Sussex Clinical Commissioning Groups Coronavirus (COVID-19) Infection Prevention and Control Guidance for Primary Care Hot Hubs Date: 03.04.2020

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Sussex Clinical Commissioning Groups Coronavirus (COVID-19) Infection prevention and control guidance for Primary Care Hot hubs Date: 03.04.2020

What is Coronavirus (COVID-19) • Coronaviruses are a large family of viruses - they cause infections ranging from the common cold to Severe Acute Respiratory Syndrome (SARS) • Coronaviruses circulate between animals and humans; sometimes new variants of the coronavirus emerge - such as COVID-19 • COVID-19 has the potential to spread widely as lack of immunity means everyone in the population is susceptible

• Symptoms start 5-11 days after exposure • Majority have fever and dry cough (rapid Symptom Proportion of onset) cases • Symptoms last 5-6 days Fever ˃37.5˚c 88% Dry cough 68% • Severe illness starts day 7 Fatigue 38% Sputum 33% . ↑ Shortness of breath Shortness of 19% breath . Lung inflammation Muscle/ joint 15% pain . Pneumonia Sore throat 14% Headache 14%

Exposure to large respiratory droplets & vomit . Coughing/sneezing onto mucous membranes (mouth/eyes) . Need close contact for this to occur (within 1 metre)

Contact with respiratory secretions • Transferred by touching mucous membranes • Tissues/surfaces contaminated with respiratory secretions *It is NOT transmitted in air except if patient undergoing a procedure that generates aerosols e.g. airway suction

*Aerosol generating procedures increase risk of aerosol spread of infectious agents irrespective of the mode of transmission

• A suitable practice/location is required for Hot hubs for suspected and confirmed Covid-19 patients.

• All patients are to be triaged to ensure they meet the case definition

• Patients will need at be able to access the sites by private car and not via public transport.

• For patients that cannot attend by private car, a home visit will be required.

Hot hub Practices should have the following

General environment • Car parking for patients • Controlled entry system • Disabled access • Toilet facilities • Natural Ventilation • Adequate storage area for PPE • Free of soft furnishings such as carpets, fabric chairs etc. • Single practices, not attached to other providers or services

General environment • Signage • Dirty/clean areas of the practice must be separated by closed doors and have signage displayed warning of the segregated area to control entry. • Non-Hot hub patients should not be able to access the practice, this should be communicated clearly. • To control entry, signage should be displayed warning of the segregated area. • Staff rest area/clean area • Staff must have access to a rest area in a clean area of the practice and access to staff toilet facilities. • This area can be cleaned as routine practice cleaning.

General environment • Remove all non-essential items from reception and consulting rooms such as toys, leaflets, magazines and all personal belongings. • Consider removing privacy curtains and window fittings that are not vertical blinds and replacing with window frosting. • Keep air condition units switched off and external windows open for ventilation. • Doors must be kept shut at all times

Consultation rooms • Multiple consulting rooms that would be suitable for frequent cleaning (Free of soft furnishings .e carpets, fabric chairs etc.) • Review what equipment is required in consulting rooms and remove, store in cupboards or cover non-essential items • Suitable hand wash facilities in each room. • All equipment used should be disposable where possible • If re-usable equipment is used, it should be decontaminated after each use. • Ensure adequate supplies of equipment are in stock and avoid leaving the room to obtain equipment during a consultation. • Computer keyboards should be able to withstand chlorine decontamination or have a cover that allows this.

Brighton and Hove CCG | Coastal West Sussex CCG | Crawley CCG | Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG Staffing Hot Hubs • Staff should be risk assessed if it is safe for them to work at the hub and excluded if they are classed as at risk such as – immune-compromised, – underlying health concerns, – over 70 or – Pregnant.

• Cohort staff working at this location where possible.

• Clinical staff should change in and out of all uniform on site. Uniforms will be laundered by an external company.

• All staff to be familiar with good hand hygiene practice.

Brighton and Hove CCG | Coastal West Sussex CCG | Crawley CCG | Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG Patient attendance ‘Hot Hubs’ • Patients should be triaged and if symptomatic of Covid19 symptoms and able to attend via private car, will be booked into the Covid19 hot hub.

• Appointments should be spread-out where possible to avoid patients congregating within the practice.

• Clinicians, wearing full PPE, should ideally collect the patient upon entry to the practice and escort them straight to the consultation room.

• If patients are required to wait, they should be encouraged to sit spaced from other patients or directed directly into the waiting/consultation room allocated.

1. Patient is triaged and allocated an appointment at the Hot Hub.

2. where there is car parking facility, the patient will park in the car park and phone the number provided. When the clinician is ready for the patient, they will be contacted and provided with clear instructions on where to go.

3. Clinician to greet patient in reception wearing full PPE (gloves, aprons and fluid repellent face mask). Patient to gel their hands and avoid touching anything such as check-in systems, door handles etc.

4. If clinician is not present, reception staff wearing full PPE to direct patient to sit in the waiting area or direct them straight to the consultation room (avoiding touching surfaces/ handles where possible)

5. The consultation room door must remain closed, air conditioning turned off and external windows open. All equipment used or exposed during the consultation must be disposed of or decontaminated.

6. The patient must be escorted out of the practice by clinician the same way they came in and asked to gel their hands upon leaving.

7. Equipment must be cleaned by either a combined detergent/disinfectant or separate solutions and must be effective against coronavirus (see advice). All surfaces to be cleaned including door handles, cupboards, computer keyboards etc.

SICP are essential to minimise risk of transmission between staff and patients

Standards should be in place for: . Hand Hygiene . Personal Protective Equipment (PPE) to protect wearer from exposure to body fluid . Safe disposal of waste and linen . Decontamination/ disinfection of environment and equipment

Hand hygiene is essential to reduce transmission of infection in health and care settings

Handwashing must be carried out thoroughly & time sufficient to inactivate the virus i.e. 40-60 seconds

Follow the 5 key moments of hand hygiene

Alcohol gel ˃60% is effective against COVID-19 Soap and water should be used if hands are soiled

Turn off tap using elbow or paper towel – Do NOT use your hands Dispose of paper towel in pedal operated bin – Do NOT use your hands to open the bin Effective Product, Effective Technique at the Appropriate Time

The PPE guidance follows the PHE recommendations which are the same for both primary care and acute hospital clinicians for the same type of consultations. PPE must be compliant with the relevant BS/EN standards (European technical standards as adopted in the UK)

Masks and goggles/ full face visor (if using) can be worn while writing up notes in the ‘clean’ room of the Hot hub unit

Examination gloves, fluid repellent aprons and fluid resistant surgical masks must be used for each patient and then removed following the donning and doffing procedure

The order to put on (don) the PPE is hand hygiene, apron, mask, (goggles/ full face visor), gloves.

The order to take off (doff) the PPE is gloves, apron, (goggles/ full face visor ), mask, hand hygiene

Brighton and Hove CCG | Coastal West Sussex CCG | Crawley CCG | Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG PPE – Personal Protection Equipment Goggles/ full face visor A risk assessment is required for the need for full face visor or goggles. If there is a chance of splash/contamination to the face a full face visor is recommended

If goggles are used these should be removed at the end of each consultation and cleaned with the rest of the contaminated equipment

Gloves and aprons Gloves and aprons are single-use, single-patient use only To be changed immediately after each patient and/or following of a procedure or task

Fluid repellant surgical masks and goggles/full face visor can be worn for seeing multiple patients i.e. for sessional use

NB A single session refers to a period of time where a healthcare worker is undertaking duties in the hot hub. A session ends when the healthcare worker leaves the care setting/exposure environment

• All PPE must be: – located close to the point of use; – Stored to prevent contamination in a clean/dry area until required for use – Disposed of after use into the correct waste stream i.e. healthcare/clinical waste, which is orange waste bags. – Worn before the patient presents and removed afterwards including hand hygiene. Masks should be removed outside of consulting rooms and disposed of in clinical waste, unless being worn as part of cleaning PPE, in which case it can be removed at the end of the cleaning procedure, inside the room.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877599/T2_Recommended_PPE_for_pri mary_outpatient_and_community_care_by_setting_poster.pdf (accessed 03.04.2020)

Setting Context Disposable Disposable Disposable Surgical Fluid resistant Filtering face Eye/face gloves plastic fluid-repellent mask surgical mask place protection apron coverall/apron respirator (FFP3)

Any setting Performing an single use 4 X single use 4 X X single use 4 single use 4 aerosol generating

procedure on a possible confirmed case

Primary care, Direct patient care – single use 4 single use X X single or X single or ambulatory possible or 4 sessional use sessional use 4,5 care, and confirmed case(s)3 4,5 other non (within 2 metres) emergency outpatient and other clinical Working in settings e.g. reception/communal optometry, area with possible or dental, confirmed case(s)3 X X X X Sessional use 5 X X maternity, and unable to mental health maintain 2 metres social distance6

Individuals Direct care to any X X own home member of the (current place household where single or risk assess single of residence) any member of the single use 4 single use X sessional use or sessional use household is a 4 4,5 4,5,8 possible or confirmed case 3,7

Direct care or visit single use 4 single use X single X X X to any individuals in 4 use 4

the extremely vulnerable group or where a member of the household is within the extremely vulnerable group undergoing shielding

Home birth where single use 4 single use single use 4 X sessional use 5 X risk assess any member of the 4 sessional use 5,8

household is a possible or confirmed case 3,7

Community- Facility with possible single use 4 single use 4 X X sessional use 5 X risk assess care home, or confirmed sessional use 5,8

mental health case(s)3 – and direct inpatients and resident care (within other 2 metres) overnight care facilities e.g. learning disability, hospices, prison healthcare

Any setting Collection of single use 4 single or X X single or X single or nasopharyngeal sessional sessional use sessional use 4,5

swab(s) use 4,5 4,5

• 1. This may be single or reusable face/eye protection/full face visor or goggles. • 2. The full list of aerosol generating procedures (AGPs) is within the IPC guidance [note APGs are undergoing a further review at present]. • 3. A case is any individual meeting case definition for a possible or confirmed case: 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 • 4. Single use refers to disposal of PPE or decontamination of reusable items e.g. eye protection or respirator, after each patient and/or following completion of a procedure, task, or session; dispose or decontaminate reusable items after each patient contact as per Standard Infection Control Precautions (SICPs). • 5. A single session refers to a period of time where a health care worker is undertaking duties in a specific care setting/exposure environment e.g. on a ward round; providing ongoing care for inpatients. A session ends when the health care worker leaves the care setting/exposure environment. Sessional use should always be risk assessed and considered where there are high rates of hospital cases. PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable. • 6. Non clinical staff should maintain 2m social distancing, through marking out a controlled distance; sessional use should always be risk assessed and considered where there are high rates of community cases. • 7. Initial risk assessment should take place by phone prior to entering the premises or at 2 metres social distance on entering; where the health or social care worker assesses that an individual is symptomatic with suspected/confirmed cases appropriate PPE should be put on prior to providing care. • 8. Risk assessed use refers to utilising PPE when there is an anticipated/likely risk of contamination with splashes, droplets or blood or body fluids. • 9. For explanation of shielding and definition of extremely vulnerable groups see guidance: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from- covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

• It is not anticipated, that clinicians will be carrying out infectious aerosol-generating procedures in a Hot hub (AGP).

• Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs;

first responders can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other personnel who will undertake airway manoeuvres.

On arrival of the team, the first responders should leave the scene before any airway procedures are carried out and only return if needed and if wearing AGP PPE.

• Intubation, extubation and related procedures • Tracheostomy / tracheostomy procedures • Manual ventilation • Open suctioning • Bronchoscopy • Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP and Continuous Positive Airway Pressure ventilation (CPAP) • Surgery and post-mortem procedures in which high-speed devices are used • High-frequency oscillating ventilation (HFOV) • High-flow Nasal Oxygen (HFNO) • Some dental procedures (e.g. high speed drilling)

Housekeeping provision at Hot hubs will need to cover a regular clean at least daily, 7 days a week. Staff undertaking this role must be competent and trained in the use of PPE and practices must have the relevant COSHH risk assessments in place for all products used.

Between patient consultations Staff must wear PPE consisting of gloves, apron and fluid repellent facemask and goggles/full face visors. This can be the same set of PPE on from seeing the patient. decontaminate horizontal surfaces, chairs, the sink, high-touch surfaces such as door handles and light switches, and any equipment used, including goggles.

Environment The ideal is to use a combined detergent/chlorine releasing solution with a concentration of 1,000-ppm av cl*. Solutions include Chlor-Clean, and Actichlor Plus

Equipment Decontaminate equipment including goggles or full face visors with disposable cloths/paper roll and a fresh solution of combined detergent/chlorine releasing solution of 1,000 parts per million available chlorine (ppm av cl) *, prepared and used as above

If you do not have a combined product, you must use a detergent solution, rinse and dry followed by a chlorine-containing disinfectant solution, making sure you follow the manufacturer’s instructions for dilution, application, contact time and instructions for rinsing or leaving to dry naturally.

If the item cannot withstand chlorine releasing agents consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent solution.

Keyboards should be able to be cleaned or have a cover that allows this. If possible, site computers in a different, ‘clean’ room to the consultation room.

During the day Frequently touched surfaces throughout the Hub should be cleaned regularly to limit environmental contamination o These can be decontaminated with the combined solution as described above o Alternatively, using combined detergent/disinfectant wipes such as Clinell Universal Wipes. If using Clinell Universal Wipes, the surface should be rubbed clean, and then left wet for 60 seconds for the disinfectant part to be effective. o If no Clinell Universal Wipes are available, detergent wipes, dried, followed by alcohol wipes with a content of 70% alcohol or higher (and allowed to dry naturally), can be used.

• Cleaning equipment should be single use where possible • At a minimum daily, a full deep clean should be completed to include a chlorine disinfection • If chlorine disinfection product is unavailable, a detergent should be used combined with a chlorine disinfectant or separately. • Ensure all surfaces are cleaned following the high to low, clean to dirty process. • All surfaces and all equipment in and out of the consultation rooms should be included in the clean. This will include blood pressure cuffs and sphygmomanometer and the non-disposable parts of otoscopes etc., even if not used in the previous consultation. • Computer keyboards should be wipe able or have a wipe able cover, or able to withstand bleach • Follow decontamination guidance for primary care

• Dispose of all waste as clinical waste

• Waste should be classified at infectious (Orange bag) and stored securely

• Ensure adequate storage for waste is available due to increase from PPE.

The appropriate use of personal protective equipment (PPE) will protect staff uniform from contamination in most circumstances. Areas of clothing left exposed by PPE are generally lower touch areas and therefore are lower risk to clinicians, who should be maintaining social distancing.

Uniforms should be: Changed into within the Hot hub and before staff leave the building Enable staff to be bare below the elbows (short sleeved or sleeves able to be rolled up for duration of shift). External laundry company will undertake appropriate decontamination of all uniforms

Practices should provide changing rooms/areas where staff can change into uniforms on arrival at work via a clean entry point.

Infection Prevention Society COVID-19 Advice and Guidance https://www.ips.uk.net/professional-practice/resources1/covid-19-advice-and- guidance/#.XnTcu3d2vIW Coronavirus (COVID-19): residential care, supported living and homecare guidance https://www.gov.uk/government/publications/covid-19-residential-care-supported- living-and-home-care-guidance COVID-19 Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England as official guidance. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/872745/Infehttps://www.england.nhs.uk/coronavirus/ction_prev ention_and_control_guidance_for_pandemic_coronavirus.pdf NHSE and NHSI Coronavirus guidance for clinicians https://www.england.nhs.uk/coronavirus/

Infection Prevention Training Package https://www.ips.uk.net/professional-practice/resources1/covid-19-advice-and- guidance/#.XnTcu3d2vIW

COVID-19; Guidance for infection prevention and control in healthcare settings, Adapted from Pandemic Influenza: Guidance for Infection prevention and control in healthcare settings 2020 Issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England as official guidance https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/fil e/872745/Infection_prevention_and_control_guidance_for_pandemic_coronavirus.pdf