Influenza and Respiratory Illness Management …€¦ · Web viewTwo types of influenza virus are recognised: type A and B. Influenza type A is further sub typed e.g. H1N1, H3N2,

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Canberra Health ServicesClinical Procedure Influenza and Respiratory Illnesses Management - Adults and ChildrenContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Background Information: Influenza (including Seasonal, Pandemic and Avian).....3

Clinical Feature......................................................................................................................3

Symptoms.............................................................................................................................3

Complications/Risks..............................................................................................................4

Infectious Agent....................................................................................................................4

Reservoir...............................................................................................................................4

Mode of Transmission...........................................................................................................4

Incubation period..................................................................................................................4

Period of Communicability....................................................................................................5

Section 2 – Measures to prevent the spread of Influenza.........................................................5

Section 3 – Initial management, assessment and testing of a patient with suspected Influenza.................................................................................................................................................. 5

Swab Collection Procedure...................................................................................................6

Performing the swab.............................................................................................................6

Section 4 – Management of an inpatient with suspected or confirmed Influenza and respiratory illnesses..................................................................................................................8

Laboratory confirmed Influenza – Contact Infection Prevention and Control......................9

Other respiratory viruses......................................................................................................9

For Paediatric Patients........................................................................................................10

Nasopharyngeal Aspirate Procedure...................................................................................10

Section 5 – Management of a patient requiring contact tracing.............................................10

Implementation...................................................................................................................... 11Doc Number Version Issued Review Date Area Responsible PageCHS18/250 1 17/12/2018 01/12/2021 Infection

Prevention and Control Unit

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Related Policies, Procedures, Guidelines and Legislation.......................................................11

References.............................................................................................................................. 11

Definition of Terms................................................................................................................. 13

Search Terms.......................................................................................................................... 13

Attachments............................................................................................................................14

Attachment 1 – Bed allocation for Adult Patients with Suspected Influenza......................15

Attachment 2 – Bed Allocation for Paediatrics....................................................................16

Attachment 3 – Contact Tracing Flowchart.........................................................................17

Doc Number Version Issued Review Date Area Responsible PageCHS18/250 1 17/12/2018 01/12/2021 Infection


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Purpose

The purpose of this document is to outline clinical procedures and processes for Canberra Health Services (CHS) staff when managing patients with suspected or confirmed Influenza or transmissible respiratory illness.

It outlines bed management including cohorting of patients with suspected or confirmed Influenza or transmissible respiratory illness, to reduce the possible spread of infection.

Back to Table of Contents

Alerts

For information on the CHS operational response to a territory wide infectious threat/pandemic due to Influenza and respiratory illnesses please refer to the CHS Infectious Threat Operational Procedure located on the Policy Register.


Scope

This procedure applies to all CHS staff working within their scope of practice including students and trainees undertaking clinical placement.


Section 1 – Background Information: Influenza (including Seasonal, Pandemic and Avian)

Clinical FeatureInfluenza (or "the flu") is an acute viral illness caused by infection with influenza viruses A and B. It mainly affects the throat and lungs but can also cause problems with the heart and rest of the body, especially in people with other health problems. Avian influenza commonly causes lower respiratory infection and may present as severe pneumonia that rapidly progresses to acute respiratory distress syndrome (ARDS).

SymptomsSymptoms usually occur one to three days after exposure to the virus, and may include sudden onset of: Fever, chills or sweats Muscle and joint aches and pains Exhaustion/lethargy Headache Light sensitivity



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Frequent coughing Sneezing Sore throat Chest pains Gastro intestinal disturbance e.g. nausea, vomiting or diarrhoea.

Most people recover within a week. Compared with many other infections (like the common cold), influenza tends to cause more severe symptoms and complications.

Complications/RisksAll people in contact with asymptomatic influenza persons are at risk of the disease. Immunosuppressed persons may be of particular concern. Complications can include pneumonia, heart failure, or worsening of other illnesses.

Infectious Agent Two types of influenza virus are recognised: type A and B. Influenza type A is further sub

typed e.g. H1N1, H3N2, H1N1 (Swine) and H5N1 (Avian) Minor changes in the virus are responsible for annual epidemics. Major viral changes,

which occur infrequently, result in pandemics Avian Influenza is a disease of birds caused by a type A strain of the influenza virus. In

humans it is acquired directly from birds and is not thought to spread person to person.

Reservoir Humans are the primary reservoir for human influenza viruses Aquatic birds are the natural reservoir for subtypes of type A Influenza and these can

infect a range of mammals Pigs are the reservoir for swine influenza.

Mode of Transmission Aerosolised respiratory secretions are the main source of person to person

transmission, but the virus can be transmitted by direct contact with contaminated objects or surfaces. The virus may persist on surfaces for a few hours

Avian Influenza acquisition from birds requires direct contact with respiratory secretions and faeces of infected birds. Undercooked poultry may also be a source.

Incubation periodShort, usually 1-4 days. Avian influenza is 2-4 days, though can be up to 8 days or more.

Period of CommunicabilityIn adults, communicability is greatest from one day before symptoms and for the first 3-5 days of illness. In children it is thought to be for up to 7-10 days after onset of illness. Communicability may be longer in severely immunocompromised individuals. Avian Influenza patients may remain infectious for up to 3 weeks.



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Section 2 – Measures to prevent the spread of Influenza

Annual vaccination particularly for those groups most at risk. For further information, refer to the Australian Immunisation Handbook, 10th Edition, 2013 procedure located on the Policy Register or via the web https://immunisationhandbook.health.gov.au/

Health care workers should receive an annual influenza vaccination. Influenza vaccination for Canberra Health Services staff is available during advertised periods throughout the year through the Occupational Medicine Unit (OMU). For further information, please refer to the OMU intranet site

The time from vaccination to protective antibody response is approximately 2 weeks Avian Influenza prevention includes avoidance of sick birds and their faeces, good

personal hygiene and antiviral therapy if exposed.


Section 3 – Initial management, assessment and testing of a patient with suspected Influenza

Assessment and triage of patients presenting with an influenza-like illness (ILI) enables the clinician to order testing and treatment. Patients are then placed in additional precautions to prevent the transmission of illness and disease.

AlertOnly take swabs from patients with acute symptoms (onset within preceding 72 hours).



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https://healthhub.act.gov.au/emergency-safety/work-health-and-safety/occupational-medicine-unit-omu

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Do not use bacterial swabs for specimen collection. If in doubt contact the CHS Pathology laboratory or Population Health (available through Canberra Health Service switch) for advice.

Swab Collection ProcedureInitial preparation and considerations Choose an area to carry out the swab collection procedure where the patient can rest

their head supported by a wall, bed or on a high backed chair with sufficient room for you to stand beside (not in front of) the patient/client

Ensure the area is well lit and that hand washing facilities or alcohol based hand rub and appropriate infectious waste disposal facilities area available

Remember to wash and dry hands, or use alcohol based handrub before and after the procedure.

Gloves, P2/N95 mask and eye protection must be worn when collecting nose and throat swabs

Masks should not be touched during wear and should not be worn around the neck at any time. When the masks are removed they should be handled by the ties or elastic of the mask only

Gloves, gowns and masks should be disposed of in an infectious waste bag.

Obtain required materials Personal Protective Equipment (PPE) for the Health Care Worker taking the swab,

including gown, gloves, eye protection (goggles or face shield) and a P2/N95 mask One red top, viral culture swab with viral culture medium for nasal or throat swab. (PICS

ID 114780) as per image 1 below.

Image 1: Viral culture swab Image 2: Tip of Floq Swab

Performing the swabPreparation by Health Care Worker: Explain the procedure to the patient and obtain consent Perform hand hygiene Don PPE in the order of gown, surgical mask, eye protection, and gloves



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Place patient standing or sitting with head resting supported against a supporting surface

Image 3: Note depth of swab Image 4: Agitate container to mix fluid with viral swab

Nasopharyngeal/Deep nasal swab procedure: A nasopharyngeal flocked swab is the preferred specimen, followed by a deep nasal

swab, to ensure adequate cellular material containing virus Stand at the side of the patient’s head and place your non-dominant hand on the

patient’s forehead with your thumb at the tip of the nose Measure the distance from the tip of the nose to the ear canal, then halve this distance

to ensure the swab is inserted safely Insert the flocked end of the red-top, dry, sterile swab horizontally into the nasopharynx

(As per image 3). It is not uncommon for the patient to have a tear from the corresponding eye when the swab is at the nasopharynx

Rotate the swab twice (2 x 360 degree turns) to ensure the swab contains epithelial cells (not mucus)

Withdraw the swab from the nostril. Place the swab in the labelled tube breaking the swab along the line.

Agitate the container to mix contents thoroughly with viral medium (as per image 4).

Throat swab procedure: A throat swab may be provided in addition to a nasopharyngeal swab or when there is a

contra-indication or difficulty in collecting a nasopharyngeal swab Stand at the side of the patient’s head and ensure their head is resting against a wall or

supporting surface Place your non-dominant hand on the patient’s forehead Ask the patient to open his/her mouth widely and say “aaah” Use a wooden spatula to press the tongue downward to the floor of the mouth. This will

avoid contamination of the swab with saliva



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Insert a red-top flocked swab into the mouth, avoiding any saliva Place lateral pressure on the swab using a tongue depressor in order to collect cells from

the tonsillar fossa at the side of the pharynx Rotate the swab twice (2 x 360 degree turns) against the tonsillar fossa to ensure the

swab contains epithelial cells (not mucus) Remove the swab and place it directly in its labelled tube breaking the swab along the

line.

Labelling and storage of specimen: Please refer to the Patient Identification – Pathology Specimen Labelling procedure

(CHHS18/124) for further information Label the swabs with the patient’s full name, date of birth, MRN, specimen site and date

of collection. The specimen container and/or the accompanying request form should include the name of the facility

Remove PPE in order as follows: remove gloves, perform hand hygiene, remove goggles or face shield, gown and mask. Then perform hand hygiene again

Refrigerate the specimen until it is sent to the laboratory. Do not freeze the specimen. The specimens should be packaged in a small insulated bag/box (with ice bricks) for transport to the pathology laboratory. Specimens should preferably be sent on the day of collection or the following day.

Pathology Request Form: Ensure that the request form has the site of the specimen (e.g. nasopharyngeal or

throat) and the required tests (e.g. respiratory virus PCR) Specify if a particular pathogen is suspected (e.g. pertussis or whooping cough) Include relevant clinical history such as recent overseas travel, intensive care admission

and immunosuppression, as this may influence laboratory testing protocols.


Section 4 – Management of an inpatient with suspected or confirmed Influenza and respiratory illnesses

Refer to Attachment 1 Flowchart for Bed allocation of Adult patients with suspected or confirmed Influenza for further details.

Refer to Attachment 2 Flowchart for Bed allocation of Paediatric patients with Respiratory tract infections for further details.



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AlertAn admitted patient who has been diagnosed with Influenza and has been in a shared room for more than one day must stay in that room. Do not move the patient.

For the management of other patients in the shared room who have already been exposed, see Box 3 of Attachment 1.

However, if an immunocompromised patient is in a room with a patient who has been diagnosed with Influenza, it is appropriate to move the patient with suppressed immunity e.g. with chronic lung disease, heart failure, or neurological impairment which compromises respiratory function. Do not move the patient with Influenza.

Patients who present with acute onset febrile respiratory illness or ILI during influenza season require infection prevention and control management when the availability of isolation beds is limited.

Cohorting of patients requires the direction of Infection Prevention and Control (IPC). Any area/ward where patients have suspected influenza may require outbreak management strategies and bed containment to prevent the spread of illness or disease.

It is the responsibility of the team leaders and CNCs to contact IPC if a cluster of cases of suspected disease occurs. If this occurs after hours, it is the responsibility of the nursing team leader to contact the afterhours CNC. The afterhours CNC must then contact the Infectious Diseases physician on call to report the cluster of cases on the ward.

Laboratory confirmed Influenza – Contact Infection Prevention and Control Place hospitalised patient in Droplet precautions with the door closed where possible. Staff and visitors are to wear a surgical mask Hospitalised patient’s room and environment should be cleaned daily and receive an

infectious discharge clean If transporting the patient from the Emergency Department (ED) or for a procedure, the

patient must wear a surgical mask, unless they are in respiratory distress, in which case the patient should have an oxygen mask in place, and the healthcare worker must wear a mask.

Other respiratory virusesRespiratory Syncytial Virus (RSV), Rhinovirus/Enterovirus, Human Parainfluenza virus 1, 2, 3, & 4, Human Metapneumovirus, Adenovirus.

Maintain Droplet Precautions and contact precautions until 24 hours post resolution of fever and respiratory symptoms.



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For Paediatric PatientsPlease refer to the Acute Management of Bronchiolitis Clinical Practice Guideline located on the Policy Register for further information. Specific considerations: In Paediatrics the cohort room patients and beds / cots spaces must be greater than one

(1) metre apart This does not apply to children with chronic lung or heart disease, malignancies or

immunosuppression, where cohorting would place them at risk of more severe disease. Such patients with respiratory illness will need to be isolated in a single room and not cohorted

Patients with confirmed diagnoses of diarrhoea and/or Pertussis-like symptoms are also excluded from this plan. Such patients can be isolated in single rooms or cohorted following advice from Infection Prevention and Control.

Nasopharyngeal Aspirate ProcedurePlease refer to the Sydney Children’s Hospital procedure for nasopharyngeal aspirate collection located on the Policy Register.


Section 5 – Management of a patient requiring contact tracing

Contact Tracing Staff who identify a patient with a diagnosed or suspected respiratory infectious disease or illness are required to contact the team leader of OMU and the Infection Prevention and Control Unit (IPCU) during business hours or the afterhours CNC after hours

The afterhours CNC is responsible for checking the Series of National Guidelines, available at http://www.health.gov.au/cdnasongs, for the identified respiratory infectious illness.

Patients are to be placed in the correct additional precautions and the CNC of the ward or area (or afterhours CNC) is to compile a list of contacts of the index case (infected person) including clinical and non-clinical staff. Patients presenting to the emergency department may have been in the waiting room, in which case the EDIS administrator needs to be contacted to provide a list of patients who were seen in the ED at the same time as the index case. The list must include persons who presented to ED up until one hour after the infected person has left the department or is moved to isolation.

If the patient is identified with a notifiable disease, it is the responsibility (during business hours) of the IPCU to notify the public health officers from the Health Protection Service After hours it is the responsibility of the Infectious Diseases physician on call or the admitting officer to notify Public Health Officers from Health Protection Service.

Refer to Attachment 3 Contact Tracing Flowchart for further details.



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http://www.health.gov.au/cdnasongs

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Implementation

This procedure is to be communicated to all CHS staff via the Deputy Director General email policy alerts. Staff will be reminded by email each year of the procedure on the management of respiratory illnesses.

This procedure will be distributed to the Bed Access Unit and other relevant clinician areas for tabling at ward/area meetings.


Related Policies, Procedures, Guidelines and Legislation

Procedures Australian Immunisation Handbook, 10th Edition, 2013

https://immunisationhandbook.health.gov.au/ Canberra Hospital and Health Services Clinical Procedure - Adult Nebulisation Therapy Canberra Hospital and Health Services Clinical Procedure Healthcare Associated

Infections Paediatrics - Acute Management of Bronchiolitis Clinical Practice Guideline Sydney Children’s Hospital Nasopharyngeal Aspirate Procedure CHHS – Pathology Specimen Labelling procedure (CHHS18/124)

Guidelines CHHS -NSW Kids and Families Children and Infants: Acute Management of Bronchiolitis

Clinical Practice Guideline (Paediatrics) Guidelines for the Prevention and Public Health management of Influenza Outbreaks in

Residential Care Facilities in Australia; Communicable Disease Network of Australia (CDNA) August 2015


References

All documented information has been aligned against the National Safety and Quality Health Service (NSQHS) Standards actions list for Healthcare Acquired Infections (HAI).

1. ACT Health, Reporting Of Notifiable Conditions Code Of Practice 2017, http://health.act.gov.au/datapublications/codes-practice/reporting-notifiable-conditions-code-practice-2017



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http://health.act.gov.au/datapublications/codes-practice/reporting-notifiable-conditions-code-practice-2017

http://health.act.gov.au/datapublications/codes-practice/reporting-notifiable-conditions-code-practice-2017

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2. CHHS18/119 Paediatrics - Acute Management of Bronchiolitis Clinical Practice Guideline, Paediatrics - Acute Management of Bronchiolitis Clinical Practice Guideline.docx

3. Communicable Diseases Network Australia, Series of National Guidelines – Hepatitis A, Measles, Pertussis, Avian Influenza, Legionellosis http://www.health.gov.au/cdna (Accessed November 2018)

4. Health Protection Services, Communicable Disease Control http://www.health.act.gov.au/public-information/public-health/communicable-diseases

5. Medicines Poisons and Therapeutic Goods Act 2008 http://www.legislation.act.gov.au/a/2008-26/current/pdf/2008-26.pdf

6. Public Health Act (1997) https://www.tga.gov.au/scheduling-medicines-poisons


Definition of Terms

Cohorting: the placement of individuals with the same infectious illness in a shared setting or room.

Epidemic: a disease that spreads and affects a large number of people at the same time with a common, localised demographic feature.

Index case: the first case of an illness Infectious disease: transmissible illness caused by infectious agents. Patients with an

infectious disease (confirmed or suspected) require isolation and infection prevention and control management.

Infection Prevention and Control: the policies and procedures of a hospital or other health facility to minimise the risk of spreading of healthcare- or community-acquired infections to patients or members of the staff.

Nebuliser: a device for producing an aerosol. Notifiable disease: an illness or disease which by law must be reported to governmental

agency. NSAID: Non-steroidal anti-inflammatory drug Pandemic: occurring throughout the population of a country, a people or the world. PCR: Polymerase chain reaction, a laboratory technique of molecular biology used to

amplify and simultaneously quantify a targeted DNA or RNA molecule Pertussis: whooping cough PPE: personal protective equipment worn by healthcare workers to prevent the

transmission of infectious microorganisms. P2/N95 mask: a particulate filter personal respiratory protection device, capable of

filtering 0.3 micrometre particles. Antiviral therapy: an antiviral medicine for treatment of influenza in

people 2 weeks of age and older and for prevention of influenza in people 1 year of age and older.



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https://www.tga.gov.au/scheduling-medicines-poisons

http://www.legislation.act.gov.au/a/2008-26/current/pdf/2008-26.pdf

http://www.health.act.gov.au/public-information/public-health/communicable-diseases

http://www.health.gov.au/cdna

http://inhealth/PPR/default.aspx

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Search Terms

Influenza, Flu, Children, cohorting, Emergency Department, Infection Control, Paediatrics, Respiratory, Bronchiolitis, Influenza like illness, contact tracing


Attachments

Attachment 1 – Management of Patients with Suspected InfluenzaAttachment 2 – Bed Allocations for PaediatricsAttachment 3 – Contact Tracing Flowchart

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 17 December 2018 Updated changes to

whole document ED CSS CHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS16/078 Influenza and Respiratory Illness Management Procedure



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Attachment 1 – Bed allocation for Adult Patients with Suspected Influenza

List 1 Underlying co-morbid conditionsHaematological malignancy, Oncology treatments, Radiation oncology treatments, Chemotherapy treatmentsEnd stage lung disease, Home oxygen therapy, Cystic fibrosis, Non-invasive ventilationSolid organ transplantModerate or severe cardiac diseaseHigh dose corticosteroids, Immunosuppressive therapy

Other underlying conditions While acknowledging that pregnancy is not a co-morbid condition, pregnant women are

to be managed as those in List 1.



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Attachment 2 – Bed Allocation for Paediatrics



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Attachment 3 – Contact Tracing Flowchart



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Documents

Influenza and Respiratory Illness Management …€¦ · Web viewTwo types of influenza virus are recognised: type A and B. Influenza type A is further sub typed e.g. H1N1, H3N2,