Review of the response to the H1N1 Flu Pandemic 2009/2010 WLMHT

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1 Contents 1 Introduction Command and Control Lessons identified Command and Control Internal Communication Lessons identified Internal Communications External Communications Lessons identified External Communications Working with Partners Influenza Pandemic Committees (IPCs) Lessons identified Working with Partners Vulnerable Groups Lessons identified Vulnerable Group Personal Protective Equipment (PPE) Lessons identified PPE Antivirals Lessons identified Antivirals Vaccine and vaccine consumables Lessons identified Vaccine and vaccine consumables Increasing capacity Lessons identified Increasing Capacity Reporting Lessons identified Reporting Flu/winter assurance process Lessons identified Flu/Winter Assurance The next steps Conclusion Appendix A Table of lessons identified and action plan Page 1

2 1 INTRODUCTION In April 2009 the world became aware of cases of illness caused by a novel influenza virus, then termed swine influenza A/H1N1. Over the following five days, the World Health Organisation (WHO) announced that the global pandemic alert level had increased from WHO Phase 3 to WHO Phase 5. On 11 June, WHO declared WHO Pandemic Phase 6 and the official start of the first pandemic of the 21 st century. The first UK cases were reported in Scotland on 27 April, and the first in London on 30 April Cases continued to increase and London saw the peak of the first wave in July. The pandemic was originally managed through containment measures (treating cases and providing antiviral prophylaxis to their contacts) which included some school closures. There was a brief period of outbreak management in London (a less stringent version of containment limited prophylaxis and contact tracing), before the whole country moved to the treatment phase (no prophylaxis or contact tracing) in response to the rapidly increasing number of cases. Following the first wave London saw a reduction in the number of cases over the school summer holidays which started to increase around the beginning of September when children returned to schools, a second wave commenced and the number of cases increased. In November, the vaccine became available and was offered to the first at-risk groups, those being pregnant women, household contacts of the immune-compromised, people aged 6 months to under 65 years in the seasonal flu risk groups and those aged over 65 years in the clinical seasonal flu risk groups; and frontline health and social care workers. When more vaccine became available the vaccine was offered to healthy children aged between 6 months and 5 years old. In January and February 2010, the numbers of cases reduced to an extent that the National Pandemic Flu Service was decommissioned (11 February) and new flu cases were managed through GP consultations. WLMHT Key Events A Trust Pandemic Flu Steering Group met monthly throughout the year to develop response and recovery plans. Additionally, each SDU had local arrangements to regularly review and implement the actions arising from the Steering Group. SDUs also established and maintained links with local PCT Flu Planning Groups. Patient care management flow charts were developed and training organised to provide refresher training for some dual trained nurses and training in the use of face masks. Patients who fell into one or more of the high risk groups were identified. A Trust wide pandemic flu tabletop exercise was carried out in September 2009 attended by the Department of Health Flu Lead. The Trust Flu Plan was submitted to the Trust Board in October and assessed as green by NHS London in November. Trust Policy and guidance and information from the Department of Health was published via a window on the front page of the Exchange. Also, key messages were issued using Monday Matters and Team Briefings. The first batch of swine flu vaccine was received in November and arrangements made to make this available to patients in high risk groups and front line staff. Due to the limited number of vaccines initially available and some uncertainty about future deliveries, priority 2 Page

3 staff were identified within the front line group, and they were targeted to receive the vaccine. With the benefit of hindsight in the knowledge that sufficient quantities of the vaccine would be available, the vaccine should have been made immediately available to all front line staff. The take-up of the swine flu vaccine by staff over the period of availability was under 25%. The take-up of flu vaccine was higher than previous years but below reported take-up in some other London Trusts. All patients were offered the vaccine but take-up was also generally disappointing. The Trust had one unconfirmed case of swine flu an in-patient in Hounslow. Whilst there were reported cases amongst staff, these were not significant in number and sickness levels were down on the corresponding period for the previous year. As a result, the Trust did not need to implement its Command & Control arrangements in full although at the outset of the outbreak at the end of last summer, SDUs were meeting daily to monitor the situation and link with their respective PCT Planning Groups. The bad weather in January tested some business continuity elements of the flu plans, particularly at Broadmoor Hospital. Page 3

4 2 COMMAND AND CONTROL The Trust Command & Control arrangements were developed from existing emergency planning/business continuity arrangements to manage incidents or crisis situations potentially resulting in significant disruption to services. A Trust Steering Group met regularly during 2009 to develop response and recovery plans and each SDU emergency planning lead established links with their local PCT Flu Planning Group. The Trust s Pandemic Flu Plans were tested during a Trust wide flu pandemic tabletop exercise held in September At the outset of the swine flu outbreak in the UK, daily communication meetings were being held to monitor the situation. With only one suspected case amongst the Trust s in patients and sickness levels amongst staff lower than the corresponding period for last year the Trust s Command and Control arrangements were not tested in full. However, through day to day planning and response to suspected cases, aspects of the Trust plan were tested and whilst generally they worked well a gap was identified with regard to the involvement and engagement of medical staff. 2.1 Lessons identified Command and Control Steering Group and SDU flu groups met regularly sub groups formed as necessary Command arrangements not needed but business continuity plans tested to some extent during severe weather outbreak in January Daily Communication Briefings Links with PCT Flu Planning Groups Care Management Flow Chart Tabletop Exercise Ensuring compliance with agreed procedures Ensuring clearly defined roles and responsibilities for SDU medical leads 3 INTERNAL COMMUNICATION Existing internal communications processes (e.g. the Exchange, Monday Matters, Team Briefing) were used to inform staff of the Trust s management arrangements and guidance from the Department of Health. The response to suspected cases indicated that some key messages were not being received or understood by all staff. It was also noted that social care staff working in H&F do not have access to the Exchange. The development of team briefing and a model for internal communications to improve assurance that information has been delivered, understood and acted upon was a key learning outcome. To assist this process, information received by the Trust needs to be evaluated and communicated in a way in which it can be best understood and acted upon by Trust staff. 3.1 Lessons identified Internal Communications Flu section on Trust intranet Care Treatment flow chart Flu plans agreed by Trust Board & SDU SMTs Promoting good health practice Ensuring procedures are received, understood and acted upon 4 Page

5 Develop health promotion campaign to increase vaccine take-up amongst staff and patients Ensuring access to information Avoiding information overload and potentially conflicting information Ensuring direct care staff promote good health practice 4 EXTERNAL COMMUNICATIONS Although there were existing emergency planning links between SDUs and key agencies, the planning for a flu pandemic has strengthened these, perhaps due to focusing on one issue that was a high priority for all concerned. Individual SDU flu leads have been engaged with their respective PCT Flu Planning Groups and have found these to be both informative and supportive. An area for review is the information given to carers to ensure they are well informed and able to advise and support patients this could play a part in increasing the take-up of the vaccine by patients in the future. 4.1 Lessons identified External Communications Links between SDUs and PCT Flu Planning Groups, HPUs and Acute Trusts Information for carers 5 WORKING WITH PATNERS INFLUENZA PANDEMIC COMMITTEES (IPCS) As above, individual SDU flu leads have been engaged with their respective PCT Flu Planning Groups and have found these to be both informative and supportive. Because the Trust linked with a number of IPCs there were occasionally local differences but this did not result in any significant problems. There was also close and effective partnership working between Pharmacists. PCTs and Acute Trusts were supportive in providing training as required e.g. use of face masks, refresher training for dual trained nurses. At Broadmoor Hospital, where suspected cases of swine flu were routinely subject to swab tests throughout the containment and treatment phases, the local HPU provided great support in ensuring that results were turned around within 24 hours. 5.1 Lessons identified Working with Partners The meetings built upon existing multi agency working and were very positive and worthwhile Building on partnerships, review plans to ensure the lessons learned are incorporated within flu plans Page 5

6 6 VULNERABLE GROUPS Vulnerable in patients were identified using the DH criteria. There were some difficulties in identifying vulnerable residents in the community because there was no mechanism in place to identify such vulnerability or extract it from information systems. Earlier and more comprehensive criteria from the DH on vulnerability would have been useful. Work is also required within the Trust to develop its criteria for identifying vulnerable patients. 6.1 Lessons identified Vulnerable Group Lists of in-patients in high risk groups were maintained Regular physical health reviews Area s for development Introduce formal systems of identifying patients at risk (MEWS) and monitoring practice against achievement (QOF) Develop Trust criteria for identifying vulnerable patients during a flu pandemic Target groups for education to encourage a greater take-up of vaccine Maintain up to date database of patients with physical illnesses 7 PERSONAL PROTECTIVE EQUIPMENT (PPE) Trust requirements were identified in 2008 as part of an NHS Supply Chain stockpiling arrangement for avian flu. Orders were placed for 25% of the Trust stockpile in February 2009 and received within quoted delivery times. Initially, it was not thought that FFP3 face masks would be used in MHTs but guidance from the DH subsequently indicated that their use should form part of our contingency plans. When general guidance is being issued, the implications for MHTs and in particular secure facilities should be considered and included. 7.1 Lessons identified PPE Early identification of Trust requirements Procurement process Ensuring wards maintain appropriate PPE stocks at all times The needs of mental health and secure mental health facilities should be considered and included within any future DH guidance about the use of FFP3 face masks 8 ANTIVIRALS Effective liaison between the Trust and PCT Pharmacists ensured that no problems were encountered with supply. Stock was available through local PCTs. There were also no issues locally with regard to stock management or its issue. At Broadmoor Hospital, the local PCT/HPU continued to support swab testing of patients during the treatment phase given the particular issues of containment in a closed institution. 6 Page

7 They were also prepared to issue antivirals as a prophylaxis treatment for staff that had contact with a confirmed case. 8.1 Lessons identified Antivirals Effective liaison between Pharmacists Continuation of swab testing for patients in closed institutions None 9 VACCINE AND VACCINE CONSUMABLES It was not clear initially how much of the vaccine would be available and when. This led to some staff being turned away and with the benefit of hindsight the vaccine should have been made available immediately to all front line staff. Unlike the antivirals, the vaccine could only be obtained via Ealing PCT. Whilst distribution was manageable, it would have been easier for each service to obtain the vaccine via their local PCT. Nursing staff were identified in some parts of the Trust to support the Occupational Health Department in providing the vaccine. Walk in clinics were also arranged to improve accessibility. The multi dose vial meant that a minimum of 10 staff/patients needed to be booked and attend in order to avoid wastage. A single dose would have made planning and delivery much easier. There were also two types of vaccine, which restricted the Occupational Health Department if staff needed a second inoculation having had the first at their GP and the types did not match. Take up of the vaccine amongst staff through the Occupational Health Department was less than 30%. If a much higher percentage of staff wanted the vaccine there would be capacity issues for the Occupational Health Department to manage. The health promotion campaign for the flu vaccine is to be reviewed and links are to be made with other MHTs to share learning Lessons identified Vaccine and vaccine consumables Walk in clinics for staff Training of some nursing staff to provide vaccines in support of the OHD Flu vaccine offered to all patients Improved take-up on previous years (although progress still to be made) Area s for development Vaccines to be made available via local PCT Improving accessibility for ward based staff, staff working nights Include in flu plan the need to deploy additional resources to support physical healthcare and Occupational Health staff during peak periods Develop flu education programme for patients (i.e. routine physical healthcare reviews, MDT meetings, physical healthcare link nurses, ward community meetings, one to one Page 7

8 consultations with Health Centre professionals) 10 INCREASING CAPACITY This was not a significant issue for the Trust but the London SDUs were party to discussions through their local PCT Flu Planning Groups about identifying bed capacity and mechanisms for doing so. There was also consideration about the sharing of such information with neighbouring boroughs with regard to mutual aid arrangements. With regard to the Trust s capacity to manage during a crisis, further consideration needs to be given to the part that could be played by volunteers. The benefits of bank staff to provide support during a crisis also needs to be considered as part of each SDUs contingency/business continuity planning. The Trust Policy for the redeployment of staff has been through its consultation phase but has yet to be agreed Lessons identified Increasing Capacity Involved in discussions at PCT Flu Planning Groups Ensure there are mechanisms for identifying capacity and sharing information Explore potential for use of volunteers during a flu pandemic and benefits of nursing bank for inclusion in business continuity plans Ensure policies/plans are in place for the redeployment of staff within and to other SDU services as required 11 REPORTING The Trust has completed SitRep and FluCon reports weekly/daily as required by DH/NHS London. Information has been collated by the Trust IT Department and submitted electronically. For those involved in gathering the information one common report rather than two would have been helpful Lessons identified Reporting Internal Trust communication worked efficiently and effectively and reports were submitted as required Area s for development Consideration to be given by DH/NHS London about unifying/streamlining reporting arrangements 12 FLU/WINTER ASSURANCE PROCESS Self assessments were completed by the Trust and submitted as required. The Trust s flu plan was assessed as green by NHS London in November 2009 having initially been assessed as amber. Whilst the checklist issued by NHS London provided a good framework 8 Page

9 to ensure the plan covered all essential elements, a flu plan template would have been useful in order that the information was provided in a common format by all Trusts. Such a template may have also helped Trusts with sharing information, enabling easier comparison. Occasionally, information coming from the DH and NHS London was found to be fragmented and confusing Lessons identified Flu/Winter Assurance G ood practice Self assessments & checklists Ensuring information from the DH and NHS London is coordinated and joined up An annual programme of what is required from Trust s with regard to emergency planning and business continuity assurance would improve planning and efficiency locally 13 THE NEXT STEPS The Trust and individual services within it have held debriefs to evaluate/review the effectiveness of flu plans. The Trust has also taken part in local PCT Flu Planning Group debriefing sessions. The lessons learned will be incorporated into Trust flu and business continuity plans. Progress in relation to the attached action plan is to be monitored by the Trust Flu Steering Group. A list of tasks required to maintain the Trust flu plan in a state of readiness is being prepared and will also be monitored by the Trust Flu Steering Group. A copy of this report is to be submitted to the Trust Board on 30 th March CONCLUSION A number of staff across the Trust have individually and collectively demonstrated a high level of commitment, energy and skill in developing the Trust s pandemic flu plans. Worthy of special mention are those in infection control, physical healthcare, occupational health, pharmacy and the membership of the Trust Steering Group and local SDU planning groups. We thank everyone who has contributed in what has been another challenging year for the Trust. Steve Trenchard Director of Nursing and Patient Experience March 2010 Page 9

10 15 Appendix A Table of lessons identified and action plan No. Lesson identified Action Owner Target date for completion 1 Ensuring a clearly defined role for Issue to be raised with the Steve Trenchard 31 May 2010 medical staff in the planning and Executive Team and Operational management of a pandemic flu Board to determine role and outbreak responsibilities 2 Ensuring information is evaluated and disseminated in a format relevant to the Trust with actions as appropriate 3 Develop criteria for identifying vulnerable patients during a flu pandemic Trust/SDU Leads to evaluate and cascade information using team briefing and ensuring any requirements are acted upon Criteria for identifying vulnerable patients during a flu pandemic to be developed Trust/SDU Leads Carol Scott/Dr Tim Bullock Ongoing as information is received 31 May 2010 Date completed 4 Improving take up of flu vaccine amongst staff 5 Improving take up of vaccine amongst patients Introduce formal systems of identifying patients at risk Develop promotion campaign, the use of walk in centres and vaccination at ward level. Other London MHTs to be contacted to learn from their experiences. Ensure robust flu education programme including: regular physical health reviews, MDT meetings, physical health care link nurses, ward community meetings, one to one consultations etc. Clinical Directors Occupational Health Department Clinical Directors 31 August August 2010 Ongoing 6 Ensure the contingency plans for supporting the delivery of critical services are robust Ensure carers are provided with information/guidance Explore potential for use of volunteers during a flu pandemic Communications Dept. SDU EP Leads/Pat McGrath 31 August 2010

11 Ensure best use of nursing bank Ensure policy/procedures for the deployment of staff within and to other SDU services as required SDU Directors Ongoing Director of HR/SDU EP Leads 31 August 2010 Page 11