President update 31st March 2020  Latest NHS E HPN patient letter for circulation

President update 31st March 2020 Latest NHS E HPN patient letter for circulation

Dear members

Please share this updated letter C0106 HPN COVID patient information_UPDATED_27 March  with families of children on home parenteral nutrition. It outlines plans that home care providers are putting in place and changes that families may expect. 

Please be aware of the latest advice. 

 “Keeping yourself safe”

“The government is regularly updating its guidance on at-risk groups. In light of the  latest information your hospital teams now consider that patients on HPN are a high risk group, as you/your child have significant organ impairment (GI) and a central venous access device in place. This advice is endorsed by the British Society of Gastroenterology. It advises you to follow the guidance on ‘shielding’ stringently, as outlined by the government, and you are strongly advised to stay at home and avoid any face-to-face contact for at least 12 weeks in the first instance.
This can be challenging but the consensus is it is the best way to keep yourself/your child safe”.

Kind regards
Sue Protheroe
BSPGHAN President 31/03/20
e-mail President@bspghan.org.uk

President update Monday 30th March 2020- Endoscopy and IBD statements from ESPGHAN

President update Monday 30th March 2020- Endoscopy and IBD statements from ESPGHAN

This is a challenging time but amid the concern, there are uplifting stories of how people are looking out for each other and communities pulling together. The children’s rainbows of hope in windows and the national clap for carers to celebrate the work of the NHS and care workers on Thursday were much appreciated.   

Information is useful—but too much information can be unhelpful. I have limited news updates to new information from consensus sources. We don’t generally benefit from watching the news over and over. Try to focus instead on the things you need to get done. Value the rest of the time to relax with your family or friends and reach out to those who may not have such good support networks as you may have. 

The bulletins below have some reassuring observations for our patients.

I hope that these help guide your practice while working differently.

1 )Statement “Gastrointestinal endoscopy in children and COVID 19 pandemic” – ESPGHAN  Endoscopy Special Interest Group

http://www.espghan.org/societal-papers/covid-19-informational-statements/

“..elective procedures – especially those such as upper gastrointestinal (GI) endoscopy which is an ‘aerosol-generating procedure’ (AGP) – should be put on hold at present. Equally ileocolonoscopy, given that we know now that COVID-19 can be excreted in stools. Local and physician judgment should occur when determining which patients require urgent endoscopic diagnostic testing, but these should be kept to a minimum. Obviously, life-saving endoscopy such as GI bleeding and button battery ingestion are mandatory and should not be deferred. In the event of endoscopy being required a full personal exposure protection package should be worn by those in the immediate vicinity of the endoscopy including an FPP3 mask or equivalent”

3) Letter from  Lorenzo d’Antiga, Italy  “Coronaviruses and immunosuppressed patients” https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/lt.25756

Preliminary experience so far show that children under 12 years of age do not develop coronavirus pneumonia regardless of their immune status although they get infected and can spread the infection. Immune suppressed patients are not at risk for severe pulmonary disease compared with the general population. 

2) Article “COVID-19 and paediatric inflammatory bowel diseases: global experience and provisional guidance (March 2020) from the Paediatric IBD Porto group of ESPGHAN”.   see PDF attached  https://bspghan.org.uk/jpgn-s-20-00391

Preliminary data for PIBD patients during COVID-19 outbreak are reassuring.

IBD per-se does not currently seem to be a risk factor for acquiring SARS-CoV-2, nor for a more severe infection. Standard IBD treatments including biologics should continue at present

4) Surveys – please report cases of COVID-19

  1. a)  “PedIBD and Covid-19” ESPGHAN Porto IBD Group   https://research.szmc.org.il/redcap/surveys/?s=FP38CNWRLE
  2. b) “EoE/EGID and COVID-19 ”

http://www.espghan.org/societal-papers/covid-19-informational-statements/

https://redcap.clalit.co.il/redcap/surveys/?s=PHLW7EC8WD

Best wishes 

Sue Protheroe

President 30 March 2020

President update 31st March 2020  Latest NHS E HPN patient letter for circulation

BSG/JAG statement on personal protective equipment (PPE)

  • All upper GI endoscopy should be considered high risk and enhanced PPE is recommended for all patients, regardless of any risk stratification.
  • BSG also considers lower GI endoscopies to be aerosol generating procedures (AGP) but the evidence for this is less strong and there is insufficient evidence to consider these as high risk at the present time
  • Risk stratification of patients by symptoms and temperature is of limited value, given the widespread prevalence and incubation period of up to 14 days
  • We recognise the limited availability of PPE, especially FFP3 masks, and so case selection is critical, focussing only on emergency and absolutely essential procedures. Minimising the volume of emergency activity will help preserve PPE supply.

Notes on FFP3 masks and enhanced PPE

  • Proper fitting and testing prior to use
  • Although ‘single use’ can use for several hours if not removed/contaminated
  • FFP3 uncomfortable after prolonged wearing, may affect ease of procedure
  • Cannot e.g. use phone, visit, toilet, eat or drink once enhanced PPE is on
  • Meticulous removal of enhanced PPE is vital; follow PHE advice
  • For COVID-positive patients – consider wearing full visor and surgical mask over FFP3 mask. This minimises risk of contamination of FFP3 mask and prolongs use

Further Key points for Optimal Practice

For known COVID-positive patients

  • Scope in designated, different area of the department
  • Designated, separate recovery area
  • Minimal furniture and equipment in room
  • Minimum essential staff in room

Remember

  • PPE is only part of the strategy to prevent and control transmission of infection
  • Team organisation –essential staff only in procedure room
  • Don’t share PCs, keyboards, phones etc – or clean thoroughly between users


The situation is rapidly evolving and this guidance may be updated regularly

President update 31st March 2020  Latest NHS E HPN patient letter for circulation

President’s Update 27th March 2020

Dear members

I hope that BSPGHAN can help you feel as safe as possible, find guidance you need, allow remote peer support and provide clarification if existing advice is not clear. 

People are  pulling together and supporting each other locally and nationally and please keep on doing this to help us share the current burden of uncertainty. 

Buddy up. 

Ask each other “ Are you OK?”

These principles in these exceptional times may be useful to prioritise –

·         To keep our teams and patients safe

·         To support each other 

·         To be up to date and to work by the best evidence that is available

·         To manage our patients with highest standards possible, making decisions case by case

·         To work within our existing resources and use resources fairly taking account of all patients including those outside our care

·         To ensure we are not putting others at a disadvantage or at risk by what we do. 

We may reach out to ethical principles, including justice, to guide decision making under these difficult times. 

We have been lucky while working in the NHS that we haven’t had to make such tough decisions and we are seeing truly exceptional circumstances.

Also 

·         Be aware of delayed presentation to hospital of children due to family’s reluctance to come to hospital

·         Keep families well informed and signposting to regularly updated resources (eg CLDF, CCUK https://www.crohnsandcolitis.org.uk/news/coronavirus-covid-19-advicehttps://childliverdisease.org/coronavirus-updates/)

·         Reinforce the vital work of all the wider team to your Trust so that they can continue support of children to help them stay well and avoid hospital admission

·         Please see guidance from BIFA / BAPEN for HPN patients during COVID19 pandemic   https://www.bapen.org.uk/about-bapen/bapen-special-interest-groups/bifa

Paediatric endoscopy

·         The best available information for professionals in making decisions remains with the BSPGHAN endorsed BSG / JAG guidance

Endoscopy activity and COVID-19: BSG and JAG guidance 
BSG rationale around current advice to all Endoscopy Units    

·         We will not put members in a position where BSPGHAN guidance is impossible to implement.

·         The decision to go ahead with an endoscopy has to be a case by case decision.

·         There is no place for routine work

·         Endoscopy should be done only if it’s an emergency requirement to manage that patient.

·         Lifesaving management of GI bleeding is the priority

·         Local implementation of national guidance is needed since  resources ( PPE, paediatric staff, lists) are not the same in each centre.

·         Decisions to proceed to theatre will involve wider discussion and each Trust has a SOP

·         PPE is needed for all close work that may involve production of an aerosol even with asymptomatic patients who aren’t febrile, coughing or ill. 

·         If a trust has lists and PPE and operators, then diagnostic work that is deemed to be an emergency may carry on. 

·         In reality, there may be less availability of resources, PPE may be scarce, and no diagnostic work may be possible

·         BSPGHAN endorses that it is acceptable to have a  “treat first and investigate later” policy if resources are not available to proceed to endoscopy and to minimise risk to yourself, anaesthetic and theatre colleagues 

·         Case by case anonomised, remote discussion with peers can be useful to inform treatment decisions.

In summary, please  implement at national guidance at a local level to offer the best practice for patients that is safest for your team and can be provided within existing resources

Modified BSG risk criteria for paediatric IBD patients  – March 2020(adapted by Richard Russell from BSG guidance)

Highest Risk ‘Shielding’ $Moderate risk ‘Stringent social distancing’Lowest risk ‘Social distancing’
 1. PIBD patients who have a co-morbidity (respiratory, cardiac, hypertension or diabetes mellitus) and are on any therapy for IBD (per middle column) except 5ASA, budesonide, EEN/MEN or rectal therapies  
2. PIBD patients regardless of co-morbidity and who meet one or more of the following criteria: 
·         on oral or intravenous steroids equivalent to prednisolone ≥20 mg per day * 
·          new induction therapy with combo therapy (starting biologic within previous 6 weeks) 
·         moderate-to-severely active disease despite immunosuppression/ biologics 
·          short gut syndrome requiring nutritional support 
·          requirement for parenteral nutrition
Patients on the following medications: 
· Ustekinumab 
· Vedolizumab 
· Methotrexate 
· Anti-TNF alpha monotherapy (infliximab, adalimumab, golimumab) 
· Thiopurines (azathioprine, mercaptopurine) 
· Calcineurin inhibitors (tacrolimus or ciclosporin) 
·Janus kinase (JAK) inhibition (tofacitinib)
· Combination therapy in stable patients** 
· Immunosuppressive/biologic trial medication 
Patients on the following medications: 
· 5ASA
· Rectal therapies 
· Orally administered topically acting steroids (budesonide or beclometasone) 
· Exclusive enteral nutrition/minimal enteral nutrition
· Antibiotics for bacterial overgrowth or perianal disease 

$ UK government COVID 19 terminology

* For patients <40kg this means >0.5mg/kg per day of oral steroids, for patients >40kg then its 20mg per day or higher 

** Established on this for more than 6 weeks

Stay safe and I hope you all get some rest this weekend. 

Thanks for reaching out to colleagues, particularly who may be isolated,  and please ask if they are ok. 

All the best. 

Sue 

President update 31st March 2020  Latest NHS E HPN patient letter for circulation

President Update 26th March 2020

I know that you are all supporting each other and working together in new ways remotely and face to face.

Please do sign post your families to the excellent links that are updated regularly for patients with IBD by CCUK https://www.crohnsandcolitis.org.uk/news/coronavirus-covid-19-advice

See  https://childliverdisease.org/coronavirus-updates/ for patients with liver disease

I want to draw your attention to the Urgent message from BSG/JAG on Endoscopy 26/3/20 ( message below) and message

Summary of message

  1. Stop 
  2. Review 
  3. Re-organise NOW

Below also see Updated Intercollegiate General Surgery Guidance on COVID-19               25th March 2020

https://www.rcsed.ac.uk/news-public-affairs/news/2020/march/intercollegiate-general-surgery-guidance-on-covid-19

Risk situations in surgery also include:

  • Approaching a coughing patient, for example, even if COVID-19 has not been diagnosed. Protection including eye shield is needed.
  • Naso-gastric tube placement is an aerosol generating procedure (AGP). AGPSs are high risk. Full PPE is needed. Consider carrying out in a specified location.
  1. Only emergency endoscopic procedures should be performed . No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used

GI Endoscopy Activity and COVID-19: Next steps

INTRODUCTION

The BSG has produced recommendations(1,2) based on the best available evidence from China(3), Italy(4) and the USA(5) that show:

  • The virus causing COVID-19 is potentially present in all GI secretions.
  • That all endoscopic procedures, but particularly upper GI endoscopy, are aerosol generating procedures (AGP).
  • That transmission can occur at the time of endoscopy.

Endoscopy activity and COVID-19: BSG and JAG guidance (1)
BSG rationale around current advice to all Endoscopy Units (2)

We have received reports that some centres are continuing to run booked endoscopy lists, requiring patients:

  • To travel.
  • To enter hospitals already treating significant numbers of COVID-19 patients.
  • To wait in areas that do not meet any of the Government’s social isolating directives.

For these reasons, the BSG has recommended that all but emergency procedures should stop immediately.

  1. The main issues of contention remain whether Urgent 2 Week Wait (2WW) patients, (or Urgent Suspected Cancer (USC) patients in Scotland,) and patients already diagnosed as FIT positive under Bowel Cancer Screening Programs (BCSP), should be “paused” during the current crisis. 

How any potential damage from delayed diagnosis can be mitigated.

 

2WW/USC, and BCSP referrals: Relative Diagnostic Yield.
The Risks of Pausing

  • 2WW/USC referrals – yield of cancer = 3% 
  • Bowel cancer screening programmes (BCSP) (FIT+) – yield of cancer = 8-10% 
  • Another, small percentage of patients will have advanced disease at the time of referral and the delay will not alter their prognosis, which unfortunately will already be very poor. 
  • For this group, a delay of 3 months is unlikely to materially alter the risk of an adverse outcome.  
  • Some of those who do not have established malignancy will have benign lesions such as polyps. 

In the majority of these cases, progression to malignancy, if it occurs, may take years. 

  • Conclusion: Very few patients are likely to come to harm from a pause of 3 months.  

Risks of continuing 2WW/USC, BCSP and urgent referrals. 

  • Removing polyps, particularly those over 1 cm, carries risks of haemorrhage and perforation often requiring admission to hospital.  
  • During the COVID-19 crisis, ICU beds are unlikely to be available and even urgent surgical procedures will be restricted.   
  • The risks of death from polypectomy usually quoted, are based on entry into a hospital operating under normal conditions, but not during a COVID-19 epidemic, where the risks of death will be significantly higher. 
  • Patients who are diagnosed with cancer may not be offered surgery at the height of the epidemic. Their anxiety is likely to be equal to or even greater, than those with a positive FIT test whose colonoscopy is paused. 

In addition: 

  • All patients attending for a non-emergency endoscopy now enter a high-risk environment. 
  • The benefit of endoscopy may be offset by the risk of COVID-19 infection to themselves. 
  • The majority will be older than 60 years with higher mortality from COVID-19 if they become infected. 
  • They become a potential risk to their families and contacts. 
  • Patients with asymptomatic COVID-19 infection pose a significant risk to staff.  By definition, their infection will not be detected before having a procedure.  
  • The aerosol or droplets take up to an hour disperse, so they remain a risk to staff and other patients after they leave the room. 
  • Endoscopic procedures generate aerosols, so staff will require PPE at an appropriate level, at a time when it will be in short supply. (See PPE recommendations from the BSG pending further Government recommendations.)

Conclusions: 

There is, therefore, little evidence that a pause of 3 months will pose a significant risk to the great majority of 2WW/USC or BCSP patients, although it is accepted that a small number of patients may have a delay in their diagnosis. 

On the other hand, a much larger number of patients and staff will be put at significant risk of COVID-19 if the 2WW/USC and BCSP is continued even at a scaled-down level. 

Conclusions and Actions.

  • Stop all non-emergency endoscopy immediately. 
  • Triage plan to identify patients who fall into the emergency category. The evidence base for this is laid out in previous BSG documents. (1) and follows experience from China(3), Italy(4) and the USA(5).  
  • List all patients on to a separate Urgent Deferred Waiting List to prioritise their investigation when services resume.  

For patients needing immediate investigation, the British Society of Gastrointestinal and Abdominal Radiology (BSGAR) have issued pragmatic guidance for the Investigation of patients with lower GI symptoms during the COVID-19 epidemic. 

Conclusion: The BSG/JAG guidance on prioritisation should be followed by all units.  This will be updated regularly. 

Looking to the Future

Hospitals should ONLY resume endoscopy for 2WW/USC, BCSP patients when: 

  • National circumstance permit. Further guidance will be issued. 
  • Sufficient PPE, appropriate for the current risk level, is available for staff. 
  • Patient flow is safely adjusted through units to minimise risk. 

2WW/USC patients may need to be reassessed to determine if their cancer risk has changed by phone triage.


Summary

  1. Stop 
  2. Review
  3. Re-organise NOW

 

President update 31st March 2020  Latest NHS E HPN patient letter for circulation

President update 23rd March 2020

Dear members

I would like to draw your attention to 3 important items today 23/3/20.

  1. 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.

https://www.bsg.org.uk/covid-19-advice/bsg-advice-on-ibd-patient-risk-groups/

https://www.bsg.org.uk/covid-19-advice/bsg-basl-advice-on-heptalogy-patient-risk-groups/

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.

Emergency deliveries

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.

Phone Lines
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.

 

President update 31st March 2020  Latest NHS E HPN patient letter for circulation

COVID 19 update – President upate Guidance for Endoscopy activity re Coronavirus and expanded BSG consensus advice on management of IBD plus guidance on IBD and hepatology patient risk groups

Dear Members

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

  1. New BSPGHAN Endoscopy advice to be read in conjunction with the latest BSG\JAG advice  https://t.co/3b1rhbnGt0?amp=1
  2. https://www.ncp.co.uk/parking-solutions/free-parking-nhs-staff/ How to register for free NCP parking
  3. Recommendations to the Regional Homecare Specialists regarding provision Home Parenteral Nutrition services.
  4. 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. 
  1. Specialty guides for patient management during the coronavirus pandemic

https://www.england.nhs.uk/coronovirus/secondary-care/other-resources/specialty-guides/

 

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.

 

  1. 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

Important Notes

  • 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.
  1. 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.

E-prescribing

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.

HPN prescribing 

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

https://www.bsg.org.uk/covid-19-advice/bsg-advice-on-ibd-patient-risk-groups/

Guidance on  hepatology patient risk groups

https://www.bsg.org.uk/covid-19-advice/bsg-basl-advice-on-heptalogy-patient-risk-groups/

Sue Protheroe
22nd March 2020

President update Monday 30th March 2020- Endoscopy and IBD statements from ESPGHAN

COVID-19 update to BSPGHAN members 17/03/20

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. 

General advice

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 EnglandHealth Protection ScotlandPublic Health Wales and Public Health Agency Northern Ireland.

Paediatric advice

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 .

  1. 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/). 

Research

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. 

Sue Protheroe

President 17 March 2020

President update Monday 30th March 2020- Endoscopy and IBD statements from ESPGHAN

New Message from the President

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

National Audit of the quality standards for Paediatric Gastroenterology, Hepatology and Nutrition (‘PGHAN Audit’)

National Audit of the quality standards for Paediatric Gastroenterology, Hepatology and Nutrition (‘PGHAN Audit’)

The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) has commissioned the Royal College of Paediatrics and Child Health (RCPCH) to deliver the National Audit of Quality Standards for Paediatric Gastroenterology, Hepatology and Nutrition (‘the PGHAN Audit’). We seek to work with clinicians throughout the UK to improve the health outcomes for children that require gastroenterology, hepatology and nutritional services.

The National Audit will be based on the 2017 Quality Standards for Paediatric Gastroenterology, Hepatology and Nutrition. The 2017 Quality Standards sought to improve the health outcomes and quality of life for all infants, children and young people with gastroenterology, liver or intestinal disorders by reducing the variation in care by clinicians and ensuring equitable services throughout the UK.

The National Audit will aim to define clinical pathways of paediatric gastroenterology, hepatology and nutritional services throughout the UK. We will collect and share data to support UK clinicians that require resources to improve their gastroenterology, hepatology and nutritional services.

Data Submission

Registration now open

The registration of the PGHAN Audit lead will take approximately two minutes using https://tinyurl.com/PGHANAudit.

We would be extremely grateful if you could encourage your local Health Board/Trust to identify a

 PGHAN Audit lead(s) and ask them to complete the registration form by 18 March 2020.

The audit will be released from April 2020.

Data and report will be released in July 2020.

Enquiries

If you have any further enquiries about the PGHAN Audit, please contact pghan.audit@rcpch.ac.uk

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