High consequence infectious disease (HCID) pathway (Guidelines)

Who to contact

How to contact 

Take full travel and presentation history remotely. The following checklist may be helpful. Face to face assessment is NOT recommended at this stage. 

1. Travel history (including dates, countries and regions),
2. Any history of fever or feeling feverish, date of onset
3. History of symptoms, dates of onset
4. Activities, living conditions and animal contact during travel
5. Contact with unwell people (including dates of last contact, countries and region where contact occurred)
6. How unwell patient is in terms of systemic symptoms and trajectory
7. Whether patient has respiratory symptoms
8. Information relevant to differential diagnoses
9. Immunosuppressed?

Once you have taken the history, if you have any concerns call infection specialist (see contacts). If no concern regarding HCID then leave this pathway and follow standard clinical care pathways.

Unwell patient at home or in community setting pending full assessment

PAG discussion for a patient deteriorating at home or in community will include SAS. The usual preferred pathway is for SAS attendance to patient. If SAS are unable to attend in the required timeframe, the PAG may recommend that the patient’s exposed family members transport the patient to nearest RGH or Raigmore.

All RGHs and Raigmore should have a HCID plan in place with a designated single room suitable for stabilisation of an unwell patient pending SORT ambulance retrieval.

Receiving clinician MUST be told of HCID status of patient so they can arrange safe receipt of patient into the healthcare facility.

This is a HIGH IMPACT situation and is likely to have knock-on effects for healthcare delivery in the location. 

To ensure effective communication cascades and safe management of patient, the Action Cards in the section below MUST be followed by:

• Lead Clinician for the patient
• Lead Nurse for the location
• Duty Infectious Diseases Consultant
• NHSH Duty Microbiologist
• Duty Infection Control Nurse (to be added)
• NHS Location Duty Manager
• Domestic Services Manager
• Laboratory Senior BMS

Action card 1: Suspected HCID ongoing management: Lead clinician for the patient (usually Consultant or GP)

Action card 2: Suspected HCID ongoing management: Lead Nurse for Location

Action card 3: Suspected HCID ongoing management: Infectious Diseases Consultant

Action card 4: Suspected HCID ongoing management: NHSH Consultant Microbiologist

Action card 5: Suspected HCID ongoing management: Domestic Services

Action card 6: Suspected HCID ongoing management: NHSH location Duty Manage

Action card 7: Suspected HCID ongoing management: Laboratory Senior BMS

Action card 8: Moving patient to another location in same building

Patients designated 'suspected HCID' represent a high infection control risk.

• Advice is available from the duty infection control nurse for your area (9am to 5pm) in collaboration with the duty consultant microbiologist (on call 24/7), see: Contact details.
• National guidance is here National Infection Prevention and Control Manual: Addendum for High Consequence Infectious Disease (HCID)

PPE

• A store of HCID assessment PPE should be available in each NHSH hospital. Location of the PPE should be specified in the site HCID plan. Follow your site plan regarding getting additional sets of PPE.
• Staff should not care for a patient with suspected HCID unless they have been trained and deemed competent in the donning and doffing of the PPE. High Consequence Infectious Diseases (HCID) | Turas | Learn (nhs.scot)

Patient placement

• All NHSH hospitals should have a HCID plan which assigns a space for temporary isolation of patients with suspected HCID pending transfer, including designated ‘donning’ and ‘doffing’ areas for putting on and removing PPE. The plan should include whether any adjacent clinical spaces need to be closed.
• The isolation room should be a single room, ideally negative pressure but neutral pressure is ok if negative pressure not available. Positive pressure rooms should NOT be used. Room should have ensuite facilities or at least a dedicated commode, as well as significant areas of surrounding space. It is vital that there are clearly segregated areas for 'donning' and 'doffing' PPE, as described in National Infection Prevention and Control Manual: Addendum for High Consequence Infectious Disease (HCID). 

Waste

• Waste from possible HCID patients should be stored in the patient’s room until instructions given by Infection Control Doctor regarding disposal.

Linen

• Contaminated clothing or linen are potential sources of transmission.

Exposed locations

• Any location exposed to a patient categorised as ‘suspected HCID’ should be closed immediately to new transfers / admissions / discharges until risk assessment by infection control doctor or nurse has been performed, and any cleaning required completed.

Infection prevention and control in community setting

• There are no national guidelines specifically for community setting. Bespoke guidance will be given by the infection control doctor and Consultant in Public Health on a case by case basis.

Samples can be taken in NHSH on a case by case basis as directed by Microbiology or Infectious Diseases consultant. This may be to assess urgently for a likely differential diagnosis (such as malaria), or to do some diagnostics that may allow stepdown of the case from HCID pathway.

Authorisation

Each patient sample MUST be authorised by Duty Consultant Microbiologist BEFORE they are taken. The Duty Consultant Microbiologist then informs the receiving laboratories of the samples.

Samples that may be authorised

• For reference laboratory testing for the HCID: sample type and test depends on the HCID in question
• For other tests: only if clinically indicated
  • EDTA and serum blood tubes (for local FBC, U&E, etc) ONLY if clinically indicated
  • EDTA (FBC tube) sample for malaria testing
  • Blood cultures
  • Viral throat swab (for testing for respiratory pathogens by PCR)
  • Urine in plain universal for legionella and pneumococcal antigen test

Transport within NHS Highland sites

For transport of samples from patient to a laboratory on the same site as the patient, samples are transported by hand in ‘HCID sample containers’. (These are the same as the containers used for viral haemorrhagic fever).

• These containers should be available at each A&E department.
• Their location should be specified in the site HCID plan.
• If not, these are available from Microbiology during office hours, and Raigmore A&E out of hours.
• One container is required for each laboratory, eg. Blood Sciences and Microbiology.
• Each box contains a hard plastic container with lid, bubble wrap, and absorbent material.
• Consultant Microbiologist will inform the Laboratories that specimens are expected.

Onward Transport

For onward transport from the Laboratory, or transport from one NHS Highland site to another, specimens MUST be packaged in Category B transport containers.

Collecting Samples

1. Collecting blood requires:
   • A doctor who takes the blood
   • An assistant who waits at the door of the room
   • A trolley stationed outside the room in the clean zone should be available to use as a 'work station' for the assistant 
2. Assemble equipment to take into room:
   • disposable tourniquet
   • dedicated sharps bin
   • clinical waste bag
   • prelabelled specimen tubes
   • extra alcohol wipes to wipe gloved hands and tubes
3. Assemble materials for assistant:
   • Separate specimen bag for each sample, with each bag containing absorbent tissue
   • Specimen request forms must be removed from the specimen bag at the perforation, and left in clean zone away from patient room.
4. Assemble materials for packaging:
   • Separate hard container for each lab (i.e. one for Blood Sciences, and one for Microbiology)
   • Cushioning material, such as bubble wrap or paper towels
   • Label the container with the destination lab to avoid mix-ups
5. Put on PPE as per section: Infection prevention and control.
   • Assistant PPE is gloves, apron, eye protection and surgical mask
6. Doctor to take samples from patient as usual with room door shut.
   • Remember, the viral swabs need to be removed from the transport medium and discarded into the clinical waste PRIOR to replacing the tube cap.
   • Ensure cap is screwed down tightly.
   • After filling the tubes, the doctor should wipe his/her hands with an alcohol soaked wipe, then wipe each specimen tube individually.
7. Approach door and signal for assistant outside to open door but not enter room.
   • Assistant to hold open separate specimen bag containing absorbent tissue for each tube.
   • The doctor from the patient’s room should drop a single blood bottle into each bag using a 'no touch technique'.
   • The bags are placed on the trolley.
8. Assistant and doctor remove PPE in normal way.
9. Away from patient room in clean area:
   • Wearing clean gloves, assistant to close each bag, wrap the bag in cushioning material (such as bubble wrap or paper towel, and put into separate hard container for each lab.
   • Put on clean gloves
   • Close lid of hard container.
     • If there is an outer cardboard box: put hard container in box with request form.
     • If there is no outer box: carry the hard container and the request form separately. Don't put the request form into the hard container.
10. Samples and request forms
    • To be delivered by hand to laboratories. Do NOT use pneumatic tube.

Assess HCID risk:

• Follow the NHS Highland HCID triage algorithm below
• Or national resources High consequence infectious diseases (HCID) - GOV.UK.

NHS Highland HCID triage algorithm

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