Clinical Director for Women s and Children s Division

Transcription

1 MANAGEMENT OF PANDEMIC FLU IN THE MATERNITY SERVICES CLINICAL GUIDELINES Register No: Status: Public Developed in response to: Contributes to CQC Core Standards No: 9, 12 Consulted With Post/Committee/Group Date Anita Rao/Alison Cuthbertson Miss Dutta Sam Brayshaw Alison Cuthbertson Paula Hollis Chris Berner Doug Smale Louise Teare Claire Fitzgerald Deborah Lepley Clinical Director for Women s and Children s Division Consultant for Obstetrics and Gynaecology Consultant Anaesthetist Head of Midwifery Lead Midwife Acute Inpatient Services Lead Midwife Clinical Governance Emergency Planning Officer Consultant Microbiologist/ Director of Infection Prevention Pharmacy Senior Librarian, Warner Library August 2017 Professionally Approved By Miss Rao Peter Fry Lead Consultant for Obstetrics and Gynaecology Chief Operating Officer Intrapartum NICE Guidelines RCOG guideline August 2017 Version Number 3.0 Issuing Directorate Women & Childrens Ratified By DRAG Chairmans Action Ratified On 29 th October 2017 Trust Executive Sign Off Date November 2017 Implementation Date 7 th November 2017 Next Review Date October 2020 Author/Contact for Information Sarah Moon, Specialist Midwife Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians Distribution Method Intranet & Website. Related Trust Policies (to be read in Standard Infection Prevention conjunction with) Hand Hygiene Guideline for Maternity Record Keeping including Documentation in Handheld Records Severely Ill Pregnant Patient Guideline to Assist Medical and Medical and Midwifery Staff in the Provision of High Dependency Care and Arrangements for Date and Timely Transfer to ITU Pandemic Influenza Policy and Plan Document Review History: Review No Reviewed by Active Date 1.0 Sarah Moon 27 January Carol Hunt November Sarah Moon 7 th November 2017

2 INDEX 1. Purpose 2. Equality and Diversity 3. Recommended Actions at Different Stages during the Pandemic 4. Incidence 5. Background 6. Antiviral Treatment for Pandemic Flu 7. Key Planning Principles 8. Managing Maternity and Obstetric Services during an Influenza Pandemic Wave 9. Cohorting 10. Visitors before, during and after birth 11. Breastfeeding Advice 12. Information and Communications 13. Staff and Training 14. Professional Midwifery Advocates 15. Audit and Monitoring 16. Guideline Management 17. Communication 18. References 19. Appendices Appendix A - Breastfeeding and Pandemic Flu Advice Appendix B - Flu Pandemic Algorithm for the Maternity Unit Appendix C - Pandemic Flu - Guidance for Health Care Staff

3 1.0 Purpose 1.1 Maternity Services will need to continue to function throughout a pandemic to provide care for pregnant patients, new mothers and their babies including those with normal health, those with a complicated pregnancy and those who develop influenza. These plans include provision for both outpatient and inpatient services. 2.0 Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Recommended Actions 3.1 Following the H1N1 pandemic, new strategies have been put in place, to manage the next flu pandemic. The World Health Organisation (WHO) will monitor the global impact of any future pandemic flu. However, the Department of Health (DoH), Public Health England (PHE) and NHS England will continually monitor the situation in the UK and if necessary PHE will declare a pandemic flu prior to WHO. When the next pandemic flu is identified current information regarding the virus and up to date treatment regime will be issued by PHE and DoH for health professionals and health promotion information via the media for members of the public. Maternity Services will react as advised by these agencies to give the latest evidence based care and advice. 4.0 Incidence 4.1 When a new influenza A virus emerges a pandemic can occur, as this virus is new the human population has no immunity to it and the virus has the potential to spread quickly from person to person. Due to worldwide travel the epidemic has the potential to spread globally. It is not possible to predict which portion of the population will be most severely affected, however pregnant women are at a greater risk of developing influenza. Influenza pandemics are a natural phenomenon that have occurred from time to time for centuries including 3 times during the 20th century. 5.0 Background 5.1 In a normal influenza season around 1 in 10 pregnant women are exposed to influenza, in a pandemic this will increase considerably. 5.2 Due to some of the physiological changes that occur in pregnancy pregnant women and fetuses are at greater risk for influenza and associated complications. The immune system is altered so that the pregnant woman is at greater risk of viral infections. In the later stages of pregnancy lung capacity is reduced resulting in pregnant women being more susceptible to pneumonia. 5.3 Pregnant women are now well-recognised as being at significantly increased risk of complications, from influenza infection. They are at greater risk of hospitalisation and have a mortality rate several times higher than that for non-pregnant women in the same age group. The greatest risk is of severe chest infection, due to the flu itself, or to secondary bacterial infection; commonest in the second and third trimesters of pregnancy. 5.4 Increased severity from influenza infection in pregnancy is associated with pre-existing asthma, maternal smoking and obesity. Pregnant patients admitted to hospital with

4 H1N1 (2009) infection were three times more likely to deliver pre-term. However, pregnant women should also avoid the risk of severe feverish illness at any stage of pregnancy. It is important to remember that flu can cause other types of illness at any stage, including diarrhoea and/or vomiting, muscle and joint inflammation andrarely meningitis. 5.5 Pandemic Flu usually occurs in waves lasting approximately 15 weeks, one of these waves but not necessarily the first will predominate, however, there will be a surge locally lasting between 3 to 5 weeks. Adults who have flu are infectious for five days following the onset of symptoms, children seven days and people who are immune-compromised for much longer 6.0 Antiviral treatment for Pandemic Flu (Refer to Appendix A) 6.1 While vaccination is considered the first line of defence against flu, antiviral medicines are effective in treating flu, and experience has shown them to be safe at all stages of pregnancy. 6.2 In England, pregnant patients and their healthcare advisors usually elected to use inhaled zanamivir during the recent pandemic, except for patients with asthma or other lung disorder likely to cause bronchospasm (asthma-like symptoms). 6.3 GPs can prescribe antiviral medicines according to the latest guidance. 6.4 Hospital doctors can also prescribe antiviral medicines based on a clinical or laboratory diagnosis of flu. 7.0 Key Planning Principles 7.1 It is important that maternity service response plans for pandemic influenza are consistent with national planning assumptions and are made using the same principles: Joint working and integrated planning between all key agencies Flexible planning to deal with a range of possible scenarios and clinical attack rates Flexible thinking in bolstering local staff capacity Advising and enabling symptomatic influenza patients to remain at home, whenever possible Facilitating rapid access to antiviral medicines Reducing (some) routine activity but continuing to make essential care available 8.0 Managing Maternity and Obstetric Services during an Influenza Pandemic Wave 8.1 Infection control and related considerations- It is generally accepted that people are infectious while they are symptomatic with influenza. However, the virus can be detected at low levels from the respiratory tract of infected people a short while (typically up to 12 hours, occasionally up to 24 hours) before they develop symptoms. Small children may be infectious for a few days longer than adults. 8.2 Seasonal influenza can be transmitted through close contact with an infected coughing or sneezing person and it is assumed that a future pandemic influenza virus will have similar transmission features. The most important and likely routes of transmission are through droplets and direct/indirect contact.

5 8.3 Aerosol transmission, where very small particles remain suspended in the air and travel over long distances, may occur during certain healthcare procedures such as intubation, manual ventilation and suctioning or cardiopulmonary resuscitation. Specific precautions for example wearing correct personal protective equipment (PPE) and FFP3 masks when carrying out these procedures. 8.4 The most important methods of infection control are respiratory, hand hygiene, and surface cleaning. Staff should use appropriate PPE as recommended by the Department of Health; however, they should be trained in its proper use and in how to don and remove it safely. 8.5 It is probably not feasible to put a mask on an infected woman during childbirth. Therefore, it may be necessary to allow the midwife to wear a mask should she wish to do so, although there may then be subsequent communication problems. Women should only be advised to wear a mask if being moved to another ward or to X-ray. 8.6 Observations should be recorded on the maternity early warning obstetric system (MEOWS) chart. The respirations should be recorded at least 4 hourly and documented in the patient s healthcare records. (Refer to the guideline for the severely ill pregnant patient ; register number 09095)). 8.7 Normal spillage control and terminal cleaning of delivery rooms and ward areas, according to local policy, will be sufficient to ensure good infection control during an influenza pandemic. 8.8 During a pandemic flu surge staffing levels could be as low as 50%. Maternity managers should collaborate at least daily to prioritise care and staffing levels. 9.0 Cohorting (Refer to the guideline entitled Pandemic Influenza Policy and Plan; register number 06060; Appendix 8) 9.1 Stage 1: The Maternity Unit has the capacity to manage four patients affected with the Flu virus initially room 9 (for one patient) and rooms 12, 13 and 14 (if more than one patient) on the Labour Ward as this area can be isolated from the surrounding ward areas. Unless bereaved woman using one of these rooms, then escalate straight to Antenatal Ward In addition and with the exception of an obstetric emergency, those patients on the Day Assessment Unit / Triage who require transfer to the Labour Ward will need to go through the Postnatal Ward and all staff should cease walking through DAU to reach the Labour Ward. Patients who have flu will have to be nursed by the same midwife who will not be able to care for patients who are asymptomatic. Midwives and MCA s caring for these patients would be people who have recovered from the virus themselves or have had the appropriate flu vaccine All patients to be assessed using MEOW scoring Anaesthetic/ obstetric review which will determine if transfer to Broomfield required 9.2 Stage 2: Close Antenatal Ward (DAU) DAU transferred to Antenatal Clinic. Antenatal and triage to be transferred to the Postnatal Ward.

6 9.2.1 Stop Parent Craft Classes and reduce Antenatal Clinics to primigravida and high risk women. Midwife antenatal checks to be undertaken via phone for low risk women Divert low risk births to other agreed community facilities depending on relevant geographical area Postnatal women to be discharged home as soon as is possible following N96 check Stage 3: Lead Midwife for Infant Feeding will give telephone support to postnatal women to encourage/support breastfeeding. Utilise peer support groups to support breastfeeding mothers and involve NCT Community Midwives to stop doing postnatal home visits. Start a clinic for day 5 new born spot screening and 10th day discharge in the Antenatal Clinic at Broomfield, St Peters, Maldon and WJC, Braintree Open the Antenatal Ward for Swine flu patients to be cohort Nursed, caring for Antenatal and Postnatal women. Staffing of all units to include Community Midwives. 9.4 It will be equally important to remain vigilant for pregnant or recently delivered patients who develop symptoms during a hospital stay, so that they can be moved away from susceptible asymptomatic patients without delay. 9.5 The aim is to provide home births, whenever it is safe for women who make this choice. Home birth may help to protect a woman and her baby from contact with others who have influenza. However, staff shortages may mean that a planned home birth is no longer possible. 9.6 Other factors which will influence this may include the family situation, particularly whether or not a father, other partner, supporter, or other children at home are currently suffering from pandemic influenza. Individual decisions about the ability to go ahead with a home birth will need to be made at, or near to, the time of delivery. Furthermore, the woman needs to identify a carer who is not infected to support her in labour and in the initial postnatal period. 9.7 If a pregnant woman has been in contact with a family member that has contracted pandemic flu then they should be offered prophylactic anti-viral treatment. 9.8 Following delivery well mothers and their babies should be discharged home as soon as possible. 9.9 Staff will not be able to wear their uniform to or from work changing facilities will have to be made available. Staff should be advised to wash uniforms in less than a half load with a hot wash, then a tumble dry and ironing is sufficient to destroy any viral particles Maternity Services will have to maintain the ability to respond to emergency situations during the pandemic Visitors Before, During and After Birth 10.1 Healthcare contact with pregnant patients should be minimised to essential contact only. Community healthcare staff, including midwives, may have contact with other patients

7 who are ill with pandemic influenza. These staff should follow appropriate infection control procedures to prevent the spread of influenza between patients Visitors to maternity wards before and during birth should be restricted to one person who does not have symptoms of influenza. The same person should be the only visitor allowed on the postnatal ward before discharge. Personal birth companions should be shown the appropriate hand hygiene and explanation of isolation precautions The only people with influenza symptoms allowed on to maternity wards should be pregnant patients, and they should be cared for in an area separate from pregnant patients without symptoms Mothers should be advised to limit visitors to new babies for the first few weeks of life in order to reduce the risk of exposure to pandemic influenza. Visitors should be discouraged if they have pandemic influenza symptoms or have recently recovered from it. All visitors should be requested to follow strict respiratory and hand hygiene when in contact with the new baby, as should all family members living with the new baby Breastfeeding Advice 11.1 Women who are breastfeeding should continue while receiving antiviral treatment or prophylaxis as they are not contraindicated in breastfeeding. See Appendix A 11.2 In particular mothers should feed on demand. Where possible additional formula should not be used so that the infant receives as much of the maternal antibodies as possible If a mother is ill, she should continue breastfeeding and increase feeding frequency. If she becomes too ill to feed then expressing milk may still be possible It the baby becomes too ill to breastfeed then expressed milk should be used Mothers who have been infected by pandemic flu but are no longer feverish should be encouraged to express breast milk for their baby s use if possible, though milk expressed while a mother is feverish should be discarded Mothers who are able to breastfeed, but who have residual respiratory symptoms, should be advised to wear a surgical face mask and use strict hand and respiratory hygiene while feeding their baby. Until a mother s symptoms resolve she should, where possible, delegate bottle feeding and other childcare procedures to a helper who is not ill with influenza Information and Communications 12.1 Communication will be essential during a pandemic, not just with patients but also with healthcare colleagues within and between specialities. Pregnant women and new mothers will need information about their pregnancy and pandemic influenza. The government will provide this information via Public Health England 12.2 Consideration should be given to the fact that recent immigrants are overrepresented among pregnant women, and that they may not have English as their chosen language. This may be particularly relevant if healthcare staff need to wear masks when attending to a symptomatic pregnant woman. These women may need help in understanding how to comply with infection control procedures.

8 12.3 Staff caring for pregnant patients will need regular and easy access to information about the developing pandemic to ensure that they are able to provide an informed service to their patients. This includes staff from community care and maternity services specialists involved in antenatal and postnatal care Ready access to information and advice, particularly on immunisation and antiviral treatments which may be available and on possible effects and complications of influenza must be accessible to all staff. It may be useful for maternity services to have brief daily meetings to co-ordinate care and share information Midwives and obstetricians should be educating the women regarding the signs and symptoms of Flu and the importance of good personal hygiene If a woman suspects that she is developing Flu she should stay at home, either call NHS 111NHS or go on line to NHS choices on and follow the links for the flu symptom checker. Otherwise the woman should telephone her GP. They will then be advised about getting anti-virals and how to manage their symptoms The Trust will ensure women have easy access to midwives through telephone contact, as well as an alternate point of contact should their midwife develop pandemic influenza. Pregnant women will need up to date information about the local impact of influenza: i.e. where to obtain help and advice, what immunisation and treatments are available, where to go for their antenatal care or delivery, what to do if they develop influenza at the time of their delivery, and how to recognise influenza in themselves or their baby. Midwives who are immune-compromised or pregnant could monitor these phone lines The Trust will make sure that information provided by the Government is made available to pregnant women and new mothers Staffing and Training 13.1 All midwifery and obstetric staff must attend yearly mandatory training which includes skills and drills training i.e. infection prevention related topics and early recognition of the ill patient All midwifery and obstetric staff are to ensure that their knowledge and skills are up-to-date in order to complete their portfolio for appraisal Professional Midwifery Advocates 14.1 Professional Midwifery Advocates provide a mechanism of support and guidance to women and midwives. Professional Midwifery Advocates are experienced practising midwives who have undertaken further education in order to supervise midwifery services and to advise and support midwives and women in their care choices Audit and Monitoring 15.1 Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy (register number 08076), the Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual audit work plan; to encompass national and local audit and clinical governance identifying key harm themes. The Women s and Children s Clinical Audit Group will identify a lead for the audit.

9 15.2 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk Management Group (MRMG) and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings The audit report will be reported to the monthly Directorate Governance Meeting (DGM) and significant concerns relating to compliance will be entered on the local Risk Assurance Framework Key findings and learning points from the audit will be submitted to the Patient Safety Group within the integrated learning report Key findings and learning points will be disseminated to relevant staff.

10 16.0 Guideline Management 16.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site Quarterly memos are sent to line managers to disseminate to their staff the most currently approved guidelines available via the intranet and clinical guideline folders, located in each designated clinical area Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly Quarterly Clinical Practices group meetings are held to discuss guidelines. During this meeting the practice development midwife can highlight any areas for further training; possibly involving workshops or to be included in future skills and drills mandatory training sessions Communication 17.1 A quarterly maternity newsletter is issued and available to all staff including an update on the latest guidelines information such as a list of newly approved guidelines for staff to acknowledge and familiarise themselves with and practice accordingly Approved guidelines are published monthly in the Trust s Focus Magazine that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via Regular memos are posted on the guideline notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders References Department of Health (2008) Pandemic influenza - Guidance on preparing maternity services in England. DoH; September World Health Organisation (2010) Update on influenza H1N1 (2009) for providers of maternity services. WHO: November. Public Health England, Pandemic Influenza Response plan Pandemic Influenza NHS guidance on the current and future preparedness in support of an outbreak. October HSE pamphlet guide to the FFP3 Respirator National Influenza Group

11 Appendix A Breastfeeding and Pandemic Flu Advice Women who are breastfeeding should continue while receiving antiviral treatment or prophylaxis as they are not contraindicated in breastfeeding. In particular mothers should feed on demand. Where possible additional formula should not be used so that the infant receives as much of the maternal antibodies as possible. If a mother is ill, she should continue breastfeeding and increase feeding frequency. If she becomes too ill to feed then expressing milk may still be possible. It the baby becomes too ill to breastfeed then expressed milk should be used. The risk for pandemic flu transmission through breast milk is unknown. However, reports of viraemia with seasonal influenza infection are rare. Mothers who have been infected by pandemic flu but are no longer feverish should be encouraged to express breast milk for their baby s use if possible,though milk expressed while a mother is feverish should be discarded. Motherswho are able to breastfeed, but who have residual respiratory symptoms, shouldbe advised to wear a surgical face mask and use strict hand and respiratoryhygiene while feeding their baby. Until a mother s symptoms resolve she should,where possible, delegate bottle feeding and other childcare procedures to a helperwho is not ill with influenza. It is unlikely that a mother will be able to pass immunity from natural pandemic influenza infection to her baby through breastfeeding, as viral immunity does not cross into breast milk as well as bacterial immunity. Antiviral treatment Antiviral drugs are not a cure, but can aid recovery if taken within 48 hours of symptoms developing. There are two possibilities; Oseltamivir (Tamiflu) and Zanamivir (Relenza). Oseltamivir and its active metabolite, oseltamivir carboxylate, are excreted into human breast milk in very small amounts. Limited data suggest that clinical sequelae from maternal treatment would not be expected in a breastfed infant. There are no data on zanamivir use during lactation but based on limited bioavailability the systemic exposure of a breast fed infant from maternal treatment is expected to be insignificant. The overall consensus is that treatment with either drug is not a reason to discontinue, or put limitations on, breast feeding full-term or pre-term infants. Due to the very small amounts transferred into breast milk, and the limited oral bioavailability of either drug, the benefits of breast feeding are considered to outweigh any, albeit unidentified, risks. Reducing the risk of transmission from mother to baby As with general precautions, mothers should take steps to reduce the risk to their infant by washing their hands frequently with soap and hot water or a sanitiser gel and by using clean tissues to cover their mouth and nose when coughing or sneezing. Tissues should be binned after use. 11

12 Mothers and infants should stay as close together as possible and encouraged to have early and frequent skin-to-skin contact with their infants. Babies hands should be washed if they have been in their mouth. Limit sharing of toys and other items that have been in infants' mouths. Wash thoroughly with soap and water any items that have been in infants' mouths. Keep dummies (including the dummy ring/handle) and other items out of adults' or other infants' mouths prior to giving to the infant. The available scientific evidence shows that the basic face masks do not protect people from becoming infected and that the best way of reducing the risk of transmission is by hand washing and using and disposing of tissues. CATCH IT, BIN IT, KILL IT. General treatment of symptoms for breastfeeding women include drinking plenty of fluids and relief of symptoms with paracetamol or ibuprofen to control any fever. Paracetamol is well tolerated and is licensed for women during pregnancy and for small children. It is also widely used for neonates, particularly in hospital and specialist care, although not specifically licensed for this group. Over-the-counter influenza treatments containing decongestants and/orsedatives in addition to paracetamol and are not recommended. They are only marginally effective and there is also a risk that safe paracetamol dosage could be exceeded if over-the-counter remedies are used while paracetamol is also being taken. Instead nasal decongestant sprays, steam inhalations and a simple cough linctus can be used alongside paractamol (DH Pandemic flubfn drugs in breastmilk information) There are also suitable antibiotics, should these become necessary for the treatment of complications, such as bacterial respiratory infections. See external link to for further information about treatments for coughs and colds remedies & breastfeeding Pregnancy and Pandemic Flu Advice As with many drugs, oseltamivir and zanamivir have not been specifically tested in pregnancy and breastfeeding and therefore are not licensed for this use. For both products (ieoseltamivir and zanamivir), use in pregnant and lactating women is only recommended based on the individual risk benefit assessment of the treating physician. Zanamivir results in significantly less systemic exposure than oseltamivir and therefore also significantly less potential exposure to the foetus. And therefore Relenza is the recommended antiviral for pregnant women. Pregnant women should use paracetamol to control fever. Pregnant women should not take non-steroidal anti-inflammatory drugs for the treatment of flu symptoms, because they may interfere with the baby s pulmonaryblood flow. (DH Pandemic Flu guidance) 12

13 Flu Pandemic Algorithm for the Maternity Unit Appendix B Suspected Case Does it meet case definition? YES Isolate immediately Staff need to Wear P.P.E. Review by Obstetric Registrar or consultant on call Limit the number of staff entering side room to a minimum Contact Consultant Microbiologist if clinical advice needed Contact Infection Prevention team (leave a message if out of hours) Inform the Bed Office, Head of Midwifery This is to be used in conjunction with the current W.H.O H1N1 Flu Pandemic Algorithm 13

14 Pandemic Flu Guidance for Health Care Staff Appendix C 14