INFLUENZA PANDEMIC PLAN · SFHFT Critical Care Surge Plan Neighbouring CCG’s, Hospitals and EMAS...

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OFFICIAL

INFLUENZA PANDEMIC PLAN

January 2018 Written by: Emergency Planning Officer Date (Original): Version 1 March 2009 Approved by: Trust Executive Team Date: July 2018

Revised Date: Version 6 Feb 2018 Review Date: Ongoing as national guidance is received This plan will be subject to ongoing review and revision by the Emergency Planning Team in the light of new national and regional guidance and following experience of H1N1 (Swine Flu) 2009/10.

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Amendment description

Date of Amendment Meeting Ratified at:

Update of planning assumptions from DH. Revised appendix 2 critical services

November 09 Weekly operational Pan flu meetings

Updated following outcomes of H1N1 outbreak 2009/10

August 10 EMB

Updated following Publication of the UK Influenza Pandemic Preparedness Strategy 2011 and Health and Social Care Influenza Pandemic and Response 2012 and NHS restructure 2013

2013/14 EPT CMT Feb 14

Version: 5 (7)

Date: Feb 2018

Date Ratified:

Date due for Review: Feb 2021

Approval:

Author: M Stone

Job Title: Emergency Planning Officer

Consultation: Trust Executive Team, Clinical Management Team, Pre Pandemic Planning Group and Resilience Assurance Committee

Distribution: Clinical Directors

Service Directors

Heads of Service

Divisional HR Managers

Deputy Directors of Nursing Services

Heads of Nursing

Executive Directors

Modern Matrons

Contracts Management Team

NHS and External Stakeholders

Executive Sponsor Simon Barton, Chief Operating Officer, SFH Accountable Emergency Officer

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and update of Trust MIP

Three year review 2017/18 Board Risk Committee

CONTENTS PAGE No. 1. Plan Statement 5 2. Foreword 6 3. Introduction 6 4. Aim 7 5. Objectives 7 6. Context 7 7. Risk Assessment 9 8. Trust Planning Assumptions 10 9. Data Collection / SITREP Reports 10 10. Nature of Threat 10 11. Phases of a Pandemic-Health and Social Care Structures 11

11.1 Vaccination 11 11.2 Antiviral Collection Points (ACP’s) 11 11.3 Antibiotics 11 11.4 National Pandemic Flu Service NPFS) 11 11.5 National Guidance for Secondary Care 11 12. Facemasks and Respirators 15

13. Criteria for Admission 15 13.1 Self-care 16 13.2 Managing surge 16 13.3 Ethical considerations 16 13.4 Vulnerable groups 17 13.5 Admission Guidance for Adults 17 13.6 Admission Guidance for Children 17 13.7 Discharge Guidance for Adults 17 13.8 Discharge Guidance for Children 18 14. Trust Response including Command and Control within the Trust 18

14.1 Pre and during Pandemic Period 18

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14.1.1 Business continuity planning 22 14.1.2 Mortuary Arrangements and excess deaths 22

14.1.3 Bed escalation 22 14.2 Pandemic Influenza Control team (PICT) 22 14.3 Capacity 23

14.4 Managing the response 24 14.5 Communications 24 14.6 Staff Well-being 24 14.7 Visitors 25 14.7.1 Patients “self-presenting” 25 14.7.2 Return to Background Influenza Activity 26 15. Recovery 26 16. References 26 17. Appendices (separate document available on Intranet) 28 Note: appendices 1 – 23 include operational documents from individual departments collated in this plan.

Appendix 1 National and Local Command Structure Appendix 2 Critical and non-critical services template Appendix 3 Communications Strategy Appendix 4 Infection Control Pandemic Flu Appendix 5 Occupational Health Pandemic Flu Business Continuity Plan Appendix 6 Pharmacy Pandemic Flu Business Continuity Plan Appendix 7 Human Resources Pandemic Flu Business Continuity Plan Appendix 8 Soft FM Pandemic Flu Business Continuity Plan Appendix 9 Hard FM -Berendsen Appendix 10 Procurement Pandemic Flu Business Continuity Plan Appendix 11 Finance Pandemic Flu Business Continuity Plan Appendix 12 Critical Care Expansion Plan Appendix 13 Health Informatics Pandemic Flu Business Continuity Plan Appendix 14 Mid-Trent Critical Care Network Influenza Pandemic Plan Appendix 15 Trust Corporate Business Continuity Strategy Appendix 16 Maternity Services plan for pregnant women Appendix 17 Training & Education Programme Appendix 18 Patient Administration Pandemic Flu Business Continuity Plan Appendix 19 Nottinghamshire County Antivirals Plan-Pending Appendix 20 Chaplaincy Appendix 21 Radiology Service Operational Continuity Appendix 22 Therapy Services Appendix 23 Recovery

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1. PLAN STATEMENT

1.1 Accountability

The Trust Executive Team is responsible for ensuring a robust plan is in place together with adequate resources to deliver that plan should an influenza pandemic occur that seriously affects the Trust’s ability to provide essential services.

1.2 Scope

This plan will apply to all staff, patients, contractors and visitors on any Sherwood Forest Hospitals NHS Foundation Trust (SFH) site during a declared Influenza Pandemic. It is not applicable for dealing with normal seasonal flu activity.

1.3 Audience

This is a Trust wide document and is intended for all personnel, wards and departments who would have a role to play in planning for and responding to an outbreak of pandemic influenza.

The plan will also be shared with regional colleagues from NHS England Regional and our CCG partners

1.4 Development of the Document

This is a living document, which will be updated to reflect changes in provision and location of services and amended as systems of preparedness are enhanced and strengthened.

1.5 Equality and Diversity

This plan aims to ensure that all patients, carers and relatives who are on site at Sherwood Forest Hospitals NHS Foundation Trust during an influenza pandemic receive safe and effective medical and social care with due regard to age, disability, gender, race, religion and belief or sexual orientation, in an appropriate environment which upholds their privacy and dignity.

1.6 Review The plan will be reviewed:

following an incident when the plan is activated

following experiences of any experience of an Influenza Pandemic.

following changes to the guidance or the circumstances of the Trust

every three years by the stakeholders involved in its development 1.7 Supporting Documentation

This plan should be read and implemented in conjunction with other National and local plans and guidance documents including:

NHS England Operating Framework for Managing the Response to Pandemic Influenza October 2013

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UK Influenza Pandemic Preparedness Strategy 2011 and DH Health and Social Care Influenza Pandemic and Response Guidance 2012

SFHFT Major Incident Plan 2014

SFHFT Pandemic Influenza Communications Strategy(appendix 3 to this plan)

SFHFT Winter Pressures Plan

SFHFT Business Continuity Policy 2016

SFHFT Critical Care Surge Plan

Neighbouring CCG’s, Hospitals and EMAS Influenza Pandemic Plans

CCA 2004 Category 1 partner agencies’ Influenza Pandemic Plans

Nottingham and Nottinghamshire LRF Pandemic Influenza Plan

Nottingham and Nottinghamshire LRF Excess Deaths Plan

East Midlands Mass Vaccination Framework

Storage and Distribution of Antivirals 2. Foreword

Pandemic influenza is recognised by the Government as the single most disruptive event facing the UK today. As such it remains at the top of the UK Government National Risk Register. The 2009/10 A(H1N1) influenza pandemic has not altered the likelihood of a future pandemic, and the generally mild nature of the 2009/10 event must not be taken as an indicator of the severity of future such events. The NHS England Operating Framework for Managing the Response to Pandemic Influenza sets out the roles, responsibilities and functions of NHS England in preparing for and responding to an influenza pandemic. It is intended to complement and support existing plans, policies and arrangements. NHS England is responsible for the command, control, communication, coordination and leadership of the NHS in the event of a major incident or emergency. All NHS England staff should be aware of the key aspects of pandemic influenza preparedness and response and be able to identify how they will be involved in a pandemic response. NHS England and the NHS in England cannot prepare for or respond to a pandemic in Isolation. NHS Improvement (NHSI) and Clinical Commissioning Groups (CCGs) are key partners throughout NHS pandemic preparedness and response. Local Health Resilience Partnerships (LHRPs) will oversee health pandemic preparedness and act as a conduit for health to engage with Local Resilience Forum (LRF)-wide preparedness arrangements. Public Health England (PHE) and the local authority Directors of Public Health (DsPH) also have roles to play in pandemic influenza resilience. It is essential our planning is undertaken in partnership with others to ensure the best possible outcomes.

This plan has been prepared to facilitate a swift co-ordinated response from Sherwood Forest Hospitals NHS Foundation Trust (SFHFT) in the event of an influenza pandemic, using national guidance as an overarching framework and following lesson learnt form the H1N1 pandemic in 2009. This plan details the specific actions to be considered by the Trust in partnership with the North Nottinghamshire CCG cluster, other local hospitals, East Midlands Ambulance Service, and the Nottinghamshire Local Health Resilience Partnership, SFHFT

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needs to ensure that appropriate response arrangements are in place to maximise the health resource available, during and after the outbreak of pandemic flu.

3. Introduction

The plan provides a specific framework to prepare for and manage an influenza pandemic affecting Sherwood Forest Hospitals NHS Foundation Trust. In the event of an influenza pandemic the plan will be activated in conjunction with part or all of the Trust’s Major Incident Plan and Business Continuity Plans. The plan will form part of a co-ordinated multi-agency response in accordance with the Civil Contingencies Act 2004. The plan is based on regional and national guidance developed by the Department of Health, Cabinet Office and Public Health England and should be read in conjunction with these National Guidance documents.

4. Aim

The aim of the plan is to outline how integrated preparedness and effective response to pandemic influenza will be achieved and how it will be integrated with the wider health community.

5. Objectives The objectives of the plan are to:

summarise and collate the key policies and procedures which would be activated in the event of an outbreak of pandemic influenza

outline the roles and responsibilities of key responders in a pandemic flu situation

give an overview of the response to ensure an understanding of partnership working across Nottinghamshire and the wider emergency planning community

identify issues that will require prompt action when the notification of Pandemic Flu is made and the UK enters the Detection and Assessment phases.

ensure that all essential core services are identified and maintained during a pandemic

maintain the ability to cope with large numbers of ill patients and staff

reduce morbidity and mortality from influenza illness

ensure that appropriate command and control structures are in place to effectively manage the Trust’s response

contain and minimise the spread of the virus within Sherwood Forest Hospitals

ensure that all staff are adequately protected

minimise where possible disruption across all services

ensure that the return to normal working is as rapid and efficient as possible

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promote effective co-operation with partner health organisations in the community

6. Context

Due to the unpredictable nature of influenza pandemics, response plans should be flexible and adaptable. During a pandemic, the assumptions on which to base the response will be updated in the light of emerging knowledge about the developing scenario.

Despite this unpredictability, there are some key assumptions that will help to inform planning:

The World Health Organization carries out influenza surveillance and monitoring activity and collects and analyses virological and epidemiological data from countries, areas and territories around the world.

A pandemic is most likely to be caused by a new subtype of the Influenza virus but plans could be appropriately adapted and deployed for any epidemic infectious disease.

An influenza pandemic could emerge at any time of the year anywhere in the world, including in the UK. Regardless of where or when it emerges, it is likely to reach the UK very rapidly and, from arrival, it will probably be a further one to two weeks until sporadic cases and small clusters of cases are occurring across the country.

The potential scale of impact, risk and severity from related secondary bacterial infection and clinical risk groups affected by the pandemic virus will not be known in advance.

It will not be possible to completely stop the spread of the pandemic influenza virus in the country of origin or in the UK, as it will spread too rapidly and too widely.

Initially, pandemic influenza activity in the UK may last for up to three to five months, depending on the season. There may be subsequent waves of activity of the pandemic virus weeks or months apart, even after the WHO has declared the pandemic to be over.

Following an influenza pandemic, the new virus is likely to persist as one of a number of seasonal influenza viruses. Based on observations of previous pandemics, subsequent winters are likely to see increased seasonal flu activity compared to pre-pandemic winters.

Health and social care planning assumptions

Public Health England (PHE) modelling assumes that 50% of the population will be infected. Health services should continue to prepare to provide advice and treatment for up to 30% of all symptomatic people in the usual pathways of primary care. Between 1-4% of symptomatic patients could require hospital care, depending on the severity of illness caused by the virus. Of these, up to 25% may require critical care.

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Staff absence is likely to follow the wider community profile. In a widespread and severe influenza pandemic affecting 50% of the population, between 15- 20% of staff might be absent on any given day during peak weeks. However, these figures may be reduced by the impact of antiviral and antibiotic countermeasures depending on the effectiveness of these measures.

With the experience of previous outbreaks, the demand on hospitals could be varied, but a virulent strain could see hospitals working to maximum capacity, even in the absence of ‘winter pressures’. The increased demand upon services could be further compounded by staff sickness and the absence of staff caring for family members. It is imperative therefore that contingency plans are in place to deal with this eventuality.

It can be assumed that the carrying capacity of the hospital will be determined chiefly by the staff available to care for patients and bed availability. Staff absences could lead to bed closure, a combination of Staff and Bed Capacity will act as a trigger to move through the escalation levels of the hospital’s contingency plans.

The Pandemic Influenza Control Team will be established to meet weekly in response to DH instruction to nominate a Pandemic Influenza Director Lead. The triggers will be tracked weekly by the Control Team, which will authorise action to respond to the level of the confirmed cases or alternatively the level of staff absence.

These meetings will be increased until the control team will be meeting daily or until an incident room is established to run 24 hours a day during the peak of the surge.

There are legal duties placed upon the Trust to ensure that patients, staff and visitors are protected from harm. The Health and Safety at Work Act (1974) states that employers and employees are accountable to ensure that the workplace is free from hazard.

7. Risk Assessment

7.1 Risk

The Community Risk Register for Nottinghamshire currently rates the risks of a Pandemic (risk #H23) as “Very High” and the top rated risk for the region. A influenza pandemic may put at risk the Trust’s ability to maintain services; partly because of an increase in demand for care, partly because the social infrastructure will be jeopardised but also by high levels of sickness absence amongst clinical staff groups..

Staff are likely to be absent from work through personal illness, the need to look after family members who are ill, bereavement, fear of infection, the impact of public health measures such as school closures and possible transport difficulties.

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7.2 Impact

The impact of a pandemic on health and social services is likely to be intense, sustained, and nationwide, with a surge peak of 6-8 weeks. The increase demand for these services will be as a result of:

the increased workload associated with patients with influenza and its direct complications including the impact on both adult and paediatric critical care capacity

disruption to community services, leading to an increase in admissions

the particular needs for infection control facilities and equipment

depletion of the workforce and informal carers due to sickness

delays in dealing with other medical conditions

disruption to the supply chain supporting hospitals

pressure on mortuary facilities due to an increased number of deaths and delays in registration and funerals

Health services should continue to prepare to provide advice and treatment for up to 30% of all symptomatic people in the usual pathways of primary care. Between 1-4% of symptomatic patients could require hospital care, depending on the severity of illness caused by the virus. Of these, up to 25% may require critical care.

7.3 Trust Risk rating Taking account of the rating of the regional Community Risk Register and potential impact on services, the risk rating is judged to be Very High.

8. Trust Planning Assumptions

The Influenza Pandemic Plan for SFHFT is based on the following assumptions and principles:

All sites of the Trust will be engaged in the response to an influenza pandemic

Divisions and departments will be responsible for developing/reviewing and implementing their own specific business continuity plans within the framework of the SFHFT Influenza Pandemic Plan

Most health (including provision of antiviral treatment and vaccination) and social care for people with symptoms of pandemic flu will be carried out in the community

Effective communication will be essential to maintain services. This will be conducted through the PICT and done via formal SITREPS, forwarded to external partner agencies

key policies and procedures must be robust and flexible to meet changing demands and unanticipated issues

acute services are part of wider health and social care response

unprecedented demand on emergency services may result in deferment of elective and non essential work

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high levels of staff absenteeism are likely (between 15 to 20% of the workforce may require time off at some stage over the entire period of the pandemic with individuals absent for a period of seven to ten working days)

staff will be redeployed to areas of greatest need within the Trust

the Trust’s obligations regarding the health and safety of its staff and visitors must be maintained

local NHS organisations have developed a mutual aid agreement which could be implemented in an emergency. However, due to the widespread nature of a pandemic it is expected that the capacity for mutual aid would be minimal. (Non-clinical mutual aid, e.g. assistance with transporting patients, may be available from non-health Category 1 responders e.g. local authorities, as considered in the LRF Pandemic Flu Plan.)

there may be an sharp increase in hospital mortality rates and mortuary capacity may become limited very quickly

9. Data collection/SITREP reports

Some data will need to be collected for forwarding to the CCG cluster, NHS England (Commissioning Board) Area Team and DH via the SITREP process. It is envisaged that this data will be tracked daily along with other figures on bed capacity, Critical Care capacity, cancellations of surgery and staff absence etc, to inform the Pandemic Influenza Control Team in order that they may make decisions on how and when to implement this plan.

10. Phases of the Influenza Pandemic-Health and Social Care Response

The UK Influenza Pandemic Preparedness Strategy 2011 outlines a new approach to the indicators for action in the UK in a future pandemic response that is no longer linked to the WHO global phases. This takes the form of a number of phases named: Detection, Assessment, Treatment, Escalation and Recovery. A pre-pandemic planning and preparation period precedes these.

Although the strategy incorporates indicators for moving from one phase to another, the phases are not numbered as they are not linear and it is possible to move back and forth, overlap or jump phases. 11.1 Vaccination Frontline health and social care staff will be a priority group for vaccination. Encouraging vaccine uptake to become the norm in inter-pandemic years, ensuring open communication about the risks and benefits, providing opportunities for staff to access the vaccine easily both in and out of hours, and providing leadership through example, all contribute to successful uptake. Professional bodies may also play a role in encouraging uptake. 11.2 Antiviral Collection Points (ACPs) Antiviral collection points are nominated locations within the community where

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flu friends can collect antiviral medicines on behalf of a symptomatic person, on presentation of the person’s valid authorisation. Antiviral collection points are likely to be required, irrespective of whether the NPFS is in use. 11.3 Antibiotics DH will arrange a stockpile of antibiotic medication which will be delivered to the CCG for onward distribution as required to maintain supplies. 11.4 National Pandemic Flu Service (NPFS)

When there is evidence of sustained community transmission or a large number of de novo cases, an England-wide decision will be made to move from the initial response phase to a response designed to mitigate the impact of the disease on the individual, society and the NHS. The NFPS will be mobilised by the Department for Health

11.5 National Guidance for Secondary Care The NFPS will define the impact levels of the pandemic as follows: In a low impact pandemic, there may be no significant deferral of normal activities. However, some small or specialist services, such as intensive care, may still come under pressure dependent upon the disease characteristics and the emerging at risk groups. In hotspot areas, increased referrals to primary care services are likely to cause knock on effects to ED services. Effective coordination between in and out of hours services, and clear local public communication, will be needed to ensure members of the public understand where to find advice and assistance on influenza, so that capacity still remains for non-flu patients.

Where possible, hospitals will need to adopt cohort arrangements to support infection control. This will affect routine arrangements in EDs, and may reduce the flexibility of ward areas. Preparations for potential further escalation will include the review of patients with long-term conditions and planning for potential reduction in outpatients’ clinics. Continuity arrangements for staff and supplies should also be confirmed in preparation for a high impact pandemic affecting non-health services. Careful consideration should be given to planning for the necessary reductions in non- critical work and expansion of capacity in other areas that will be required in a moderate or severe service impact pandemic.

In a pandemic of moderate impact, hospitals will need to respond to increasing referrals of respiratory patients requiring higher levels of care. Prioritisation of in and out patient resources may be required to enable the maximum numbers of beds to be available. As the pressure on all services increases, it will be even more important for community, hospital, social care and ambulance services to agree prioritisation across the local area, maintain close communication and make best use of available skills of staff.

In a high impact pandemic, staff absences may add to these difficulties. A key challenge in sustaining essential care will be the ability to use available staff flexibly and cooperatively when necessary between organisations. A high

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impact pandemic may also result in increased numbers of deaths. It will be important to plan appropriately so that death and cremation certification can be managed as effectively as possible.

Maternity care Planning for maintenance of essential maternity services will be important and the principal of choice for women should continue as far as possible. The UK National Screening Committee has provided guidance on antenatal care which will assist in planning to maintain essential testing. Antenatal classes should be maintained during a pandemic, although pregnant women and midwives should be advised not to attend classes if they are unwell with influenza-like symptoms. For women with flu symptoms who may require Caesarean section, consideration should be given to whether it is reasonable to delay. Good infection control measures will be important. Blood services Blood donor sessions will be expected to continue as an adequate supply of blood is critical to the provision of acute healthcare, and will be vital for the emergency care for many patients including those requiring extracorporeal membrane oxygenation (ECMO). Blood and Transplant Services will therefore continue using health messages to encourage the public to donate blood. Care must be taken to communicate early with local blood services to ensure that facilities required for ACPs do not conflict with blood donor session venues. During and after a severe pandemic the blood supply chain may take longer to recover and rebuild stocks than the rest of the NHS. Therefore, it is vitally important that blood services be consulted before resumption of business as usual activities that require blood products. As acute care will continue to be provided, tissue and organ donations to support life-saving transplantation procedures will also need to be maintained if possible. The Advisory Committee on the Safety of Blood, Tissues and Organs has issued advice which is available on the Department of Health website. Critical care

Critical care services are regularly utilised at a high bed occupancy rate of around 98-100% and are therefore likely to come under significant pressure even in an early stage or low-impact pandemic. This may continue throughout the pandemic, depending upon the length of stay of patients, and pressures may remain after other services in primary and secondary care have returned to normal levels of activity. Any increase in the requirement for critical care beds requires a prompt and flexible response to manage and match increased demand.

As a result of lessons learned from this pandemic, measures were developed to expand the capacity of intensive care services as set out in the Report of the Swine Flu Critical Care Clinical Advisory Group. These included:

identifying potential extra bed capacity in related areas, such as operating theatre recovery suites, step-down and high-dependency care

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facilities;

maximising the use of stockpiled equipment;

broadening the training of staff who could support these beds to increase available staff numbers;

supporting more formal cross-training and experience between adult and paediatric services to increase the ability to provide more flexible and overlapping services;

supporting the specialist staff who would have to manage the triage, admission and discharge of patients;

supporting accurate and timely data on critical care capacity including adult paediatric and specialist beds, and

supporting collaborative working across Acute hospital Trusts to provide mutual aid – such practice in line with escalation plans of critical care networks.

Where plans to increase capacity require the suspension of some or all high risk elective surgery, such suspension should be in line with local critical care network escalation plans and should differentiate time-critical from non time- critical surgery. During periods of high pressure in hospitals where doctors may be diverted to provide care for critically ill patients, consideration should be given to utilising the skills of other healthcare professionals including nurses and specialist clinical pharmacists for supporting the provision of some clinical services. There is considerable variation in the type and level of general ward care between hospitals and across regions, so local plans are necessary to make the best, most flexible adjustments to demand. Guidance is available in Pandemic flu: managing demand and capacity in health care organisations (surge). The guidance was based on advice from the Intensive Care Society the Paediatric Intensive Care Society and the Faculty of Intensive Care, as well as individual experts within the specialty. Information is continuously updated on their web pages. When demand for critical care services threatens to exceed capacity, pressure on healthcare services can be mitigated initially by careful selection of patients for hospital assessment and admission, and subsequently by a coordinated approach to patient pathways to higher levels of care. The CATs and model hospital pathways are available to assist decision making. Provision should also be made for interim, respite or step-down care for patients who are less likely to benefit from critical care, or who have received critical care but now require a lower level of care. Various tools, such as Sequential Organ Failure Assessment, Modified Early Warning Score, and Paediatric Modified Early Warning Scores, can assign patients into approximate prognostic groups and aid decisions on required levels of care. However, they cannot reliably predict the likelihood of a poor outcome. Clinical judgement therefore remains essential in making decisions on admission to, and discharge from, critical care. During care, decision support tools can aid assessment of a patient’s response and likely prognosis.

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The ethical framework can support staff in addressing the ethical issues which may arise and provides a framework of the principles involved in making difficult decisions for individual situations. The availability of established clinical ethics committees or support groups at a local level may also be helpful.

Information on the benefits of various clinical interventions in managing a new pandemic disease may be limited, especially during the early stages of the pandemic. While laboratory and investigative test results can help, there is great benefit in sharing information and pooling experience. In the H1N1 (2009) influenza pandemic, a series of clinical teleconferences engaged intensivists from the UK and other severely affected countries in sharing clinical information and best practice. This forum also provided surveillance information on case-numbers, age-groups affected and localities with high numbers of cases, which greatly aided decision-making and planning for service provision.

Difficult triage decisions were not called for during the H1N1 (2009) influenza pandemic. However, such a discussion forum would permit sharing of effective decision criteria and greatly increase confidence in triage decision-making. Such peer engagement is also known to be a valuable addition to more formal counselling and planned ‘down time’ in supporting staff who are working under severe pressure, and in aiding recovery afterwards. Advice is contained in Psychosocial care for NHS staff during an influenza Collaborative intensive care networks working across geographical areas can play a key part in pandemic management in:

real time data gathering to provide information on numbers of influenza cases in Critical Care and clinical relevance in the context of other Critical Care activity;

identifying pressure points in the service and providing advice about appropriate actions to maximise capacity and minimise disruption to other users of Critical Care;

collating and sharing of clinical experience locally, nationally and internationally;

facilitating mutual aid between organisations within and outside the Network boundaries, including the transfer of critically ill patients between Acute Trusts, and

promotion and co-ordination of training to staff to give them enhanced competencies to treat adult and paediatric critically ill patients.

12. Facemasks and respirators

Surgical facemasks and respirators have a role in providing healthcare worker protection, as long as they are used correctly and in conjunction with other infection control practices, such as appropriate hand hygiene. Fluid repellent surgical masks provide a physical barrier and minimise contamination of the nose and mouth and should be worn by health and

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social care workers for any close contact with patients (i.e. within one metre) with symptoms of influenza. For closer contact and aspiration treatments see Trust Infection Control guidance. There is a national stockpile of surgical facemasks for health and social care workers.

NHS England holds emergency stocks of face masks and appropriate PPE for distribution should a new virus emerge. (See Infection Control appendix 4)

13 Criteria for Admission In the appendices to this plan, there a number of clinical pathways based on DH guidance for the assessment and treatment of adults, children, maternity, and critical care. 13.1 Self-Care Together with partner health and social care organisations the Trust recognises that wherever possible patients should be managed and cared for at home, with only patients presenting complex symptoms being admitted into acute hospitals. The Trust will support self-care by giving advice to all patients and visitors. Staff training will ensure that staff are aware of the best self-care advice according to national guidance. Self-care advice will be promoted through the Trust’s pandemic influenza communications strategy, local health and social care networks, and the national communications strategy, which will include messages delivered through the media. 13.2 Managing Surge

The Trust will work with health and social care partners to produce a common admission and discharge criteria which follows DH Guidance and advice provided by the British Thoracic Society. As the pandemic escalates and triggers for action are reached, non-urgent hospital admissions and non-urgent outpatient attendances may be stopped in order to minimise the potential for the spread of infection and to re-deploy staff as appropriate. Actions should align with the Trusts Critical care Surge Plan

13.3 Ethical Considerations Given the expected levels of additional demand, capacity limitations, staffing constraints and potential shortages of essential medical material, hard choices and compromises are likely to be necessary in the field of health and social care. People are more likely to accept the need for the consequences of difficult decisions if these have been made in an open, transparent and inclusive way. Local preparations for an influenza pandemic will be based on widely held ethical values, and the choices that may become necessary will be discussed openly as plans are developed so that they reflect what most people will accept as proportionate and fair. Throughout the pandemic resources will be limited and it will be necessary to apply a strict, consistent admission criteria to ensure that only those who need acute care in a hospital environment are admitted. As resources become more limited it may be necessary to further restrict the admission criteria. This must be seen to be agreed in a way that is fair to all and does not unlawfully discriminate. Wherever it is necessary to restrict healthcare a clear record of the decision making process will be made.

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The Committee on Ethical Aspects of Pandemic Influenza (CEAPI) developed an ethical framework, which was first published in 20074. It has been reviewed by CEAPI in the light of the experience in the H1N1 (2009) influenza pandemic. The committee has concluded that it remains appropriate and fit for purpose in planning for a future pandemic. The routine use of these principles can act as a checklist to ensure that all ethical concerns have been considered. This will support professional groups of staff in resolving ethical issues that may arise from the demands of their work. Such decisions will be made by a specially established clinical group, led by the Medical Director, following National and Local NHS Guidance and Protocols.

13.4 Vulnerable Groups It is anticipated that some patients presenting to the hospital will not meet the admission criteria and therefore will not be admitted. It is recognised however that some of these patients may be at risk if not admitted due to their vulnerability. The CCG will be immediately advised that these patients have been refused admission so that a community assessment of their health and social needs can be made. Vulnerable groups and individuals with long-term conditions should be identified and supported by all partner agencies, particularly during the admission and discharge process from hospital. Vulnerable groups might include:

children

older people

people living alone

travellers

non-English speakers

people who are clinically at risk

people needing palliative care

homeless people

people from residential or nursing home care

asylum seekers

people requiring regular medication or medical support equipment

people with mobility, sensory or mental impairment

people not registered with a GP 13.5 Admission guidance for adults Patients with new or worsening symptoms – particularly shortness of breath or recrudescent fever not responding to treatment – will be examined to assess the presence and severity of influenza related symptoms.

patients with worsening of pre-existing co-morbid medical conditions will be managed according to best practice for that condition with reference to published disease-specific guidelines, if available

in patients with influenza-related pneumonia hospital referral and assessment should be considered for patients with a CRB-65 score of 1 or 2 (particularly score 2) and urgent admission for those with a CRB-score of 3 or more

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patients with bilateral chest signs of pneumonia should be referred to hospital for assessment regardless of the CRB score

a patient’s social circumstances should also always be taken into account 13.6 Admission guidance for children Children who are severely ill should be referred for assessment for admission. Indicators of severe disease are:

cyanosis

severe dehydration

altered conscious level

complicated or prolonged seizures

signs of sepsis such as extreme pallor, hypotension or a floppy infant

signs of respiratory distress such a markedly raised respiratory rate, grunting, intercostal recession or breathlessness with chest signs

13.7 Discharge guidance for adults Patients should be reviewed within 24 hours of discharge home. Those with two or more of the following unstable clinical factors should be considered for continued hospital care:

temp > 37.8C

heart rate > 100/min

respiratory rate > 24/min

systolic blood pressure < 90mm Hg

oxygen saturation < 90%

inability to maintain oral intake

abnormal mental status 13.8 Discharge guidance for children All children should be assessed for discharge at least twice daily. Children should not remain in hospital if they are receiving therapy that could be given in the community. In previously healthy children suitable discharge would be if the child:

is clearly improving

is physiologically improving

can tolerate oral feeds

has a respiratory rate < 40/min (92% on air 14 Trust Response including Command and Control within the Trust

The command and control element of the Trust response will be determined by the Executive Lead for Emergency Planning. . 14.1 Pre and during Pandemic Period

Upon the advice of PHE the Trust will convene its Pre-Flu Pandemic Group, whose role it is to ensure the Trust is brought up to a “fully prepared” status. This will include the formation of the Pandemic Influenza Control Team. Once the PICT is

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formed and the PFPG is confident that all preparations have been made, it will stand down and handover the day-to-management of the outbreak to the PICT. The Pre Flu Pandemic Group, which reports to the Trust’s Board Risk Committee, includes the following members:

Executive Lead For Emergency Planning (Chief Operating Officer)

Executive Nurse

Patient Safety Manager

Emergency Planning Officer

Head of Nursing for Emergency Care

Infection Prevention and Control Specialist

Clinical lead

Occupational Health Manager

Diagnostic and Rehabilitation Divisional Representative

Pharmacy Manager

Human Resources Manager

Communications Manager

Contract Management Team Representative/Soft FM Supplies Manager

Supplies Manager

Health Informatics Manager

Staff side Representative

Representative from Newark Hospital/MCH/AHV

Representatives from other directorates eg finance, and partner organisations eg local CCG, East Midlands Ambulance Service, PTS Contractor will be invited to join the Group or attend meetings as necessary.

Using a risk assessment based approach a planning programme will be developed to include responsibilities as follows:

Executive Lead for Emergency Planning

will keep the Board informed of preparations for response to influenza pandemic

will maintain links with the Local Health Resilience Partnership and LRF

will liaise with service directors to ensure robust business continuity arrangements are in place


will ensure the preparation and co-ordination of robust pandemic flu plans

will assist in exercising pandemic flu plan Clinical lead

will develop a system to identify patients in high risk groups who will need to be immunised whilst in-patients, unless contra-indicated

will prepare, and ensure appropriate implementation of, guidance for medical staff on the management of influenza cases

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Infection Prevention and Control Team with support from link health Professionals

will develop an operational policy (appendix 4) that prioritises its workload during the pandemic period

will raise awareness and deliver training for all relevant Ward/Departmental staff around all aspects of Respiratory precautions.

will support Trust wide training initiatives’ for staff in the use of Personal Protective Equipment (PPE)

will liaise with managers from Medirest with regard to support for staff employed in Support Services.

will continue to promote the use of Standard Precautions.

will actively support the management of capacity and flow throughout the Trust

Occupational Health Team

will develop an operational pandemic influenza business continuity plan (appendix 5)

will develop guidelines for the exclusion from duty of staff deemed to be an infection risk

will identify health care workers at high risk of complications of pandemic influenza (e.g. pregnant women, immuno-compromised workers) and discuss with staff and line managers redeployment options

will work with HR to develop a system to track, monitor and report staff sickness absence across all Trust sites

will develop plans for the provision of psychological and social support for staff

Diagnostic and Outpatients Divisional Representative

will lead on the provision of diagnostic, specimen taking and therapy services

will ensure business continuity arrangements are in place in respect of handling patient records

will arrange for procedures to be undertaken on the ward and for patients not to be moved around the hospital if possible

will clarify arrangements for those patients who must leave the segregated care area for urgent and essential procedures, e.g. those patients who may have to transfer to medical imaging

will produce and adapt to the needs of individual departments operational policies that clarify the arrangements for transferring patients around the hospital, and prepare special infection control guidance to be taken into consideration in individual departments

liaise with the National Blood Service on anticipated changes in hospital activity as a result of the pandemic influenza

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Medical Equipment Maintenance Department (MEMD)

will undertake a risk assessment associated with levels of equipment, e.g. pulse oximeters, available to the wards designated to receive patients with influenza, and ensure that all ventilators are fully functional and identify extra ventilator capacity if possible

Pharmacy Department

will specify the mechanism for the issue of anti-viral agents to symptomatic patients

will ensure sufficient suitable storage space has been identified for vaccine supplies

will ensure adequate and continuing supplies of pharmaceutical products

will develop an operational policy (appendix 6) that prioritises its workload during the pandemic period

will pre-determine the stock levels of consumables, drugs etc for each of the wards/areas designated for use during the pandemic period

Human Resources Department

will develop and implement an HR pandemic flu business continuity plan in line with DH guidance (appendix 7)

will utilise ESR to audit clinical and non-clinical skills which staff may have but not use in their current role, and which may be crucial to redeployment

will map what clinical/non clinical roles redeployed staff will be required to perform during a pandemic

will develop a system of identifying staff who have recovered from influenza and/or have received a full course of vaccination against the pandemic strain, and can be prioritised for the care of patients with pandemic influenza or units where the introduction of influenza would have serious consequences

will work with Occupational Health to develop and test a procedure for recording and reporting to management staff absence on a daily basis

will liaise with the Training and Education department to facilitate implementation of the Trust’s Influenza Pandemic Training and Education Programme (appendix 17).

will ensure that staff details for each ward/department are up to date

will identify routes to accessing additional staff resource

will advise on staff transport issues if services are disrupted

will liaise with the Trust’s Accommodation Manager and advise on provision of accommodation for staff who are unable to commute to and from work

will consider the possibility of expanding nursery facilities in the event of schools closure

will liaise with Staff Side and communications team to ensure that: staff are prepared for responding to an influenza pandemic and appropriately trained and briefed; training on appropriate professional practice during a pandemic is delivered; staff concerns and expectations are addressed; staff groups likely to need rapid re-certification/CRB checks to enable them to work are identified.

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Communications Team

will develop a comprehensive strategy (appendix 3) covering all aspects of communicating pandemic influenza information and advice to the public, patients, staff, and other stakeholders

Contract Management Team Representative(SDCP) / Medirest Supplies Manager

will consider and advise on stockpiling disposable linen in the event of laundry services being greatly reduced due to staff shortages

will consider and advise on the stockpiling of food/water and other consumable goods

will develop pandemic influenza contingency plans with external contractors to ensure continuity of supplies and services (appendix 10)

Procurement Department

will develop a procurement influenza pandemic business continuity plan (appendix 10)

will pre-determine the stock levels of consumables for each of the newly designated wards

will identify critical supplies in order to place advance orders for PPE items

will calculate anticipated requirements for other consumables and notify NHS Logistics

Health Informatics Service (NHIS)

will identify across Nottinghamshire HIS a route to obtaining extra staff resource

will develop a business continuity plan (appendix 13) to ensure continued provision of essential health informatics services

Staff Side Representative

will support the consultation and communications strategy by working with HR lead

Representative from Newark Hospital & Mansfield Community Hospital

will support the plan as directed by the Exec Lead for Emergency Planning.

. Volunteers

The Trust may consider the use of health service experienced volunteers to support staff during a pandemic if staff numbers are affected. It may be possible to use ex-staff and “bank” staff to support patient care subject to contract and indemnity arrangements being pre-prepared. Other volunteers would normally be directed to our existing Voluntary Services Manager who would recruit them to the existing Volunteers based at KMH or Newark. Screening of volunteers, especially those who will work with children and vulnerable adults, contract, indemnity arrangements and CRB checks need to be considered.

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The use of volunteers at short notice should be in accordance with the Major Incident Plan and MIAC 45 Voluntary Services Organiser.

Security Robust security arrangements including alarms, cctv, 24 hour man-guard patrols and automated and manual lock-down facilities are in place at the Trust. The contract with the Trust’s security company ensures priority for the Trust in the event of staff shortages. 14.1.1 Business Continuity Planning

The Trust’s corporate Business Continuity Strategy, Is aligned with ISO 22301and compliant with the Civil Contingencies Act 2004. All divisional business continuity plans have been produced with specific reference to a Flu pandemic and will complement the Trust’s Business Continuity Strategy.

14.1.2 Mortuary Arrangements and Excess Deaths

The current standard store at King’s Mill Hospital is 89 spaces with 11 at Newark Hospital. The projected scale of excess deaths in a pandemic, is likely to present many challenges for local services. In view of the number of deaths expected, local authorities, in conjunction with the Coroner, will make provision for additional storage capacity. A sub group of the Local Resilience Forum (LRF) has developed an Excess Deaths Plan, which will become part of the overarching LRF Mass Fatalities Plan. Home Office guidance will be followed in relation to certification, referral to the Coroner of deaths occurring within 24 hours of admission to hospital (where death is influenza related), referral to the Coroner for other deaths and documentation required for cremation.

14.1.3 Bed Escalation

Demand for hospital admissions for acute respiratory and related conditions are likely to increase by at least 25%. The Trust’s bed escalation plan will aim to maximise capacity by possibly curtailing elective admissions and converting elective wards into medical and isolation wards. Bed utilisation as demand peaks will be reviewed and revised dynamically using the triggers as described in section 6. As the pandemic escalates non-urgent hospital admissions and non-urgent outpatient attendances may be stopped in order to minimise the potential for spread of infection and to re-deploy staff as appropriate. A list of essential and non essential services is attached at the end of this plan

14.2 Pandemic Influenza Control Team (PICT) If a new Pandemic virus emerges, the Chief Executive will establish and Chair a weekly a Pandemic Influenza Control Team during critical Pandemic phases which will include the:-

Exec Lead for Emergency Planning (C.O.O)

Executive Nurse

Clinical Director

Microbiology Consultant

HR Executive Director

Communications Manager

Patient Safety Lead

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Lead for Infection, Prevention & Control

Other members co–opted as required

This will be escalated as necessary to bi-weekly, then daily until an incident room is established or until there is no longer a requirement to meet.

The Chief Executive will instruct all directorates/departments to ensure and confirm that their preparations and Business Continuity Plans are up to date and current.

The Pandemic Influenza Control Team will monitor national guidelines and ensure that the Trust’s plan is reviewed and revised accordingly and changes communicated through the appropriate channels.

The PICT will:

review the plan and note the actions required

contact and brief all departments to ensure preparedness

liaise with the communications team to ensure that links with other agencies are in place

monitor the developing situation

consider itself on standby As the response is escalated the PICT will consider the initiation of the Trust’s Major Incident Plan along with the Winter Plan and will:

meet daily to review DH and PHE situation updates and agree necessary action

establish contact with health community partners and the LRF

ensure the implementation of the influenza pandemic communications strategy

ensure all reporting requirements are met

ensure that key personnel (eg senior nurses) are kept updated on all decisions so that progress against the plan can be cascaded to all staff

ensure that effective mechanisms are in place to continuously monitor demands on the Trust from patient workload and staff absence

review and collate information about bed capacity and resource available

curtail elective admission and convert elective wards into medical and isolation wards

Consideration must be given at all times to the fact that there will be a ‘rising tide’ of demand and that the Pandemic Influenza Control Team (PICT) will have to be sustained over a period of approximately three months. 14.3 Capacity

Capacity will be created by the cancellation of non-critical activities and the redeployment of staff and resources, in line with the Trusts' Surge Plan. Non-ward nursing staff will be utilised and annual and study leave will be cancelled. Staff may be required to alter their shift patterns and work at different hospital sites. (appendix 7)

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In the early stages of the pandemic specialties will continue to provide services classified as ‘critical’. If demand increases to the extent that the Trust is likely to cease to function as an effective unit specialty services will be discontinued. All patients who attend or are referred to hospital for consideration for inpatient care will be assessed by a senior clinician in ED and a decision will be made whether or not to offer treatment. This decision will be based on resource required to offer treatment and the likelihood of recovery, with the likely result that treatment will not be offered to patients who would normally receive care. The model to be used for triage will be the County-wide Admission and Discharge Criteria which is based on DH Guidance and under development by the Nottinghamshire Health and Social Care Pandemic Influenza Steering Group.

Capacity issues in the Integrated Critical Care Unit will be addressed according to the Maximising Critical Care Adult and paediatrics and the ICCU’s influenza pandemic business continuity plan (appendix 12).

Admission into the Integrated Critical Care Unit for patients with Pandemic influenza symptoms will be triaged using the Mid-Trent Critical Care Network plan (appendix 14) and the maximising critical care plan

14.4 Managing the response The Pandemic Influenza Control Team will:

decide the level of response demanded by the current level of activity

oversee bed/activity management and scale down elective and non-urgent activity as necessary to re-deploy wards as emergency admissions facilities

ensure that all non-essential Trust meetings have been cancelled

organise secretarial support for pandemic influenza related meetings, using the Trust’s trained loggists where possible

ensure that all significant decisions are logged appropriately and preserved safely (MIP Action Card 11)

monitor staff shortages to ensure safe levels are maintained. If this is no longer possible take decisions to close areas and merge staffing complements

oversee the production and review of emergency rotas

ensure that arrangements are in place for staff who arrive for work ill or become ill during their shift to be sent home and instructed not to return to work until fit to do so

ensure absence reporting system is effectively implemented

identify wards for re-designation on a planned basis

where possible use bed web to provide a real time bed state. If bed web is not available clinical site co-ordinators will provide bed states in accordance with the control team’s demands

collect data on numbers of patient and staff who are ill showing symptoms of influenza. Information collated will include patient name, date of birth, date and time of onset of symptoms, ward or department

14.5 Communications

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The Pandemic Influenza Communications Strategy will be fully implemented and the Head of Communications will report directly to the PICT. 14.6 Staff well-being The following principles will be adhered to while the response is under way:

staff movement will be kept to a minimum to reduce the risk of cross infection

staff will not be asked to undertake tasks they have not been prepared for

the skill mix of individual departments will be considered and where possible staff allocated to ensure an appropriate skill range

staff caring for patients with pandemic influenza will not be moved to other non infected areas

members of staff who arrive for work ill or become ill during their shift must be sent home and not return to work until fit to do so

good health and safety at work practice will include the provision of a safe environment for all staff

staff will not be asked to work excessively long hours and will be encouraged to take adequate rest and refreshment periods

psycho–social support will be available for all staff if and when required

staff may have their normal shift patterns altered to take account of service priorities and will be expected to be flexible throughout the emergency

14.7 Visitors

A decision on managing and controlling visitors will be taken to minimise infection risks, provide appropriate PPE for visitors, and curtail or restrict visits as necessary (see appendix 3, Communications Strategy).

14.7.1 Patients ‘self-presenting’ Patients who self-present at Trust hospitals will be managed in accordance with existing procedures and systems for rapid identification and isolation of infectious patients. The clinical pathway for adults with flu attending ED will be followed.

14.7.2 Return to Background Influenza Activity

After the outbreak of influenza has been contained and Trust activity is returning to the inter-pandemic level, the Emergency Planning Lead will arrange debriefs with the Pandemic Influenza Control Team, the Resilience Assurance Committee, and other senior managers in order to:

evaluate the effectiveness of the Trust’s response to the pandemic

evaluate the effectiveness of department/ward business continuity plans

undertake a series of de-brief sessions with members of staff to listen to their experiences and collate their suggestions and recommendations for enhancing the plan

ensure there is psycho-social support available to staff who require it

identify any education or training needs in preparation for the next pandemic

review and revise the existing plan in light of any lessons learnt

write a report for the Board Risk Committee detailing lessons learnt and actions to be taken

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15. Recovery As the impact of the pandemic wave subsides and it is considered there is no threat of further waves occurring the Trust will move into the recovery phase. The objective will be to return to inter-pandemic levels of activity as soon as possible, although the pace of recovery will depend on the residual impact of the pandemic, ongoing demands, backlogs, staff and organisational fatigue, and continuing supply difficulties. The Executive Team will take the strategic lead in co-ordinating the Trust’s return to normality, with operational support from divisions and departments. The restoration of services and the return to normality will be managed in a sustainable way that takes account of persistent secondary effects eg loss of skilled staff and their experience, backlog of work resulting from postponement of treatment for less urgent conditions, patients whose existing illnesses have been exacerbated by influenza(see full Recover Appendix 23).

16. References

This policy and procedure has been written with reference to: Department of Health (2012) Health and Social Care Influenza Pandemic and Response Department of Health (2011) U K Influenza Pandemic Preparedness Strategy Department of Health (2010) Report of the Swine Flu Critical Care Clinical Group and Key Learning Points for Future Surge Planning Department of Health (2010) Review H1N1- An independent review of the UK

response to the 2009 influenza pandemic, Dame Deirdre Hine, Department of Health (2009) Managing influenza-like illness (ILI) in nursing and residential homes during the current influenza pandemic (WHO Phase 6) Department of Health (2009) Critical care strategy: managing the H1N1 flu pandemic Department of Health (2009) Pandemic influenza: paediatric clinical pathways; information for health care professionals working in hospitals Department of Health (2009) Swine flu - planning assumptions Civil Contingencies Secretariat (2007) Preparing for Pandemic Influenza, Guidance to Local Planners. London, Cabinet Office Department of Health (2005) UK Health Departments, Influenza Pandemic Contingency Planning, Operational Guidance for Health Service Planners in England, March 2005

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Department of Health (2007) Pandemic Flu: A National Framework for Responding to an Influenza Pandemic Department of Health (2007) Pandemic Influenza: Guidance on Preparing Acute Hospitals in England Department of Health (2007) Pre-Pandemic and Pandemic Influenza Vaccines, Scientific Evidence Base Department of Health (2007) Pandemic Influenza: Guidance for Infection Control in Hospitals and Primary Care Settings Department of Health (2008) Pandemic Influenza: Guidance for Infection Control in Critical Care Department of Health (2008) Pandemic Influenza: Human Resource Guidance for the NHS Department of Health (2008) Pandemic Influenza: Guidance on the Management of Death Certification and Cremation Certification Home Office (2008) Planning for a Possible Influenza Pandemic: A Framework for Planners Preparing to Manage Deaths Department of Health (2008) Pandemic Influenza: Surge Capacity and Prioritisation in Health Services Department of Health (2008) Possible Amendments to Medicines and Associated Legislation during an Influenza Pandemic Department of Health (2008) Pandemic Influenza: Framework Guidance on Preparing Maternity Services in England for an Influenza Pandemic Department of Health (2006) Clinical Guidelines for Patients with Influenza like Illness during a Flu Pandemic Cabinet Office (2007) Preparing for Pandemic Influenza: Guidance to Local Planners Cabinet Office (2008) Preparing for Pandemic Influenza: Supplementary Guidance for Local Resilience Planners British Medical Association (2006) Service Continuity Planning for Pandemic Flu Doncaster and Bassetlaw Hospitals NHS Foundation Trust Influenza Pandemic Plan (November 2008) Health Protection Agency (2005), Influenza Pandemic Contingency Plan, Version 8, October 2005 Mid Trent Critical Care Network (2007) Influenza Pandemic Plan NHS Nottinghamshire County Pandemic Flu Plan (2009) NHS Nottinghamshire County Operational Management Plan for Antivirals during an Influenza Pandemic (January 2009) Nottingham City CCG Pandemic Influenza Tactical Plan (2008) Nottingham and Nottinghamshire LRF Pandemic Influenza Plan (2008) Nottingham University Hospitals Influenza Plan and Procedure (2008) East Midlands Ambulance Service Influenza Plan (2009) Detailed information about Influenza and Pandemic Flu may be obtained from: http://www.dh.gov.uk/pandemicflu http://www.who.int/topics/influenza/en/ http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PandemicInfluenza/

http://www.dh.gov.uk/pandemicfluhttp://www.who.int/topics/influenza/en/http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PandemicInfluenza/

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17. Appendices See Separate Document Available on intranet, follow Link:- http://sfhnet.nnotts.nhs.uk/CorporateInfo/deptbrowse.aspx?recid=3211&homeid=1&mode="new

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