I would like to draw your attention to 3 important items today 23/3/20.
- Letter from Simon Stevens
This sets out important actions that the NHS should put in place to redirect staff and resources, building on multiple actions already in train. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf
To: Free-up the maximum possible inpatient and critical care capacity.
- Prepare for, and respond to, the anticipated large numbers of COVID-19 patients who will need respiratory support.
- Support staff, and maximise their availability. Play our part in the wider population measures newly announced by Government.
- Stress-test operational readiness.
- Remove routine burdens, so as to facilitate the above
2. Letter from CMO Stephen Powis (attached)
Advice concerning those who are or may be at increased risk of severe illness from COVID-19
Please see a letter suitable to be sent to families in annex 3.
Patients on immunosuppression therapies sufficient to significantly increase risk of infection have been outlined in the BSG Guidance which has been updated today 23/3/20.
Our advice today when we called families of children and young people with IBD in the high risk category, (see guidance – while on steroids prednisolone equivalent to or greater than 20mg, or within 6 weeks of starting a biological therapy, or with severe active disease), was to reassure that Covid19 appears not to cause such severe disease in children and young people.
We reinforced that patients should continue their usual treatment, including infusion therapy, and to continue to contact their IBD team by phone if they have symptoms eg fever, typical features of a relapse. The team will assess each patient case by case and advise accordingly.
3. HOMECARE (Home Parenteral nutrition) advice from 23/3/20 issued by Susan Gibert, who is leading on COVID-19 for Homecare
This has been sent to all regional homecare leads who will disseminate to the trusts.
NHSE contract – CCGs (12 week rule)
In TVW I have gained agreement that NHSE and CCGs will not be expecting the homecare activity to have been recorded within the usual time frames. It might be a good idea to do the same in your regions.
Delivery windows – relaxation of expectation
I have agreed with NCHA members that the NHS will not be expecting homecare providers to ‘hit’ their 2 hour delivery windows. Deliveries may need to move to all day windows in the near future, and if this is necessary can we agree to be supportive please? Homecare providers and hospitals are asked to be extra vigilant with the delivery address details as patients may no longer be at their usual work or residential addresses.
We may reach a time where same day, next day and emergency deliveries are no longer possible. We may need to consider adjusting buffer stock in patients’ homes. At the moment, we do not have the reassurance that there is stock to do this, but it is something that we need to bear in mind for the coming weeks.
Homecare providers are experiencing high volumes of calls, this has led to longer wait times. Patients are also reporting that their hospital clinical teams are no longer manning some NHS helplines (as specialist nurses are being called to ward and other duties). Please can you ensure that you use the correct line of communication as per local agreements. If the route of contact is via your BDM, RBM etc, please can you refrain from ringing the homecare providers?
Equally if your CNS staff are being called to the front line, please can you ensure that the homecare providers have a contact number or email for an alternative contact? If in doubt, the pharmacy homecare team will be contacted for all enquiries that have not been dealt with in a timely manner. In TVW we will be ensuring that the pharmacy contacts are up to date, if you could do the same, that would be great.
Dr Sue Protheroe,
Consultant Paediatric Gastroenterologist,
Birmingham Women’s and Children’s Hospital.
Birmingham. B4 6NH. U.K.
Tel 0044 121 333 8705
Fax 0044 121 333 8701
Chair NHS England Clinical Reference Group, Paediatric Medicine.
President of British Society of Paediatric Gastroenterology, Hepatology & Nutrition.
I trust this this finds you, family and colleagues well and bearing up in these difficult times. We find ourselves under exceptional circumstances. I am indebted to members for coming together to support each other. We will need to step forward, share our skills as best and as appropriate as we can and reach out to those professionals who are most stretched.
“…….and there are no more surgeons, urologists, orthopedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us”. Dr Daniele Macchine, Bergamo, Italy, 9 March 2020”
I would like to draw your attention to the following-
Guidance for children’s services from NHS E and Advice on Covid 19 prevention and control to best keep yourself and your patients safe, to be used in conjunction with local policies https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
- New BSPGHAN Endoscopy advice to be read in conjunction with the latest BSG\JAG advice https://t.co/3b1rhbnGt0?amp=1
- https://www.ncp.co.uk/parking-solutions/free-parking-nhs-staff/ How to register for free NCP parking
- Recommendations to the Regional Homecare Specialists regarding provision Home Parenteral Nutrition services.
- Advice is being prepared for us to manage the most vulnerable patient groups and for families of children on hone PN that should be available tomorrow.
- Specialty guides for patient management during the coronavirus pandemic
Whilst demand may be more felt in adult services, given current understanding of the virus, paediatric services have a key role to play. Children’s hospitals, working with District General Hospitals, will need to provide a regional and national response to pressures on the NHS. The elective component of our work may be curtailed, and resources diverted to areas of greater need. However, non-elective patients will continue to need high quality care and we need to ensure that they receive the care that is appropriate. We should seek the best local solutions to continue the proper management of unwell neonates and children while protecting resources for the response to coronavirus.
The following principles should guide how we run our services during the outbreak:
- Follow Public Health England guidance.
- Keep children out of the healthcare system, unless essential.
- Use telemedicine and other non-direct care, when appropriate.
- Plan for stopping elective procedures and treatments that may consume critical care and ward resources.
- We should advise patients with specific conditions such as IBD and those on home PN to still make sure that they seek advice in from their speciality nursing /medical teams in the event of fever or typical symptoms of relapse of their condition.
If you find that parents are not seeking advice, it would be good to know, and I can ask the RCPCH and NHS E to help reinforce this message for parents?
As the situation is changing very rapidly, with different resource strains in the adult sector, and events may overtake our advice with paediatric anaesthetists being pulled to work in the adult sector. Any guidance regarding endoscopy should acknowledge the principles above, e.g. that our patients should continue to receive the best care that is appropriate; that we may need to seek best solutions locally and to divert resources to areas of greater need so that they are used equitably, fairly and effectively.
- Advice for Planning Endoscopy Activity during COVID-19: Consensus document prepared by Dr Christine Spray and Dr Babu Vadamalayan on behalf of BSPGHAN with advice also taken from BSG guidance (20/03/2020).
It is clear proactive planning for hospital services is essential over the coming weeks and months.
All Trusts are taking measures to reduce in & out-patient activity to reduce risk of exposure to COVID – 19 for patients and staff, especially from asymptomatic carriers
It is also recognised resources including staff, theatre supplies and PPE are limited and need to be available for patients and staff who require them as a priority
The BSG have documented guidance re endoscopy services in order to address the above concerns: http://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/
- Endoscopy Teams are advised to follow both national guidance for reducing transmission of infection with COVID19 (websites above) but also agree their own local protocols and policies in collaboration with senior management, Infectious Disease or Infection Control teams. There are both general measure that should be followed and specific measures around personal protective equipment (PPE).
- PPE for endoscopy procedures – advice is that standard infection control measures should be followed except for aerosol generating procedures (AGP) in patients at high risk of or with confirmed COVID19 infection. AGP in this context means upper GI procedures and for patients who fall into this category, enhanced PPE is recommended including FFP3 masks. Endoscopy teams should also consider enhanced PPE for emergency and out-of-hours procedures and also consider arrangements for the most appropriate location to perform these within their hospital. Units are encouraged to ensure staff know how to be fitted for the appropriate size of FFP3 mask and how to put on PPE correctly.
- Official advice is that enhanced PPE is not currently felt to be necessary for upper endoscopy in patients at low risk or for lower GI procedures. Concerns have been raised that the virus may be faecally transmitted but there is presently insufficient evidence to recommend the use of enhanced PPE measures for lower GI procedures. Stocks of FFP3 masks are also limited and their use needs to be carefully prioritised. This is; however, a rapidly changing situation and teams should check regularly for updates to both local and national guidance
BSPGHAN suggest these principles and guidance are considered for patients considered to require endoscopy by their Consultants. Requirement for endoscopy should be risk assessed and deferred or delayed if possible.
- categories are suggested:
- Need to continue:
- Newly presenting acutely unwell patients with likely IBD
- Unstable known IBD patients who require urgent endoscopic assessment to understand appropriate change in treatment, when all other measures have been assessed as an alternative & failed
- Seriously unwell children who require endoscopy for diagnosis and therapeutic endoscopy for treatment, including significant acute UGI bleed, acute oesophageal obstruction including food bolus obstruction & stricture & gastrointestinal obstruction needing urgent decompression/stenting
- Urgent inpatient nutrition support – PEG/NJ tube
- Upper GI endoscopies for portal hypertension for patients who bled within the last 6 months and still in the eradication process.
- Defer until further notice
- All non-urgent routine symptomatic patients and those for routine planned endoscopic review including planned dilatation for stricture or achalasia & polyp surveillance
- Known IBD patients planned to undergo routine reassessment
- Needs discussion
- Patients positive for COVID – 19 to be considered for diagnosis and treatment based on clinical grounds rather than tissue diagnosis after discussion with parents
- Unwell patients with possible Coeliac disease who do not fit the criteria for non-biopsy diagnosis pathway
- Newly presenting patients with likely IBD
- This list is neither exhaustive nor prescriptive and is meant to serve as a guide to clinical teams when planning during the current emergency.
- The situation continues to evolve rapidly, and this advice may change from day-to-day, so clinicians and managers need to check regularly and look for updates and briefings from the relevant Government agencies in the four nations.
- Teams need to consider resources- both staff and equipment (PPE and endoscopy kit) – when planning and think well ahead as we get closer to the peak of the outbreak.
- Systems need to be in place to keep records of patients who have been deferred or cancelled so that either alternative arrangements (e.g. clinic follow up, radiological imaging) can be made or rebooking can occur when it is safe to resume normal activities. Local discussions with colleagues in Radiology may also be helpful when considering this.
More general and operational considerations
- Restricting numbers of staff in rooms for all procedures –e.g. limit trainees (may be redeployed anyway)
- Assessing stocks of consumables and devices daily – without panic buying. Keep in touch with suppliers and local representatives regarding the supply chain in the coming weeks
- Considering alternatives for diagnostic testing – Calprotectin; radiology (already hard-pressed); telephone triage of e.g. 2WW referrals.
- Free car parking
NCP are offering NHS staff free parking at over 150 car parks across the UK, in support of efforts at this current time. NHS staff should pre-book online and is valid for bookings and exits until end of April, when they’ll review the situation
The following information has been provided by Susan Gibert, chair of NHMC.
Changing ordering (PONs) and clinical validation
If hospitals are planning on planning on changing any of the aspects of their prescribing, please can they liaise with their homecare providers before doing so, this includes:
- Changing prescription length – the length of prescription validity must be clear on each prescription
- Changing clinical validation (stopping clinical validation in the case of staff shortages)
- Changing Purchase Order Numbers (PONs) or not adding PONs to prescriptions due to staff shortages
If hospitals do not inform their homecare provider in advance, there is a risk that prescriptions / documents with queries will be placed in the Document Under Investigation (DUI) files and will not be acted upon. Please instruct your hospitals to check the DUIs carefully. Homecare providers have agreed to pro-actively manage DUIs to reduce the risk.
It is essential that the process for adding ‘wet’ indelible ink signatures continues as per the current agreed process with the individual homecare providers.
Prescription renewal / repeat prescription / prescription management
Some hospitals have asked homecare providers to increase the notice given for repeat prescription requests.
All hospitals / clinical areas that receive 5 to 6 weeks’ notice for repeat prescription requests will move to 8 weeks.
The prescription due date will not change, and hospitals that do not need advanced notice will need to ‘ignore’ the requests that they do not need.
Please note this measure only relates to prescriptions that are already requested 5 to 6 weeks ahead, no changes are anticipated for other therapies at this stage.
The homecare providers agreed that a consistent approach is essential to maintain patient safety so please encourage your hospitals to comply with the above.
This is a temporary measure that will be reviewed on an ongoing basis and after a return to business as usual (BAU) in due course.
Changing / increasing quantities of medicines supplied
This needs to be managed carefully and there needs to be national oversight of any proposed changes to existing prescribing and / or supply.
Manufacturers of pharma funded schemes are being asked on an individual basis, whether there is sufficient stock in the supply chain to increase stock of medicines in patients’ homes. Only if there is sufficient stock guaranteed for all patients to receive more buffer stock, will homecare providers be permitted to increase delivery quantities and reduce delivery frequency.
Homecare providers and manufacturers are in the information gathering phase. Once there is a clearer picture of stock availability and which patients will benefit from increased buffer stock in their homes, more information will follow.
At the moment clinicians are asked to kindly maintain current prescribing patterns.
Prescriptions for HPN, should include a prescription for fluids and / or multi chamber bags as agreed by the HPN stakeholder group. Please refer to specific guidance from the HPN stakeholder group for further information. It has been confirmed that where multiple prescribers usually sign HPN prescriptions, one signature will be sufficient, as this is the legal requirement.
Mitigation / Risk Management
Hospitals and patients being cared for in secondary care, may benefit from increased access to homecare medicines services. Any ‘extra’ resource needs to be managed carefully and there needs to be national oversight. If hospitals wish to commence new services, this could be managed in a variety of ways:
Hospitals may contact their chosen / preferred homecare provider directly
Hospitals may contact their regional homecare specialist
It would be helpful to have oversight of which patient cohorts would benefit from accessing homecare services and which services hospitals have asked homecare providers to start providing (OPD services and other secondary care services). Please could you liaise with your regional homecare specialist and / or your regional pharmacy procurement specialist for more support and local information.
Expanded BSG consensus advice on management of IBD plus guidance on IBD
Guidance on hepatology patient risk groups
22nd March 2020
Dear BSPGHAN members
I trust that this message finds you and your families well.
I will try to provide updates if I receive advice which will help members plan services and support challenges due to workforce shortages.
Speciality specific advice
Please see COVID-19: BSG and BASL advice for healthcare professionals in Gastroenterology and Hepatology for speciality advice on Covid 19 for healthcare professionals in Gastroenterology and Hepatology.
There is likely to be several changes in the guidance over this week and follow the most up to date guidance from https://www.england.nhs.uk/coronavirus/ and specifically for your area, see the following links Public Health England, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland.
The RCPCH are monitoring the evolving public health challenge of COVID-19 – and the risks and impacts on members and the wider child health workforce, and on children and young people. They have produced guidance for paediatric services and links to information from statutory bodies in all UK nation.
What we know so far
We know that children of all ages in China were susceptible to COVID-19. Clinical manifestations of pediatric patients were generally less severe than those of adults’ patients. We do not know which groups are at more at risk than others , but young children, particularly infants, underlying pulmonary pathology, and immunocompromising conditions have been associated with more severe outcomes with non- COVID-19 coronavirus infections in children. Paediatrics. 2020; doi: 10.1542/peds.2020-0834
Advice for families
Patients should continue following regional safety netting advice if parents are worried that their child is unwell.
Currently, national advice should be followed regarding attendance at school, need for testing or attendance at hospital for assessment
People should now avoid non-essential contact and to stop all unnecessary travel.
Local and regional paediatric services are putting in place detailed plans to treat and support all children who have severe COVID-19 infection. There is a national plan in place for the management of children requiring intensive care management (PICU). NHS Trusts are working in conjunction with the Regional and National NHS Command Structure, to agree what support to the wider NHS will look like and to free up capacity for care, including intensive care beds.
What BSPGHAN is doing
BSPGHAN is linking with key stakeholders rapidly to protect patients who we suspect may be more vulnerable to the knock on effects of the pandemic on healthcare resources.
The risk may increase over the coming days and disruption to routine delivery of care will affect all patients .
- Home parenteral nutrition patients
The HPN National Framework in England is coordinating an action plan for hospital teams and home care providers and is preparing a statement for professionals and patients, to include children. It is envisaged that there will be a coordinated plan for potential disruption to home and hospital PN compounding, deliveries and supply and home care services. Home PN teams are already in touch with patients advising that there will be notified about changes in the way services are delivered.
- Liver and intestinal Transplant patients – Please look at advice British Transplantation Society
- IBD patients We have linked in with the BSG and we are exploring if a national coordinated response can be given from NHS E to secure access for children on biological therapy, and their routine blood monitoring. I will keep you updated when more advice becomes available. See the BSG COVID-19 Guidance and Advice Knowledge Hub and BSG and BASL COVID-19 Advice for Healthcare Professionals in Gastroenterology and Hepatology.
- Endoscopy teams are advised to follow national guidance for reducing transmission of infection with COVID19 but also agree their local protocols and policies in collaboration with management, Infectious disease or Infection Control teams (see BSG link for their advice on cancellation of endoscopy https://www.bsg.org.uk/covid-19-advice/).
Please see linked here a statement about the impact of COVID-19 on research funded or supported by NIHR.
The priority is the safety of our patients and health professionals and families. BSPGHAN has cancelled the annual trainees and associates’ meeting in May. We are all now working in different ways, running virtual clinics, prioritising essential versus non-essential contacts, cancelling elective theatre lists and redeploying staff.
As advised, individual treatment plans will need to be made between the patient, family and physician.
President 17 March 2020
Dear members I trust that this message finds you well. I am writing to notify you that following guidance, we have taken the decision to cancel our annual trainees and associates meeting in May. The priority is the safety of our staff, patients and families. Trusts will be running incident management teams to deal with local issues and prioritising delivery of care.
To access regular advice, please see the RCPCH guidance for paediatric services with links to information from statutory bodies in all UK nations that will be regularly updated. I have contributed to advice being prepared to plan for services for our patients and to support challenges that will be faced by our workforce.
Please check the daily NHS England advice for health professionals at https://www.england.nhs.uk/coronavirus/ .
Please see COVID-19: BSG and BASL advice for healthcare professionals in Gastroenterology and Hepatology for speciality advice on Covid 19 for healthcare professionals in Gastroenterology and Hepatology.
Sue Protheroe President 15.3.20