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6. Concept of operations - a proposed operational response
6.1 Timing
In planning the operational response to pandemic influenza, clarity around the signs or events that would trigger the implementation of surge plans, and some indication of the timing between each trigger, are important. Evidence from previous pandemics suggests that this will not be straightforward, as it is impossible to forecast the precise characteristics, spread and impact of a new influenza virus strain.
Figure 3 illustrates the course of the 1957/58 Asian flu pandemic with the current UK alert levels; Figure 4 illustrates the 1968 Hong Kong flu pandemic similarly. These tables show a delay of some weeks (12 and 18 weeks respectively) between influenza being identified in the UK (alert level 2) and it becoming widespread (alert level 4).
Figure 3: Course of the first wave, 1957/58 Asian flu pandemic
Figure 4: Course of the first wave, 1968/69 Hong Kong flu pandemic
Current modelling suggests that, from the time a pandemic begins in the country of origin - likely to be in South-East Asia, the Middle East or Africa - it may take as little as two to four weeks to build from a few cases to around 1,000 cases and could reach the UK within another two to four weeks. Once in the UK, it could spread to all major population centres within one to two weeks, with its peak potentially only 50 days from initial entry to the UK.
This would give a range of seven to 18 weeks between UK alert levels 2 and 4. Furthermore, in the period after the first wave, the UK will probably be at UK alert level 2 for an indefinite period before renewed influenza activity causes a sudden escalation to UK alert level 3/4 or the World Health Organization ( WHO) declares the pandemic over and there is a global move to WHO Phase 1 or 2.
While the current UK alert levels are useful indicators of seminal events at a national level, they are probably not sensitive enough or specific enough to determine local operational responses. Knowing that the pandemic strain is in the UK ( UK alert level 2) is a seminal event, triggering increased surveillance and preparedness; suspending elective surgery at this point could result in operations being deferred for a prolonged period in some regions and could give the feel of a 'phoney pandemic' to those involved. Whether an outbreak in a locality signifies the start of UK alert level 3 or 4 will be a matter of historical perspective.
6.2 Stages of surge
From an operational perspective, a pandemic consists of three stages:
- pre-surge - when UK alert level 1 is declared. It will continue into UK alert level 2. Even at alert level 3 there will be places unaffected and still in the pre-surge phase
- surge - when local triggers indicate the potential for a sudden escalation in patient numbers, eg an influenza death, an outbreak in a school or other institution or increased staff absence
- recovery - when it is clear that local influenza activity is declining.
Figure 5: The pandemic curve
Source: Pandemic flu: A national framework for responding to an influenza pandemic
6.2.1 Pre-surge
General preparation for a pandemic and activation of business continuity plans would take place at WHO Phase 5; however, the declaration of UK alert level 1 would trigger the pre-surge preparation for the NHS. This would involve making sure that operational plans are tested; staff education, training and upskilling are implemented; and stores and supplies are topped up. Surveillance would be enhanced, and the algorithms on returning travellers developed by the Health Protection Agency would be widely distributed.
Examples of the types of activity that might take place at this stage are listed in Table 3.
Table 3: Examples of activities in the pre-surge stage, UK alert level 1
Primary care | Secondary care |
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- Ensure that business continuity plans are in place and tested
- Normal local admission and referral criteria apply
- Consider identifying patients with chronic problems for review
- Initiate training/upskilling programmes for staff with specific pandemic support and cross-cover roles
- Update staff infection control guidance
- Outpatient referrals as normal
- Electives as normal
- Reinforce messages on self-care and how to protect and look after yourself
| - Ensure that business continuity plans are in place and tested
- Normal local admission criteria apply
- Initiate training/upskilling for staff with specific pandemic support and cross-cover roles
- Update staff infection control guidance
- Some hospitals may wish to use this period to fast-track urgent elective procedures and investigations
- Links between district general hospitals and paediatric intensive care units should be reinforced and any extra training needs addressed
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On the declaration of UK alert level 2, processes commenced in UK alert level 1 would continue but, in addition, surveillance should be intensified to allow the start of the surge to be identified locally, since the start of any local pandemic activity may differ by two to three weeks across the UK (Table 4).
This stage would also see the activation of the arrangements and procedures for the assessment and management of people with influenza-like illness, as described in Pandemic influenza: Guidance for infection control in hospitals and primary care. See also Pandemic influenza: Guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England and equivalent guidance in the devolved administrations, for guidance on specific primary care access arrangements.
Table 4: Examples of activities in the pre-surge stage, UK alert level 2
Primary care | Secondary care |
|---|
- Increase surveillance for influenza-like illness and ensure that reporting mechanisms and reporting of influenza-like illness are agreed and in place
- Reinforce infection control advice and procedures
- In consultation with strategic health authorities and the health departments of the devolved administrations, consider suspending screening programmes and health promotion clinics to ensure that patients with chronic conditions are reviewed and any developing issues addressed
- Be prepared to switch to surge mode of operating at short notice
- Normal local admission and referral criteria would apply
- Reinforce messages on self-care and how to protect and look after yourself
| - Increase surveillance for influenza-like illness and ensure that facilities and procedures for the triage, isolation, assessment and treatment of affected patients and their contacts are in place
- Reinforce infection control advice and procedures
- In consultation with strategic health authorities and the health departments of the devolved administrations, consider suspending screening programmes and moving to symptomatic testing of suspected cancers
- Be prepared to switch to surge mode of operating at short notice
- Normal local admission criteria still apply
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6.2.2 Surge
For reasons described in section 6.1, the use of the UK alert levels beyond alert level 2 will be of limited value in determining when to introduce locally planned surge responses, and it is likely that the activation of the surge stage will be determined in consultation with strategic health authorities in England or health boards of the devolved administrations.
It is likely that there will be two steps to the surge response:
- Initially, efforts will concentrate on expanding capacity: cancelling all elective procedures, dealing with emergencies only, early discharge and redeployment of staff. This is likely to offer increased capacity for only a few days.
- The second stage of the surge response will involve the introduction of prioritisation criteria and restrictions on treatment options - to be introduced when deemed necessary in the local setting. This should be introduced for as short a period as practicable, due to the nature of the restrictions.
It is important to remember that it is likely that over 40% of the total patient volume will occur over a two-week period at the peak of the pandemic. Examples of activities in the surge stage are given in Table 5.
Table 5: Examples of activities in the surge stage
Primary care | Secondary care |
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- Business continuity plans activated
- Quality and Outcomes Framework in England and similar schemes in the devolved administrations suspended
- All but essential elective procedures cancelled
- Emergency admissions only
- Introduce phased responses to any increasing demand
- Balance of probability for urgent referrals shifts from possible to probable, e.g. overt cancer signs
- Palliative care supported
| - Business continuity plans activated
- Quality assurance and performance management frameworks and targets suspended
- All but essential elective procedures cancelled
- Phased admissions and treatments policy introduced and implemented as necessary
- Palliative care facilities supported and expanded if possible and feasible
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6.2.3 Recovery
On the basis of previous pandemics, it is likely that the initial local surge will last for three to four weeks before there is evidence of patient numbers tailing off. The decision about the relaxation of prioritisation criteria will have to be made locally, according to resource availability, and will be dictated partly by staff availability. It is likely that the priorities will be to restore pre-surge standards of clinical care in the emergency setting, followed by the gradual resumption of urgent and then non-urgent elective procedures (Table 6). During this recovery period, the emphasis will be on getting services back to normal, learning from the experiences of the first wave, refining the response and preparing for a potential second wave. However, this needs to be set against the situation where they may be many tired and bereaved people and large backlogs of annual leave. 16, 17
Table 6: Examples of activities in the recovery stage
Primary care | Secondary care |
|---|
- Gradual relaxation of restrictions on admissions
- Phased reintroduction of general consultations
- Gradual reintroduction of non-emergency outpatient referrals and investigations
- Reintroduction of screening programmes
- Gradual reintroduction of quality assurance and performance frameworks and targets
| - Gradual relaxation of restrictions on admissions and treatment policies
- Reintroduction of pre-pandemic standards of clinical care for emergencies
- Phased reintroduction of elective treatments and investigations
- Gradual reintroduction of quality assurance and performance frameworks and targets
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6.3 Command and control
The command and control arrangements pertinent to an influenza pandemic are described in the National framework. However, there are specific decisions relating to operational issues that need clarification.
Any phased reduction of the quality and performance frameworks in primary and secondary care during the pre-surge and surge periods would need to be agreed and understood in advance of the pandemic.
The trigger to activate surge plans should be authorised at health authority/board level, 18 taking account of the local epidemiology during the pandemic. Once activated, local escalation would occur in response to the demand for healthcare and the availability of local resources. For example, suppose that during UK alert level 2, three outbreaks of influenza are identified in a locality in England. The strategic health authority, local health services and Health Protection Agency will quickly convene to decide whether this indicates the beginning of the pandemic in the locality. If it is considered likely that the data indicate the beginning of the local surge, then a decision will be made about the area to which the activation trigger should apply and local health organisations will then move to surge mode. Any further escalation of the response will be determined locally in the light of local influenza activity and the availability of local resources.
What will be essential in the pre-pandemic period will be discussion and agreement about who makes the decision in the locality around further escalation of the pandemic response after the surge has been activated.
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