Chapter 5 Infectin Preventin & Cntrl Chapter 5 Infectin Preventin & Cntrl 1 Intrductin a. Scpe/Purpse b. Mde f Transmissin f Influenza Virus c. Pandemic Influenza Phases d. Infectin Preventin and Cntrl Cnsideratins During Pandemic Influenza 2 Infectin Preventin and Cntrl Cnsideratins During Pandemic Influenza a. Inter-Pandemic and Pandemic Alert Perids (Phases 1-5) - All Treatment Areas b. Pandemic Perid (Phase 6) All Nn-Influenza Treatment Areas c. Triage: Assessment f Influenza Symptms 3 Pandemic Perid Pandemic Designated Areas a. Acute Care b. Lng term Care c. Ambulatry Care d. Cmmunity Health Centres, Physicians Offices, Walk-in Clinics e. Hme Care f. Public Health 4 Pst Pandemic All Treatment Areas 5 Glssary 6 References Appendices (see Appendix Chapter) 5.1 Triage and Assessment Strategies 5.2 Influenza Assessment Tl 5.3 Assessment Algrithm 5.3.1 Adult Pint f Entry Respiratry Infectin Screening 5.3.2 Pediatric Pint f Entry Respiratry Infectin Screening 5.4 Perinatal/Obstetrical Cnsideratins 5.5 Interim Measures t Optimize Bed Availability During Influenza A H1N1 Pandemic 5.6 Organizatinal Risk Assessment and Checklist 5.7 Pint f Care Risk Assessment Table 1: Identificatin f the Physical Setting and Level f Patient Interactin Table 2: Identificatin f the Patient Clinical Status and Surce Cntrl Capability Table 3: Level f Precautins Matrix Table 4: PPE Required Fr Levels f Precautins Fr Influenza Pandemic P1
5.8 Quick Reference Guidelines fr H1N1 5.8.1 Quick Reference Guideline fr Health Care Wrkers fr H1N1 Influenza A Acute Care Settings 5.8.2 Quick Reference Guideline fr Health Care Wrkers fr H1N1 Influenza A Lng Term Care Settings Available at: WRHA Insite > Prgrams > Infectin Preventin & Cntrl > PCH Manual 5.8.3 Quick Reference Guideline fr Health Care Wrkers fr H1N1 Influenza A Cmmunity Settings - Available at: WRHA Insite > Prgrams > Infectin Preventin & Cntrl > Cmmunity Manual 5.8.4 Quick Reference Guideline fr Health Care Wrkers fr H1N1 Influenza A Hme Settings Available at: WRHA Insite > Prgrams > Infectin Preventin & Cntrl > Cmmunity Manual 5.9 Enhanced Drplet/Cntact Precautins 5.9.1 Acute Care Enhanced Drplet/Cntact Precautins 5.9.2 Lng Term Care/Persnal Care Hme Enhanced Drplet/Cntact Precautins Available at: WRHA Insite > Prgrams > Infectin Preventin & Cntrl > PCH Manual 5.9.3 Cmmunity Enhanced Drplet/Cntact Precautins - Available at: WRHA Insite > Prgrams > Infectin Preventin & Cntrl > Cmmunity Manual 5.9.3.1 Cmmunity Enhanced Drplet/Cntact Precautins Hme Settings 5.9.3.2 Cmmunity Enhanced Drplet/Cntact Precautins Clinic Settings 5.9.3.3 Cmmunity Enhanced Drplet/Cntact Precautins Cmmunity Settings 5.10 Enhanced Drplet/Cntact Precautins Sign 5.11 Manitba Naspharyngeal Aspirate/Swab Fact Sheet P2
1. INTRODUCTION A cmprehensive infectin preventin and cntrl prgram frms the basis f a successful pandemic influenza plan. Adherence t infectin preventin and cntrl plicies and prcedures is imperative t minimize the transmissin f influenza whether r nt vaccine and antiviral medicatins are available. Rutine Practices and Additinal Precautins t prevent the transmissin f infectin during the delivery f healthcare, in all healthcare settings during a pandemic, are imprtant. Certain precautins may be feasible nly in the pandemic alert and early pandemic perids, as they may nt be achievable r practical as the pandemic spreads and resurces (equipment, supplies, and human resurces) becme scarce. Strict adherence t hand hygiene is the crnerstne f infectin preventin and cntrl and may, at times, be the nly significant preventative measure available during a pandemic. The infectin preventin and cntrl guidelines in this sectin are critical t minimizing the transmissin f pandemic influenza. The chapter is brken dwn int infrmatin specific t all healthcare settings s all sites can use and adapt it fr their areas. A pandemic is a disease utbreak ccurring wrldwide and affecting a large number f peple. An influenza pandemic ccurs when a new influenza virus emerges and the general ppulatin has little r n immunity. The disease spreads easily persn-t-persn, causing serius illness. It can sweep acrss the cuntry and arund the wrld in a very shrt perid f time. Vaccines may be limited r cmpletely absent at the beginning f a pandemic. It is difficult t predict when the next influenza pandemic will ccur r hw severe it may be. Wherever and whenever a pandemic starts, the wrld ppulatin will be at risk. Cuntries may be required t clse brders r implement travel restrictins. An especially severe influenza pandemic culd lead t high levels f illness, death, scial disruptin, and ecnmic lss. Everyday life may be disrupted as a large percentage f the ppulatin may becme seriusly ill at the same time. Impacts culd range frm schl and business clsures t the interruptin f basic services such as public transprtatin and fd delivery. An influenza pandemic is prjected t have a glbal impact n mrbidity and mrtality, thus requiring a sustained, largescale respnse frm the healthcare cmmunity. It is expected such an event will quickly verwhelm the healthcare system lcally, reginally, and natinally. The number f healthcare wrkers available t respnd t these increased demands will be reduced by illness rates similar t pandemic influenza attack rates affecting the rest f the ppulatin. Healthcare wrkers and healthcare resurces will als be expected t cntinue t meet nn-pandemic assciated healthcare needs. a. Scpe/Purpse Implementatin f this plan r any part f it wuld be directed by the Winnipeg Reginal Health Authrity (WRHA) in cnsultatin with Manitba Health. This dcument prvides guidance and infrmatin n infectin preventin and cntrl prcedures fr staff wrking in WRHA healthcare settings fr all pandemic influenza phases. These guidelines are t be incrprated with ther Infectin Preventin and Cntrl (IP&C) guidelines and recmmendatins currently in place. This dcument may evlve as infrmatin P3
n the pandemic virus emerges. Users are strngly urged t refer t the mst up t date versin f this dcument psted n the WRHA intranet site. b. Mde f Transmissin f Influenza Virus The influenza virus is transmitted primarily by drplets In rder t feel cnfident in caring fr influenza patients during a pandemic, clinicians need t knw hw t prtect themselves and prtect thers. Be it seasnal r pandemic influenza, all influenza viruses are transmitted in the same way: primarily by drplets. Primarily by drplets reflects that in certain circumstances, drplets can turn int aersl particles, typically during aerslizing prcedures, such as intubatin. Additinally, influenza may be transmitted by direct r indirect cntact. Respiratry viruses are spread by either drplet r airbrne transmissin. The main difference between the 2 types f transmissin is: drplets drp, and airbrne particles flat. Drplets are larger and generally easier t cntrl than the smaller airbrne particles. Mst cld viruses are spread by drplets. Drplet transmissin f influenza virus: Drplets generally travel abut 1-2 metres befre they drp. Virus can survive n hard surfaces fr up t 48 hurs; sft surfaces fr up t 12 hurs; hands fr 5-10 minutes. Peple can be inculated with the influenza virus either by direct cntact with the mucus membranes f the eyes, nse, and muth, r frm indirect cntact via hands (r anything else) that has tuched a surface cntaminated by virus-filled drplets, which then cmes int cntact with smene s eyes, nse r thrat. Thrugh hand washing with sap and water is an effective way t decntaminate hands; alchl-based hand rub applied thrughly n the hands until it dries is equally effective and is the preferred methd f hand hygiene in the healthcare setting. c. Pandemic Influenza Phases The Wrld Health Organizatin (WHO) has develped a Pandemic Influenza Alert Classificatin system, and will identify which phase is ccurring internatinally and declare the beginning f a pandemic. The Public Health Agency f Canada (PHAC) will declare the beginning f the pandemic perid in Canada. Wrld Health Organizatin Pandemic Phases Perid Phase Descriptin Inter Pandemic Perid* Pandemic Alert Perid** Phase 1 Phase 2 Phase 3 Phase 4 N new influenza virus subtypes detected in humans. An influenza virus subtype that has caused human infectin may be present in animals. If present in animals, risk f human infectin r disease is cnsidered t be lw. N new influenza virus subtypes detected in humans. Hwever, a circulating animal influenza virus subtype pses a substantial risk f human disease. Human infectin(s) with a new subtype, but n human-t-human spread, r at mst rare instances f spread t a clse cntact. Small cluster(s) with limited human-t-human transmissin; P4
spread is highly lcalized suggesting virus nt well adapted t humans. Phase 5 Larger cluster(s) but human-t-human spread still lcalized, suggesting virus is becming increasingly better adapted t humans, but may nt yet be fully transmissible (substantial pandemic risk). Pandemic Perid Phase 6 Pandemic phase; increased and sustained transmissin in general ppulatin. Pst Pandemic Perid Return t Inter Pandemic perid. Surce: Wrld Health Organizatin, 2005. *The distinctin between Phase 1 and Phase 2 is based n the risk f infectin r disease frm circulating strains in animals. **The distinctin between Phase 3, Phase 4 and Phase 5 is based n the risk f a pandemic. d. Infectin Preventin and Cntrl Cnsideratins during Pandemic Influenza Sme IP&C strategies may be achievable nly in the early pandemic perid and nt achievable as the pandemic spreads and resurces (e.g., equipment, supplies, rms, and human resurces) becme scarce. The cmplexity f managing high-risk patients will be greatest in acute care hspitals cntinuing t admit patients with ther cmmunicable respiratry diseases. IP&C resurces may need t be priritized. Critically evaluate situatins in which Persnal Prtective Equipment (PPE) is indicated. If a sufficient supply f PPE is nt available, healthcare facilities may cnsider reuse f sme dispsable items nly as an urgent and temprary slutin, and nly if the item has nt been bviusly siled r damaged (e.g. creased r trn). Infectin Preventin & Cntrl (IP&C), and Occupatinal and Envirnmental Safety and Health (OESH) must be invlved in the decisin t reuse PPE. Rutine Practices and Additinal Precautins t prevent transmissin f infectin during a pandemic are imprtant. Adherence t IP&C precautins t limit healthcare-assciated transmissin shuld include: Educatin f staff, patients and visitrs regarding the transmissin and preventin f influenza; infrmatin must be understandable and applicable. Cntrls, such as the segregatin r chrting f patients with pandemic influenza frm thse with ther medical cnditins. Measures such as restricting ill wrkers and visitrs frm the site, and psting pertinent signage in clear, unambiguus language. Prir t any patient interactin, all Health Care Wrkers (HCWs)/ther staff have a respnsibility t always assess the infectius risk psed t themselves, ther patients, visitrs, and cwrkers by a patient, situatin r prcedure. The risk assessment is based n prfessinal judgment abut the clinical situatin and up-t-date infrmatin n hw the specific healthcare rganizatin has designed and implemented engineering and administrative cntrls, alng with the availability and use f PPE. Current recmmendatins frm PHAC suggest: Cmpliance with hand hygiene, Rutine Practices and Additinal Precautins. Prcedure r surgical masks, and face and eye prtectin t be used as standard prtective measures. P5
N95 respiratr, eye and face prtectin, a gwn, and glves wrn during aersl-generating medical prcedures (e.g., endtracheal intubatin r brnchscpy). KEY POINTS Patients with symptms f influenza shuld be separated frm nn-influenza patients as rapidly as pssible in all healthcare settings. Patients with influenza shuld be managed separately until discharged. Whenever pssible, separate staff shuld care fr influenza and nn-influenza patients. The separatin f symptmatic patients is imprtant in the cntainment f influenza. Careful cnsideratin f flexible accmmdatin and staffing arrangements is required. Patients remain n Additinal Precautins until discntinuatin criteria are met. 2. INFECTION PREVENTION AND CONTROL GUIDELINES a. Inter-Pandemic and Pandemic Alert Perids (Phases 1-5) - All Treatment Areas All treatment areas shall fllw Rutine Practices and Additinal Precautins as utlined in the WRHA IP&C Manuals. All staff shall practice Respiratry Etiquette ( Cver Yur Cugh ) and encurage patients and visitrs t d the same. Specific patients (e.g., elderly, yung children) may need assistance with cntainment f respiratry secretins; thse wh are immbile will need a receptacle (e.g. a plastic bag) readily at hand fr immediate dispsal f tissues, and a supply f hand hygiene prducts and tissues. In additin t Rutine Practices, Drplet/Cntact precautins shuld be taken fr paediatric and adult patients with knwn/suspected influenza. (see Appendix 5.9) Fr a mre cmplete discussin f Rutine Practices and Additinal Precautins refer t the WRHA IP&C Manual at http://hme.wrha.mb.ca/prg/ipc/manual.php b. Pandemic Perid (Phase 6) - All Nn-Influenza Treatment Areas During an influenza pandemic, healthcare facilities will be required t care fr current patients as well as thse requiring care specific t the pandemic. All necessary effrts will be used t maintain clean r nn-influenza care areas within healthcare facilities s that specific areas within each facility are designated as influenza r nn-influenza treatment areas. All patients shuld be triaged prir t placement in nn-influenza treatment areas. Refer t Sectin 2c, Triage: Assessment f Influenza Symptms i. Overview Staff prviding care will adhere t current IP&C practices, based n the principles f Rutine Practices and Additinal Precautins. P6
A high index f suspicin is required t identify ptentially infectius individuals. Patients shuld be assessed fr influenza symptms every 4-6 hurs t priritize thse requiring urgent attentin and Enhanced Drplet/Cntact precautins. (see Appendices 5.9 and 5.10) ii. Hand Hygiene Hand hygiene is the single mst imprtant practice t reduce the transmissin f infectius agents in healthcare settings. Strict adherence t hand hygiene recmmendatins is required. If the patient washrm must be used fr hand hygiene, avid cntaminatin f hands frm cntaminated surfaces r bjects. Strategically placed alchl-based hand rub and bxes f tissues may enhance hygiene practices. Staff, patients, and visitrs shuld be encuraged t practice basic hygiene measures such as respiratry etiquette and hand hygiene t minimize ptential influenza transmissin. iii. Patient Placement If pssible, patients with influenza symptms shuld be physically separated frm thse withut influenza symptms: Perfrm an influenza assessment using the Influenza Assessment Tl (see Appendix 5.2) including whether the patient needs t be mved t a designated influenza area. Place symptmatic patients n Drplet/Cntact Precautins in a single rm, r chrt with anther patient with influenza. iv. Cntact Tracing f Rmmates Rmmates are thse patients currently in the same rm as the surce patient, as well as any patient wh has shared a rm with the surce patient within the perid f cmmunicability. Fr pen units (e.g., the intensive care unit), rmmates are thse patients n either side f the affected patient, r any patient within 2 metres f the affected patient. Cntinue rmmate mnitring fr signs and symptms f influenza every 4 hurs, fr ne perid f incubatin after last cntact. Cntacts shuld nt be transferred t anther rm r care area fr the perid f incubatin (treat as a chrt fr ne incubatin perid). Cntinue unit mnitring beynd the surces rm fr additinal cases f illness (i.e., assess all patients n the unit fr symptms cmpatible with influenza every 4-6 hurs fr the perid f incubatin). c. Triage: Assessment f Influenza Symptms i. Assessment During an influenza pandemic, there will be a large number f peple seeking assessment fr Influenza-Like illness (ILI). Assessment guidelines have been develped P7
t evaluate the needs f each individual and t assist in the efficient triage f influenza patients in a crisis (see Appendices 5.1, 5.2 and 5.3). It may be necessary during the pandemic t have segregated triage areas fr influenza and nn-influenza patients. ii. Acute Care and Lng term Care Settings Facilities need t be prepared fr triaging, assessing, and managing a large number f peple. Whenever pssible, staff wrking with symptmatic patients/residents shuld avid wrking with patients/residents wh are nt symptmatic (staff chrting). This can be accmplished as fllws: Attempt t assign the same staff t assist symptmatic patients/residents. Keep symptmatic patients/residents in rm until symptms cease. Limit mvement f patients t medically essential purpses. Implement visitr restrictins. Grup activities shuld be cancelled. Fr exceptins, cnsult IP&C. iii. Ambulatry Care and Cmmunity Health Centres Definitins fr Ambulatry Care and Cmmunity Health Centres are prvided in this chapter s Glssary. Early recgnitin f patients/clients with symptms cmpatible with pandemic influenza will be imperative t determine flw and minimize cntact between symptmatic and asymptmatic patients/clients. When a pandemic is declared, each site shuld pen a triage area(s) fr client assessment in cnsultatin with the related Infectin Preventin and Cntrl prgram. Fllw the recmmendatins fr triage described in the Acute Care and Lng Term Care Settings. In additin, implement a telephne triage plan, based n reginal pandemic management directives. During telephne bkings, staff shuld inquire whether symptms are present as utlined in the Influenza Assessment Tl (see Appendix 5.2). Appintment scheduling fr patients/clients with respiratry symptms shuld be crdinated t avid expsure f patients/clients withut symptms. Nn-urgent visits shuld be cancelled. If telephne triage is nt apprpriate, cnsider actively screening patients/clients at the entrance t the clinic. If pssible, use a separate entrance fr symptmatic individuals and immediately lead them t an examinatin rm. iv. Screening All patients/residents wh present t a healthcare setting shuld be screened fr fever and respiratry symptms. This shuld include: Passive Screening - Visual alerts psted at the entrances t all healthcare settings asking patients/residents t reprt whether they have fever and any new r wrsening respiratry symptms, and Active Screening: - At first cntact, staff asks abut fever and respiratry symptms. Respiratry symptms include cugh, sre thrat, cryza (runny nse), and myalgias (general bdy aches). Refer t Influenza Assessment Tl (Appendix 5.2) and Pint f Entry Respiratry Screening (Appendix 5.3). Every effrt t separate patients/residents with pandemic influenza frm thse withut shuld be made. Identify a designated self-cntained area f the facility fr the triage, P8
treatment, and care f patients/residents with suspected/cnfirmed pandemic influenza. Drs shuld be clsed between influenza and nn-influenza areas. All individuals will be required t dn a prcedure r surgical mask prir t entry int the islatin rm/bed space. Ideally this area shuld: Be designated fr thse peple presenting with influenza. Include a receptin/triage area separate frm the rest f the facility. Have a separate entrance/exit frm the rest f the facility, if feasible. Nt be used as a thrughfare by ther patients/residents, visitrs, r staff. This includes patient/resident transfers, staff ging fr meal breaks, etc. Patients/residents wh reprt fever and respiratry symptms shuld be instructed t: Clean their hands with an alchl-based hand rub (r sap and water if immediately available). Dn a prcedure r surgical mask. Maintain a separatin frm ther patients/residents f 2 metres, minimum 1 metre. If this is nt pssible in the waiting rm setting, he/she shuld be placed immediately in an exam rm. T cntrl entry, signs designating the area as an islatin unit r area shuld be psted at all apprpriate entrances and exits. Psted signs must als alert everyne t the precautins t be adpted. Ensure clear directins t pandemic influenza assessment areas and admissin areas. There shuld be a nursing statin with administrative and supply strage space as clse t the entrance as pssible. Maintain a minimum f 4 metres (12 feet) between the administratin area and patient/resident care areas. Staff must determine the need fr PPE in accrdance with IP&C guidelines and the ptential risks invlved with patient care activities. Limit the number f persnnel t thse necessary fr patient care and supprt. v. Self-Assessment and Initial triage Public educatin may help peple t d their wn persnal assessment and thus reduce unnecessary strain n the healthcare system. Health Links-Inf Santé can assist with cnducting initial telephne assessments. These assessments will serve t determine whether a client is unlikely t have influenza and can stay at hme, r whether she/he needs t be seen by a clinician fr further assessment. Even with such mechanisms in place, there will be peple wh will need t be clinically assessed. Triage persnnel in the influenza assessment centres will need t be educated regarding hw t use algrithms t decide if and when clients can be sent hme with instructin and fllw-up, managed in an ambulatry site, r admitted t an acute care hspital. Fllw Appendix 5.3 (Pint f Entry Respiratry Screening), fr guidance regarding the management f triaged individuals with suspected r cnfirmed influenza (see als Appendix 5.2). P9
vi. Assessment Prcess Organize the assessment area t minimize crwding, and prvide fr apprpriate spatial separatin f 2 metres, minimum 1 metre, between patients/clients in assessment centres, waiting areas, and patient care areas. Whenever pssible, use single rms fr clients with symptms cmpatible with influenza. When single rms r physical barriers are nt pssible, ensure spatial separatin f tw metres, minimum 1 metre, is maintained between patients/clients. Ensure assessment staff is evaluating nt nly the patient s/client s symptms but als the symptms f the persn accmpanying the patient/client. Fllw Enhanced Drplet/Cntact Precautins (Appendices 5.9 and 5.10). Assessment Criteria fr Persns Accmpanying Patient/Client If the persn accmpanying the patient/client has symptms cmpatible with influenza and the patient/client has n influenza symptms and is NOT at high risk f severe cmplicatins frm influenza: Cnsider patient/client expsed t pandemic influenza. Cnsider symptms are cmpatible with pandemic influenza. Infrm the accmpanying persn with symptms cmpatible with influenza they may stay with this patient/client. Infrm the accmpanying persn with symptms cmpatible with influenza if they leave the patient s/client s bedside, they must leave the patient/client area and leave the facility; r wait in the Influenza Assessment area. They may NOT g t the cafeteria, visit ther patients/clients/residents, r wait in any public area. If the persn accmpanying the patient/client has symptms cmpatible with influenza and the patient/client has n symptms cmpatible with influenza but is AT high risk f severe cmplicatins: Cnsider patient/client expsed t pandemic influenza. Cnfirm the symptms are cmpatible with pandemic influenza. Infrm the accmpanying persn with symptms cmpatible with influenza they must leave the patient s/client s bedside and must leave the facility. If the accmpanying persn is required t stay, e.g. parent, they must fllw respiratry etiquette including the use f a mask, at all times. 3. PANDEMIC PERIOD - PANDEMIC DESIGNATED AREAS Please nte, the decisin t implement segregated influenza and nn-]influenza areas wuld be determined by the WRHA IP&C prgram, in cnjunctin with Manitba Health. A. Acute Care a. Admissin/Discharge Limit admissin f influenza patients t thse with severe cmplicatins wh cannt be cared fr utside the hspital setting. If a patient is discharged while pssibly still infectius, patient and family members shuld be educated abut hand hygiene, respiratry etiquette, the use f a prcedure mask by a cughing patient, and additinal IP&C measures, accrding t current recmmendatins. P10
b. Accmmdatins/Chrting Refer t Triage, Assessment f Influenza Symptms in Sectin 2c f this chapter. Refer t Triage and Assessment Strategies, Appendix 5.1. Refer t Influenza Assessment Tl, Appendix 5.2. Refer t Pint f Entry Respiratry Screening, Appendix 5.3. Every effrt shuld be made t segregate patients with suspected r cnfirmed influenza frm thse wh d nt have signs and symptms f respiratry illness. Place symptmatic patients n Enhanced Drplet/Cntact Precautins, Appendices 5.9 and 5.10. Single rm preferred. Chrt patients if necessary. Assign patients with cnfirmed pandemic influenza t the same rm. If labratry testing t cnfirm the virus is limited, chrt cases based n symptms cnsistent with pandemic influenza. Patients wh have recvered frm influenza are cnsidered immune. They may be mved int the nn-influenza chrt area after the perid f cmmunicability f the pandemic strain has passed. As the pandemic prgresses, the suspect/expsed chrt and the cnfirmed influenza chrt may require a merge. Refer t Appendix 5.5, (Interim Measures t Optimize Bed Availability in Acute Care Facilities) during Influenza A H1N1 Pandemic. Maintain chrt principles until pandemic has been declared ver and directin received frm the WRHA. c. Aersl-Generating Medical Prcedures (AGMPs) Refer t the Glssary in this chapter fr a list f AGMPs. Perfrm a risk assessment based n prfessinal judgement abut the prcedure and current infrmatin t determine the apprpriate administrative cntrls, envirnment cntrls, and PPE. Refer t Appendix 5.7 (Pint f Care Risk Assessment). Whenever pssible, ensure AGMPs are cnducted in a cntrlled setting. This requires early recgnitin f patients wh may require high-risk interventins (e.g., intubatin, brnchscpy) in rder t avid emergency situatins. Perfrm these prcedures in an Airbrne Infectin Islatin Rm (AIIR). The availability f these rms may be limited. These rms shuld be used fr individuals with diseases transmitted by the airbrne rate. If this is nt pssible, perfrm the prcedures in a single rm. If a single rm is nt available, a minimum f 2 metres separatin with privacy curtains shuld be used. All persnnel in the rm must wear PPE (e.g. gwns, glves, N95 respiratrs, and eye prtectin). D nt delay urgent prcedures waiting fr an AIIR. d. Care f the Deceased Cmply with established recmmendatins frm Rutine Practices fr care f the deceased. In Autpsy/Pathlgy rms, all persnnel in the rm must wear PPE (e.g. gwns, glves, N95 respiratrs, and eye prtectin) during aersl-generating prcedures. P11
e. Duratin f Additinal Precautins IP&C will advise regarding discntinuing Additinal Precautins based n the current recmmendatins frm the WRHA and MB Health. f. Envirnmental Cntrl Adhere t established recmmendatins fr husekeeping, and linen/laundry and waste dispsal (see Chapter 10, Equipment and Supplies, Nutritin and Fd Services; Laundry Services; Medical Device Reprcessing). Refer t WRHA IP&C Nn-critical, Re-useable Items Plicy 90.00.040, web link: http://hme.wrha.mb.ca/prg/ipc/files/manualhspital_plicy.pdf n page 15. Dishes Special precautins are nt required. Fllw Rutine Practices. Envirnmental Cleaning and Disinfectin/Husekeeping Frequency f envirnmental cleaning and disinfectin shuld be increased during a pandemic. Perfrm meticulus daily cleaning and disinfectin f envirnmental surfaces and nn-critical patient care items. Surfaces frequently tuched by hands (e.g., medical equipment) and thse ptentially cntaminated by cughing patients, shuld be cleaned and disinfected frequently (at least twice daily), and when knwn t be cntaminated. Reduce clutter t allw fr cleaning and disinfectin. Equipment Cleaning and Disinfectin Cmply with established plicies and prcedures fr cleaning, disinfectin, and sterilizatin f patient care equipment. Laundry Special precautins are nt required. Fllw Rutine Practices. Physical Setting Ensure the accessibility and availability f supplies: Tissues and n-tuch receptacles fr used tissue dispsal. Alchl-based hand rub and/r hand washing supplies (sap, water, paper twels). Prcedure r surgical masks fr persns wh are cughing. Remve any frequently handled unnecessary items frm waiting rms, i.e. magazines and tys. Waste Special precautins are nt required. Fllw Rutine Practices. g. Labratry Best Practices It is vital t btain a labratry sample in rder t cnfirm r rule ut the diagnsis f pandemic influenza. P12
A decisin may be made later in the pandemic t cease testing fr pandemic influenza unless the patient is in specific high risk grups. T take a naspharyngeal swab: Ensure the crrect viral swab kit is used, (refer t Manitba Naspharyngeal Aspirate/Swab Fact Sheet, Appendix 5.11) and that it is nt past its expiry date. Ensure bth the specimen and the requisitin are clearly labeled with the patient s name and anther unique identifier, such as date f birth r healthcare number. It is imprtant t nte the expsure histry and clinical symptms n the lab requisitin. h. Signage and Infrmatin sheets Pst signs at all entrances infrming patients, family members, visitrs, vlunteers, and staff regarding respiratry etiquette, hand hygiene, and the need fr immediate reprting f symptms f a respiratry infectin Respiratry etiquette and hand hygiene signs are available in the WRHA IP&C Manual, link: http://hme.wrha.mb.ca/prg/ipc/manual.php Prvide infrmatin sheets n pandemic influenza. Infrmatin pamphlets are available n the WRHA Internet, in the Pandemic Influenza sectin. i. Staff The designated pandemic influenza chrt area shuld be restricted t nly thse staff necessary fr patient care and supprt. This staff cannt be assigned t flat r care fr patients in nn-influenza care areas. Staff may be assigned t pandemic designated areas in cnsultatin with WRHA Occupatinal and Envirnmental Safety and Health (OESH). (see Appendices in Chapter 6) j. Transprt/Transfer See Appendix 5.9.1 Acute Care Enhanced Drplet/Cntact Precautins. k. Visitrs Visitrs shuld be infrmed when the facility has an influenza utbreak. Visitrs, including children, with symptms f influenza shuld nt visit. There will be n restrictins fr visitrs, including children, wh: d nt have symptms related t pandemic influenza have recvered frm the pandemic influenza strain have been immunized against the pandemic strain at least 2 weeks previusly Special exemptins may be made fr symptmatic visitrs t visit a terminally ill patient r sick child: Symptmatic visitrs allwed t visit terminally ill patients shuld nt visit any ther patient, r any ther public area f the facility. Visitrs shuld bserve respiratry etiquette while in the facility. All visitrs shall perfrm hand hygiene n entry and exit f the islatin rm/bed space and when therwise apprpriate while in the facility. Visitrs shall be ffered the same PPE that HCWs are wearing. Instruct visitrs abut the apprpriate use f PPE and hand hygiene. P13
Visitrs shuld be restricted t 1 patient nly t prevent inadvertent influenza transmissin t ther patients. Parents r guardians must ensure children adhere t hygiene practices, and respiratry etiquette. When asymptmatic parents/guardians visit their symptmatic child/children, they shuld be infrmed f the Need fr hand hygiene. Chice t use PPE while in the patient s rm. Ptential inability t visit their child, shuld the parent/guardian develp symptms. Restrictins t visit ther patients if the parent/guardian chses nt t wear PPE If there is an utbreak r there is influenza transmissin within the facility, visitrs wh have nt yet had pandemic influenza, r thse wh have nt been immunized against the pandemic strain f influenza in the previus 2 weeks, shuld be discuraged frm visiting. Nte: Visitr restrictins may change n a case-by-case basis. B. Lng term Care a. Admissin/Re-admissin/Discharge New admissins and residents returning frm medical prcedures/cmmunity activities i.e., funerals, shuld be cnsidered expsed t pandemic influenza and must be assessed every 4-6 hurs fr symptms cmpatible with pandemic influenza. Refer t the Influenza Assessment Tl (Appendix 5.2). Expsed individuals are managed in a designated islatin rm/space fr 1 incubatin perid. If this is nt feasible, mnitr the resident in his/her rm. Symptmatic residents will be placed n additinal precautins fr 1 perid f cmmunicability after the nset f influenza symptms. Admit/re-admit withut restrictins: Persns frm acute care r the cmmunity wh have recvered frm pandemic influenza. Persns wh have been immunized against the pandemic influenza strain at least 2 weeks earlier. If a resident is discharged while pssibly still infectius, resident and family members shuld be educated abut hand hygiene, respiratry etiquette, the use f a prcedure mask by a cughing resident, and additinal IP&C measures accrding t current recmmendatins. b. Accmmdatin/Chrting Refer t Triage Sectin 2c, Triage: Assessment f Influenza Symptms Refer t Influenza Assessment Tl, (Appendix 5.2). Every effrt shuld be made t segregate residents with suspected r cnfirmed influenza frm thse wh d nt have signs and symptms f respiratry illness. Place symptmatic residents n Enhanced Drplet/Cntact Precautins (see Appendices 5.9 and 5.10) Single rm preferred. In a shared rm, maintain a distance f 2 metres, with a minimum f 1 metre between residents (see Appendix 5.9). P14
Chrt residents if necessary. Assign residents with cnfirmed pandemic influenza t the same rm. If labratry testing t cnfirm the virus is limited, chrt cases based n symptms cnsistent with the pandemic influenza. Refer t Appendix 5.2 (Influenza Assessment Tl). Residents wh have recvered frm influenza are cnsidered immune. They may be mved int the nn-influenza chrt area after the perid f cmmunicability f the pandemic strain has passed. As the pandemic prgresses, the suspect/expsed chrt and the cnfirmed influenza chrt may require a merge. Maintain chrt principles until pandemic has been declared ver and directin received frm the WRHA. Grup Resident Activities All rganized cmmunity scial activities, including family hme visits and all utside appintments, shuld be cancelled unless deemed medically essential. c. Aersl-Generating Medical Prcedures (AGMPs) Refer t the Glssary in this chapter fr a list f AGMPs. Perfrm a risk assessment based n prfessinal judgement abut the prcedure and current infrmatin t determine the apprpriate administrative cntrls, envirnment cntrls, and PPE. Refer t Appendix 5.7 (Pint f Care Risk Assessment). Whenever pssible, ensure AGMPs are cnducted in a cntrlled setting. This requires early recgnitin f patients wh may require high-risk interventins (e.g., intubatin, brnchscpy) in rder t avid emergency situatins. Perfrm these prcedures in an Airbrne Infectin Islatin Rm (AIIR). The availability f these rms may be limited. These rms shuld be used fr individuals with diseases transmitted by the airbrne rate. If this is nt pssible, perfrm the prcedures in a single rm. If a single rm is nt available, a minimum f 2 metres separatin with privacy curtains shuld be used. All persnnel in the rm must wear PPE (e.g. gwns, glves, N95 respiratrs, and eye prtectin). D nt delay urgent prcedures waiting fr an AIIR. d. Care f the Deceased Cmply with established recmmendatins frm Rutine Practices fr care f the deceased. e. Duratin f Additinal Precautins IP&C will advise regarding discntinuing Additinal Precautins based n the current recmmendatins frm the WRHA and MB Health. f. Envirnmental Cntrl Adhere t established IP&C recmmendatins fr husekeeping, and linen/laundry and equipment and waste dispsal. Refer t WRHA IP&C Nn-critical, Re-useable items Plicy 90.00.040 page 15, web link http://hme.wrha.mb.ca/prg/ipc/files/manualhspital_plicy.pdf P15
Dishes Special precautins are nt required. Fllw Rutine Practices. Envirnmental Cleaning and Disinfectin/Husekeeping Frequency f envirnmental cleaning and disinfectin shuld be increased during a pandemic. Perfrm meticulus daily cleaning and disinfectin f envirnmental surfaces and nn-critical resident care items. Surfaces frequently tuched by hands (e.g., medical equipment) and thse ptentially cntaminated by cughing residents, shuld be cleaned and disinfected as frequently as pssible, at least twice daily and when knwn t be cntaminated. Reduce clutter t allw fr cleaning and disinfectin. Handle siled equipment, laundry/linen, and waste t prevent cntaminatin f clthing and the envirnment. Equipment Cleaning and Disinfectin Cmply with established plicies and prcedures fr cleaning, disinfectin and sterilizatin f resident care equipment. Laundry Special precautins are nt required. Fllw Rutine Practices. Physical Setting Ensure the accessibility and availability f supplies: Tissues and n-tuch receptacles fr used tissue dispsal Alchl-based hand rub and/r hand washing supplies (sap, water, paper twels) Prcedure r surgical masks fr persns wh are cughing Remve any frequently handled unnecessary items frm waiting rms, i.e., magazines, games. Waste Special precautins are nt required. Fllw Rutine Practices. Labratry Best Practices It is vital t get a labratry sample in rder t cnfirm r rule ut the diagnsis f H1N1. g. Labratry best practices t take a naspharyngeal swab: It is vital t btain a labratry sample in rder t cnfirm r rule ut the diagnsis f pandemic influenza. A decisin may be made later in the pandemic t cease testing fr pandemic influenza unless the patient is in specific high risk grups. T take a naspharyngeal swab: Ensure the crrect viral swab kit is used, (refer t Manitba Naspharyngeal Aspirate/Swab Fact Sheet, Appendix 5.11) and that it is nt past its expiry date. P16
Ensure bth the specimen and the requisitin are clearly labeled with the patient s name and anther unique identifier, such as date f birth r healthcare number. It is imprtant t nte the expsure histry and clinical symptms n the lab requisitin. h. Signage and Infrmatin sheets Pst signs at all entrances infrming residents, family members, visitrs, vlunteers and staff regarding respiratry etiquette, hand hygiene, and the need fr immediate reprting f symptms f a respiratry infectin. Respiratry etiquette and hand hygiene signs are available in the WRHA IP&C Manual, link: http://hme.wrha.mb.ca/prg/ipc/manual.php Prvide infrmatin sheets n pandemic influenza Infrmatin pamphlets are available n the WRHA Internet, in the Pandemic Influenza sectin. i. Staff The designated pandemic influenza chrt area shuld be restricted t nly thse staff necessary fr resident care and supprt. This staff cannt be assigned t flat r care fr residents in nn-influenza areas Staff may be assigned t pandemic designated areas in cnsultatin with WRHA Occupatinal and Envirnmental Safety and Health (OESH). (see Appendices in Chapter 6) j. Transprt/Transfer See Appendix 5.9.2 Lng Term Care/Persnal Care Hme Enhanced Drplet/Cntact Precautins. k. Visitrs Visitrs shuld be infrmed when the facility has an influenza utbreak. Visitrs, including children, with symptms f influenza shuld nt visit. There will be n restrictins fr visitrs, including children, wh: d nt have symptms related t pandemic influenza have recvered frm the pandemic influenza strain have been immunized against the pandemic strain at least 2 weeks previusly Special exemptins may be made fr symptmatic visitrs t visit a terminally ill patient r sick child: Symptmatic visitrs allwed t visit terminally ill patients shuld nt visit any ther patient, r any ther public area f the facility. Visitrs shuld bserve respiratry etiquette while in the facility. All visitrs shall perfrm hand hygiene n entry and exit f the islatin rm/bed space and when therwise apprpriate while in the facility. Visitrs shall be ffered the same PPE that HCWs are wearing. Instruct visitrs abut the apprpriate use f PPE and hand hygiene. Visitrs shuld be restricted t 1 patient nly t prevent inadvertent influenza transmissin t ther patients. Parents r guardians must ensure children adhere t hygiene practices, and respiratry etiquette. P17
When asymptmatic parents/guardians visit their symptmatic child/children, they shuld be infrmed f the Need fr hand hygiene. Chice t use PPE while in the patient s rm. Ptential inability t visit their child, shuld the parent/guardian develp symptms. Restrictins t visit ther patients if the parent/guardian chses nt t wear PPE If there is an utbreak r there is influenza transmissin within the facility, visitrs wh have nt yet had pandemic influenza, r thse wh have nt been immunized against the pandemic strain f influenza in the previus 2 weeks, shuld be discuraged frm visiting. Nte: Visitr restrictins may change n a case-by-case basis. C. Ambulatry Care a. Appintment Scheduling - Patient/Client Referrals Evaluate patient/client appintments and, if pssible priritize ambulatry care visits t thse patients/clients fr whm hspitalizatin (fr pandemic influenza r ther medical cnditins) may be prevented. Nn-urgent visits t the ambulatry care facility shuld be cancelled r rescheduled, as apprpriate. Initiate any alternate care plans as determined by reginal pandemic management directives. Implement a telephne triage plan t screen patients/clients fr symptms cmpatible with pandemic influenza prir t arrival at the clinic. During telephne bkings, staff shuld inquire whether symptms are present (as utlined in the Influenza Assessment Tl, see Appendix 5.2). If telephne triage is nt apprpriate r feasible, cnsider actively screening patients/clients at the entrance t the clinic. Screen patients/clients fr symptms cmpatible with pandemic influenza prir t arriving at clinic/treatment appintments. In shared settings, maintain a distance f ideally 2 metres; minimum 1 metre, between patients/clients. In settings where a patient/client arrives fr a scheduled appintment, advise them t: Call his/her care prvider in advance f a scheduled visit t advise them f any respiratry symptms. Tell the receptinist r nurse f his/her symptms prir t, r immediately upn arrival t the clinic. Reschedule nn-]urgent visits, if medically apprpriate. When patients/clients with symptms cmpatible with pandemic influenza are identified: Cancel/pstpne/reschedule the appintment, if medically apprpriate, until the perid f cmmunicability has passed and symptms reslved. Direct thse wh need medical assessment fr symptms cmpatible with pandemic influenza t lcal centres when apprpriate. Appintment scheduling fr patients/clients with respiratry symptms shuld be crdinated t avid expsure f thse withut symptms. If apprpriate, cnsider scheduling appintments fr thse with symptms cmpatible with P18
pandemic influenza at the same time. Maintain a distance f ideally 2 metres; minimum 1 metre. Ensure assessment staff evaluates nt nly the patient s/client s symptms but als the symptms f the persn/s accmpanying them t the appintment. If feasible, implement a prcess fr prescriptin renewal that des nt require the patient/client t visit the clinic/ffice (e.g., telephne prescriptin renewal). b. Accmmdatin/Chrting See sectin 2c Triage, Assessment f Influenza Symptms Refer t Triage and Assessment Strategies (Appendix 5.1) Refer t Influenza Assessment Tl (Appendix 5.2) Refer t Pint f Entry Respiratry Screening (Appendix 5.3) Every effrt shuld be made t segregate patients/clients with suspected r cnfirmed influenza frm thse wh d nt have signs and symptms f respiratry illness. Minimize time spent in waiting rms. Place symptmatic patients/clients n Enhanced Drplet/Cntact Precautins (see Appendices 5.9 and 5.10) A single examinatin/treatment rm is preferred. Chrt patients/clients if necessary. Assign patients/clients with cnfirmed pandemic influenza t the same rm. Maintain chrt principles until pandemic has been declared ver and directin received frm the WRHA. c. Aersl-Generating Medical Prcedures (AGMPs) Refer t the Glssary fr a list f AGMPs. Perfrm a risk assessment based n prfessinal judgment abut the prcedure and current infrmatin t determine the apprpriate administrative cntrls, envirnmental cntrls, and Persnal Prtective Equipment (PPE). (see Pint f Care Risk Assessment, Appendix 5.7 ) Whenever pssible, AGMPs are cnducted in a cntrlled setting. This requires early recgnitin f patients/clients wh may require high-]risk interventins (e.g., intubatin, brnchscpy) in rder t avid emergency situatins. Perfrm these prcedures in an Airbrne Infectin Islatin Rm (AIIR). If this is nt pssible, perfrm the prcedures in a single rm. The availability f these rms may be limited. If a single rm is nt available, a minimum f ideally 2 metres; minimum 1 metre, separatin with privacy curtains shuld be used. All persnnel in the rm must wear PPE (e.g., gwns, glves, N95 respiratrs, and eye prtectin). D nt delay urgent prcedures waiting fr an AIIR. d. Care f the Deceased Cmply with established recmmendatins frm Rutine Practices fr care f the deceased. P19
e. Duratin f Additinal Precautins IP&C will advise regarding discntinuing Additinal Precautins based n the current recmmendatins frm the Winnipeg Reginal Health Authrity and Manitba Health. f. Envirnmental Cntrl Adhere t established IP&C recmmendatins fr husekeeping, linen/laundry, equipment and waste dispsal. Refer t WRHA IP&C Nn-critical, Re-useable items Plicy 90.00.040 page 15, web link http://hme.wrha.mb.ca/prg/ipc/files/manualhspital_plicy.pdf Dishes Special precautins are nt required. Fllw Rutine Practices. Envirnmental Cleaning and Disinfectin/Husekeeping Frequency f envirnmental cleaning and disinfectin shuld be increased during a pandemic. Perfrm meticulus daily cleaning and disinfectin f envirnmental surfaces and nn-critical patient/client care items. Reduce clutter t allw fr cleaning and disinfectin. Surfaces frequently tuched by hands (e.g., medical equipment) and thse ptentially cntaminated by cughing patients/clients, shuld be cleaned and disinfected as frequently as pssible, preferably after each patient/client, and when knwn t be cntaminated. Handle siled equipment, laundry/linen and waste t prevent cntaminatin f clthing and the envirnment. Equipment Cleaning and Disinfectin Cmply with established plicies and prcedures fr cleaning, disinfectin and sterilizatin f patient/client care equipment. Laundry Special precautins are nt required. Fllw Rutine Practices. Physical setting Ensure the accessibility and availability f supplies in patient/client care and waiting areas: Tissues and n-tuch receptacles fr used tissue dispsal Alchl-based hand rub and/r hand washing supplies (sap, water, paper twels) Prcedure r surgical masks fr persns wh are cughing Remve any frequently handled unnecessary items frm the waiting rms, i.e. magazines, tys Waste Special precautins are nt required. Fllw Rutine Practices. P20
g. Labratry Best Practices It is vital t get a labratry sample in rder t cnfirm r rule ut the diagnsis f pandemic influenza. A decisin may be made later in the pandemic t cease testing fr pandemic influenza unless the patient is in a specific high risk categry. T take a naspharyngeal swab, see Appendix 5.12 Manitba Naspharyngeal Aspirate/Swab Fact Sheet. Ensure the crrect viral swab kit is used and that it is nt past its expiry date Ensure bth the specimen and the requisitin are clearly labeled with the patient s/client s name and anther unique identifier such as date f birth r healthcare number It is imprtant t nte the expsure histry and clinical symptms n the lab requisitin. h. Signage and Infrmatin Sheets Pst signs at all entrances infrming patients/clients, family members, visitrs, vlunteers, and staff regarding respiratry etiquette, hand hygiene, and the need fr immediate reprting f symptms f a respiratry infectin Respiratry etiquette and hand hygiene signs are available in the WRHA IP&C Manual, link: http://hme.wrha.mb.ca/prg/ipc/manual.php Prvide infrmatin sheets n pandemic influenza. Infrmatin pamphlets are available n the WRHA Internet in the Pandemic Influenza sectin. i. Staff The designated pandemic influenza chrt area shuld be restricted t nly thse staff necessary fr patient/client care and supprt. This staff cannt be assigned t flat r care fr patients/clients in nn-influenza care areas. Staff may be assigned t pandemic designated areas in cnsultatin with WRHA Occupatinal and Envirnmental Safety and Health (OESH) (see Appendices in Chapter 6) j. Transprt/Transfer Limit transprt and mvement f patients/clients utside the pandemic designated area t thse deemed medically essential. Ntify the receiving area, in advance, regarding required precautins. Patients/clients with influenza shuld nly be transferred under previusly established guidelines f the receiving facility. Patient/client must perfrm hand hygiene and wear a prcedure r surgical mask fr transprt; patient/client des nt wear a gwn r glves. If an air leak is present (e.g., patient/client wearing mask t deliver xygen therapy), lsely cver the muth r nse with a faceclth r similar clth. Clths used t cver the site f the leak are cnsidered cntaminated. If unable t keep a mask n a child, use tissues t cver the nse and muth. An incubatr can be used in infant transprt instead f a mask r tissues. HCW shuld perfrm a risk assessment t assess the hazards/risks quickly, determine what the level f risk is, and t determine the apprpriate persnal prtective equipment required befre, during and after the transprt. P21
Identify apprpriate paths, separated frm main traffic rutes as much as pssible, fr entry and mvement f patients/clients with suspected r cnfirmed influenza in the facility. Determine hw traffic pathways will be cntrlled and secured (e.g., dedicated crridrs and elevatrs). k. Visitrs Visitrs including children shuld be restricted when the facility has an influenza utbreak. If there is an utbreak r there is influenza transmissin within the facility, visitrs wh have nt yet had pandemic influenza, r thse wh have nt been immunized against the pandemic strain f influenza in the previusly 2 weeks, shuld be discuraged frm visiting. Visitrs, including children, with symptms f influenza shuld nt visit. Visitrs shuld bserve Respiratry etiquette n entry and exit frm the facility. Nte: Visitr restrictins may change n a case-by-case basis. Family/Supprt Persns Accmpanying Patient/Client: There will be n restrictins fr an essential supprt persn accmpanying a patient/client wh: D nt have symptms f pandemic influenza. Have recvered frm the pandemic influenza strain. Have been immunized against the pandemic strain at least 2 weeks previusly. Is a required asymptmatic supprt persn accmpanying the patient/client Minimize the numbers f supprt persns wh accmpany the patient/client and restrict their cntact t the persn wh they are accmpanying. All patients/clients and supprt persns shall practice respiratry etiquette while in the facility. All supprt persns shall perfrm hand hygiene n arrival t and departure frm the clinic and r treatment area and when therwise apprpriate while in the facility be encuraged and taught t perfrm hand hygiene n arrival t and departure frm the clinic r treatment area. Supprt persns accmpanying the patient/client shall be ffered the same PPE that Health Care Wrkers (HCWs) are wearing. Instruct supprt persns abut the apprpriate use f PPE and hand hygiene When asymptmatic parents/guardians visit their symptmatic child/children, they shuld be infrmed f the: Need fr hand hygiene. Chice t use PPE while in the patient s rm. D. Cmmunity Health Centres, Physician s Offices, Walk-in Clinics a. Appintment Scheduling - Patient/Client Referrals Evaluate patient/client appintments and if pssible priritize visits t thse clients fr whm hspitalizatin (fr influenza r ther medical cnditins) may be prevented. Nn-urgent visits shuld be cancelled r rescheduled as apprpriate. P22