients categorised as “High Possibility of MERS-CoV or WN-CoV” should 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 ED 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 or WN-CoV screen (which may take up to 48 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 ED, 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. The patient should wear a mask for transfer.

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 or WN-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 or WN-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/WN-CoV 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/WN-CoV 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 the ED. 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 / WN-CoV

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 or WN-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, MERS-CoV or WN-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, MERS-CoV or WN-CoV. All HCWs who have had contact with patients with VHF, MERS-CoV or WN-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 the Emergency Department 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 the Emergency department and SSU will be identified and trained annually in how to manage patients at risk of VHF/MERS-CoV/WN-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 with a suspected VHF will have a completed interhealth care transfer form

Matrons/IPCT

Audit

Every case IPC Operational Group

90% of permanent nursing and senior medical staff in ED and the SSU will be ‘fit tested’.

Matrons Audit Annual IPC operational Group

Immediate Isolation Matrons/IPCT Audit Every case IPC Operational Group

Practice ‘dry run’ exercise IPCT/ECC Matron/ ED medical team

Exercise 3 yearly 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 ED 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. For the 2020 revision, further consultation has taken place with the ED and short stay unit.

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

Embedded in the document. 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

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 Colindale Duty Doctor (to authorise WN-CoV testing) 0208 200 4400 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

http://www.royalfree.nhs.uk/


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 ED 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 ED Entrance

ED 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-CoV/WN-CoV’ to room E4 ED. (Possible MERS-CoV/WN-CoV patients should be asked to wear a mask for transfer) (4) Route for at risk patient from room E4 to room 2 on SSU.


Appendix 4ii: Diagram of ED 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) and (2) should be closed for swipe access only to prevent access or manned by staff to control access. Doors (3), (4) and (5) should be kept closed. Secure perimeter must be established preventing access of patients, visitors and unnecessary staff at points A (closed door/manned entrance) B, C (curtain) and D (closed door). Ideally, room E3 should be vacated and left empty if practical.

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 access 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 the ED, room 2 on the SSU and room 1 on the assessment unit for the arrival of a patient with possible VHF, MERS-CoV or WN-CoV:

Empty the room of all unnecessary equipment and any existing waste.

For room E4 in ED and room 1 Assessment unit, ensure that the ‘back door entrance’ to the room is shut (and if possible locked).

For room 2 on SSU and room 1 on the assessment unit 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 ED: 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 unit, 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 the ED). Wellington boots and larger equipment can be found in the *MAJEX room at the front of the ED – entrance outside the ED in ambulance bay. The access code for this room is available from the nurse in charge in ED. 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 ED 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/WN-CoV along with characteristics of these rooms and advice regarding surrounding locations.

Location Role Location Characteristics Surrounding locations

ED room E4 Immediate assessment. (first 30 mins-2 hours)

Readily available for swift access in ED However, room is NOT pressurised – therefore: only suitable for initial assessment (<2 hours). Back door must be shut. Requires considerable effort to safely manage area concerned as listed. Will disrupt department activity.

If E4 is used for VHF/MERS assessment: Rooms E3 should ideally be closed. Area needs to be partitioned off and access controlled to prevent other patients, visitors or press accessing the 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 Unit 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, MERS-CoV or WN-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: - Director of Infection Prevention and Control - Head of Infection Control - Infection control doctor and/or Consultant Microbiologist(s) - Responsible clinician (ED, Medical and/or ITU consultant) - Infection prevention and control nursing team - Bed manager - Senior matron - Waste manager - Domestic 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 (Newcastle Hospitals NHSFT) - Consultant in Infectious diseases (Newcastle Hospitals NHSFT) - Other representation from Newcastle Hospitals NHSFT or University College Hospitals

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