SESLHD PROCEDURE COVER SHEET · 2019-07-11 · SESLHD PROCEDURE COVER SHEET . COMPLIANCE WITH THIS DOCUMENT IS MANDATORY . This Procedure is intellectual property of South Eastern

SESLHD PROCEDURE COVER SHEET

COMPLIANCE WITH THIS DOCUMENT IS MANDATORY This Procedure is intellectual property of South Eastern Sydney Local Health District.

Procedure content cannot be duplicated. Feedback about this document can be sent to [email protected]

NAME OF DOCUMENT

Management of Acute Viral Respiratory Illness

TYPE OF DOCUMENT

Procedure

DOCUMENT NUMBER

SESLHDPR/581

DATE OF PUBLICATION

July 2019

RISK RATING

Medium

LEVEL OF EVIDENCE

National Safety and Quality Health Service Standard: 3 – Preventing and Controlling Infections

REVIEW DATE July 2022

FORMER REFERENCE(S)

None

EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR

Kim Brookes, SESLHD Director Clinical Governance

AUTHOR

SESLHD Infection Prevention and Control Manual Working Party [email protected] Adapted from POWH, and St Vincent’s

POSITION RESPONSIBLE FOR THE DOCUMENT

SESLHD Infection Prevention and Control Manual Working Party [email protected]

KEY TERMS

Respiratory Viruses Droplet Precautions Surgical Mask Particulate Mask

SUMMARY

Prevention of transmission of respiratory viral infection between healthcare workers, patients and their visitors and enable appropriate accommodation and management.

mailto:[email protected]



SESLHD PROCEDURE Management of Acute Viral Respiratory Illness SESLHDPR/581

Revision 1 Trim No. T17/16101 Date: July 2019 Page 1 of 16 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY

This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.

1. POLICY STATEMENT

Prevention of transmission of respiratory viral infection between healthcare workers, patients and their visitors; and enable appropriate accommodation and management. Infrequently, any of these viruses can cause more severe illness including pneumonia. This more often occurs in patients who have clinical risk conditions (defined in the Immunisation Handbook). Caution needs to be exercised as respiratory virus infection can occur with more than one agent.

2. BACKGROUND

Respiratory viruses can cause mild to moderate illness in most people; however, vulnerable patients can be at risk of severe disease. Healthcare workers should ensure that all efforts are made to minimise the risk of transmission of all influenza-like illness (ILI) within HCFs, with a focus on protecting patients, visitors and staff.

3. RESPONSIBILITIES 3.1 Directors of Clinical Operations and Directors of Nursing and Midwifery:

• Ensure that compliance is monitored and evaluated.

3.2 Patient Flow Managers: • Ensure patients requiring admission with suspected acute respiratory viral

infection are isolated correctly to reduce risk of transmission to others.

3.3 Nurse Unit Managers: • Maintain a high index of suspicion for acute respiratory viral illness all year

and manage according to this guideline • Clinical picture overrides diagnostic testing results for isolation and

management purposes i.e. Influenza A/B, RSV may be negative however patients remain symptomatic and may have Enterovirus which has not been excluded

• Ensure protocols are in place to alert family and visitors to exclude themselves from visiting if they are unwell with an acute viral respiratory illness

• Manage HCW with respiratory illness according to facility guidelines • Promote seasonal influenza vaccination for staff and patients.

3.4 NSW Health Pathology Randwick Area Virology Laboratory, Serology and Virology

Division: • Provide support for increased diagnostic testing seasonally and on the advice of

the Public Health Unit, with feedback to clinicians via EMR and Infection Prevention and Control reporting.

• Reference testing for respiratory viruses and molecular diagnostics.




3.5 Medical staff or Nurse Practitioner: • Ensure appropriate ordering of specimens as per Table 1: Virus Panel Testing • Ensure adequate handover to nursing staff when respiratory viral illness is

suspected • Ensure follow-up of exposed occurs as per Influenza Control guidelines.

3.6 All Healthcare Workers (HCW):

• Participate in the seasonal influenza vaccination program and comply with mandatory vaccination requirements as per Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases

• Risks assess and manage all patients as per procedure • Adopt Droplet Precautions and attend to increased cleaning of frequently touched

surfaces to manage patients with acute viral respiratory illness • Provide patient and consumer NSW Health fact sheets • Use spacers for respiratory tract medication delivery unless contraindicated • Staff to remain at home when unwell with a respiratory illness. See Table 3:

Infectious period from onset of symptoms for isolation requirements.

3.7 Infection Prevention and Control Staff: • Support clinicians in the management of cases and contacts.

3.8 Patient/Consumer:

• Be encouraged to be involved in education and consideration for treatment including providing information NSW Health fact sheets

4. DEFINITIONS

Adenovirus: most commonly presents as a ‘common cold’ and most commonly causes illness of the respiratory system; however, depending on the infecting serotype, they may also cause more severe illnesses and presentations. Bocavirus (HBoV): is a parvovirus that has been suggested to cause human disease. It is a probable cause of lower respiratory tract infections, although this is still controversial. Enterovirus: is one of the major causative agents for hand, foot and mouth disease and is very common. It is often found in the respiratory secretions (e.g., saliva, sputum, or nasal mucus) and stool of an infected person. Case: a person presenting with acute onset influenza like illness. Contacts: are patients, their carers or staff that were in direct contact with a case e.g. same room or area, or providing care for the case. Contacts of high risk: high risk immunocompromised, >65 yrs, ATSI or pregnant patients or children contacts if there is a high suspicion of influenza (as per Ministry of Health) Coronavirus: (common, not MERS-CoV or SARS-CoV) most commonly presents as a ‘common cold’ and can cause mild to moderate upper respiratory tract infections with runny nose, cough, sore throat and fever. In a few cases may

https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2018_009.pdf

https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2018_009.pdf

https://www.health.nsw.gov.au/Infectious/factsheets/Pages/default.aspx

https://www.health.nsw.gov.au/Infectious/factsheets/Pages/default.aspx

https://en.wikipedia.org/wiki/Illness

https://en.wikipedia.org/wiki/Respiratory_system

https://en.wikipedia.org/wiki/Parvovirus

https://en.wikipedia.org/wiki/Lower_respiratory_tract_infection

https://en.wikipedia.org/wiki/Hand%2C_foot_and_mouth_disease




progress to pneumonia. Droplet Precautions: precautions applied to patients known or suspected to be infected with pathogens that can be transmitted by droplets to reduce the risk of transmission. Influenza-like Illness: flu signs and symptoms usually come on suddenly. People who are sick with flu often feel some or all of these symptoms:

• Fever* or feeling feverish/chills • Cough • Sore throat • Runny or stuffy nose • Muscle or body aches • Headaches • Fatigue (tiredness) • Some people may have vomiting and diarrhea, though this is more common

in children than adults *It’s important to note that not everyone with flu will have a fever.

Influenza A and B: or the flu is a highly contagious respiratory illness caused by influenza viruses. There are three main types of influenza virus that cause infection in humans - types A, B and C - and many sub-types or strains. Influenza virus subtype C is not thought to cause serious infection frequently. Influenza can occur throughout the year but influenza activity usually peaks in winter. Parainfluenzae: viruses cause a spectrum of respiratory illnesses, and can cause bronchiolitis (inflammation of the small breathing tubes of the lung) and pneumonia (infection of the lung) in the very young. Along with RSV, parainfluenzae viruses are also leading causes of hospitalisation in adults with community-acquired respiratory disease. Polyomaviruses: Wu Ki an emerging viral illness human polyomaviruses, KI polyomavirus and WU polyomavirus may be detected in individuals with respiratory symptoms or in those co-infected with a respiratory virus. Post exposure prophylaxis: contact tracing should be considered when patients or staff working in high risk settings (hospital wards specifically for people who are immunosuppressed or neonatal wards) have been exposed to a confirmed infectious case of influenza. Vulnerable patients who are close contacts should be advised of their risk and, if indicated, in consultation with their health care provider, should be offered early treatment should symptoms develop. Respiratory viruses Influenza A, Influenza B, Parainfluenza, Respiratory Syncytial Virus (RSV), and Human Metapneumovirus are acute viral infections of the respiratory tract characterised by fever, cough, myalgia, headache, prostration, coryza or sore throat. They may progress to pneumonitis or pneumonia, particularly in the immunocompromised host. Rhinovirus: can cause mild illness with a sore throat, runny nose followed by coughing and sneezing.




Respiratory syncytial virus: or RSV, is a virus that causes respiratory infections. Illness is common in children under two years of age. In this age group RSV can cause bronchiolitis (inflammation of the small breathing tubes of the lung) and pneumonia (infection of the lung). Infections peak in late autumn or winter in NSW. Surgical Mask: a fluid resistant single use loose fitting mask that covers the nose and mouth. Particulate mask (P2, N95 or PFR95): a mask which provides a tight facial seal with a face-seal leakage of <10% and ability to filter particles one micron in size in the unloaded state with a filter efficiency of greater than/equal to 95% given flow rates of up to 50 litres per minute. Pooled swab: the collection of a single throat and nose swabs from patients with suspected viral respiratory illness. A pooled swab is collected by first swabbing the oral pharynx, the same swab is then used to swab the inside of the nares.

5. PROCEDURE

5.1 Flow Chart for Assessment and Management of Acute Viral Respiratory Illness

Refer to Appendix 1 Flowchart for management of Influenza-like-illness (ILI)

• Note: Patients presenting to the Emergency Department with acute onset febrile respiratory illness requiring admission must not be delayed in their transfer to a ward bed by waiting for the result of a respiratory viral screening test. Isolate with droplet precautions.

• Patients who are identified as a high falls risk may need to be placed in an area where ability to visually observe patient can be achieved to ensure safety. Please contact site Infection Prevention and Control Consultant or contact Infectious Diseases Consultant on call to help with risk assessment.

5.2 Respiratory Virus Testing For isolation purposes, the key factors to consider are: • Day of symptom onset • Infectious Period • De-isolation criteria, outlined at Table 3: Infectious period from onset of symptoms

for isolation requirements

Obtain throat and nose pooled swab from patients with a rapid onset currently or recently febrile respiratory illness and coryzal symptoms or high risk patients with a suspected viral respiratory illness that may not be acute.

Obtain one (1) pooled swab from oral pharynx, the same swab is then inserted into the nare. Viral respiratory swabs are green in colour. If in doubt, please contact your laboratory service.




5.3 Ordering Respiratory Virus Screening Panels on EMR Clinicians to order respiratory virus screening based on clinical assessment as per Table 1

• Respiratory Virus Screen (Influenza A/Influenza B/RSV) on EMR, Panel 1 • Respiratory Virus Screen (Adenovirus/ Enterovirus/ Parainfluenzae/Human

Metapneumovirus), Panel 2 • Respiratory Virus Screen (Rhinovirus/ Coronaviruses/ Bocavirus), Panel 3 • Respiratory Screen (Mycoplasma pneumoniae (MP), Chlamydophila pneumoniae (CP),

Legionella pneumophila (LP), Haemophilus influenzae (HI), Streptococcus pneumoniae (SP), Bordetella pertussis (BP) and Bordetella parapertussis (BPP)), Panel 4. Note that routinely Haemophilus influenzae (HI), Streptococcus pneumoniae (SP) are suppressed on EMR as they are often commensals (ie usual) flora of some patients. Results are available on request.

Diagnosis of respiratory viruses other than Influenza/RSV are particularly clinically significant for the following groups:

• Adults: Immunocompromised patients with acute respiratory illness e.g. Haematology patients, solid organ transplants, Immunology patients.

• Paediatrics: Immunocompromised patients (as above); moderate-severe viral exacerbations of chronic airways disease (e.g. asthma, CF).

• Any: patients with severe pneumonia clinically where viruses are suspected, particularly in ICU

*All viruses can be ordered using one swab Table 1: Respiratory Virus Panel Testing Virus Panel When to Order Each Panel

NB. One or More Panel Can be Ordered On Each Specimen

Panel 1:Influenza A/B, RSV All acute respiratory illnesses where diagnosis will change treatment or infection control decisions (immunocompetent and immunocompromised patients).

Panel 2: Adenovirus, Enterovirus, Parinfluenzae 1-4, Human Metapneumovirus

Adults: Immunocompromised patients with acute respiratory illness e.g. Haematology patients, solid organ transplants, Immunology patients.

Paediatrics: Immunocompromised patients (as above); suspected enterovirus infections; moderate-severe viral exacerbations of chronic airways disease (e.g. asthma, CF).




Panel 3: Rhinovirus, Coronaviruses, Bocavirus

Adults: Immunocompromised patients with acute respiratory illness e.g. Haematology patients, solid organ transplants, Immunology patients.

Paediatrics: Immunocompromised patients (as above); moderate-severe viral exacerbations of chronic airways disease (e.g. asthma, CF).

Panel 4: Mycoplasma pneumoniae (MP), Chlamydophila pneumoniae (CP), Legionella pneumophila (LP), Haemophilus influenzae (HI), Streptococcus pneumoniae (SP), Bordetella pertussis (BP) and Bordetella parapertussis (BPP)

Adults: Immunocompromised patients with acute respiratory illness e.g. Haematology patients, solid organ transplants, Immunology patients. Paediatrics: Immunocompromised patients (as above); moderate-severe viral exacerbations of chronic airways disease (e.g. asthma, CF).

NB Clinical picture overrides diagnostic testing results for isolation and management purposes i.e. Influenza A/B, RSV may be negative; however, patients remain symptomatic and may have Enterovirus which has not been excluded.




4.4 Collection Respiratory Viral Swabs

4.5 Collection of Rapid Viral Swab

http://www.health.nsw.gov.au/Infectious/Influenza/Pages/resp-collection.aspx




4.5.1 Collection using Rapid swab

1. Open the individual collection package that contains the swab and Xpert Viral Transport

Medium tube. Set the tube aside before beginning to collect the specimen. 2. Open the collection swab wrapper by peeling open the top of the wrapper. Remove the

swab, taking care not to touch the tip of the swab or lay it down. 3. Hold the swab in your hand, placing your thumb and forefinger in the middle of the swab

shaft across the scoreline. 4. Gently insert the swab into the nostril. Keep the swab near the septum floor of the nose

while gently pushing the swab into the post nasopharynx. 5. As a visual reference, the swab should be inserted about half the distance from the opening

of the patient’s nostril and the ear. Rotate the swab several times 6. While holding the swab in the same hand, aseptically remove the cap from the tube. Insert

the swab into the tube with the transport medium. 7. Identifying the scoreline, break the swab shaft against the side of the tube. If needed, gently

rotate the swab shaft to complete the breakage. Discard the top portion of the swab shaft. Avoid splashing contents on the skin. Wash with soap and water if exposed.

8. Replace the cap onto the tube and close tightly. Send immediately to pathology




4.6 Ordering Rapid swab on EMR • Clinician to Order Rapid Influenza and RSV PCR** on EMR

**Clinicians who order a rapid swab can add further panel testing by free texting “Respiratory Virus Screen multiplex” on request form prior to sending specimen to lab. An additional green tip swab does not need to be sent.

• Rapid Influenza/RSV testing of nasopharyngeal swabs may be most appropriate in high risk patients where an urgent result is required (within one to four hours). This could include*: • patients with severe respiratory infection requiring admission to hospital or patients

requiring non-invasive ventilation

• vulnerable groups of patients with respiratory illnesses (transplant patients, other immunocompromised patients, patients with serious comorbidities)

• ICU patients with flu-like symptoms

• Inpatients with symptoms suggestive of influenza e.g. oncology, geriatric, paediatric patients.

• Institutional outbreaks as directed by the Public Health Unit or infection control units and for contacts of patients diagnosed with influenza

4.7 Collection of Serology • In general, serology is of limited value in the diagnosis of acute respiratory

illness. Consultation with the infectious diseases team, the Microbiology laboratory or the Serology and Virology Division laboratories (SAViD) at SEALS is recommended.




5. Contacts of Case Manage as per Table 2- Summary of contact screening requirements.

Table 2 - Summary of Contact Screening Requirements

Virus Incubation (days)

Infectious period (days)

Contact tracing yes/no

Management

Influenza A & B

1-2

Normal host 3-5 Yes Monitor temperature 4/24 for 72 hours.

Isolate if becomes symptomatic with droplet precautions Consider Antivirals for Influenza A and B contacts if necessary in particular for the at risk groups as per Influenza Control Guidelines or advice from Infectious Diseases team. RSV- Contact Infectious Diseases for advice

Immunocompromised >10

Yes

Parainfluenza 2

Normal host 3-5 No Immunocompromised >10

Yes

Respiratory Syncytial Virus

2

Normal host 3-5 No

Immunocompromised >10

Yes

Human metapneumovirus

3-5

Normal host- variable No

Immunocompromised- variable

Yes



Contact tracing yes/no

Management

Rhinovirus

½-3

Normal host- variable No

In the event of an outbreak, monitor patient’s temperature 4/24 for 72 hours.

Isolate if become symptomatic with droplet precautions.

Immunocompromised- variable

No, unless outbreak

Coronavirus Variable

Normal host- variable No Immunocompromised- variable

No, unless outbreak

Bocavirus 7-13


No, unless outbreak

Adenovirus Variable


No, unless outbreak

Enterovirus Variable


No, unless outbreak

Polyomaviruses Wu Ki

3-10


No, unless outbreak

https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/influenza.aspx





6. Infectious Periods/ and Clearance

Table 3: Infectious period from onset of symptoms for isolation requirements NB: If patient has been febrile, then must be afebrile 24 hours prior to de-isolation. Not everyone with influenza or other respiratory virus will have a fever.



De-isolation in days (if afebrile for 24 hours prior) Antiviral No antiviral

Influenza A & B

1-2

Normal host 3-5 3 5 Immunocompromised >10 7 10

Parainfluenza

2

Normal host 3-5 n/a 5 Immunocompromised >10 n/a 7

Respiratory Syncytial Virus

2

Normal host 3-5 n/a 5 Immunocompromised >10 7 7

Human Metapneumovirus

3-5

Normal host- variable n/a 5

Immunocompromised - variable n/a 7

Rhinovirus

½-3

Normal host- variable n/a 3 Immunocompromised - variable n/a 5

Coronavirus

Variable

Normal host- variable n/a 3

Immunocompromised - variable n/a 5

Bocavirus

7-13

Normal host- variable n/a Consult with

ID/ Infection Control Immunocompromised -

variable Adenovirus

Variable

Normal host- variable n/a

Consult with ID/ Infection

Control Immunocompromised - variable

Enterovirus

3-10




Polyomaviruses Wu Ki

Variable







7. Cohorting when Isolation needs exceed availability of single rooms • Only same viruses can be cohorted together. Refer to Appendix 2

Table 4: Isolation Requirements - Droplet Precautions

Requirements Droplet Precautions Single room Yes with ensuite facilities or dedicated bathroom or cohort with patient(s) with

same microorganism and maintain greater than one metre separation. Clear visible signage of precautions required.

Negative pressure No

Hand hygiene Yes Hand Hygiene with alcohol based hand rub or liquid soap and water. Five Moments of hand hygiene for patient care (Clean In – Clean Out)

Gloves Yes for anticipated contact with blood and body substances.

Apron/Gown Yes, if soiling or splashing are likely. Remove before leaving patient’s room.

Protective eyewear/goggles

Yes, if patient coughing, sneezing or aerosol producing procedure.

Mask Yes, Surgical. P2/N95 mask (only if aerosol producing procedure). Remove last after leaving patient’s room. Perform hand hygiene.

Patient care equipment

Clean / process before next patient as per SESLHDGL/029 Infection Control: Cleaning (Shared) Patient Care Equipment Guideline

Transport of patients

Surgical mask for patient when they leave the room. Patients on nasal prongs can have a surgical mask over the top of the nasal prongs. Patients to be provided an opportunity to perform hand hygiene prior to transport. Limit transfer to other wards/facilities. Notify area receiving patient and transport staff of precautions to be maintained.

Room cleaning Refer to Table of Infectious Diseases, Modes of Transmission and Recommended Precautions for Staff and Patients to Prevent Transmission (Appendix of SESLHDPR/357 Standard and Transmission Based (Additional) Precautions with Infectious Diseases)

Education Provide NSW Health Influenza Fact Sheet

8 TREATMENT

• There are limited treatment options for patients with respiratory viruses. Patients with confirmed influenza A or B may benefit from treatment with a neuraminidase inhibitor. This should be administered within 48 hours of symptoms developing in order to be effective. In some situations treatment of RSV infections is indicated, although this is highly specific to certain groups of immunocompromised patients (eg lung transplant recipients).

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Infection_Control/default.asp






http://www.health.nsw.gov.au/Infectious/factsheets/Pages/influenza_factsheet.aspx




• The use of antiviral drugs for contacts should occur as per Influenza Control Guidelines, or as per assessment by treating teams and infectious diseases clinicians

• The use of antiviral drugs for respiratory viruses should be discussed with the Infectious Diseases or Respiratory Teams. Antivirals are restricted antimicrobials and approval on GuidanceMS must be obtained prior to administration.

• Influenza virus antivirals (neuraminidase inhibitors Zanamavir – Relenza® or Oseltamivir – Tamiflu®) are not effective against any other viruses apart from influenza A and B.

• Ribavirin may be used to treat RSV.

9. OUTBREAK • If three or more cases of respiratory viral disease occur in the same time period in

a ward, or bed unit this must be managed as per SESLHDPR/130 Outbreak Management

10. DOCUMENTATION

• Health Care Records

11. AUDIT

• Annual influenza vaccination rates of healthcare workers. • Outbreak investigation reports, facility Infection Prevention and Control Committee. • Personal Protective Equipment compliance audits from the facility audit program.

12. REFERENCES

• SESLHDPR/277 Influenza Clinics for Seasonal Influenza • SESLHDPR/270 Influenza - Critical Care Escalation and Management • NSW Ministry of Health - Respiratory Collection Information • NSW Ministry of Health Influenza Guidelines • CEC Infection Prevention and Control Practice Handbook • Communicable Diseases Branch. 2018. Influenza Control Guidelines • Centre for Disease Control and Prevention Influenza Case Definition • NSW Ministry of Health - PD2017_013 Infection Prevention and Control Policy • Clinical Excellence Commission Infection Prevention and Control Handbook 2017



http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/a-z/o.asp



https://www.seslhd.health.nsw.gov.au/policies-and-publications/functional-group/64




http://www.health.nsw.gov.au/Infectious/Influenza/Pages/resp-collection.aspx

http://www.health.nsw.gov.au/Infectious/Influenza/Pages/default.aspx

http://www.cec.health.nsw.gov.au/patient-safety-programs/assurance-governance/healthcare-associated-infections/key-documents


https://www.cdc.gov/flu/

https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2017_013

https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/CEC%20Infection-Prevention-and-Control-Practice-Handbook-V2-Updated-1-Sep-2017.pdf




8. REVISION AND APPROVAL HISTORY

Date Revision No. Author and Approval

26 May 2017 Draft Kim Brookes, Executive Sponsor, approved final draft for progression

02 June 2017 Draft Processed by Executive Services prior to submission to CQC

June 2017 0 Approved by Clinical and Quality Council

June 2019 1 Minor review approved by Executive Sponsor. Updated and included cohort flowchart. Updated references to procedures and hyperlinks and definitions. Removed Appendix 2, Respiratory Viral Illness Risk Matrix. Updated treatment to include use of Ribavirin to treat RSV.

July 2019 1 Tabled at July 2019 Quality Use of Medicines Committees (QUMC) for approval to publish.

July 2019 1 Approved by Quality Use of Medicines Committee. Procedure published.




Appendix 1: Flowchart for Management of Influenza-like Illness (ILI)




Appendix 2: Isolation of Viral Respiratory Illness/ Cohorting same viral illness