INFECTION PREVENTION & CONTROL PROTOCOL FOR SEASONAL INFLUENZA

Transcription

1 INFECTION PREVENTION & CONTROL PROTOCOL FOR SEASONAL INFLUENZA Department / Service: Infection Prevention and Control Originator: Dr Mary Ashcroft, Heather Gentry Infection Control Doctor Lead IPC Nurse Accountable Director: Mari Gay Approved by: Trust Infection Prevention & Control Committee Date of approval: February 2016 or chairs approval First Revision Due: February 2018 and annually as PHE guidance issued Target Organisation(s) Worcestershire Acute Hospitals NHS Trust Target Departments All clinical departments Target staff categories All clinical staff Overview: This protocol describes the Infection Control precautions for the immediate management of cases of seasonal influenza including H1N1 (Swine flu). Note: Clinical management of patients is included in this document as Seasonal influenza clinical management guideline under appendix 1. National clinical guidance is available on the Gov.uk website under Please refer to the Trust Management of Infection Prevention and Control Policy WAHT-CG-043 Key amendments to this Document: Date Amendment By: Oct 11 New document Feb 12 Format change to protocol, previously WAHT-CG-708 Dec 2014 Protocol updated Heather Gentry Lead June 2015 Nov 2015 Additional information added: definitions, isolation of contacts and prophylaxis of at-risk staff Protocol and references updated following the issue of revised PHE guidance in August and September 2015: use of antiviral agents and infection control precautions. Appendices reviewed and updated. Nurse IPC Mary Ashcroft Consultant Microbiologist Heather Gentry Lead Nurse IPC WAHT-INF-033 Page 1 of 22 Version 2.1

2 Nov 2015 Seasonal influenza clinical management guideline under appendix 1 Dr Hugh Morton and Dr Thekl Gee Consultant Microbiologists References: click on relevant links to be directed to the document Trust Code: Trust Management of Infection Prevention and Control Policy WAHT-CG-043 General Decontamination Protocol WAHT-INF-009 Hand Hygiene Policy WAHT-INF-002 Isolation Policy WAHT-INF-015 Gov.uk website for documents listed below [online] available at: [Accessed 13th February 2016] HSE (2013) Respiratory protective equipment at work A practical guide HSG53 (Fourth edition, published 2013). [online] available at: [Accessed 7th November 2015] NHS Employers Flue fighter campaign [online] available at: [Accessed 7th Nov 2015]. NHS England PHE (2013) A guide to the FFP3 respirator leaflet v2 [online] available at: [Accessed 7th November 2015]. NHS England PHE (2013) How to put on and check an FFP3 respirator [online] available at: [Accessed 7th November 2015]. NHS England PHE (2015) guidance on use of antiviral agents for the Treatment and prophylaxis of seasonal influenza: ( ) v6.0, September 2015 [online] available at: ment_data/file/457735/phe_guidance_antivirals_influenza_201 5_to_2016.pdf [Accessed 7th Nov 2015]. NHS England PHE (2015) Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings [online] available at: [Accessed 7th Nov 2015]. PHE Letter to clinicians regarding the use of antivirals in influenza Nov 2014 [online] available at: ment_data/file/370676/letter_to_clinicians.pdf [Accessed 7th Nov 2015]. WAHT-INF-033 Page 2 of 22 Version 2.1

3 Contents page: 1. Introduction 5 2. Scope of this document 5 3. Definitions 5 4. Responsibility and Duties 6 5. Protocol detail Patients who are suspected of suffering from influenza Outcome of assessment How to swab for influenza Isolation of patients Cohort isolation Period of isolation of patients Isolation of contacts Period of isolation of contacts When a contact develops flu-like symptoms Patient personal protective equipment Staff personal protective equipment For general care (excluding aerosol inducing procedures) For aerosol inducing procedures Hand hygiene Equipment Waste and linen management Visitors Cleaning Transfers to other departments within the same hospital Transfers or admission of patients from other healthcare providers 1 14 WAHT-INF-033 Page 3 of 22 Version 2.1

4 5.15 Staff vaccinations and prophylaxis Care of the cadaver Background Consultation Approval process Equality requirements Financial risk assessment 15 Appendices 1. Seasonal influenza clinical management guideline (click here) Summary guide level of PPE Mask usage information 19 Supporting Documents Supporting Document 1 Supporting Document 2 Supporting Document 3 Checklist for review & approval of a key document Equality Impact Assessment Financial Risk Assessment WAHT-INF-033 Page 4 of 22 Version 2.1

5 1. Introduction This protocol is designed to be used for the management of patients presenting with symptoms of seasonal influenza. It is assumed that patients will present either: in A & E or a suspicion will be raised concerning an existing in-patient (including MAU) or a suspicion will be raised concerning a patient attending clinic appointments or there will be a GP referral 2. Scope of this document This protocol covers infection control precautions for health care staff, patients and visitors within acute Trust clinical settings. 3. Definitions Seasonal influenza, or 'flu', is a highly contagious acute viral infection that affects people of all ages. It typically starts suddenly with fever, chills, headache, aching muscles, extreme fatigue and a cough or other breathing difficulties. While most people recover without complications in 1-2 weeks, flu can cause serious illness and death, especially in those with risk factors for complicated influenza. Uncomplicated influenza: Influenza presenting with fever, coryza, generalised symptoms (headache, malaise, myalgia, arthralgia) and sometimes gastrointestinal symptoms, but without features of complicated influenza. Complicated influenza: Influenza requiring hospital admission and/or with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical condition. Risk factors for complicated influenza: Neurological, hepatic, renal, pulmonary and chronic cardiac disease. Diabetes mellitus Immusuppression Age over 65 years Pregnancy (including up to two weeks post partum) Children under six months of age Morbid obesity (BMI>40) WAHT-INF-033 Page 5 of 22 Version 2.1

6 4. Responsibility and Duties The Acute Trust IPCT has the responsibility to implement this protocol and all clinical staff in the Acute Trust has the responsibility to follow it. 5. Protocol Detail 5.1 Patients who are suspected to be suffering from influenza should be placed immediately in a room separate from other patients while they are being assessed. A full history should be taken to obtain the following information; Flu vaccination history Is the patient pregnant? Been in contact with a confirmed or suspected case of seasonal flu? Fever or history of fever >38 C plus at least two of the following: Cough Sore throat Runny se (coryza) Limb/joint pain Headache Diarrhoea and/or vomiting Does the patient have any risk factors for complicated influenza as outlined previously in section 3. Neurological, hepatic, renal, pulmonary and chronic cardiac disease. Diabetes mellitus Immusuppression Age over 65 years Pregnancy (including up to two weeks post partum) Morbid obesity (BMI>40) If seasonal flu is likely please inform the Infection Prevention & Control Team (IPCT) at WRH Ext: or at the Alex on Ext: Out of hours please leave a message on the answer phone where it will be dealt with the following working day. WAHT-INF-033 Page 6 of 22 Version 2.1

7 5.2 Outcome of assessment: Case Actions Precautions Influenza is the primary suspected diagsis based on clinical symptoms Take viral throat swabs Start antivirals Isolate in a single room Staff to wear PPE (aprons, gloves and mask) refer to mask Influenza is possible or unlikely cause for symptoms Take viral throat swabs usage poster Isolate if possible otherwise risk assess patient based on symptoms for care within a bay Viral swabs are available from virology or A&E departments. NB: if viral swabs available use a dry sterile swab, cut swab into a dry sterile container. 5.3 How to swab for influenza (also refer to appendix 1 for pictorial guide): Taking the nasal swab tilt the patient s head back slightly, bend the flexible wire of the sterile nasal swab in a small arc and gently insert the swab along the medial part of the septum until it reaches the posterior nares. Rotate the swab a few times, remove and place into the media. You will need to snap the swab in order to fit it into the tube. Taking the throat swab vigorously swab the posterior pharyngeal wall and then place the swab into the media tube. Break the swab so that it fits into the tube. Only use n-wired swab to take throat swab. Diagram 1 below: The black dots show the area to be swabbed when sampling the throat. WAHT-INF-033 Page 7 of 22 Version 2.1

8 Swabs will be tested in-house and significant results communicated to the ward as soon as possible however clinical staff must check for results at least daily on the ICE system. 5.4 Isolation of Patients (NB: Risk Assessment for the prioritisation of side rooms flowchart to be used click here for Ward Forms on the Infection Prevention & Control webpage on Trust Intranet) In A&E or MIU, patients should be assessed in a single room with the door shut. Patients who have been accepted from GP referral by a senior member of the admitting medical team should be admitted directly to an isolation room preferably on Avon 3 if at the WRH site and the respiratory ward at the Alexandra site. Inpatients identified on general wards or MAU should be isolated immediately in a single room and advice sought from the IPCT. In all cases: The door must be closed An isolation door tice should be attached to the door. (See isolation Policy on Intranet WAHT-INF-015). Ensure the need to wear masks is indicated to all persons entering the room). Appropriate personal protective equipment should be placed outside the room if t readily available. WAHT-INF-033 Page 8 of 22 Version 2.1

9 If single rooms are in short supply and laboratory confirmation is awaited, after a documented risk assessment, it may be feasible to prioritise patients with cough and sputum production for single room placement, (PHE 2015, p9) Also, it may be reasonable to assume that patients admitted with complications of influenza, and have therefore had symptoms for 3 4 days, and who are NOT immucompromised, are less infectious than those admitted with new influenza-like symptoms (PHE, 2015 p 9) Cohort Isolation In the event of individual isolation facilities being exceeded within the Trust a cohort area(s) may be required on a section of Avon 3 at WRH, Ward 5/ Ward 12 at the Alexandra site or as advised by the IPCT. The trigger for cohort isolation of patients will include 4 or more patients of the same gender with a suspected or confirmed influenza strain or local intelligence of an escalation in potential cases. Infection Prevention & Control measures will be adapted to apply to these circumstances and guidance will be given, if necessary Period of isolation of patient When the patient has completed 5 days of antiviral treatment, and has clinically improved they can be moved out of isolation at the discretion of the IPCT. Exceptions may apply in particular vulnerable patients e.g. immusuppressed/children and will be advised on an individual basis by the IPCT. 5.5 Isolation of contacts Contacts are defined as patients who are nursed in the same bay as an affected patient with flu. If they are at-risk of complicated influenza (outlined previously) they must be offered anti-viral prophylaxis providing it can be given within 48 hours of contact (after 48 hours on specialist advice only discuss with Microbiology Consultant). In addition patients without risk factors may be offered anti-viral prophylaxis at the discretion of the IPCT. Contacts may be isolated in a single room or cohorted in a bay with other contacts. Masks are t required to be worn if contacts are asymptomatic Period of isolation of contacts Contacts should stay in isolation for a minimum of four days after last contact with an affected patient; this may be longer at the discretion of the IPCT When a contact develops flu-like symptoms It is very important to be aware that should a contact develop flu-like symptoms whilst on prophylactic anti-viral treatment the dose must be increased to a treatment dose and started from day 1 of treatment schedule. WAHT-INF-033 Page 9 of 22 Version 2.1

10 5.6 Patient Personal Protective Equipment The patient should wear a surgical fluid shield if they need to be transported through the hospital. If the patient is wearing a mask staff transporting the patient will t be required to wear a mask; if the patient is unable to wear a mask for any reason, then healthcare workers transporting or accompanying the patient who will be required to come within two meters of the patient should wear a fluid shield face mask. 5.7 Staff Personal Protective Equipment For General care (excluding aerosol generating procedures (AGPs)): Protective Clothing To be worn by all staff with direct contact or on entering the room An apron (available in all areas) should be worn while carrying out the initial assessment of a patient. Non-sterile examination gloves are to be worn to reduce the level of contact with virus from the patient or their environment. This makes hand hygiene more effective. Masks Surgical (fluid shield) masks will be suitable for most tasks and must be worn by all staff when entering a patient room. It is important that each mask is applied properly. Surgical fluid shield masks are to be worn by patients if they require transportation within the hospital e.g. to radiology (see section 5.6 above) Dispose of gloves and apron in the infected (orange bag) waste bin inside the room immediately before you leave the room and wash hands. Remove the mask inside/outside the room, and dispose of as infected (orange bag) waste (in sluice if bin available outside room). Wash or gel hands after disposing of the mask. Do NOT reuse any of these items. The same mask should t be worn from one room/bay to ather. However, when patients are cohorted in one area and multiple patients require care, it may be more practical to put on a surgical fluid shield mask on entry to the area and keep it on for the duration of the care activities or until the mask requires replacement (when it becomes moist or damaged or is or removed between patients). WAHT-INF-033 Page 10 of 22 Version 2.1

11 PPE Details Order for putting on (all outside room) Order for taking off Face mask fluid shield surgical mask * 1 3 outside room Apron Plastic 2 2 inside room Gloves Nitrile procedure gloves 3 1 inside room *See paragraph above For aerosol generating procedures, e.g. suction, NIPP: Aerosol generating procedures include: Induction of sputum Cardio Pulmonary Resuscitation (CPR) Intubation, extubation & related procedures e.g. manual ventilation/ open suctioning NIPPV, BiPAP, CPAP, HFOV Bronchoscopy Dental procedures NB: Administration of humidified oxygen and nebulisers are NOT considered to be aerosol inducing procedures. FFP 3 masks are required for AGPs for seasonal influenza, however, if staff can be identified who are currently trained in the use of FFP3 masks a supply of FFP2 duckbill masks are held in stock as it is easier to undertake a visual fit check test and see the mask is filtering. As soon as all staff are FFP3 trained the FFP2 mask will be phased out. 5.8 Hand Hygiene Essential before and after all patient contact, removal of protective clothing and cleaning of the environment Use soap and water (especially after removing gloves or if hands soiled) or use sanitizing hand rub if hands are physically clean or on exiting the room Staff must t wear rings, wrist-watches and wrist jewellery HCWs should t wash their hands in patient washrooms / en-suite facilities use dedicated hand wash sinks WAHT-INF-033 Page 11 of 22 Version 2.1

12 For further guidance click here for Hand Hygiene Policy (WAHT-INF-002) 5.9 Equipment Use single patient use / dedicated equipment where possible in isolation room (remove n-essential items prior to occupation) Dispose of single use equipment as clinical waste inside room Ventilators should be protected with filters and standard decontamination procedures followed Closed system suction should be used Crockery should be treated as rmal and washed using the ward dishwasher (where available) or returned to central wash up in the Catering Department (Redditch and Kidderminster) 5.10 Waste and Linen Management Dispose of all waste as hazardous (kwn infected orange bag) waste Patients should be encouraged to use the en-suite facilities, however if required, urine / excreta should be disposed of via the sluice room Linen should be placed in a red alginate liner bag within the room and placed into the red plastic outer bag outside the door of the room and taken directly to the disposal cupboard 5.11 Visitors The number of visitors should be restricted as far as possible and agreed with the Nurse in Charge Contacts who show evidence of symptoms should t visit as they may spread the infection to others Visitors or carers entering the isolation room who will already have been exposed to the patient do NOT need to wear any protective clothing unless involved in direct care when gloves and aprons may be used. Visitors and carers should be requested to use hand sanitising gel when entering an isolation room/cohort bay and to hand wash prior to leaving the room. Hand sanitising gel should then be used again after exiting the room. WAHT-INF-033 Page 12 of 22 Version 2.1

13 5.12 Cleaning Standard isolation room cleaning to be implemented and ward housekeepers / domestic staff informed Domestic staff must be made aware of the need for additional precautions (see below) Daily cleaning should be carried out with Tristel Fuse solution Domestic staff to wear protective clothing as indicated above (5.7) The isolation area should be cleaned after the rest of the ward area Dedicated or preferably disposable equipment must be used for cleaning Re-usable cleaning equipment must be decontaminated following each use in accordance the Decontamination Policy (WAHT-INF-009) Dispose of all cleaning cloths and either launder mop heads after each use or use disposable. The rooms in A&E / MIU or any cubicle where patients with suspected influenza are assessed should be cleaned and disinfected before ather patient is seen or cared for in that environment Routine cleaning of nursing equipment can be undertaken with the usual green sanitising wipes available taking care to follow and s clean technique so as t to re-contaminate surfaces. Red HPV clean the area and change and launder curtains after patient discharge. If unable to vacate area for HPV amber clean and curtain change and Datix Transfers to other departments within the same hospital Where possible, all procedures and investigations should be carried out in the single room. Only a minimal number of staff should be present in the room during any procedures. If clinical need dictates, patients may be transferred to other departments and the following procedure would then apply: Ideally patients should be at the end of a list to allow appropriate decontamination after any procedure The receiving department must be informed in advance of the transfer The patient must be taken straight to, and return from, the investigation / treatment room, and must t wait in a communal area The patient should wear a surgical fluid shield mask this will prevent large droplets being expelled into the environment by the wearer WAHT-INF-033 Page 13 of 22 Version 2.1

14 . Portering and escort staff need t wear masks during transit if the patient is able to wear a mask. Gloves and aprons should be worn for direct contact with the patient. The trolley / chair should be wiped with a detergent wipe after use Staff carrying out procedures/investigations must wear the protective clothing indicated above (5.7). The treatment / procedure room should be cleaned with Tristel solution and all equipment as per Decontamination Policy. For high numbers of patients requiring X-ray, it may be necessary to dedicate a specific room in which patients can wait to avoid queues in the Radiology Department. If ambulance transfer is required, they must be informed in advance by ward staff so that Infection Prevention & Control measures should be taken Transfers or admission of patients from other healthcare providers Where patients are to be transferred to or from other healthcare providers it is essential if they are transferring to ather hospital, they are assessed for any need to be quarantined or isolated on transfer. If unsure discuss with the IPC Team BEFORE transfer. Where patients are being transferred to us from ather care environment, if there is any possibility they may have been exposed to influenza they should be isolated and assessed Staff vaccinations and prophylaxis vaccinations do t give immediate or full protection against all potential strains, and do t replace the need for adherence to infection prevention and control precautions as outlined above Staff who, during the course of their work, have come into contact with patients who are diagsed with actual or suspected influenza (refer to earlier definitions) and who are themselves at-risk of complicated influenza (refer to earlier definitions) should be offered anti-viral prophylaxis within 48 hours of contact. This should be arranged via the Occupational Health Department. Out of hours there is a PGD allowing the clinician looking after patient or OOH nurse practitioner to provide prophylaxis. If repeated or ongong exposure is suspected please discuss with the Microbiology Consultants. Staff are encouraged to participate in the annual OHD vaccination programme in the autumn. If you have missed the scheduled clinics it is recommended you still seek vaccination via Occupational Health (please remember annual vaccination is required to update your protection). WAHT-INF-033 Page 14 of 22 Version 2.1

15 Frequency of vaccination will be advised on an annual basis, further advice is available from Occupational Health and will be posted on the Trust Intranet. If a member of staff is off sick with flu-like symptoms they should inform the Occupational Health Department and should come back to work when they feel well eugh Care of the Cadavar Mortuary staff need to be aware of any infection, bagging of the cadaver is advised. Viewing of the body, embalming and other hygienic preparations in the mortuary are permitted. 6. Policy Background Information 6.1 Consultation All policies will conform to the Trust s standard structure and format and other requirements, as per Trust Policy for Policies (the development, approval and management of key documents WAHT-CG-001). All draft policies will be circulated to key stakeholders and representative of the target audience for comment prior to finalisation before being approved submitted for approval. 6.2 Approval process The final draft will be checked to ensure it complies with the correct format and that all supporting documentation has been completed appropriately. Infection Control policies and procedures will be submitted to the TIPCC for approval before document code and version number will be confirmed and the policies released for placement on the Trust intranet and hard copy production. This policy will also be presented to the Trust Board for final approval, as per the Trust s Policy for Policies. 6.3 Equality requirements The equality risk assessment for this policy has been undertaken and meets all the required standards (see Appendix 2). 6.4 Financial risk assessment Where resources are required to support Infection Prevention and Control strategy or policy implementation, the financial implications will be identified through the Trust s business planning procedures. Individual Directorates will also identify financial implications of complying with policies and procedures, WAHT-INF-033 Page 15 of 22 Version 2.1

16 (eg identifying staffing establishment requirements which are adequate to enable compliance with mandatory training requirements). See Appendix 4. WAHT-INF-033 Page 16 of 22 Version 2.1

17 Appendices Appendix 1 click below for document. Seasonal Influenza Clinical management Guidelines 2015/2016 NOTE: A hard copy has been issued to wards in December 2015 always check intranet version which will contain any updates or amendments to treatment. WAHT-INF-033 Page 17 of 22 Version 2.1

18 APPENDIX 2 click here for Summary Guide of Levels of PPE NOTE: A hard copy has been issued to wards in December 2015 always check intranet version which will contain any updates or amendments to treatment. WAHT-INF-033 Page 18 of 22 Version 2.1

19 WAHT-INF-033 Page 19 of 22 Version 2.1

20 Supporting Document 1 Checklist for review and approval of key document This checklist is designed to be completed whilst a key document is being developed / reviewed and should be used for new key documents, or existing documents, requiring a major review. A completed checklist will need to be returned with the document before it can be published on the intranet. 1 Type of document Protocol 2 Title of document Infection prevention & control protocol for seasonal influenza 3 Is this a new document? Yes No If, what is the reference number WAHT-INF For existing documents, have you included and completed the key amendments box? 5 Owning department Infection Prevention and Control 6 Clinical lead/s Dr Mary Ashcroft and Heather Gentry 7 Pharmacist name (required if medication is involved) 8 Has all mandatory content been included (see relevant document template) 9 For policies and strategies, does the document have a completed Equality Impact Assessment included? 10 Please describe the consultation that has been carried out for this document Yes N/A Yes Yes No No No Members of the IPC Team and TIPCC Once the document has been developed and is ready for approval, send to the Systems and Standards department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be returned to yourself, to submit to relevant committee for approval. 11 Step 11 To be completed by Systems and Standards Department Is the document in the correct format? Yes No Has all mandatory content been included? Yes No Date form returned / / 12 Please state the name of the approving body (person or committee/s) 13 Approval date 14 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this should be saved under TIPCC As per title of policy saved under Infection Prevention and Control WAHT-INF-033 Page 20 of 22 Version 2.1

21 Supporting Document 2 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. 1. Does the policy/guidance affect one group less or more favourably than ather on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Yes/No Comments Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? n/a 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? n/a n/a WAHT-INF-033 Page 21 of 22 Version 2.1

22 Supporting Document 3 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. INFECTION PREVENTION & CONTROL PROTOCOL FOR SEASONAL INFLUENZA 1. Does the implementation of this document require any additional Capital resources Yes/No 2. Does the implementation of this document require additional revenue 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice Yes seasonal increased usage of masks Yes FFP3 maskfit testing and ongoing updating 5. Are there additional staff training costs associated with implementing this document which cant be delivered through current training programmes or allocated training times for staff Yes FFP3 maskfit testing and ongoing updating Other comments: Although a seasonal rise in cases is seen, the preparatory work (training, PPE stock pile management and issue of PPE stock during influenza season) is year round. If the response to any of the above is yes, please complete a business case which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-INF-033 Page 22 of 22 Version 2.1