Managing Influenza Outbreaks in Retirement Home Settings: It s Not Like Long Term Care

Transcription

1 Managing Influenza Outbreaks in Retirement Home Settings: It s Not Like Long Term Care

2 Background Influenza outbreaks (OBs) occur in Long Term Care Homes (LTCHs) and Retirement Homes (RHs) throughout the year but are more common from fall to early spring 1. The Health Unit s role in outbreak control Supportive Retirement Homes Act, 2010 Regulation 166/11

3 The local picture The outbreak season: levels of flu in the community and institutional settings. Local Influenza Statistics: influenza-only outbreaks 68 sporadic cases influenza-only outbreaks 38 sporadic cases

4 Objectives of our study 1. Examine influenza outbreak trends in LTCHs and RHs. 2. Compare and contrast the successes and challenges of current influenza outbreak control measures in both these settings. 3. Consider implications for public health support of retirement homes in their efforts to prevent and manage influenza outbreaks.

5 One of these things is not like the other Both are congregate living facilities However, they have: Different sleeping arrangements Differing staffing levels Differing levels of staff interaction and familiarity Differing approaches to managing health care needs of residents

6 Methods Chart review of institutional outbreaks in which influenza was the only pathogen isolated (LTCH, N=4: RH, N=2). Compared and contrasted: Length of time it took the facility to recognize an outbreak Duration of the outbreak Attack rate Length of time to initiate antivirals for both treatment and prophylaxis Staff immunization rates at the time of the outbreak Rate of hospitalizations Rate of chest x-ray confirmed pneumonia Mortality rate

7 Measures The Health Unit compared and contrasted the successes and challenges each setting experienced with: 1. Conducting Surveillance and Reporting Outbreaks 2. Initiating Antivirals for Prophylaxis and/or Treatment 3. Immunizing Staff and Residents vs Influenza 4. Isolating Cases 5. Restricting Social Activities and Admissions 6. Excluding Staff 7. Using Personal Protective Equipment (PPE)

8 1. Surveillance Long-Term Care Homes Well developed surveillance processes in place resulting in timely identification and reporting of OBs in 3 of 4 homes. Experienced registered staff who: Assess residents regularly and identify new cases promptly; Retirement Homes One retirement home linked to a LTCH that provides: Access to registered staff; Access to other outbreak resources; for example, NP swabs, antiviral treatment and prophylaxis. Have a high level of comfort with specimen collection.

9 1. Surveillance Long-Term Care Homes Retirement Homes Surveillance processes well developed. However, delays in outbreak recognition, reporting, and implementation of control measures at one LTCH b/c staffing primarily casual, less familiar with them. Staff have minimal interaction with most residents, leading to a delay in identifying illness/cases. Surveillance processes not well established leading to difficulties with outbreak recognition. Successes Lack of registered staff resulting in: Inconsistent assessment of residents; Failure to recognize new cases; Problems collecting specimens.

10 2. Antiviral Use Long-Term Care Homes Retirement Homes Standing orders exist for residents leading to timely initiation of antiviral prophylaxis and/or treatment. Contracts with pharmacies allowing for pre-planning and easier access to antivirals during an outbreak. Successes

11 2. Antiviral Use Long-Term Care Homes Retirement Homes Residents have their own family doctors and purchase medications on their own making it difficult for staff to ensure timely access and initiation of antivirals. Lack of understanding re the necessity for and appropriate use of antiviral medications during an influenza outbreak. Successes

12 3. Influenza Immunization Long-Term Care Homes Retirement Homes Staff provide influenza vaccination to residents early in the influenza season resulting in higher rates of resident immunization (96.5%).

13 3. Influenza Immunization Long-Term Care Homes Low staff immunization rates. Retirement Homes Residents receive their influenza vaccination at their family doctors offices or in community clinics. This may have contributed to lower rates of resident influenza vaccination. Low staff immunization rates. Successes

14 Influenza Immunization 100.0% 90.0% Comparison of staff and resident influenza immunization rates 96.5% 80.0% 70.0% 75.2% Vaccination Rate 60.0% 50.0% 40.0% 60.9% 66.8% Longterm Care Homes Retirement Homes 30.0% 20.0% 10.0% 0.0% Residents Staff

15 4. Isolation of Cases Long-Term Care Homes Retirement Homes Cases promptly isolated to their rooms/bed spaces as per MOHLTC guidelines. Cases asked to self-isolate in their living quarters ( their home ).

16 4. Isolation of Cases Long-Term Care Homes Retirement Homes Difficult to keep cases isolated to rooms on locked unit. Decreased understanding (resident and staff) regarding infectious disease transmission and the rationale behind case isolation. Successes

17 5. Restriction of Social Activities and Admissions Long-Term Care Homes Retirement Homes Activation staff provide small group activities for well residents on units that are in isolation, consequently decreasing the emotional impact of confinement to the unit.

18 5. Restriction of Social Activities Long-Term Care Homes Retirement Homes Well residents were impacted by changes to the social activities schedule leading to distress.

19 6. Staff Exclusion Long-Term Care Homes Retirement Homes Exclusion policies are implemented when outbreaks declared leading to decreased transmission. Exclusion policies are implemented when outbreaks declared leading to decreased transmission.

20 6. Staff Exclusion Long-Term Care Homes Retirement Homes Difficulty enforcing exclusion policy for the entire duration of the outbreak leading to potential increases in transmission.

21 7. Availability and Use of PPE Long-Term Care Homes Retirement Homes PPE adequately stocked and stored in appropriate locations throughout the facility supporting access.

22 7. Use of PPE Long-Term Care Homes Retirement Homes In 1 home, PPE was not stored in an appropriate or easily accessible location due to the facility design and fire regulations.

23 Summary The relatively low vaccination rate in residents of 1 RH coupled with a delay in prophylaxis was associated with an increased rate of hospitalizations. Despite data quality limitations, it seems reasonable to conclude that outbreak control was most influenced by the length of time it took to initiate prophylaxis. This finding is also supported in the literature 3,4,5.

24 A picture is worth a 1000 words Table 1. The length of time to initiate prophylaxis was associated with increased rate of hospitalization % 30.0% Length of Time (Days) % 20.0% 15.0% 10.0% Percentage Length of time for initiation of antivirals (prophylaxis) Proportion Hospitalized 5.0% 0 RH2 LTCH4 LTCH2 LTCH3 LTCH1 RH1 Setting 0.0%

25 Summary One LTCH and 1 RH had delays in initiating prophylaxis in residents leading to longer outbreak and more hospitalizations. Delay in the LTCH was due to casual staff failing to recognize an OB over the holiday period. This is an issue the Health Unit has encountered in the past. Delay in the RH was attributable to multiple reasons which highlights the complexity of outbreak control in these settings.

26 What happened in influenza outbreaks: 5 in long term care homes, 2 in retirement homes Duration of outbreaks in retirement homes ranged from 7 (RH A) to 17 (RH B) days. RH B took 8 days to start Tamiflu. The attack rate was 25% compared to 6% in RH A. The rate of hospitalizations was similar

27 What happened in Duration of outbreaks in long term care homes ranged from 12 to 18 days The attack rates ranged from 9 to 50% The home with the highest attack rate had the longest outbreak and an unknown respiratory and enteric pathogen circulated at the same time

28 What happened in All homes started Tamiflu within 48 hours of outbreak identification However 3/5 outbreaks were identified in response to ++ reports of illness in residents (i.e. 7 ill residents at time of call) Rates of hospitalization did not correlate with duration of outbreak or attack rate In the 2 outbreaks that it took 48 hours to arrange Tamiflu, 3 residents hospitalized; however, 3 residents also hospitalized in outbreak in which Tamiflu started the same day

29 Recommendations With increasing frailty of residents in retirement homes (thereby delaying entry into LTCHs), and with the introduction of the Retirement Home Act, the Health Unit should try to work more closely with these homes to support them with outbreak prevention and control At the same time, it appears our LTCHs still need our help

30 Recommendations Support includes: Helping the Infection Control (IC) lead to improve surveillance and reporting processes; Educating staff, residents, and their families about the use of antivirals as an outbreak control measure; Collaborating with the IC lead to develop a process that enables quick and easy access to influenza vaccination and antiviral medication i.e. admission orders, pharmacy on-call, onsite influenza clinics; Working with the IC lead to improve access to PPE when the facility is in outbreak; Working with the IC lead to increase hand sanitizer accessibility year round and not just during outbreaks..

31 Self-reflection We need to look at our outbreak data in a more systematic way, tracking and trending over time.

32 References 1. Ministry of Health and Long Term Care (October 2004.) A Guide to the Control of Respiratory Infection Outbreak in Long-Term Care Homes, p Ministry of Health and Long Term Care (2008.) Ontario Public Health Standards: Institutional/Facility Outbreak Prevention and Control Protocol, p Centers for Disease Control and Prevention (2011.) Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, 4. British Columbia Provincial Infection Control Network (February 2007.) Respiratory Infection Outbreak Guidelines for Healthcare Facilities, p Booy R, Lindley RI, Dwyer D, et al (2012.) Treating and Preventing Influenza in Aged Care Facilities: A Cluster Randomized Control Trial. PLOS ONE, Vol.7, Issue 10.