© G20040302

NCA COVID-19 Outbreak Control Process And Management

Background Between 10 – 20% of COVID-19 infections are thought to occur as a result of healthcare. Healthcare onset COVID-19 infection (HOCI) are associated with increased harm and mortality and reducing these is a clear patient safety issue. Early identification of increased incidences of infection and outbreaks are key components in reducing HOCI and are central to understanding COVID-19 transmission within healthcare , providing transparency on performance and supporting a focus on the culture of continuous improvement. The purpose of the document is to provide a clear process to aid the identification, management and reporting of HOCI cases. The process set out in this document must be adhered to ensuring that:

Outbreaks of COVID-19 are identified rapidly and managed according to national guidance

Patient Safety Incident Analysis or alternative investigation process, for post day 8 and day 15 are completed, with lessons learned identified and shared

COVID-19 cases are reported accurately via the daily covid sitrep for both patients and staff

Processes for management of COVID 19 cases are in line with national guidance

All potential outbreaks are escalated to the North West Incident Coordination Centre (ICC) via daily sit rep reporting (Appendix 6). Outbreak procedures in line with COVID guidance should be followed

Processes for management of COVID 19 cases are in line with national guidance

All actions are logged with completion dates

Identifying HOCI Although there are technically three categories for determining potential healthcare acquired cases, for the purposes of defining an outbreak NHSI/E advise that only probable and definite cases of HOCI will be considered as below:

1. Healthcare-Onset Probable Healthcare-Associated (HO-pHA) – First positive specimen date 8-14 days after admission to trust

2. Healthcare-Onset Definite Healthcare-Associated (HO-dHA) – First positive specimen date 15 or more days after admission to trust.

Each case falling within these categories will undergo a rapid Root Cause Analysis (rRCA – Appendix 2) to establish how the transmission has occurred, whether there are any other linked cases that might indicate ongoing transmission, and to establish and share learning. . Identifying an Outbreak of HOCI

An outbreak of HOCI is defined as two or more cases occurring within the same ward/ environment within 14 days of each other

The outbreak control process must be initiated when two or more cases are identified

NCA COVID-19 OUTBREAK CONTROL PROCESS AND MANAGEMENT

If two patients in a ward test positive the whole ward (both patients and staff) should be tested for COVID-19. If a healthcare worker tests positive for COVID-19, contacts should be determined and the colleagues who they have had significant contact with should be identified and tested. (Appendix 4). For management of an outbreak of HOCI please see (Appendix 3). COVID-19 is a notifiable organism and as such Public Health England (PHE) is made aware via laboratory reporting as routine. PHE and the senior leadership teams of the NCA should be notified promptly of COVID-19 outbreaks by the NCA IPC team, this will be communicated to the Consultant in Communicable Disease Control (CCDC). In addition, due to the additional pressures of the pandemic, the NCA should escalate information about their outbreaks to the CCG, CQC and NHSE/I as soon as they themselves are aware of them (Appendix 3 and 5). Untoward incident: a single inpatient who develops COVID-19 more than 7 days after admission. Cluster: the detection of unexpected, potentially linked cases. It is important that such cases are appropriately recorded and managed for audit purposes and to support surveillance and any future outbreak management. High prevalence: an above-average number of HOCI cases aggregated over the preceding 4 weeks. Organisations with high prevalence may be required to perform additional testing on request of NHSI/E/PHE. Management of COVID Outbreak Follow established outbreak control methodology for managing an outbreak (Appendix 3), in addition:

A post infection review or rapid RCA is completed on patients where a transmission has occurred (Appendix 2).

Staff contacts will be identified and managed in line with the national and NCA test and trace processes, and local occupational health processes.

Regular outbreak meetings will take place where minutes are recorded and at the end of the outbreak a report is provided, in line with established PHE guidance on outbreak management

There is evidence that the Infection Prevention and Control Board Assurance Framework is completed (organisational responsibility)

There is evidence that the Infection Prevention and Control COVID-19 Management Checklist has been used

Evidence of completed actions are recorded on action plan template, with identified action owners and dates of completion (outbreak meeting minutes, action log and report)

Lessons learned are collated and disseminated within the organisation and regionally

There is evidence that risk assessments have been undertaken for black and minority ethnic (BAME) staff

Governance The national challenge due to COVID-19 requires absolute clarity in the ongoing management and recognition of HOCI incidents. All COVID-19 outbreak incidents must be escalated through the standard organisational governance processes up to Board level. In addition, these incidents will be escalated to NHSE/I via the agreed EPRR command and control arrangements through the Northwest Incident Control Centre (NW ICC) Single Point of Contact (Appendix 3). Outbreaks are then reviewed by a weekly NW governance panel. Organisations identified as high outliers will be contacted and asked to complete further actions. Incident Reporting Cases of HOCI should be reported via the Datix route Serious Incident Reporting Serious incidents can extend beyond incidents that affect patients directly and include incidents, which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare. In terms of Patient safety incident reporting during the COVID-19 Pandemic, organisations should continue to report anything of concern. Clinical and professional judgement should be used when considering what to identify as a Serious Incident (SI). The 2015 SI Framework promotes identification and reporting of SIs based on the potential for learning, future risk reduction and the consequences of any recurrence of the incident. Where there is any evidence that the COVID-19 infection may have been healthcare -acquired and a death from COVID-19 has resulted, this is potentially a Serious Incident if the infection was acquired due to problems in healthcare care provision, such as problems with IPC processes. Whether SJR, RCA or some other method is the right one to generate that learning is dependent on the circumstances and is therefore for local decision. The scale and scope of resultant investigations should be proportionate to ensure resources are effectively used. Organisations will need to be sure that any decision making is defensible and taken openly and transparently, including in discussion with relevant patients’ families and the staff involved.

Appendix 1 Identification of a Case of Healthcare Onset COVID-19 Infection (HOCI)

Identification of a case of HOCI *

Clinical team and IPC team informed. Clinical team conducts a rRCA and

completes a Datix

Any other linked cases identified

2 or more cases = Outbreak Control Process Initiated by IPC

team (Appendix 3)

Senior Leadership Team Informed.

NCA IPC team informs relevant key stakeholders (e.g NHSE/I,

NW ICC, PHE)

No other identified linked cases =

untoward incident. Monitor area closely

and have a low threshold for further suspicion/testing for

COVID-19. Consider other

aspects of patient that may increase the risk of onward transmission from the positive patient such as delirium

and ability to adhere to IPC measures. Discuss with IPC team if additional

risks identified

Management of Positive Patient

Transfer positive patient to single room or COVID-19 positive cohort area.

If patient in a bay with others close bay (ward if Nightingale) to new admissions. This is now a COVID-19 contact. No transfers out to other wards unless to a contact cohort area or urgent clinical lead

Terminal clean of the area required.

All patients now commence 14 days isolation: document start date in all patients’ notes Swab all exposed patients immediately. Re-swab all exposed patients between days 5 to 7 after exposure irrespective of symptoms

Re-swab and isolate any patient who becomes symptomatic within the 14 days isolation.

Re-swab all patients between days 13 to 14.

Bay may re-open once 14 days has elapsed since exposure and no further positive patients

Appendix 2 COVID-19 Rapid Root Cause Analysis (rRCA)

DEMOGRAPHICS

Organisation where Specimen Taken

Ward/area Date of Positive Specimen

Date of Result

Patient identifier

Date of Birth Gender Date of Admission

Screened on admission

Y/N

Reason for Admission

Past medical History

Ethnicity

Date of Discharge/Death COVID on death certificate

COVID infection

Symptoms: Y/N Date started

Cough Y/N Temperature Y/N Anosmia Y/N

Category of Infection:

Probable 8-14 days Healthcare Acquired 14+ days

Risk Factors:

CHRONOLOGY

Patient Journey

Isolation

Date Isolated Treatment

Patient Contacts

Staff Contacts if PPE breached:

Environmental

Cleaning Audit Date Score Hand Hygiene Audit Date Score

Personal Protective Equipment

Audit Y/N Score Compliance Issues

Organisational Issues

Availability of Supplies

Staffing Availability

Bed Capacity

Lessons Learned and Where Learning Shared (e.g safety huddles, meetings etc)

Communication and Escalations

IPCC

PHE

NHSE/I

CQC

Appendix 3 Outbreak Control Process COVID-19

Probable Confirmed

IPC Team Inform Senior

Leadership Team

Convene an Outbreak

Control Group (OCG)

OCG

Collate outbreak timeline and review cases

Review IPC measures and checklist

Advise on outbreak control measures including: -contact tracing -patient testing -staff testing -operational measures (ward closure etc) -cleaning -communications plan -frequency of meetings -re-opening of any closed areas

Identifies and confirms outbreak information submitted to correct source

Declares when outbreak is over (no new cases within 14 days).

Ensures outbreak information is submitted for 28 days as per PHE guidance

OCG Membership

DIPC

DoN

Lead Nurse IC

Consultant Micro

Governance

Clinical leads for area

Clinical/operational manager

Domestic services manager

PHE

Comms team

OH if staff

Co-opted staff members as appropriate

Outbreak Information Required

At outbreak start completed IIMarch* to be sent to DoN IC and once approved to: england.eprrnw@nhs.net ICC.Northwest@phe.gov.uk

Daily Sit-rep* to : NCA.COVID-19@pat.nhs.uk england.eprrnw@nhs.net

Minutes of OCG

Completed IIMarch* once outbreak declared over

Outbreak report summary and learning identified to be presented through Care Organisation Infection Prevention and Control Committees

*Lead Nurse/Outbreak manager responsibility. Sit reps must be submitted no later than 9am daily, 7 days a week for 28 days following commencement of outbreak. If

no outbreaks a nil return must also be made daily.

Management of Outbreak of COVID-19 Patients and/or Staff

mailto:england.eprrnw@nhs.netmailto:ICC.Northwest@phe.gov.ukmailto:NCA.COVID-19@pat.nhs.ukmailto:england.eprrnw@nhs.net

Appendix 4 Staff Contact Tracing and Management

Staff notified they are a contact of

a confirmed case in the community by NHS test and trace

Staff notified that they are a contact of a co-worker who is a

confirmed case

Inform their line manager

Self-isolate for 14 days from date of positive contact .

If symptoms develop during this time get tested for COVID-19.

Follow Test and Trace flowchart

above

Wearing PPE?

Any breeches in PPE identified?

Direct Contact: Face to face contact

within 1m for 1 minute or more

Proximity Contact: within 2m of someone

for 15 minutes or more

Yes No

Line manager assess nature of contact

Yes No

No further action

required

14 day self-isolation

period required

14 days over? return to work

if well

Appendix 5 HOCI Escalation Process

NCA identifies HOCI case

Clinical lead completes rRCA

Any other linked cases identified

if 2 or more cases outbreak control

process instigated

Senior leadership team informed.

Relevant stakeholders in

formed (ICC NW/PHE/CCG etc)

Learning disseminated interanlly and

externally

Sit reps submitted

Results reviewed by

NHSE/I

Trusts with outlier staturs

requested review of

information

NCA completes management

checklist

Submit checklist via governance

processes and up to NHSE/I

GM HOCI panel review

information submitted

Appendix 6 COVID-19 Outbreak SitRep

Daily Sit-Rep Date of Report:

Date Outbreak Declared

Care Organisation

Ward/Area

New or Continuous

No Staff Positive this Outbreak

No Staff in Isolation (neg or awaiting test)

No of Patients Positive

No Patients in Isolation (neg or awaiting test

Number Probable HOCI (8-14 Days)

Number Definite HOCI (>15 Days)

Operational Impact (e.g bay closed/ward closed)

Date Outbreak Declared Closed

RAG rating (red/amber/green)

UPDATE or NIL Return delete as appropriate

Nil further to Report Updated

Appendix 7 IIMarch Template for Reporting to ICC NW COVID-19 Outbreak Ward: Care Organisation: Date:

Element Key questions and considerations Action

I Information What, where, when, how, how many, so what, what might?

Timeline and history (if applicable), key facts reported using

M/ETHANE

I Intent Why are we here, what are we

trying to achieve? Strategic aim and objectives, joint

working strategy

M Method How are we going to do it? Command, control and co-

ordination arrangements, tactical and operational policy and plans,

contingency plans

A Administration What is required for effective,

efficient and safe implementation? Identification of commanders, tasking, timing, decision logs, equipment, dress code, PPE,

welfare, food, logistics

R Risk assessment What are the relevant risks, and what measures are required to

mitigate them? Risk assessments (dynamic and analytical) should be shared to

establish a joint understanding of risk.

Risks should be reduced to the lowest reasonably practicable level by taking preventative measures, in

order of priority. Consider the hierarchy of controls.

Consider Decision Controls

C Communications How are we going to initiate and

maintain communications with all partners and interested parties? Radio call signs, other means of

communication, understanding of inter-agency communications,

information assessment, media handling and joint media strategy

H Humanitarian issues What humanitarian assistance and human rights issues arise or may

arise from this event and the response to it?

Requirement for humanitarian assistance, information sharing and

disclosure, potential impacts on individuals’ human rights

Appendix 8 COVID-19 Measures ImplementationChecklist

COVID-19 MEASURES IMPLEMENTATION CHECKLIST

Standard Infection Control Precautions-Applies to all staff, in all care settings Patients, staff and visitors are encouraged to minimise COVID-19 transmission through: • Good hand hygiene and respiratory hygiene • Social distancing wherever possible In addition, all staff are requested to: • Adhere to social distancing, particularly when in non-clinical areas eg during work breaks and in communal areas. • Stagger breaks to limit the density of staff in any one specific area(s).

Patient placement/assessment of risk/cohort area

Comments/notes

Emergency department, admission and waiting areas Patients are triaged rapidly to segregate and maintain separation in space and/or time between possible and confirmed COVID- 19 patients and non-COVID-19 patients. Suspected cases are asked to wear a face mask. There is physical separation of reception staff eg perspex screens. On admission Possible cases (awaiting lab confirmation) and confirmed cases are isolated in a single room with clinical wash hand basin and en-suite facilities. If single rooms are in short supply, priority is given to patients who have excessive cough and sputum production. Single rooms in non-COVID-19 areas are reserved for patients requiring isolation for other (non-influenza-like illness) reasons. Prioritising of patients for isolation other than suspected or confirmed COVID-19 patients is decided locally, based on patient need and local resources. Possible cases (awaiting lab confirmation) should be cohorted separately (ideally in single rooms) until confirmed. Patients with new onset symptoms are isolated immediately and contacts traced. Cohort areas are established for multiple cases of confirmed COVID-19, ideally in a designated, self-contained area. Patients should be separated by at least 2 metres and privacy curtains/screens used between bed spaces to minimise opportunities for close contact. The segregated area is not being used as a thoroughfare by other patients, visitors or staff. Doors to isolation/cohort rooms/areas are closed and signage is clear.

Patient placement is reviewed daily as the care pathway changes

Staff cohorting Dedicated teams of staff are assigned to care for patients in isolation/cohort rooms/areas for their entire shift. There is consistency in staff allocation, reducing movement of staff and the crossover of care pathways between planned and elective care pathways and urgent and emergency care pathways; reducing movement of staff between different areas.

Ensure all patient placement decisions and assessment of infection risk (including isolation requirements) is clearly documented in the patient notes and reviewed throughout inpatient stay

Personal protective equipment (PPE)

General ward All staff working in designated COVID-19 areas routinely wear fluid resistant surgical masks (FRSM). Staff providing direct care within 2 metres of a possible/confirmed case are wearing disposable aprons, gloves, FRSM and eye/face protection, when in the patients’ immediate care environment. Link to PPE table.

High risk areas A filtering facepiece (FFP) respirator gown/coveralls is in place and risk assessed. Where an aerosoal generating procedure (AGP) is a single procedure, PPE is single use.

PPE must be: • Available at point of use and stored in a clean dry area. All staff (clinical and non-clinical): • are trained in putting on and removing PPE. • know what PPE they should wear for each setting and context. • have access to the PPE that protects them for the appropriate setting and context. • perform hand hygiene following removal of PPE. Single/sessional use Gloves and aprons are single use as per standard infection control precautions (SICPs), with disposal after each patient contact, task or procedure. Respiratory and eye/facial protection may be used for a session of work. Gown/coverall may be worn for a session of work in high risk areas

Surgical facemasks All possible/confirmed inpatients wear a surgical facemask (if tolerated and does not compromise clinical care).

Safe management of care equipment

Single-use items are in use where possible. Dedicated, reusable, non-invasive care

equipment is in use and decontaminated between each use and prior to use on another patient. See Routine decontamination of reusable non-invasive patient care equipment flowchart. Fans that re-circulate the air are not in use.

Decontamination of the care environment

Domestic teams are assigned to COVID-19 cohort area/wards. All areas are free from non-essential items and equipment.

Isolation room/cohort area (cleaning of isolation areas is undertaken separately to the cleaning of other clinical areas.)

There is at least twice daily decontamination of the patient isolation room/cohort area, toilet and bathroom and staff areas, including areas where PPE is removed. Manufacturers’ guidance and contact times for cleaning and disinfection products are followed. There is decontamination of ‘Frequently touched’ surfaces at least twice daily and when they are known to be contaminated with secretions/blood/bodily fluids. Frequently touched surfaces include: • Toilets and commodes (particularly if patients have diarrhoea). • Door/toilet handles, locker tops, over bed tables, bed rails, desktops and electronic equipment – eg mobile phones, desk phones and other communication devices, tablets, keyboards; particularly where these are used by used by many people. • Rooms once vacated by staff following AGP (clearance times in isolation room 10-12 ACH wait minimum 20 minutes or single room with 6 ACH wait minimum of 1hr). ‘Terminal’ decontamination is undertaken following transfer, discharge, or once the patient(s) is no longer considered infectious. Communal cleaning trollies are not taken into patient rooms.

Hand hygiene

Staff undertake hand hygiene as per WHO 5 moments, using either an alcohol-based hand rub (ABHR) or soap and water. Hands are dried with soft absorbent, disposable paper towels from a dispenser are available for use to dry hands, located close to handwash sinks and beyond risk of splash contamination. How to wash and dry hands posters are clearly displayed in all public toilets and staff areas. Staff are aware of the importance of skin care.

Movement restrictions/transfer/discharge

Moving patients within healthcare Patients with possible/confirmed COVID are not moved to other wards/departments unless for essential care. If necessary: • Staff at the receiving destination are informed that the patient has possible or confirmed

COVID-19. • Patient is wearing a surgical face mask during transportation. • Patients are taken straight to and returned from clinical departments. • If possible, patients are placed at the end of clinical lists.

Waste

Disposal and transport of all waste related to possible/confirmed cases is classified as Category B clinical waste (orange bag).

Linen

All linen is managed as ‘infectious’ linen. Disposable gloves and apron are worn when handling infectious linen. All linen is handled inside the patient room/cohort area. A laundry receptacle is available as close as possible to the point of use for immediate linen deposit. All linen bags/receptacles are tagged with ward/care area and date. All used/infectious linen is stored in a designated area whilst awaiting collection

Respiratory Hygiene

Patients are supported with hand hygiene and provided with disposable tissues and a waste bag. Symptomatic patients may wear a surgical face mask if tolerated: • In common waiting areas. • During transportation. • In clinical areas. A surgical face mask should not be worn by patients if there is potential for their clinical care to be compromised.

Visitors

Signage regarding any visitor restrictions is clearly visible.

Version 3 - 6 October 2020