1 - CIDRAP



Clinical care

The algorithms and protocols that follow are designed to be used by health care staff or others who will be undertaking the initial triage and by staff designated to the care of specific groups in the community. It is assumed that there will be an unprecedented number of individuals requiring care and the plan is designed to evaluate the needs of individuals so that they receive optimum care with the resources available.

The health care management systems developed are for the following groups:

• Adults (Healthy senior adults living independently in the community can be evaluated as per adults although those over the age of 65 should be closely monitored as they are at increased risk of complications

• Children

• Pregnant women

• Individuals in nursing or care homes

Management of Adults with Pandemic Influenza

Patient Care Pathway

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Patient Care Pathway Glossary

|Terminology |Definition |

|Non Flu Area |An area set aside for the examination and treatment of patients|

| |without flu like symptoms |

|Telephone Triage |Assessment of patient symptoms as given over the telephone to |

| |an experienced operator working from a pre-defined proforma |

|Home Assessment Team |A team of clinicians with the ability to undertake home |

| |assessment of patients who fall outside the patient group |

| |directive for the prescription of antiviral medication. This |

| |team may be made up of either primary or secondary care |

| |clinicians according to circumstance. |

|Rapid Response Team |A team of clinicians or ambulance paramedics who would be able |

| |to undertake a more involved assessment of patients who |

| |deteriorate rapidly in the hours subsequent to telephone triage|

| |or home assessment. |

|Sub Acute Care Facility |A care facility able to support those that cannot support |

| |themselves or rely upon the support of family in the home. The |

| |use of sub acute care facilities may also allow a more early |

| |hospital discharge to enable increased bed capacity for the |

| |acutely ill. |

|Secondary Care Assessment |Assessment in the hospital environment |

|Patient Group Direction (PGD) |A PGD is a written instruction for the supply and / or |

| |administration of a named medicine in an identified clinical |

| |situation. |

Complications of Influenza

Respiratory:

• Lower respiratory tract complications are found in 10% of 5-50 year olds. 75% after 70years of age

• Upper respiratory: Otitis Media, sinusitis, conjunctivitis

• Croup

• Bronchiolitis

• Bronchitis

• Pneumonia – 1° viral 2° bacterial Combined

• Complications of pre-existing disease

Cardiovascular:

• Pericarditis

• Myocarditis

• Complication of pre-existing disease

Muscular:

• Rhabdomyositis

• Rhabdomyolisis with myoglobinaemia and renal failure

Neurologic:

• Encephalitis

• Reyes syndrome

• Guillan Barré syndrome

• Transverse myelitis

Systemic:

• Toxic shock

• Sudden Death

Criteria for secondary care assessment:

• Temp - 35˚C or > 39˚C

• Pulse - new irregular beat or > 100/min

• BP - 100 systolic. Dizziness on standing

• Respiratory Rate - > 24/minute (tachypnoea)

• Chest pain/symptoms – any abnormality on auscultation/chest pain

• Mental State – new confusion

• O2 saturation - 90% room air

• Vomiting if very young or very old (> 3 episodes in 24 hours)

These criteria were agreed by local clinicians; however, they differ from BTS admission criteria in that in the BTS guidelines the Respiratory Rate for secondary care assessment is 30/min in adults.

Home Care:

• Paracetamol/Ibuprofen

• Fluids (hot fluids)

• Bed rest

• Decongestants

SEEK HELP IF:

• Increasing shortness of breath

• New pleuritic chest pain

• New purulent sputum

• Persistent vomiting

Co-Morbidity

• >65 years

• pregnancy (second and third trimester)

• Chronic lung disease (asthma, bronchitis, bronchiectasis, emphysema, cystic fibrosis)

• Congestive cardiac failure

• Renal failure

• Immunosuppression (AIDs, transplant recipient)

• Haematological abnormalities (anaemia, haemoglobinopathies, oncological disorders)

• Diabetes

• Hepatic disease, cirrhosis

• Patients on long-term acetylsalicylic acid therapy (for rheumatoid arthritis/ acute rheumatic fever/other)

Management of Children with Pandemic Influenza

Of all population groups children have the highest attack rate for influenza and are the major disseminators of the virus1. Children aged 6-12 months have the highest attack rates in seasonal influenza due to the waning of maternal antibodies2,3. Although uncomplicated influenza in children may be similar to the disease in adults there are significant age related differences in toddlers and infants. Symptoms in young children are such that in the normal course of events general practitioners would refer some of these young children to hospital for assessment or admission. Antiviral medication can only be prescribed to those under 23kg (7 years approximately) by a doctor. As a consequence all children under 7 years of age will need to be assessed by a doctor.

Because of the high demand for hospital paediatric beds during the pandemic period it is proposed by the clinicians in RCT that further paediatric assessment could be provided, if required by general practitioners, in a dedicated outpatient department. This would prevent ill symptomatic children from waiting in A&E or being sent directly to the paediatric wards. The possibility of using community paediatric teams to assess the children at home was discussed but was felt to be impracticable due to the scarce expertise available.

Estimating influenza hospitalisations in children

It is difficult to derive accurate population-based estimates of disease impact for children although it is recognised that influenza causes more hospitalisations and deaths among children in the developed world than any other vaccine preventable disease. Recent research, a capture-recapture study, estimated the hospitalisation rate in children under 5 years of age as being 2.4 per thousand (95% confidence interval 1.8-3.8)4. The rate varied according to age, children < 6 months of age had the highest hospitalisation rate, 9.1 per 1,000 children, followed by children 6-23 months of age with 3.0 hospitalisations per 1,000 children.

Symptoms of Influenza in Young Children

There is uncertainty as to how any new influenza virus causing a pandemic will affect children – but we know that:

• young children usually develop higher temperatures than adolescents and adults and often have febrile convulsions4,5

• in neonates and infants unexplained fever may be the only indication of influenza4,5

• Influenza is a common cause of croup, pneumonia, pharyngitis and bronchitis in young children

• 40% - 50% of those aged 3 years and under will present with gastrointestinal symptoms2,6

• In young children otitis media and non-purulent conjunctivitis is common

• 20% of infants will present with neurological symptoms – some of which will be suggestive of meningitis

• In children aged 5 years and over the most frequent symptoms are fever, cough, headache, chills, myalgia and sneezing

Table H2 - Symptom checklist for children aged 4 years and under

|Systemic |Respiratory |Non Respiratory |

|Fever > 38˚C (may fit) |Cough |Not playing |

|Apnoea |Nasal congestion |Low energy/lethargic |

| |Difficulty breathing |Poor feeding |

| |Fast Breathing* |Vomiting and diarrhoea |

| |Hoarse |Irritability/crying excessively |

| |Earache |photobia |

| | |meningism |

* Fast breathing:

• < 2 months = RR > 60/min

• 2-12 months = RR > 50/min

• 12-5 years = RR > 40/min

• > 5 years = RR > 30/min

Danger signs in children from 2 months to 4 years

• Difficulty breathing – not caused by nasal congestion

• Cyanosis – or sudden pallor

• unable to breast feed or drink

• continuous vomiting

• lethargic / seems confused

• convulsions

• has a full/sunken fontanelle

• photobia, stiff neck

Danger sign in children < 2 months

• stopped feeding well ( less than half normal feeds)

Paediatric Care Pathway

References

1. Simonsen L The global impact of influenza on morbidity and mortality. Vaccine 17 Suppl 1:S3-10.1999

2. Ryan-Poirier KA. Influenza virus infection in children. Adv Pediatr Infect Dis 1995 10:125-156

3. Giezen WP, Taber LH, Frank AL, Gruber WC, and Piedra PA. Influenza virus infection in the first year of life. Pediatr Infect Dis 1997; 11:1065 – 1068

4. Murphy BR and RG Webster. Orthomyxoviruses. , p 1397-1445. In: Fields Virology., 3rd edition, volume 1.

5. Giezen WP, Payne AA, Nelson Snyder D and Downs TD. Mortality and influenza. J Infect Dis 1982; 146:313-321

6. Paisley JW, Bruhn FW, Lauer BA and McIntosh K. Type 2 influenza in children Am J Dis Child 1978; 132:34-36

Management of Pregnant Women with Pandemic Influenza

Women with influenza infection in their second and third trimesters of pregnancy are at increased risk of hospitalization for cardio-respiratory disorders. This is probably due to the increase in heart rate, stroke volume, and oxygen consumption observed in these months, as well as to decreases in lung capacity and changes in immunological function.

Fatal influenza in pregnant women is characterized by the rapid development of cardiovascular and/or pulmonary insufficiency after several days of classical ILI. Fulminating viral or bacterial pneumonia may follow the initial viral infection. Although pregnant women do not get pneumonia more often than non-pregnant women it can cause greater resulting mortality because of physiological adaptation1

The three pandemics of last century have provided valuable information on the impact of pandemic virus on pregnant women. An increase in mortality of pregnant women, miscarriages, premature births and stillbirths was documented during the 1918-1919 and the 1957-1958 pandemics. The reported mortality rate of pregnant women admitted to hospital with influenza in 1918 was 51.4% compared with 33.3% in hospitalized influenza patients from the general population. Mortality rates among these hospitalized women were higher if pneumonia was present, with a peak at 61% during the last month of gestation. Influenza deaths in pregnant women represented 50% of all deaths in women of childbearing age, and 10% of deaths from influenza during the epidemics of 1957-1958 in New York City and Minnesota. In the 1957 – 1988 (H2N2) –.50% of the women of childbearing age who died were pregnant2.

Case reports and limited studies also indicate that pregnancy can increase the risk for serious medical complications of influenza3 A study of the impact of influenza during interpandemic influenza seasons demonstrated that the relative risk for hospitalization for selective cardiorespiratory conditions among pregnant women increased from 1.4 during weeks 14-20 of gestation to 4.7 during weeks 37-42 in comparison with women 1-6months post-partum. Women in the third trimester of pregnancy were hospitalized at a rate comparable with that of non-pregnant women with high risk medical conditions.

A recent review of pneumonia in pregnancy has shown that maternal disease, including asthma and anaemia increase the risk of contracting pneumonia. Antiviral and respiratory therapies can reduce morbidity and mortality from viral pneumonia and ITU management of respiratory compromise can reduce mortality rate.

Providing health care to pregnant women during a flu pandemic.

The aims of this health care pathway are:

• To ensure that all pregnant women understand the signs and symptoms of flu and measures that they can take to minimise exposure to the virus

• To limit exposure of women to the pandemic virus in high risk occupations

• To ensure systems are in place for early detection of illness and timely administration of antivirals if recommended by physician

• To ensure adequate observation and follow up in the community that allows for early detection of deterioration of health

• To ensure obstetric services have plans in place for

o Admission to “flu”areas of obstetric units where segregation from other obstetric inpatients can be assured

o Critical care support

o Operating theaters

o Paediatric support

To provide optimum care for pregnant women in community midwife can plays a central role. Each midwife couldl carry a case load of pregnant women for whom she will be first point of contact if symptoms of flu develop. Home assessment can then be undertaken by the midwife and antiviral therapy commenced by agreement with GP. While symptoms persist daily home visits will be undertaken and the general practitioner will be contacted in the first instance if the patient deteriorates. Hospital admission will be by agreement with the obstetric unit and to an agreed protocol.

Care Pathway

References

1. Goodnight W.H, Soper E.D. Pneumonia in Pregnancy, Crit. Care Med 205:33: (10 Suppl);S390-71

2. Glezan P et al Clin Infect Diss 1999;28:219-224

3. Prevention & Control of Influenza MMWR; 2003/52(RR08);1-36

Management of Adults in Long Term Care Facilities

Excess hospitalisation and death, and functional decline, occur in elderly individuals after epidemics of influenza. Because of their age and underlying medical conditions most frail elderly individuals living in long-term care institutions are at increased risk of influenza complications.

Influenza pneumonia and bacterial pneumonia following influenza are considered the main causes of influenza related hospitalisations in the elderly. In addition influenza may result in exacerbation of chronic obstructive pulmonary disease or congestive cardiac failure following the viral infection.

The symptoms and signs in the elderly are similar to those in younger individuals, but most cases are characterised by the presence of breathlessness, wheezing, sputum production and temperatures of >38˚C. Any acute deterioration in health status associated with fever may be a manifestation of influenza infection in elderly individuals.

Projecting the impact:

In influenza pandemic with an overall clinical attack rate of 25% the clinical attack rate in closed institutions is likely to be higher.

During outbreaks of influenza in hospital and nursing homes the attack rate (residents and workers) may be as high as 70%.

Surveillance

The early detection of influenza in the care home is crucial. Microbiological tests (bacterial and virologic) may be required depending on the clinical presentation and the resources available. Once the presence of the pandemic strain has been identified in the home further virology testing would be unnecessary and would be required only for diagnostic purposes in atypical cases.

Clinical Care

The aim of this care pathway is to manage patients within the care homes without transferring them to an acute care home. This will require the home designating an area for more acute care where more intensive monitoring can be undertaken and where parenteral therapy and oxygen therapy can be given. To achieve this all homes will have to be supported in developing policies and to support management of patients and personnel. Policies should be developed in partnership with primary and secondary care.

Seasonal flu epidemics are ideal for developing such policies and testing their efficacy. If effective the plans could operate during seasonal flu epidemics or on the occasions in the winter season when there may be pressure on availability of acute hospital beds.

The policies and training provided should include:

• A policy for the management of influenza outbreaks in the home

o To prevent influenza illness and complications in residents and staff

o To provide for timely diagnosis and appropriate management of influenza infection in patients

o To provide for timely diagnosis and management of an influenza outbreak in the care home

o To provide care for ill residents within the care home without transfer to another facility

• A plan for the designation of an “acute” ‘flu area

• A training programme for staff

o Signs and symptoms of flu

o Respiratory etiquette and hand hygiene

o Personal risk and infection control practice

o Parenteral therapy and oxygen therapy

o Management of infectious patients

o Prevention/delay of virus entry into the facility

o Monitoring patients for pandemic influenza and instituting appropriate control measures including transfer of patients to acute services for other acute illness

o Management of infectious patients

o Management of patient-care equipment

o Disposal of waste

o Linen and laundry

o Dishes and eating utensils

All sections in the training programme are covered in the Infection Control Chapter with the exception of parenteral therapy and oxygen therapy. Not all care homes will be able to provide care for ill residents unless supported by external nursing support. Primary care and acute medical services need to agree how best this element of care in the community will be supported.

Diagnosis and Management

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Pandemic Influenza: Health and Social Service Planning for Wales:

Clinical Care

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