Influenza and Respiratory Illness Management Procedure



Canberra Health ServicesClinical Procedure Influenza and Respiratory Illnesses Management - Adults and ChildrenContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc528914094 \h 1Purpose PAGEREF _Toc528914095 \h 3Alerts PAGEREF _Toc528914096 \h 3Scope PAGEREF _Toc528914097 \h 3Section 1 – Background Information: Influenza (including Seasonal, Pandemic and Avian) PAGEREF _Toc528914098 \h 3Clinical Feature PAGEREF _Toc528914099 \h 3Symptoms PAGEREF _Toc528914100 \h 3Complications/Risks PAGEREF _Toc528914101 \h 4Infectious Agent PAGEREF _Toc528914102 \h 4Reservoir PAGEREF _Toc528914103 \h 4Mode of Transmission PAGEREF _Toc528914104 \h 4Incubation period PAGEREF _Toc528914105 \h 4Period of Communicability PAGEREF _Toc528914106 \h 5Section 2 – Measures to prevent the spread of Influenza PAGEREF _Toc528914107 \h 5Section 3 – Initial management, assessment and testing of a patient with suspected Influenza PAGEREF _Toc528914108 \h 5Swab Collection Procedure PAGEREF _Toc528914109 \h 6Performing the swab PAGEREF _Toc528914110 \h 6Section 4 – Management of an inpatient with suspected or confirmed Influenza and respiratory illnesses PAGEREF _Toc528914111 \h 8Laboratory confirmed Influenza – Contact Infection Prevention and Control PAGEREF _Toc528914112 \h 9Other respiratory viruses PAGEREF _Toc528914113 \h 9For Paediatric Patients PAGEREF _Toc528914114 \h 10Nasopharyngeal Aspirate Procedure PAGEREF _Toc528914115 \h 10Section 5 – Management of a patient requiring contact tracing PAGEREF _Toc528914116 \h 10Implementation PAGEREF _Toc528914117 \h 11Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc528914118 \h 11References PAGEREF _Toc528914119 \h 11Definition of Terms PAGEREF _Toc528914120 \h 13Search Terms PAGEREF _Toc528914121 \h 13Attachments PAGEREF _Toc528914122 \h 14Attachment 1 – Bed allocation for Adult Patients with Suspected Influenza PAGEREF _Toc528914123 \h 15Attachment 2 – Bed Allocation for Paediatrics PAGEREF _Toc528914124 \h 16Attachment 3 – Contact Tracing Flowchart PAGEREF _Toc528914125 \h 17PurposeThe 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 ContentsAlertsFor 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.Back to Table of ContentsScopeThis procedure applies to all CHS staff working within their scope of practice including students and trainees undertaking clinical placement.Back to Table of ContentsSection 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 sweatsMuscle and joint aches and painsExhaustion/lethargyHeadacheLight sensitivityFrequent coughingSneezingSore throatChest painsGastro 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 AgentTwo 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 pandemicsAvian 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. ReservoirHumans are the primary reservoir for human influenza virusesAquatic birds are the natural reservoir for subtypes of type A Influenza and these can infect a range of mammalsPigs are the reservoir for swine influenza.Mode of TransmissionAerosolised 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 hoursAvian 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. Back to Table of Contents Section 2 – Measures to prevent the spread of InfluenzaAnnual 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 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 siteThe time from vaccination to protective antibody response is approximately 2 weeksAvian Influenza prevention includes avoidance of sick birds and their faeces, good personal hygiene and antiviral therapy if exposed. Back to Table of Contents Section 3 – Initial management, assessment and testing of a patient with suspected InfluenzaAssessment 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).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/clientEnsure the area is well lit and that hand washing facilities or alcohol based hand rub and appropriate infectious waste disposal facilities area availableRemember 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 swabsMasks 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 onlyGloves, gowns and masks should be disposed of in an infectious waste bag.Obtain required materialsPersonal 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 SwabPerforming the swabPreparation by Health Care Worker:Explain the procedure to the patient and obtain consentPerform hand hygieneDon PPE in the order of gown, surgical mask, eye protection, and glovesPlace patient standing or sitting with head resting supported against a supporting surfaceImage 3: Note depth of swabImage 4: Agitate container to mix fluid with viral swabNasopharyngeal/Deep nasal swab procedure:A nasopharyngeal flocked swab is the preferred specimen, followed by a deep nasal swab, to ensure adequate cellular material containing virusStand 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 noseMeasure the distance from the tip of the nose to the ear canal, then halve this distance to ensure the swab is inserted safelyInsert 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 nasopharynxRotate 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 swabStand at the side of the patient’s head and ensure their head is resting against a wall or supporting surfacePlace your non-dominant hand on the patient’s foreheadAsk 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 salivaInsert a red-top flocked swab into the mouth, avoiding any salivaPlace lateral pressure on the swab using a tongue depressor in order to collect cells from the tonsillar fossa at the side of the pharynxRotate 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 informationLabel 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 facilityRemove PPE in order as follows: remove gloves, perform hand hygiene, remove goggles or face shield, gown and mask. Then perform hand hygiene againRefrigerate 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.Back to Table of Contents Section 4 – Management of an inpatient with suspected or confirmed Influenza and respiratory illnessesRefer 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.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 ControlPlace hospitalised patient in Droplet precautions with the door closed where possible.Staff and visitors are to wear a surgical maskHospitalised patient’s room and environment should be cleaned daily and receive an infectious discharge cleanIf 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. 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 apartThis 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 cohortedPatients 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. Back to Table of Contents Section 5 – Management of a patient requiring contact tracingContact 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 , 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.Back to Table of Contents 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. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationProceduresAustralian Immunisation Handbook, 10th Edition, 2013 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 GuidelineSydney Children’s Hospital Nasopharyngeal Aspirate ProcedureCHHS – 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 2015Back to Table of ContentsReferencesAll documented information has been aligned against the National Safety and Quality Health Service (NSQHS) Standards actions list for Healthcare Acquired Infections (HAI).ACT Health, Reporting Of Notifiable Conditions Code Of Practice 2017, CHHS18/119 Paediatrics - Acute Management of Bronchiolitis Clinical Practice Guideline, Paediatrics - Acute Management of Bronchiolitis Clinical Practice Guideline.docxCommunicable Diseases Network Australia, Series of National Guidelines – Hepatitis A, Measles, Pertussis, Avian Influenza, Legionellosis (Accessed November 2018)Health Protection Services, Communicable Disease Control Poisons and Therapeutic Goods Act 2008 Health Act (1997) to Table of ContentsDefinition 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 illnessInfectious 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 drugPandemic: 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 coughPPE: 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.Back to Table of ContentsSearch Terms Influenza, Flu, Children, cohorting, Emergency Department, Infection Control, Paediatrics, Respiratory, Bronchiolitis, Influenza like illness, contact tracingBack to Table of ContentsAttachmentsAttachment 1 – Management of Patients with Suspected InfluenzaAttachment 2 – Bed Allocations for PaediatricsAttachment 3 – Contact Tracing FlowchartDisclaimer: 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 AmendedSection AmendedDivisional ApprovalFinal Approval 17 December 2018Updated changes to whole document ED CSSCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS16/078Influenza and Respiratory Illness Management ProcedureAttachment 1 – Bed allocation for Adult Patients with Suspected InfluenzaList 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 therapyOther underlying conditionsWhile acknowledging that pregnancy is not a co-morbid condition, pregnant women are to be managed as those in List 1.Attachment 2 – Bed Allocation for PaediatricsAttachment 3 – Contact Tracing Flowchart ................
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