TRUST POLICY AND PROCEDURES FOR THE MANAGEMENT OF INFLUENZA (FLU)

Transcription

1 TRUST POLICY AND PROCEDURES FOR THE MANAGEMENT OF INFLUENZA (FLU) Reference Number CL-RM Version 2.1 Status Final Author: Helen Forrest Job Title Lead Nurse - Infection Prevention and Control Version / Amendment History Version Date Author Reason 2 December October 2014 H. Forrest H. Forrest Update into a influenza policy from a pandemic flu policy Review of policy Intended Recipients: All medical and clinical staff, Associate Directors, Service Managers, Heads of Nursing, Clinical Governance Facilitators, Matrons. Training and Dissemination: Dissemination via the Trust Intranet. Annual infection prevention and control update training. To be read in conjunction with: Trust Policy for Standard Infection Control Precautions; Trust Policy and Procedure for Hand Hygiene; Trust Policy for Isolation, Trust policy for cleaning and disinfection, Trust policy and procedure for personal protective equipment In consultation with and Date: Infection Control Operational Group (October 2014) Infection Control Committee (October 2014) EIRA stage one Completed Yes Stage two Completed N/A Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Infection Control Committee Date of Issue November 2014 Review Date and Frequency December 2017 Management of Influenza Policy 1

2 Contact for Review Executive Lead Signature Approving Executive Signature Lead Nurse Infection Prevention and Control Director of Patient Experience and Chief NurseChief Nurse Director of Patient Experience and Chief Nurse Management of Influenza Policy 2

3 Contents Section 1 Introduction 2 Purpose and Outcomes 3 Definitions Used 4 Key Responsibilities / Duties 5 Managing the Policy and Procedures for Influenza 5.1 Routes of Transmission 5.2 Incubation and Communicability 5.3 Risk Factors 5.4 Initial Identification 5.5 Diagnostic Investigations How to Take a Flu Swab 5.6 Treatment and Prophylaxis 5.7 Infection Prevention and Control Measures General Control Measures Isolation Patient Transportation Hand Hygiene Personal Protective Equipment (PPE) 5.8 Infectious and Non-Infectious Waste 5.9 Linen and Laundry 5.10 Crockery and Utensils 5.11 Environmental Cleaning 5.12 Visitors 5.13 Last Offices Management of Influenza Policy 3

4 Section 6 Monitoring Compliance and Effectiveness 7 References Management of Influenza Policy 4

5 TRUST POLICY AND PROCEDURES FOR THE MANAGEMENT OF INFLUENZA 1 Introduction Influenza, or flu is a respiratory illness caused by the influenza virus. The symptoms frequently include headache, fever, cough, headache, sore throat, aching muscles and joints. Influenza occurs most often in winter and usually peaks, in the Northern Hemisphere, between December and March, affecting many thousands of people in the UK. The symptoms of influenza range from a common cold, through to severe or even fatal disease. It brings about variable effects in successive winters and can cause intense pressure on health and social care services. Influenza virus is species specific. The influenza viruses that affect animals and birds do not infect humans readily unless the virus undergoes recombination in other hosts. This makes the virus unstable and is why new strains are constantly emerging. There are three main clinical forms of influenza: 1. Seasonal Influenza Seasonal influenza occurs on an annual basis and is particularly common during the winter period. Every year human strains of influenza circulate, giving rise to clinical cases which may require hospital admission. Treatment may be required due to the direct effects of influenza virus infection or its possible complications, most commonly secondary bacterial pneumonia. Certain patient groups are particularly vulnerable to influenza, including the elderly, those with chronic respiratory disease (including asthma), chronic heart disease and chronic renal disease, chronic liver disease, diabetes and immunosuppression and those in long term nursing or residential care, or pregnant ladies. 2. Pandemic Influenza Pandemic influenza occurs when a new influenza virus subtype emerges that is markedly different from recent circulating subtypes and strains and is able to; - Infect humans of all ages, including healthy young adults. - Spread efficiently from person to person - Cause significant clinical illness in a high proportion of those infected. 3. Avian Influenza Avian influenza is a disease of birds caused by an influenza virus closely related to human influenza viruses. Transmission to humans in close contact with poultry or other birds occurs rarely and only with Management of Influenza Policy 5

6 certain strains. However, a large epidemic in birds increases the chance for genetic exchange and opportunities to infect humans. The potential for transmission of avian influenza into a form that causes disease in humans and spreads easily from person to person is a great concern for world health and would provide conditions for the start of a pandemic. Because the virus is novel in humans a high proportion of the population will have little or no immunity, producing a large pool of susceptible people, allowing the disease to spread widely and rapidly. 2 Purpose and Outcomes This policy applies to all staff in the Trust, including contracted service providers. The purpose of this policy is to: - Ensure that patients with influenza receive effective and appropriate care - Minimise the risk of transmission of influenza to patients, staff and visitors. 3 Definitions Used Influenza Pandemic Epidemic Incubation Period Influenza Virus Subtypes Aerosol Generating Procedures Direct Contact Transmission Indirect Contact Transmission Fomite A highly contagious viral infection that affects the respiratory system. An epidemic so widely spread across continents, that vast numbers of people in different countries are affected. A sudden outbreak of infectious disease that spreads rapidly through the population, affecting a large number of people. The interval between exposure to an infection and the appearance of the first symptom. There are 3 types of the influenza virus, A, B and C. Only influenza A has subtypes. Procedures that stimulate coughing and promote the generation of small particles capable of being suspended in the air. A transmission mechanism in which the infectious agent is transferred directly into the body via touching, biting, kissing, sexual intercourse or by droplets entering the eye, nose or mouth A transmission mechanism in which the infectious agent is transferred to the person by a fomite or vector An inanimate object or substance that is capable of transmitting infectious organisms from one individual to another. Management of Influenza Policy 6

7 Incubation Period Period of Communicability The time between exposure to an infectious disease and the appearance of the first signs or symptoms The time period over which an infected person can spread the infection to someone else 4 Key Responsibilities / Duties 4.1Director of Infection Prevention and Control Will provide clinical leadership and strategic direction on the management of Influenza within the organisation. Will include Influenza data in the annual Infection Prevention and Control report. Will organise and chair any relevant outbreak control meetings. 4.2 Infection Control Committee Will endorse the Influenza policy and agree any amendments to the policy as decided following any post outbreak review. Will receive reports following an Influenza outbreak and agree and monitor any relevant action plans developed. 4.3 Public Health England (PHE) Will support and advise the Trust on National and Regional guidance in relation to flu activity and precautions to be taken. Will advise on treatment guidelines. 4.4 The Occupational Health Department Will support and advise the Trust on the management of infected staff. Will co-ordinate the annual staff vaccination programme. 4.5 The Consultant Microbiologist / Infection Control Doctor Will advise medical staff on the investigation and treatment of a pandemic / suspected flu case. Will advise on specimen collection and testing requirements. 4.6 Microbiology Laboratory Will ensure relevant swabs are sent to the reference laboratory for testing Will inform the infection prevention and control team of influenza results 4.6 Medical Staff Will liaise with the Consultant Microbiologist / Infection Control Doctor regarding the continuing treatment of a patient suspected or confirmed as having influenza, as required. 4.7 Matrons/Clinical Leads / Sister / Charge Nurses Will ensure all staff are aware of and adhere to this policy. Management of Influenza Policy 7

8 Are responsible for ensuring adequate stock levels of appropriate personal protective equipment (PPE) are available in clinical areas. Inform the Infection Prevention and Control Team of any patient known or suspected of having an influenza infection. Provide visitors with the relevant information and ensure they are instructed in infection prevention and control procedures 4.8 Individual Employees Are responsible for ensuring their own practice complies with this policy and for encouraging others to do so. Are responsible for identifying and escalating if there are issues with availability of PPE. Will liaise with the infection prevention and control team to ensure all patient known of suspected influenza patients are cared for in the appropriate environment Provide visitors with the relevant information and ensure they are instructed in infection prevention and control procedures 4.9 The Infection Prevention and Control Team Will advise all relevant groups of staff on infection prevention and control precautions. 5 Managing the Policy and Procedures for Influenza 5.1 Routes of Transmission The pathogens that cause influenza are spread through one or more of four main routes: 1. Droplet Transmission Droplets greater than 5 microns in size may be generated from the respiratory tract during coughing, sneezing or talking. If droplets from an infected person come into contact with the mucous membranes of the mouth or nose, or surface of the eye they can cause infection. These droplets remain in the air for a short time and travel about 1 metre, so closeness is required for transmission. 2. The Airborne Route During and after Aerosol Generating Procedures Aerosol generating procedures can produce droplets less than 5 micron in size. These small droplets can remain in the air, travel more than one metre from the source and still be infectious, either by inhalation or mucous membrane contact. 3. Direct Contact Transmission Infectious agents are passed directly from an infected person (for example after coughing into their hands) to a recipient who then transfers the organism into their mouth, nose or eyes. Management of Influenza Policy 8

9 4. Indirect Contact Transmission This takes place when a recipient has contact with a contaminated object, such as bedding, furniture or equipment which is in the environment of an infected person. The recipient transfers the organism into their mouth, nose or eyes. 5.2 Incubation and Communicability Incubation Period The time between exposure to the influenza virus and developing symptoms is usually 2-3 days, but can range from 1-4 days Period of Communicability The period of communicability is 3-7 days, or until the patient is no longer symptomatic. Immunocompromised individuals and the seriously ill may remain infectious for a much longer period. Adults can be infectious from 24 hours before symptoms begin through to about 5 days after illness onset. Children may be infectious for 24 hours prior to the onset of symptoms to around 7 days. Severely immunocompromised people can shed the virus for weeks after the onset of illness. 5.3 Risk Factors Some people will be at greater risk of developing complications and becoming more seriously ill, e.g. people with: Chronic lung disease, including asthma Chronic heart disease Chronic Kidney disease Chronic liver disease Chronic Neurological disease Immunosuppression (whether caused by disease or treatment) Diabetes mellitus Pregnant women Young children under 5 years old People aged 65 years and older. 5.4 Initial Identification Early identification and isolation of patients with influenza is important in controlling hospital-based cross-transmission. Clinical features of influenza include: Fever, dry cough with abrupt onset. Headache, sore throat, runny or stuffy nose, aching muscles and joints and extreme tiredness. Management of Influenza Policy 9

10 5.5 Diagnostic Investigations Accurate diagnosis and assessment of the risk of transmission are essential to the management and control of influenza. Other than during an established Pandemic, laboratory confirmation should be obtained. The samples required for the confirmation of infection are nasal and throat swabs How to Take a Flu Swab The person taking the swab should wear a fluid repellent surgical face mask, plastic aprons and gloves. Viral swabs is the viral transport medium used, these can be obtained from pathology reception, Level 5, RDH. Nasal swab collection: Tilt the patient s head back slightly and gently insert the swab along the medial part of the septum, as far as possible. Rotate the swab slightly several times and then remove the swab. Use the same swab for both nostrils Insert the swab into the solution provided with the swab (It may be necessary to break the swab so that it fits inside the tube). Throat swab collection: Using the swab provided rub only the posterior pharyngeal wall. Use the same swab for both sides. Insert the swab into the same solution as the nasal swab Label the viral transport medium vial with a patient ID label. Ensure that the request form is completed fully with all patient identifiers. Mark the test section as Influenza viral PCR. Attach a risk of infection sticker. Place the VTM bottle/s into the plastic bag and seal. Dispose of all PPE as routine clinical waste and wash hands thoroughly. Send back the swabs to Pathology Reception at Level 5, which is manned 24 hours. Flu swabs are sent away to a reference laboratory for processing. Specimens received in the micro laboratory before 3pm will have result available within approximately hours. There is no need to wait for a flu swab result if the patient is medically fit for discharge. Management of Influenza Policy 10

11 5.6 Treatment and Prophylaxis Guidance for the prophylaxis and treatment of Influenza can be found on the antibiotic section of the Trust intranet The antibiotic guideline for post influenza bacterial pneumonia can be found in the influenza section of the antibiotic pages on the Trust intranet site. Patients who fall into one of the risk categories for influenza as defined by the Department of Health would usually be offered a seasonal influenza vaccine by their GP. Long stay patients in one of these categories, who are an inpatient for the duration of the vaccination season, and hence are unable to access it from their GP, should be offered an influenza vaccine by the Trust. 5.7 Infection Prevention and Control Measures General Infection Prevention and Control Measures Cover nose and mouth with disposable tissues when sneezing, coughing, wiping and blowing the nose. Dispose of used tissues into nearest lidded appropriate waste bin. Wash hands after coughing, sneezing, using tissues or contact with respiratory secretions and contaminated objects. Keep hands away from mucous membranes of eyes and nose. Certain patients may need assistance with containment of respiratory secretions including provision of tissues, disposal facilities and hand wipes. Some respiratory viruses are excreted in faeces as a general precaution, toilet seats must be down before flushing Isolation All patients with symptomatic influenza must be isolated in a single room, under Respiratory Precautions, (blue door card), according to the Isolation Policy. The isolation room door must be kept closed. The Infection Prevention and Control Team will advise patients to be cared for in a co-hort ward when the number of symptomatic patients dictate this to be necessary. Medical equipment used in an isolation room or co-horted area must not be shared with any other area or used with another patient until it has been appropriately disinfected using 1000ppm av. Chlorine. Portable fans may not be used. The use of portable X-ray machines, ultrasound scanners etc. may be preferable to the patient visiting individual departments. The number of personnel should be limited to those necessary for patient care and support. Management of Influenza Policy 11

12 A sign will be placed at the entrance to a co-horted area alerting all to the precautions to be adopted. Stocks of PPE will be available at entrance to a co-hort area Patient Transportation The movement and transport of patients from their rooms or the cohort area should be limited to essential purposes and only after consultation with the Infection Prevention and Control Team. If transport or movement is necessary a surgical mask should be worn by the patient to minimise dispersal of droplets, until the patient returns to the segregated area. If a surgical mask cannot be tolerated then good respiratory hygiene must be encouraged Hand Hygiene Hands must be decontaminated with soap and water or alcohol based hand disinfectants: Before and after all patient contact or contact with their immediate environment After removing protective clothing After decontaminating equipment Hands must be thoroughly dried after washing hands with soap and water Personal Protective Equipment (PPE) This is worn to protect staff from contamination with body fluids and respiratory secretions to reduce the risk of transmission between patients and other staff. Care in the correct donning and removal of PPE is essential to avoid inadvertent contamination Disposable Gloves Gloves do not routinely need to be worn, unless the healthcare worker is coming into contact with respiratory secretions and blood/body fluids. Gloves are strictly single use and must be changed between patients and disposed of into infectious waste. Hands must be decontaminated after removing gloves Disposable Aprons These are a single use items and should be changed between each patient contact. Full gowns are not necessary for routine care, the exception would be if extensive soiling of clothing or during aerosol generating procedures Masks Basic fluid repellent surgical masks should be worn if within 1 metre of a patient with flu like symptoms. They are simply there to provide a physical barrier to minimise contamination of facial mucosa by large droplets and to prevent touching of noses and mouths. The mask Management of Influenza Policy 12

13 should not be moved on or off the mouth and nose until it needs to be changed. One mask can be worn until it becomes moist and then changed. It does not need to be changed between patients in a cohort area. Handling of the mask should be kept to a minimum Eye Protection Eye protection must be worn if there is a risk of contamination of the eyes by blood or body fluids and during aerosol-generating procedures FFP3 Respirators FFP3 Respirators and eye protection should be worn if there is a risk of contamination of the eyes by blood or body fluids and during aerosolgenerating procedures. Examples of aerosol generating procedures include intubation and related procedures e.g. manual ventilation and suctioning, cardiopulmonary procedures and bronchoscopy. Only essential aerosol generating procedures should be carried out. Wherever possible, aerosol-generating procedures should be performed in well ventilated single rooms with the door shut, with minimal staff present. All staff required to use respirators must be fit tested according to COSHH regulations Fit tests must be carried out by a competent person who has been trained in FIT testing procedures Fit checks must be performed every time the respirators are put on. If breathing becomes difficult, the respirator becomes damaged or distorted or contaminated with body fluids, or if a proper seal cannot be maintained, the wearer should go to a safe area and change the respirator immediately. Entry to co horted area but no patient contact (A) Close patient contact (<1 metre) Aerosol generating procedures (B,C) Hand hygiene Yes Yes Yes Gloves No (D) Yes (E) Yes Plastic Apron No (D) Yes No Gown No No (F,G) Yes (G) Surgical mask Yes Yes No FFP3 respirator No No Yes Eye protection No Risk Assessment Yes Management of Influenza Policy 13

14 A B Standard Infection Control principles apply at all times. Examples of aerosol generating procedures include intubation, nasopharyngeal aspiration, tracheostomy care, chest physiotherapy. C Wherever possible, aerosol-generating procedures should be performed in side rooms or in other closed single patient areas with minimal staff present. D E F G Gloves and aprons should be worn during cleaning procedures. Gloves should be worn in accordance with standard infection control principles. Consider gowns in place of apron if extensive soiling of clothing of contact of skin with blood or other body fluids is anticipated e.g. caring for babies. If non-fluid repellent gowns are used a plastic apron should be worn underneath Putting on Personal Protective Equipment (PPE) The level of PPE used will vary based on the procedures being carried out and not all items of PPE will always be required. If full PPE is required, for example for an aerosol-generating procedure, all staff in the room should wear the following PPE. The order given here is practical but the order for putting on is less critical than the order of removal: 1. Gown (or apron if not aerosol-generating procedure) 2. FFP3 respirator (or surgical mask if not aerosol-generating procedure) 3. Goggles or face shield (for an aerosol-generating procedure and as appropriate after risk assessment). 4. Disposable gloves Removing Personal Protective Equipment (PPE) PPE should be removed in an order that minimises the potential for cross-contamination. Before leaving the area, gloves, gown and eye goggles should be removed (in that order, where worn) and disposed of as infectious waste. After leaving the area, the respirator (or surgical mask) can be removed and disposed of as infectious waste. Guidance on the order of removal of PPE is as follows: 1. Gloves Grasp the outside of the glove with the opposite gloved hand; peel off. Hold the removed glove in gloved hand. Slide the fingers of the ungloved hand under the remaining glove at the wrist. Management of Influenza Policy 14

15 Peel the second glove off over the first glove and discard appropriately. 2. Gown and apron Unfasten or break ties, from the back. Pull gown/apron away from the neck and shoulders, touching the inside of the gown only. Turn the gown /apron inside out, fold or roll into a bundle and discard. 3. Goggles or face shield To remove, handle the headband or earpieces and discard appropriately. 4. Respirator or surgical mask Follow respirator manufacturer specific instructions To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used Infectious and Non-Infectious Waste Waste generated within the isolation room or co-hort area should be treated as infectious waste, i.e. managed safely and effectively, with attention paid to disposal of items which have been contaminated with secretions / sputum (e.g. paper tissues and surgical masks) 5.9 Linen and Laundry Linen should be categorised as infected. Used linen must be handled, transported and processed in a manner that prevents skin and mucous membrane exposures to staff, contamination of their clothing and the environment Crockery and utensils All crockery and utensils must be returned to the central dishwashing facility and not washed within clinical areas. There is no requirement for disposables Environmental Cleaning All isolation rooms and co-horted areas will be cleaned with Actichlor Plus (1000ppm Av Chlorine) As a minimum patient isolation rooms / co-horted areas should be cleaned at least daily. The Infection Prevention and Control Team will advise if the frequency is to be increased. Vacuuming should be avoided. Healthcare Cleaning staff should be allocated to specific areas and must clean non-influenza areas first before moving onto any influenza isolation room / cohort areas. Healthcare Cleaning staff must be trained in the correct use of protective clothing and precautions to be taken when cleaning co-horted areas. Management of Influenza Policy 15

16 5.12 Visitors Visitors with respiratory symptoms will not be allowed to enter ward areas. All visitors entering a cohort area must be instructed to wash their hands on entering and departure and when removing protective clothing, (if worn) Last Offices When performing last offices for deceased patients, healthcare workers must follow standard infection control precautions; surgical masks and eye protection (or full face visor) must be used if there is a risk of splashes of blood or body fluids, secretions (including respiratory secretions) and excretions to the facial mucosa. Mortuary staff must be informed that the deceased had a suspected / confirmed influenza infection. 6 Monitoring Compliance and Effectiveness Monitoring Requirement : The IPCT will monitor compliance with the management of all patients known or suspected to have influenza Any non compliance issues will be reported to the divisional Matron / Head of Nursing or the site manager as appropriate. Monitoring Method: Adherence to policy will be monitored by the Infection Prevention and Control Nurse Team Non-compliance will be reported via the incident reporting system Report Prepared by: Lead Nurse Infection Prevention and Control Monitoring presented to: Report Non-compliance will be reviewed through the Infection Control Operational Group Frequency of Report As required Management of Influenza Policy 16

17 7 References Health Protection Agency, Infection Control Precautions to Minimise Transmission of Respiratory Tract Infections (RTIs) in the Healthcare Setting. Available from: ormationforhealthprofessionals/#infectioncontrol Health Protection Agency influenza website. Department of Health (2007), Pandemic Flu A summary of guidance for infection control in healthcare settings. British Thoracic Society, British Infection Society, Health Protection Agency, Department of Health, Pandemic Flu: Clinical Management of Patients with an Influenza-like illness during an Influenza Pandemic. Journal of Infection. 53(S1): S1-S58 Department of Health / Health Protection Agency (2005), Guidance for pandemic influenza: Infection control in hospitals and primary care settings. Management of Influenza Policy 17