Managing Influenza Outbreaks in LTC

Transcription

1 Managing Influenza Outbreaks in LTC David A Nace, MD, MPH, CMD Director LTC & Flu Programs University of Pittsburgh Chief of Medical Affairs UPMC Senior Communities naceda@upmc.edu

2 Objective Discuss key practical steps in the management of influenza outbreaks.

3 Influenza Outbreak Management Phases in LTC Pre-Outbreak Actual Outbreak Follow-Up

4 Pre-Outbreak Phase Vaccination * Residents HCP Surveillance Components Preparedness Planning * Not a focus of this presentation

5 Surveillance

6 Surveillance Flu occurs every year expect it! LTCF cases are often undetected Unless you are actively looking you won t see flu The frail and elderly may present with an atypical picture particularly lack of fever May present as CHF, COPD, Pneumonia Think flu if wheezing during the height of flu season or with viral URI symptoms

7 Daily surveillance Surveillance Look for ILI: Pick your definition and use it Fever AND cough/sore throat 100 degrees Fever AND respiratory symptoms Fever AND myalgias/ha/cough/coryza/pna Definition represents guidance not an absolute The frail and elderly may present with an atypical picture particularly lack of fever

8 Surveillance Track what is going on in the community PA DOH website * PA HAN CDC cdc.gov/flu * Local Health Departments * News media Test PCR ( EIA - immunofluorescence Rapid tests frequent false positives and false negatives Culture only in unusual cases takes too long to be practical * Particularly helpful in determining trends

9 Surveillance Possible Outbreak 2 or more residents in close proximity in a facility who develop a respiratory illness within hours of each other Confirmed Outbreak One laboratory confirmed case of influenza

10 Preparedness Planning

11 Preparedness Planning In our experience, most of our outbreaks are occurring Friday afternoons! Pre-Printed Antiviral Order Sheets Medical Director signs Treatment versus Prophylaxis Renal dosing Maintain a creatinine clearance/gfr list for all residents in facility

12 Actual Outbreak Isolation Precautions Antiviral Use Infection Control Practices Communication and Reporting

13 Isolation Precautions

14 Droplet precautions Surgical mask upon entering room Limit time resident out of room Mask resident if they leave room 3 foot spatial separation / curtain Private room if possible/cohorting Prophylaxis of roommate

15 Droplet precautions Put all newly confirmed or suspect cases immediately in droplet precautions 5 7 days FROM SYMPTOM ONSET* Communicate information about residents with suspected, probable, or confirmed influenza to other departments and facilities. * CDC site lists both 5 & 7 days in separate, current references

16 Antivirals

17 Patient A FLU Patiient B Patient Immunization Patient A FLU FLU HCW s Strategies to Stop Transmission of Flu in Healthcare Facilities HCW s Fellow HCW s FLU Healthcare Worker Immunization HCW s Patient Antiviral Agents

18 Antivirals Used for Treatment AND Prophylaxis Oseltamivir or zanamivir Renal Adjustment CrCl < 30 with oseltamivir Teamwork (Pharmacy/Medical Director/Nursing/Adm)

19 Immunize those who haven t had flu shot! Those who refused the flu shot and who are now ill: Educate!

20 Infection Control Practices

21 Infection Control Practices Signage Announces outbreak to visitors Instructs visitors to avoid visiting if ill or at risk Make tissues and masks available Cough etiquette Alcohol based hand gels and hand hygiene

22 Infection Control Practices Send sick staff home 24 hours after fever off meds that will mask fever Coming back try to assign to previously ill or recuperating Cancelling large group activities/restrict visitors (children 10 days and adults 5 days) #recommendations

23 Infection Control Practices Defer admissions * Close units/facility where there are symptomatic residents Limit traffic between units Track the Outbreak Line listing form * Admissions to a LTC are ELECTIVE. Patient safety comes first.

24 Communication & Reporting

25 Communication Patients and families What you know, what you are doing, who is involved, when you will update Physicians Staff

26 Reporting Health Department DOH PSA via PA-PSRS DPW if in AL / Personal Care

27 Follow-Up

28 Follow Up Infection Control / QI Team review Number of confirmed and suspected cases Duration Procedural review Barriers discussion Staff & Physician F/U Vaccination status Family F/U

29 New York City Letter Carrier October 1918 Courtesy of the National Archives

30 CDC Resources ettings.htm#recommendations PA DOH a_(flu)/14161

31 Resources American Medical Directors Association Immunization in the LTC Setting: LTC Physician Information Toolkit Series, 2010 Critical Issues in Infection Control: LTC Physician Information Toolkit Series, 2002 Society of Healthcare Epidemiologist of America Infectious Diseases Society of America

32 Resources Immunization Action Coalition Information on Mandatory Immunization Programs National Influenza Vaccine Summit American Academy of Allergy, Asthma, and Immunology Administering Influenza Vaccine to Egg Allergic Recipients vaccine.pdf

33 References - Vaccination Sand KL, Lynn J, Bardenheier B, Seow H, Nace DA. Increasing influenza immunization for long-term care facility staff using quality improvement. J Am Geriatr Soc. 2007;55: Nace DA. Improving immunization rates in long-term care: Where the forest stops and the trees begin. JAMDA 2008;9(9): Nace DA, Hoffman EL, Resnick NM, Handler SM. Achieving and sustaining high rates of influenza immunization among long-term care staff. JAMDA 2007;8(2): Nace DA, Handler SM, Hoffman EL, Perera S. Impact of the raising immunizations safely and effectively (RISE) program on healthcare worker influenza immunization rates in long term care settings. J Am Med Dir Assoc. 2012;13(9):

34 References - Vaccination Rakita RM, et al. Mandatory influenza vaccination of healthcare workers: A 5-year study. Infect Control Hosp Epidemiol 2010;31(9): Bardenheier BH, Shefer A, McKibben L, Roberts H, et al. Factors predictive of increased influenza and pneumococcal vaccination coverage in long-term care facilities: the CMS-CDC standing orders program Project. JAMDA 2005;6(5): Potter J, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. JID 1997;175:1-6. Carman WF, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000:355:93-97.

35 References - Vaccination Stefanacci RG. Creating Artificial Barriers to Vaccinations. JAMDA 2005;6(5):