Preparations for pandemic influenza Guidance for ospital medical specialties on adaptations needed for a pandemic influenza outbreak June 2009
Te Royal College of Pysicians Te Royal College of Pysicians plays a leading role in te delivery of ig-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide pysicians in te United Kingdom and overseas wit education, training and support trougout teir careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work wit government, te public, patients and oter professions to improve ealt and ealtcare. Copyrigt All rigts reserved. No part of tis publication may be reproduced in any form (including potocopying or storing it in any medium by electronic means and weter or not transiently or incidentally to some oter use of tis publication) witout te written permission of te copyrigt owner. Applications for te copyrigt owner s written permission to reproduce any part of tis publication sould be addressed to te publiser. Copyrigt 2009 Royal College of Pysicians Royal College of Pysicians of London 11 St Andrews Place, London NW1 4LE www.rcplondon.ac.uk Registered Carity No 210508 Designed and typeset by te Publications Unit of te Royal College of Pysicians ii Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Contents Contributors Preface iv v General guidance 1 Introduction 1 2 Public information 3 3 Te etical basis for decision-making 3 4 General assumptions 3 5 Aims 4 6 Inpatients 5 7 Outpatients 5 References 7 Specialty guidance Part 1: Major impact medical specialties Acute and general (internal) medicine 8 Infectious diseases and tropical medicine 11 Palliative medicine 14 Respiratory medicine 17 Part 2: Affected medical specialties Cardiology 20 Dermatology 22 Diabetes 24 Endocrinology 27 Gastroenterology and epatology 28 Genitourinary medicine 30 Geriatric medicine 32 Haematology 33 Immunology and allergy 35 Neurology 39 Oncology 40 Reabilitation medicine 43 Renal medicine 45 Reumatology 50 Appendix 51 Yellow Card: for patients likely to need a follow-up appointment during a pandemic Blue Card: for patients likely to require access to remote advice but not an appointment during a pandemic Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 iii
Contributors Rodney Burnam, Registrar, Royal College of Pysicians Simon Barton, Celsea and Westminister Hospital, London (Joint Specialty Committee for Genitourinary Medicine) David Bateman, Consultant Neurologist, Nort Cumbria Acute NHS Trust (Joint Clinical Neurosciences Committee) Cris Conlon, Reader in Infectious Diseases and Tropical Medicine, University of Oxford; Consultant in Infectious Diseases, Jon Radcliffe Hospital, Oxford (Joint Specialty Committee on Infectious Diseases and Tropical Medicine) David Crossman, Professor of Clinical Cardiology, University of Seffield (Joint Specialty Committee for Cardiology) Cris Deigton, Consultant Reumatologist, Derby City General Hospital (Joint Specialty Committee for Reumatology) William Egner, Consultant Immunologist, Seffield Teacing Hospitals NHS Trust (Joint Committee on Clinical Immunology & Allergy) Mike Galloway, Consultant Haematologist, Sunderland Royal Hospital (Intercollegiate Committee on Haematology) Lawrence Goldberg, Lead Consultant, Sussex Kidney Unit, Royal Sussex County Hospital, Brigton (Joint Specialty Committee for Renal Medicine; Renal Association) Alison Jones, Consultant in Medical Oncology, Royal Free and UCLA Hospitals, London (Joint Specialty Committee for Medical Oncology) Tara Kearney, Consultant Endocrinologist, Salford Royal Foundation Trust, Salford (Society for Endocrinology) Rosemary Lennard, Consultant in Palliative Medicine, Bradford Teacing Hospitals NHS Foundation Trust, Bradford (Joint Specialty Committee for Palliative Medicine) Wendy Makin, Macmillan Consultant in Palliative Care and Oncology, Cristie NHS Foundation Trust, Mancester (Joint Specialty Committee for Palliative Medicine) Ann Millar, Consultant Respiratory Pysician, Soutmead Hospital, Bristol (Britis Toracic Society) Jackie Morris, Honorary Consultant Pysician, University College Hospital, London (Joint Specialty Committee for Geriatrics) Roy Pounder, Emeritus Professor of Medicine, University of London; Member, Emergency Preparedness Clinical Leaders Advisory Group, Department of Healt Arcie Prentice, Consultant Haematologist, Royal Free Hospital, London (Intercollegiate Committee for Haematology) Jonatan Rodes, Professor of Medicine, University of Liverpool (Joint Specialty Committee for Gastroenterology and Hepatology; Britis Society of Hepatology) Ken Saw, Honorary Consultant Pysician and Emeritus Professor of Medicine, Queen Alexandra Hospital, Portsmout (Joint Specialty Committee for Endocrinology & Diabetes) Jackie Serrard, Curcill Hospital, Oxford (Joint Specialty Committee for Genitourinary Medicine) Jane Sterling, Senior Lecturer and Honorary Consultant Dermatologist, Addenbrooke s Hospital, Cambridge (Joint Specialty Committee for Dermatology) RM Temple, Consultant Pysician, Heart of England Foundation Trust, Birmingam (Acute & General (Internal) Medicine Committee) Cris Ward, Professor and Consultant in Reabilitation Medicine, University of Nottingam and Derby Hospitals Foundation Trust, Derby (Britis Society of Reabilitation Medicine; Joint Specialty Committee for Reabilitation Medicine) Wei Sen Lim, Consultant Respiratory Pysician, Nottingam University Hospitals, Nottingam (Britis Toracic Society) iv Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Preface Tis document is designed to indicate ow specialties could adjust teir patterns of work in order to cope during an influenza pandemic wen staff and facilities available to care for patients may be reduced. Te intended audience for tis guidance is tose involved in managing and strategic planning of clinical services, and clinical staff working in ospital specialties. It is not designed to provide detailed operational guidance for responding to an influenza pandemic, but to enable ospitals to coordinate care during a difficult period. Te College is grateful to Roy Pounder wo ad te original idea and to te cairmen of te Joint Specialty Committees and teir colleagues wo put so muc time into preparing tis guidance. We ope tat it will elp to improve care for patients. Dr Rodney Burnam Registrar, Royal College of Pysicians Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 v
General guidance 1 Introduction In te event of an influenza pandemic, many of te issues tat ospital specialties will ave to consider are generic, so general guidance is given in tese introductory sections. Te specialty guidance is divided into two main parts. Part 1 deals wit tose specialties tat are likely to be most severely affected by an influenza pandemic, wile Part 2 sets out key issues and recommendations for te remaining specialties, eac of wic will be affected to varying degrees by pandemic influenza. Important Department of Healt documents ave been produced. 1 Strategic ealt autorities and primary care trusts, all of wom will be individually responsible in teir areas for te command and control structures and management of te pandemic, ave developed, or sould be in te process of developing, teir local policies. Local response plans sould focus primarily on ways of supplementing and making te most effective use of staffing and beds, wit particular attention to facilitating rapid discarge arrangements. Alternative care sites may need to be set up, suc as private ospital/clinic facilities. Doctors sould be aware tat tere are legal issues tat may impinge on trusts influenza pandemic plans. Tese range from regulatory matters troug to concerns about staff undertaking unfamiliar roles, and trusts/specialties temporarily providing levels of treatment wic differ from tose recommended in te usual protocols. See Department of Healt guidance. 2 Influenza pandemics background information Influenza pandemics occur wit variable frequency. During te last century, tey occurred in 1918/19 ( Spanis flu ), 1957 ( Asian flu ), and most recently in 1968 ( Hong Kong flu ). Altoug it is considered inevitable tat tere will be anoter pandemic in te futur e, it is not known wen tis will occur. Wile any new strain of te influenza virus could trigger a pandemic, current concerns include H1/N1 (swine flu) virus and te possibility tat a mutation of te avian H5/N1 influenza virus could readily infect and be transmitted by umans. Wit ordinary seasonal flu usually 5 15% of te population become symptomatic, but in a pandemic tis is lik ely to be 25 50%. Te planning assumption for te UK is tat up t o 4% of symptomatic patients would warrant ospital admission (if capacity were available). UK mortality in previous pandemics as been 0.2 2% of tose wit symptoms. Current national planning assumes a case fatalit y rate of 0.4 2.5% of tose wit symptoms. Tis translates to a UK mortality of between 55,500 and, in a worst case scenario, 750,000. Te predicted progression of a pandemic across te world and in te UK is summar ised in te following World Healt Organization (WHO) and UK pases and aler t levels sown in Table 1. 1 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
WHO international pases 1 No new influenza virus subtypes detected in umans Inter-pandemic period UK impact UK not affected unless it as strong travel and trade connections wit affected country 2 Animal influenza virus subtype poses substantial risk Pandemic alert period 3 Human infection(s) wit a new subtype, but no (or rare) person-to-person spread to a close contact UK not affected unless infection starts in te UK or it as strong travel and trade connections wit affected country 4 Small cluster(s) wit limited person-to-person transmission but spread is igly localised, suggesting tat te virus is not well adapted to umans 5 Large cluster(s) but person-to-person spread still localised, suggesting tat te virus is becoming increasingly better adapted to umans Pandemic period 6 Increased and sustained transmission in general population UK alert levels 1 Virus/cases only outside te UK 2 Virus isolated in te UK 3 Outbreak(s) in te UK 4 Widespread activity across te UK Table 1. WHO international pases 3 and UK alert levels 2 for an influenza pandemic. Timing of emergency actions Altoug normal services will need to be sustained for as long as possible, at some point a fundamental sift in te pattern of care provision will be required to prioritise te needs of large numbers of infected patients, togeter wit tose of non-infected patients wit urgent clinical needs. At WHO pase 6, UK alert level 2 (Table 1), 2,3 routine activities may need to be scaled back in anticipation of a rapid surge in influenza cases in te UK. At WHO pase 6, UK alert levels 3 and 4, it is possible tat non-essential procedures will ave to be discontinued in order to maintain life-saving activities. Tus, at te earlier stages of te pandemic, it will be appropriate to postpone some routine surgery and outpatient services. At te later pases of an influenza pandemic were tere is widespread disease, it may be necessary to cancel/postpone all elective clinical functions and concentrate on expanding capacity for management of influenza and non-influenza emergency cases. Staffing factors Up to 50% of ealt workers may require time off work at some stage during te pandemic. Staff will take time off not only because of personal influenza infection (tis can take one to two monts), but also to provide care for dependants (weter ill relatives, or cildren because of Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 2
scool closures), because of family bereavement, oter psycosocial factors, fear of infection and/or practical difficulties in getting to work. At te peak of te pandemic, between 15% and 20% of staff may be absent at any one time. All ospital doctors, watever teir main specialty, are likely to be involved in te care of patients wit influenza. New working patterns and responsibilities will be needed to cope wit te demands of te acute inpatient workload, and flexible (and extended) working rotas will be needed to cover staff sortages and emergency workload. Tose unfamiliar wit acute medical problems sould receive some retraining to equip tem to manage emergencies as part of a team. An influenza pandemic will put staff under considerable pressure and tere are likely to be conflicts between staff s professional and/or contractual obligations, teir personal or family responsibilities, and concerns about risks. Te Department of Healt is working wit NHS employers to produce detailed guidance for uman resource management during a pandemic, 4 covering te etical and professional obligations of staff. 2 Public information Eac trust sould post an announcement on its website and inform te local media tat all normal outpatient services are closed, and tat patients must assume tat all teir future appointments are cancelled until furter notice. Te standard information on te Blue Access Card (see Appendix) sould be on tis notice. Telepone numbers and an email address wic can be used for enquiries by te public sould be provided. Establised clinics and departments sould ave direct lines and email addresses, to allow direct access by clinicians from outside te ospital (ie remotely). Tese sould be separate from general trust pone numbers. A national flu line service will be available for individuals wo wis to seek advice. National patient organisations may be a useful source of advice and support for patients and sould be involved in planning. 3 Te etical basis for decision-making General guidance as been provided. 5 An on-call regional advice service would also be beneficial, and would allow specialists on te front line to talk troug difficult problems and possible solutions wit a senior colleague and ensure consistency of response. 4 General assumptions An influenza pandemic (WHO pase 6) causing major disr uption to ealtcare services is likely to last about four monts. A second wave of disease may occur 3 9 monts after te first wave as subsided. At tat point tere may be a post-infection coort of staff wit immunity. 3 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
A pandemic would ave up to a 50% attack rate (50% of te population develop clinical flu during a single pandemic wave), wit a 4% admission rate for symptomatic patients. Acute medical and surgical emergencies needing immediate admission will be seen in A&E or an admissions unit. Outpatient clinics will be running at 10% of capacity. Suc a decrease of activity will inevitably increase te risk of morbidity and mortality. Te priority will be to provide te most good for te most patients. Te greatest pressure during a pandemic will be sustained by GPs and teir staff, so any new system must be easy to access. Telepone, fax and email facilities remain largely intact (60% of usual capacity). Capacity will be reduced in medical records, and medical secretarial support (20% of usual capacity). Laboratory services for baseline aematology and biocemistry tests will remain largely intact (60% of usual capacity), wit reduced outpatient venepuncture capacity (20% of usual capacity). Medical and nursing capacity will be greatly reduced, due to oter clinical priorities (10% of usual capacity). All patients seen in outpatient clinics a ve a clinical situation tat, in order of priority, is as sown in Table 2. Table 2. Priorities for outpatient appointments in te event of an influenza pandemic. Priority 1 (P1) Priority 2 (P2) Priority 3 (P3) Patients wit a life-treatening problem Patients wit conditions of life-sortening potential Patients wit conditions causing unbearable symptoms 5 Aims To ave reduced capacity in ospital outpatient clinics and da y-case wards, for bot new and follow-up appointments (to 10% of normal capacity) for te minimum amount of time necessary. To minimise day-case attendance at ospital premises, probably by providing a telepone and email advice service. To minimise contact between patients to reduce person-to-person spread. To allow ospital resources to be focused on te surge capacit y. To reduce unrealistic demands on te service. To ensure tat patients wit a good cance of recovery from oter illnesses are not adversely affected by surge prioritisation strategies for critical care. Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 4
To identify in advance were ospital assessment in te outpatient setting dur ing a pandemic is necessary and to establis and communicate a mecanism by wic appropriate patients can access te service. 6 Inpatients Estimates suggest tat existing ospital capacity may only meet 20% to 25% of te expected demand at te peak of te pandemic wave. Proportionate admission tresolds based on clinical management guidelines will terefore need to be agreed and progressively applied across specialties witin trusts. Consistency and equity in te application of suc tresolds will be an important factor in gaining public understanding and maintaining confidence (see especially te Reabilitation medicine section in Part 2). Common understanding and interpretation of tese guidelines by ealt professionals at te primary, secondary and social care interfaces are particularly important. 7 Outpatients All non-urgent outpatient activity will need to be cancelled for a period tat could be between two and five monts, depending on te beaviour of te pandemic locally. Tere will be a need to provide emergency inpatient care for influenza and non-influenza cases. Staff wo are able to attend for work, and facilities, will be triaged to life-saving work on te wards. Eac specialty as patients under long-term outpatient care wo require ongoing careful supervision to avoid serious complications of teir condition or its treatment. New referrals will be necessary for tose needing urgent outpatient assessment and management (eg inflammat ory bowel disease). All referrals sould be prioritised by te consultant to wom tey are referred, according to te criteria set out in Table 2. General management of outpatient clinics Clinic staff will need to retain referral letters after prioritisation and lists of follow-up patients until suc time as new appointments are available. (a) Follow-up outpatients A telepone outpatient service may need to be expanded/introduced, run by nurse specialists or medical staff. Establised clinics and departments sould ave direct lines and email addresses wic can be accessed by clinicians from outside te ospital. Tese sould be separate from general trust pone numbers. All appointments sould be cancelled for four monts, on a week-by-week basis, wit rare exceptions identified eiter by clinical need according to specialty guidance, or by te patient teleponing te ospital for verbal assistance and a possible clinic v isit. All outpatients likely to require follow-up witin a four-mont window sould be issued in advance wit eiter a Blue Access or a Yellow Follow-up Card (see Appendix) depending on 5 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
teir condition, tat will provide some access to specialist advice (telepone otline or email address, or bot). (b) Tose patients wo are at ig risk (identified by specialty priorities) sould be contacted by te team at te beginning of te surge so tat some follow-up arrangements can be establised. Tey sould be issued wit a Yellow Follow-up Card in advance, and eac clinic sould establis a register of suc patients (wit teir latest contact details). Patients wose conditions are not likely to require a clinic visit but will need some access to specialist advice sould be given a Blue Access Card. Patients wo are not likely to need access sould not be given a card. Some patients may only need to visit te ospital for new blood t ests for example, if receiving drugs wit a toxicity problem. Eac department needs to identify suc patients and develop a system for (a) providing te patient wit a request form, (b) reviewing te results, and (c) contacting te patient. Te standard of care for tese safety studies may ave to be lowered, according to te emergency situation. Te plebotomy service will need planning so tere is a minimal cance of cross-infection between patients. New outpatient appointments It is anticipated tat te rate of new non-influenza related referrals will fall dramatically. All new referrals must be delayed for up to four monts (eiter by te GP or te consultant), wit a few exceptions in very ig priority cases. Te referral letter sould fulfil priority criteria for eac specialty. A consultant (preferably te consultant to wom te patient as been referred) sould review every new referral, sanctioning only tose wit apparent life-treatening illness (Priority 1), or of life-sortening potential (Priority 2), or causing unbearable symptoms (Priority 3). All new patient referral letters must ave te patient s pone number, and furter prioritisation or advice may be made during an initial telepone consultation between te consultant and te patient. Additional precision in prioritisation may be acieved by review of baseline patology results, prior to any clinic appointment. Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 6
References 1 Te following page lists all te pandemic flu guidance tat as been publised by te Department of Healt: www.d.gov.uk/en/publicealt/flu/pandemicflu/dh_093202 2 Department of Healt. Pandemic flu: a national framework for responding to an influenza pandemic. www.d.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_080754 3 World Healt Organization (WHO). www.wo.int/csr/disease/influenza/pandemic/en 4 Department of Healt. Pandemic flu: uman resources guidance for te NHS. www.d.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_086833 5 Department of Healt. Responding to pandemic influenza: te etical framework for policy and planning. www.d.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_080751 Useful additional documents Britis Infection Society, Britis Torax Society, Healt Protection Agency. Pandemic flu: clinical management of patients wit influenza-like illness. Torax Jan 2007, 62(Suppl 1). General Medical Council. Pandemic influenza. Good medical practice: responsibilities of doctors in a national pandemic. London: GMC, 2009. Royal College of General Practitioners. Preparing for pandemic influenza. Guidance for GP practices. Wat to do now and in a pandemic. London: RCGP, 2008. 7 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Specialty guidance Part 1: Major impact medical specialties Acute and general (internal) medicine A Impact of a pandemic on emergency departments and medical admissions units Early in a pandemic (Pase 6, alert levels 1 or 2; see Table 1, p2), in te interests of infection control and efficiency of patient flows, trusts will need to separate individual emergency cases immediately into influenza and non-influenza cases as far as pr acticable. Furter into a pandemic (Pase 6, alert levels 3 or 4) separation and isolation of individual patients in te assessment and admission patways will not be possible. Instead trusts will need to manage te large numbers of patients presenting, by coorting influenza and noninfluenza management streams in order to minimise cross-infection. Bed demand will increase substantially during a pandemic. Trusts will need to plan for up to a fourfold increase in emergency admissions. Planning measures will include a substantial reduction in elective activity and transfer out into te community of all patients wo do not need active medical treatment in ospital. Constraints of staffing and specialist equipment (eg ventilators) are very likely to adversely affect te number of available inpatient beds. In te peak of a pandemic (weeks 6 8) up to 50% of certain staff groups (eg nursing) may not be working because of a combination of personal illness, te requirement to care for ill family members, transport disruption and cild care demands due to scool closure. B Acute pysician activity and duties during a pandemic Emergency departments and medical admissions units Acute pysicians will ave a major role in te assessment and initial management of patients presenting as an emergency wit and witout symptoms of influenza. Acute trusts are likely to designate medical admissions units (MAUs) as a coort area for te assessment and admission of patients presenting as an emergency wit influenza symptoms. MAUs designated as flu coort areas are likely to be managed primarily by te acute medical team in conjunction wit respiratory and G(I)M pysicians and, were available, infectious disease (ID) pysicians. It is anticipated tat acute pysicians will take te lead in triaging patients and coordinating te available workforce. Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 8
Central to acute trusts contingency planning is te designation of pandemic influenza coort wards. Were te MAU is te designated flu assessment area, designated flu wards are likely to be tose wards nearest te MAU in te interests of infection control witin te ospital. A likely sequence of designated flu wards identified is: MAU and/or ID wards (were available) > respiratory wards > oter medical wards. Patients located on tese wards are likely to be cared for primarily by te medical teams linked to te wards, supplemented by medical and nursing staff released from oter clinical areas (eg elective surgery medical and nursing staff). Inpatients at ig risk of deat from pandemic influenza (eg immunosuppressed patients) sould be segregated and managed in designated non-flu ward areas. It is anticipated tat EDs will maintain a separate stream for assessment and admission of medical emergencies wo do not ave influenza symptoms. Acute pysicians and geriatricians ave an important contribution to te staffing of tis non-flu stream wit particular empasis on identifying medical patients wo do not r equire admission. Were admission is required tis will be to non-flu wards geograpically separated from te influenza coort wards. Outpatient services Specialty medicine outpatient services are likely to cease or be substantially reduced during te 16-week wave of pandemic influenza. Tis will be because of prioritisation of alternative duties for staff (and te clinic area), staff absence and a reluctance of patients to attend ospital during a pandemic for any reason oter tan an emergency. Witout careful planning, cancellation of specialty medicine clinics is likely to generate additional GP referrals (and self-referrals) to te ED. Medical specialty teams sould address tis by operating virtual clinics providing specialist advice by telepone and email to primary care staff and patients, backed up by arrangements to review te patient in a clinic or domiciliary setting. Acute pysicians sould ave te opportunity to set up virtual clinics to: receive and advise remotely on patient management issues ar ising from referrals by telepone or email by GPs provide remote follow-up and support to medical patients assessed in te ED wo were not admitted receive patient self-referrals by pone or email wit medical problems as an alternative to tem oterwise attending te ED; tis service could be provided by a senior nurse in an acute medicine team wit consultant support. Tis service is likely to be most effective were virtual GP surgeries are also in place, receiving initial patient self-referrals and providing advice to patients wen referral (or self-referral) to secondary care is required. 9 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Te layout and facilities of a large outpatient department mean tat te area may well ave a specific designated function during a pandemic; for example: assessment and admission area for eiter flu or non-flu patients were alternative areas for tese distinct clinical patways cannot be found in te t rust area for te administration of antiviral agents to staff (propylactic or terapeutic) and/or for te administration of flu vaccine (once available). C GIM pysician activity and duties during a pandemic Emergency departments, medical admissions units and medical wards Tere will be tree distinct roles for GIM pysicians: working in conjunction wit acute pysicians (see above) in te assessment and management of te early admission of patients wit suspected pandemic influenza continuing care of influenza patients on flu coort wards, intensive care units (ITUs) and ig dependencey units (HDUs) caring for inpatients admitted as medical emergencies wo do not ave influenza symptoms. Outpatient services Any GIM clinic activity occurring in te trust is likely to cease altogeter. Tis activity will eiter be managed in primary care or referred to specialty medicine. GIM pysicians sould ave te opportunity to develop virtual clinics as for acute pysicians. Te specific aims of tese remote-access clinics would be to: prevent a patient oterwise presenting to te ED provide follow-up support to tose patients discarged eiter direct from te ED or following an inpatient stay. RM Temple Acute & General (Internal) Medicine Committee Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 10
Infectious diseases and tropical medicine It is likely tat infectious diseases (ID) pysicians and infectious diseases units w ill be in te forefront of te clinical care of patients during an influenza pandemic. Issues to consider will be: planning for te pandemic at t rust and community level providing advice to te trust and to GPs wen a pandemic starts agreeing admission criteria for admitting patients wit influenza to ospital providing clinical care for patients admitted to ospital liaising wit oter clinicians; particularly intensive care (ITU) and respiratory pysicians agreeing discarge criteria ensuring adequate care for tose wit oter infections tat are not influenza. A Planning for a pandemic Most ID pysicians will ave been involved wit bot teir own trusts and wit teir primary care trusts in pandemic influenza planning for some time. Tey need to provide clinical expertise and leadersip in te decision-making pr ocess and advise planners on te practicalities of decisions tat are reaced. Tey sould also elp to educate teir own ospital staff about te issues surrounding a possible influenza pandemic in order to minimise panic and to maximise te ospital s response wen a pandemic occurs. B Providing advice wen a pandemic starts ID pysicians will need to elp to allay fears and to provide clear clinical advice about wat constitutes a probable or definite case of influenza. Tey sould work in conjunction wit GPs and public ealt teams to ensure tat patients wit possible influenza are assessed and treated in te community as muc as possible to avoid unnecessary ospital attendances. Tey sould provide support to ospital emergency departments wit clear clinical advice about patients wit possible influenza wo attend te emergency department. C Agreeing admission criteria ID pysicians will need to agree, wit oters, te criteria by wic patients wit influenza are admitted to ospital. Altoug national guidelines exist, tese may be modified locally. In addition, tese agreed criteria may need substantial modification once te pandemic is underway. 11 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
D Clinical care of inpatients wit influenza Infectious diseases units will, were tey exist, be expected to take te first patients wit pandemic influenza wo need ospital admission. ID pysicians will be responsible for te clinical care of patients wit influenza and its complications. It is likely tat ID SpRs will be required to act up in some settings if senior ID pysicians are drawn in to oter operational roles in te Trust. E Liaising wit oter clinicians For inpatients, tere will need to be close links between ID pysicians and tose in intensive care units (ITU) and in Respiratory medicine to provide optimum ventilatory support for tose needing it. It is likely tat during a pandemic, not all patients needing suc support will be able to get it, so front line clinicians will ave to consider varying criteria for ITU admission etc as te pandemic progresses. Tere will need to be close working wit GPs and public ealt doctors about te pace of te pandemic and te likely clinical need as time goes on. F Agreeing discarge criteria Again, via liaison wit oters, tere will need to be clear criteria for wen patients can be discarged from ospital and wat solution can be found for tose t oo frail to go directly ome. Tese criteria will also need to be reviewed over te time of te pandemic. Tere will also need to be clarity about discarge for ITU. G Caring for tose wit infections tat are not influenza Inpatients Patients wit acute infections will still require ID expertise but may ave to be admitted to oter areas of te ospital, or in some circumstances, be treated in te community. ID pysicians will need to provide advice to oter clinicians wo may need to look after conditions wit wic tey are not usually familiar. It may be tat junior ID doc tors will ave to run a consultation service for tese purposes tat is pysically separate from te ID unit. Outpatients Many ID pysicians ave a considerable outpatient load, particularly wit people wit HIV and oter bloodborne virus infections. Arrangements will ave to be made to ensure tese patients ave access to teir regular medication and advice, for example by email or telepone, if tere are problems. It is likely tat regular outpatients will be disrupted for some weeks or monts. Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 12
Patients wit HIV may be able to be managed by parmacists in some areas and by liaising wit local genitourinary medicine (GUM) services in oters. Summary Because of te nature of te pandemic, it is likely tat most ID pysicians and units will be fully engaged wit te pandemic from te start. Teams of ID pysicians can divide te various tasks outlined above between tem, and may rotate tese tasks to avoid burnout. Te normal day-to-day function of te ID unit will be severely disrupted and trusts will ave to ensure tat teir normal acute activities are covered, as far as possible, even if it involves care of suc patients outside te ID unit, leaving te unit free to care for tose wit influenza. Cristoper P Conlon Joint Specialty Committee on Infectious Diseases and Tropical Medicine 13 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Palliative medicine A Impact 1: large number of patients dying from influenza need acute end-of-life care in ospital and community Implications Community end-of-life care will be led by primary care teams. Involvement of specialist palliative care teams will be mainly troug provision of advice rater tan face-to-face input. Palliative care teams will support end-of-life care for tose admitted to ospitals. Access to syringe-drivers and supplies of oxygen for symptom support in communities will rapidly be exausted. Proposed response Community teams sould be provided wit palliative care resource packs, not yet developed nationally. Te use of non-injectable parenteral routes for medication, including buccal/rectal, sould be maximised. A programme of rapid training for carers sould be instigated. Parmacy services sould be extended. Planning Now Develop criteria for an end-of-life integrated care patway to be used in tose dying from influenza. Develop resource pack wit medication for symptom management. Develop brief training package for carers to administer te medications. Pandemic imminent Ensure tat care teams ave local 24-our access to drug supplies/resource packs. B Impact 2: increased demand upon palliative care services by non-influenza cases In te event of an influenza pandemic it is anticipated tat palliative care teams, in addition to caring for patients wit influenza, will face an increased workload from non-influenza cases. Factors will include: existing patients wit palliative care needs wo cannot access secondary care in crisis Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 14
palliative care services are referred additional patients wo cannot access ospital care as tey do not meet te cr iteria for admission palliative treatments (eg cemoterapy, transfusion drainage of effusions) may be limited or curtailed wit additional need for community support. Implications Hospital palliative care teams will be required to facilitate patients early discarge from ospital if tey were already in ospital at te star t of te pandemic. Uncontrolled/complex problems ave to be managed at ome/ospice. Tere will be increased numbers wit distress beyond te usual palliative care population. Tere may be limited access to syringe-drivers for symptom support in community, and limited or unsustainable number of staff available to supervise use. Tere will be increasing demand on ospice beds. Proposed response Enance availability of 24-our palliative care advice by telepone for professionals and patients/relatives. Increase domiciliary services to support tose wit complex needs at ome. Reconfigure specialist palliative care services, for example: maintain ospice beds close ospice beds and staff support community care including nursing ome beds possibly redeploy ospital teams into te community. Maximise te use of non-injectable parenteral routes for medication (buccal/rectal) were possible, but te training of carers sould include giving injections. Provide additional ome palliative care packs link to extended parmacy services. Planning Now Local palliative care lead sould develop plan wit flu pandemic coordinator at primary care trust. Agree nominated ospice beds to provide palliative care resource for locality. Agree local system to prioritise access to inpatient beds. Agree system to prioritise workload in te community. Develop palliative care resource pack and brief training for carers. Pandemic imminent Ensure te list of staff wit community experience, nurse prescribers etc is up to date. Ensure local 24-our access to palliative care drugs/resource packs. 15 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
C Impact 3: depletion of existing specialist palliative care teams (up to 50% become ill) Implications Try to conserve enoug fit staff at any time to support essential activities. Maximise use of experienced/trained staff contacts wo may be drafted into action. Ensure staff take appropriate steps to reduce risk of acquiring or transmitting infection. Reconfigure services temporarily to provide support were most needed. Proposed response Staff sould be trained in infection control measures. Increase available supplies of antiviral/immunisation drugs and face masks. Cancel non-essential activities: teacing, lympoedema, day ospice respite care services. Consider switc from inpatient ospice care to community support model (see also Impact 2). Planning Now Identify palliative care leads for eac locality to work wit flu pandemic coordinators. Provide flu pandemic training programme for palliative care teams. Prepare staff lists to include retired/bank/volunteer contacts wit specialist palliative care experience. Agree plans for use of services witin eac locality. Pandemic imminent Distribute supplies, antivirals, face masks, disposable respirators. Review/update contact lists. Modify services. Wendy Makin Rosemary Lennard Joint Specialty Committee for Palliative Medicine Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 16
Respiratory medicine A Background Te Britis Toracic Society Pandemic Flu Guidelines Working Party of te Standards of Care Committee, wit te Britis Infection Society, te Healt Protection Agency and in collaboration wit te Department of Healt, recently publised guidelines for te clinical management of patients wit influenza-like illness during an influenza pandemic. 1 Te recommendations below must be considered out of te ordinary and apply only during a pandemic period. It is acknowledged tat during a pandemic, te usual standards of care in relation to outpatient priorities may not be acievable. As a specialty, respiratory medicine will be significantly affected by a pandemic, not only during te peak of a pandemic but also in its aft ermat, as many patients recovering from te complications of influenza may require specialist respiratory input. A significant increase in clinical workload following a pandemic sould terefore be allowed for, wic may require te following priorities to be applied for a p eriod of time beyond te pandemic. B Specialty priorities for outpatient review Patients wit respiratory disorders will be particularly at risk from influenza and its complications. Terefore, almost all patients wit cronic respiratory disorders will require remote access (email, fax or telepone) to specialist advice during a pandemic, and sould be issued wit a Blue Access Card (see Appendix). Symptoms consistent wit an exacerbation of an underlying respiratory disorder may resemble or be indistinguisable from te symptoms of pandemic influenza. Patients wit symptoms of pandemic influenza will be best managed according to local pandemic flu patways to ensure timely access to antivirals, and timely assessment for influenza-related complications. Also, tese patients sould be seen in setting s were te appropriate infection control measures are in place. Respiratory outpatient clinics will need to carefully consider infection control issues, bearing in mind te possible overlap in symptoms relating to influenza and te respiratory disorder in question. Triage according to infection control risks may be appropriate. For any prioritisation system to work in an emergency wen medical records and clinic staff will be depleted and under severe work pressure, preparatory work will need to be very extensive to pre-identify individual patients in te categories below and prepare follow-up/access cards etc. Patient involvement in tis process will be important, callenging and time consuming. 17 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
C Follow-up of establised outpatient attenders Patients wo may require follow-up during a pandemic (Yellow Card) Te following are considered groups of patients wose condition may very likely suffer if tey are automatically excluded from planned outpatient follow-up for over four monts, and for wom a Yellow Follow-up Card (see Appendix) sould be considered: patients wit proven malignancy patients wit unstable or brittle astma patients wit cystic fibrosis patients wit tuberculosis patients wit lung transplantation patients wit pulmonary ypertension. Patients wo may require priority access/advice during a pandemic (Blue Card) Patients wit te following conditions may be suitable for a delay of four monts for planned follow-up and sould be issued w it a Blue Access Card. Individual patients will require assessment for a Yellow Follow-up Card, depending on teir medical requirements. interstitial lung disease sarcoidosis allergic lung and broncial disorders cronic obstructive pulmonary disease (COPD) bronciectasis neuromuscular disease-related respiratory disorders. Patients wo are unlikely to require access or follow-up during a pandemic Patients wit te following conditions are likely to be suitable for a four-mont delay in outpatient follow-up: sleep-disordered breating occupational lung disease cronic coug and upper airway disorders. D New patient appointments In te context of a pandemic, respiratory symptoms and signs suc as coug, purulent sputum, breatlessness and clinical signs of lower respiratory tract infection will be very common and may be due to pandemic influenza. Patients wit symptoms of pandemic flu sould be treated according to pandemic flu patways (see above) and not referred as new patients to respiratory clinics. Infection control considerations must be taken into account in all instances. Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 18
Examples of acute respiratory symptoms, not tougt to be due to pandemic flu, tat will require te patient to be issued wit a Yellow Card and referred for outpatient consultation during an emergency pandemic period (togeter wit priority indicator P1, P2, P3; see Table 2, p4) include: stridor (P1) severe breatlessness (P1) large volume aemoptysis (P1) small volume aemoptysis (P2/3) suspected malignancy (P2) suspected tuberculosis (P1/2 also public ealt pr iority) pleural effusion (P2/3) abnormal cest X-rays (P2/3 depending on abnor mality). All oter new referrals sould be delayed (eiter by te GP or by te consultant) for four monts, unless agreed oterwise on a case-by-case basis. Tis emergency strategy will undoubtedly affect usual standards of best care. Reference 1 Lim W S. Pandemic flu: clinical management of patients wit an influenza-like illness during an influenza pandemic. Provisional guidelines from te Britis Infection Society, Britis Toracic Society, and Healt Protection Agency in collaboration wit te Department of Healt. Torax 2007;62(suppl 1);1 46. (Accessible at www.brit-toracic.org.uk/pandemicflu) Wei Sen Lim Ann Millar Britis Toracic Society 19 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Part 2: Affected medical specialties Cardiology A Background Te presenting symptoms and complaints of patients attending cardiology outpatient clinics are: cest pain (~45%) valve disease (~5%) palpitations (~25%) cardiomyopaty and Marfan s/aortic disease (~4%) eart failure (~10%) eart disease in pregnancy (~1%) syncope/dizziness (~5%) oter (~5%). * B New patients Priority 1: Apparent life-treatening illness Tis category includes patients wit: syncope associated wit exercise, wit evidence of native or prostetic valve disease or wit a family istory of sudden deat palpitations or cest pain wit collapse (patients wit cest pain sould be referred to a rapid-access cest pain clinic (RACPC)) istory of fever/malaise and aving eart valve disease, congenital eart disease or a previous istory of infectious endocarditis. Patients wit symptoms compatible wit acute myocardial infarction and tose patients wit symptoms and signs of acute pulmonary oedema will be referred to te A&E department and issued wit a Yellow Follow-up Card (see Appendix). Priority 2: Potentially life-sortening illness Patients wit te following conditions sould be issued wit a Yellow Card: unexplained syncope oter tan above sortness of breat or oedema believed to be of cardiac origin refractory to oral diuretics wit grade 3 4 symptoms and/or paroxysmal nocturnal dyspnea (PND), or believed to be of cardiac origin presenting in pregnancy istory of significant congenital eart disease wo ave become pregnant. * Figures based on a recent survey of outpatient attendance at Seffield Teacing Hospitals Trust. Tese recommendations on RACPC referrals would predict a reduction in referral rates to <20% (based on figures supplied by Professor A Timmis). Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 20
Priority 3: Intolerable symptoms Patients wit te following conditions sould be issued wit a Yellow Card: sortness of breat refractory to oral diuretics wit grade 3 4 symptoms and/or PND atrial fibrillation wit continued symptoms of sortness of breat/pre-syncope despite attempts at rate control. C Follow-up patients Tese sould be stratified along te access/follow-up card system (see Appendix). 1 Patients wo will need continued review Yellow Follow-up Card and planned appointment Pacemaker clinic patients were pacemaker is <6 monts from estimated end-of-life Defibrillator clinic patients were device is <6 monts from estimated end-of-life or as delivered >1 sock Anticoagulant clinic patients see below Pregnant patients wit establised eart disease under cardiac review 2 Patients wo may need access to outpatient review witin four monts Yellow Card only Heart failure clinic patients Patients followed because of a istory of ventricular tacycardia (VT), or survivor of out-of-ospital ventricular fibrillation (VF) 3 Patients wose appointments can be cancelled for four monts All palpitation patients witout syncope All patients wit cest pain and previous normal coronary artery disease All routine valve follow-up patients All routine post-revascularisation patients All patients followed by surveillance eco (aortic dimensions etc) All routine follow-up of patients wit atrial fibrillation or oter SVT patients 4 Patients on anticoagulants Tese patients sould attend for blood test cecks as usual Yellow Card. David Crossman Joint Specialty Committee for Cardiology 21 Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276
Dermatology A Follow-up of establised outpatients Patients wit proven malignancy (malignant melanoma, squamous cell carcinoma, cutaneous lympoma, etc): delay four monts, but establis access/follow-up card system (Blue Access Card), plus planned selective follow-up for tose patients most at r isk (Yellow Follow-up Card) (see Appendix). Patients wit unstable skin and past istory of skin malignancies: delay four monts, but establis card system (Blue Card), plus planned selective follow-up for tose patients most at risk (Yellow Card). Patients receiving immunosuppressive or anti-mitotic terapy dose and disease stable: delay four monts, but establis access/follow-up card system (Blue Card), plus planned selective follow-up for tose patients most at r isk (Yellow Card). Patients commencing immunosuppressive or anti-mitotic terapy dose and disease not stable: see as planned (Yellow Card). Patients receiving oter terapy requiring regular monitoring and prescription (eg talidomide, acitretin, isotretinoin): see as planned (Yellow Card). Patients receiving intravenous ospital treatment (eg immunoglobulin or biological terapy): see as planned (Yellow Card). Oter skin diseases: delay four monts. B New patient appointments Examples of tose new life-treatening or severe symptoms tat sould be referred for outpatient consultation (togeter wit priority indicator P1, P2, P3 and te card to be issued under te access/follow-up card system): connective tissue disease wit systemic upset (P1: Yellow Card) severe drug reactions (P1: Yellow Card) Stevens-Jonson syndrome (P1: Yellow Card) toxic epidermal necrolysis (P1: Yellow Card) erytrodermic eczema (P2: Yellow Card) pustular or erytrodermic psoriasis (P2: Yellow Card) suspected malignant melanoma (P2: Yellow Card) suspected squamous cell carcinoma (P2: Yellow Card) suspected rapidly growing skin malignancy (P2: Yellow Card) vasculitis (P2: Yellow Card) Royal College of Pysicians, 2009. All rigts reserved. www.rcplondon.ac.uk/pubs/brocure.aspx?e=276 22