1. High-Security ID services in the UK
Dr Barbara Bannister
Royal Free Hospital, London UK

2. Structure of the services
Two centres: Newcastle and London, serving UK approximately north and south of Birmingham
Funded by DH, through lead Primary Care Trust (local NHS management)
Required to use patient isolators, but only for high-risk or proven cases

3. Other risk assessments
Smallpox
Marb/Ebo
CCHF
High
Contact with case or material
Ditto: includes animals
Tick bite, infected humans/animals near
Medium
In infected area/lab/hos
End/epidemic area/lab
ditto
Low
! Illness, no exposure
Ditto

4. Support services
Both have dedicated laboratory for patient management (haematology, biochemistry, coagulometry, parasitology, bacteriology)
Viral diagnostics are provided by two National reference centres, CfI, Colindale and CEPR, Porton Down: both part of the HPA

5. Operational policies Both have risk-based SOPs
Both select and train their own team members
Both are inspected by the Health and Safety Executive, they must comply with request to upgrade facilities or policy
Both audit all admissions

6. Why use isolators?
They were already used as contingency facilities for smallpox after smallpox hospitals were closed
Isolators are much cheaper to run than ‘suited’ facilities
Teams can undertake long shifts (up to 12 hours) with only some ‘degradation’

7. Rationale for ‘medium and high’
Audit shows that 25% of high-risk patients have a diagnosis of VHF
Rapid testing by PCR is available for the four important VHFs
Medium-risk patients are admitted to an ‘intermediate’ facility , pending early diagnosis
Most suspected VHF cases actually have malaria, and need urgent, expert treatment

8. Advantages and disadvantages
Easy maintenance
Easy on staff rotas
Excellent protection from major bleeding and spillages
End of shift decontamination is change and shower only
Patient confinement
Only suitable for one or two at a time
Can handle monitoring and IPPV, PD and haemodiafiltration,but NOT dialysis
Still need aseptic techniques

9. Routine maintenance
Six-monthly isolator pressure test, filter penetration test and electrical test
Weekly autoclave cycle test
Yearly autoclave review and ‘leak’ test
Yearly facility filter penetration test
Daily gases inspection and test
Daily isolator pressure and flow recording, prefilter/gloves change, inspection, when in use
All half-suits head and visor areas wiped with HOCL between users

10. Facilities needed Shower, change, residential, rest areas
Vehicle access, separate entrance, ambulance cleaning area
Gases, vacuum, electrical supply to CCU standard
CCU, imaging, counselling, physiotherapy
On-site waste decontamination system

11. PPE for the Units Medium Normal uniforms Gown Gloves (single) Mask
Eye/face protection
High
Scrub suits
Shoe covers
Head covers
Thin gloves when in half-suits
(half-suits are waterproof, have face protection, gloves)

12. Other PPE options
‘Jupiter’ mechanically-ventilated protective hoods (available for cohorts of patients, eg with SARS)
Full, coverall Tyvek suits for admitting patients to patient isolator (with single gloves, mask and visor)