High consequence infectious disease (HCID) pathway (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Objectives

This pathway is for local implementation of national guidance to allow safe management of patients who may have a HCID.

Audience

  • All NHS Highland
  • Primary and Secondary Care
  • Adults and Children

What is a HCID?

  • High Consequence Infectious Diseases (HCIDs) are diseases that have been categorized as requiring high levels of infection control intervention to protect healthcare workers and public. They are listed here: High consequence infectious diseases (HCID) - GOV.UK

National guidance:

HCID clinical pathway: quick reference guide

Pathway  step

ACTION

1

Patient identified as needing assessment for HCID

  • Eg, due to travel history and infection presentation

Place patient away from other people and continue assessment by phone.

  • See 'Patient placement while awaiting assessment'

2

Take full travel and presentation history by phone
  • See 'History and remote assessment' and 'HCID risk assessment triage algorithm'
3

If concern re possible HCID, discuss with Infection Specialist
  • See 'Contact details'
  • See 'Infection Specialist assessment'

4

Suspected HCID: Next steps

  • Patient isolated
  • Staff wear HCID PPE
  • Key personnel informed of the patient
  • Refer to Regional Infectious Diseases Unit
  • Continue patient care
  • Public Health convene PAG (Patient Assessment Group)

All staff MUST follow role-specific action cards: 

  • See: Role specific 'action cards'
  • See: 'Suspected HCID communication cascade'

5

Patient stepped down or transferred to Regional Infectious Diseases Unit

Infection specialist contact details

Who to contact

 

North NHS Highland

Argyll and Bute HSCP
Suspected HCID (adult)

Monday to Friday 9am to 5pm

  • NHS Highland Duty Infectious Diseases Consultant

Out of hours

  • NHS Highland Consultant Microbiologist
    Note: If appropriate, NHS Highland Microbiologist may advise referrer to discuss directly with Grampian ID Consultant on-call

Monday to Friday 9am to 5pm

  • NHS Highland Duty Infectious Diseases Consultant

Out of hours

  • NHS Highland Consultant Microbiologist
    Note: If appropriate, NHS Highland Microbiologist may advise referrer to discuss directly with GGC ID Consultant on-call
Suspected HCID (child)

Local paediatrician first, then

Paediatric Infectious Diseases Consultant, GGC

How to contact 

Contact

Contact number

NHSH Infectious Diseases Consultant on call
(Monday to Friday, 9am to 5pm)

 01463 704000 Raigmore switchboard

NHSH Duty Consultant Microbiologist
(any time)
01463 704000 (Raigmore switchboard) or 
01463 704206 (Lab office)

NHSH Infection control Duty Nurse, North Highland
(Monday to Friday, 9am to 5pm)  

 01463 704000 (Raigmore Switchboard) and ask to page Duty Infection Control Nurse

NHSH Infection Control Duty Nurse, Argyll & Bute
(Monday to Friday, 8am to 5pm)

07887626539 (if answerphone follow instructions for alternative number)
OR call Admin: 01436655011 and ask for Duty Infection Control Nurse Contact
GGC Infectious Diseases Consultant on call 
Queen Elizabeth University Hospital Switchboard
(any time)
 0141 201 1100

NHS Grampian Infectious Diseases Consultant
(any time)

 0345 456 6000

Consultant in Public Health Medicine (CPHM) and Health Protection Team for NHS Highland

 Working hours: 01463 704886.
Out of hours:  01463 704000 (Raigmore switchboard)

Scottish Ambulance Service

 0345 602 3999

Imported fever service

 0844 778 8990 (Infection Specialist only)

Paediatric Infectious Diseases Consultant, GGC

 0141 201 1100 

Patient placement while awaiting assessment

Example scenario: the possibility of a HCID has been raised (for example, due to travel history) but more detailed risk assessment for HCID is pending.

Where the patient presents

Patient placement
Community
  • Patient to stay where they are.
  • History taken by telephone.
Primary Care
  • Patient to be placed in a single room or asked to wait outside or sit in their car if suitable.
  • History taken by telephone.
Secondary Care ED / Outpatient setting
  • Follow your site HCID plan. Your site lead nurse or duty manager should be familiar with this.
  • If in doubt place patient in a clinical space appropriate for their clinical presentation, away from other patients (single room preferred).
  • History taken by telephone.
Inpatient setting
  • Urgently inform the charge nurse and the patient’s consultant of the concerns. Advise that you have concerns about HCID but patient has not yet been fully assessed.
  • Nurse in charge minimise contact with other patients / staff and visitors but does not usually move patient at this stage.
  • Take further history by phone. 
Notes
  • If direct clinical care needs to be given prior to full risk assessment then make dynamic risk assessment and either don HCID assessment PPE before giving direct clinical care, or use standard precautions.
  • If patient doesn’t have own phone then department roving handset or mobile can be used. If not already plastic covered then the department device should be placed in a clear plastic bag before passing to the patient to allow decontamination after use.

History and remote assessment

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.

NHS Highland have developed a HCID triage tool that departments can use to help staff identify patients who are at risk of HCID.

  • You can consider using this tool if your patient is relatively well and stable. See HCID risk assessment triage algorithm. 
  • If your patient is unwell or unstable go straight to discussion with infection specialist.
Instant access Near-me video call can be accessed by logging into your near me account and choosing the ‘consult now’ feature. This allows you to invite the patient into a videocall using their mobile phone number or e mail.

Deteriorating patient at home or in the community

Unwell patient at home or in community setting pending full assessment

If 999 call warranted:

  • Proceed to call 999
  • Inform ambulance control of patient travel history and whether 'suspected HCID'.
    • Scottish Ambulance will call on any appropriate resources they have available to attend to a patient deteriorating at home.
  • Complete history and assessment prioritising informing infection specialist of incident / development.
    • Infection specialist then urgently informs CPHM who arrange a PAG.

If 999 call NOT warranted:

  • Urgently complete history and remote assessment, prioritising informing infection specialist of patient.
    • Infection specialist then urgently informs CPHM who arrange a PAG.

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.

Infection specialist assessment

Infection specialist to decide whether case should be managed as a suspected HCID or not.

This may require further telephone assessment of the case, and discussion with Imported Fever Service.

If patient IS suspected HCID, the infection specialist MUST:

  • Tell the lead clinician for the patient (usually the GP or Consultant) that “the patient is to be managed as suspected HCID”
  • Tell the lead clinician that this is a high impact situation, which is likely to have knock-on effects to service delivery
  • Signpost the lead clinician to their action card and inform them that they need to follow all the actions to ensure effective management and communication
  • Follow the actions in own Action Card

If patient is NOT to be managed as suspected HCID:

  • Then revert to standard pathways
  • Inform lead clinician of decision and advise them to discuss with infection specialist over subsequent days if ongoing concern.

Patient designated as 'suspected HCID': next steps

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
ALL communication responsibilities are within the Action Cards, but a communication cascade diagram is also given.
See: Suspected HCID communication cascade

Action cards

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

Suspected HCID communication cascade

HCID communication cascade

Infection prevention and control: Additional information

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

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). 
There must be NO through-flow of staff or patients i.e. the area must be contained and controlled. This may require complete/ partial closure or reconfiguration of the unit to achieve.

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.
  • Do NOT shake clothing or linen
  • Linen must NOT be returned to laundry until authorised by Infection Control Nurse or Duty Microbiologist. It should be stored securely in the location of the patient.

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.

Laboratory samples

Normally NO clinical specimens are taken from patients with suspected HCID in NHSH. Normally the patient is transferred to a Regional Infectious Diseases Unit, and samples are taken there.

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.

Point of care testing equipment, including blood gas machines, should NOT be used without prior approval of infection specialist. 

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
NB: in some areas in Argyll & Bute the colouring of tubes differs from the above.

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.

HCID risk assessment triage algorithm

Assess HCID risk:

  • If you have concerns call the Infection Specialist (see contacts).
  • If NO concerns regarding HCID, then leave this pathway and follow standard clinical care pathways.

NHS Highland HCID triage algorithm

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Abbreviations

  • CPHM: Consultant in Public Health Medicine
  • ED: Emergency Department
  • EDTA: Ethylenediaminetetraacetic Acid
  • FBC: Full Blood Count
  • FFP3: Filtering Facepiece Respirator (Class 3)
  • GGC: Greater Glasgow and Clyde
  • HCID: High Consequence Infectious Disease
  • HSCP: Health and Social Care Partnership
  • ID: Infectious Diseases
  • IPC: Infection Prevention and Control
  • PAG: Problem Assessment Group
  • PCR: Polymerase Chain Reaction
  • PPE: Personal Protective Equipment
  • RIDU: Regional Infectious Diseases Unit
  • RGH: Rural General Hospital
  • SAS: Scottish Ambulance Service
  • SORT: Specialist Operations Response Teams
  • U&E: Urea and Electrolytes

Editorial Information

Last reviewed: 01/10/2025

Next review date: 31/10/2028

Author(s): Infectious Diseases Department.

Version: 1.2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): A Cochrane: Consultant in Infectious Diseases and Microbiology.

Document Id: TAM736