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Helena Sheahan, IPCN Kerry Community Services

Patricia Coughlan, IPCN Cork Kerry Disability Services

� Guidelines & Documentation circulated� Prerequisites – Planning & Education� Requirements for prevention Requirements for prevention Requirements for prevention Requirements for prevention ---- ActionsActionsActionsActions◦ Residents and Staff Vaccination◦ Records◦ What supplies are needed?◦ Monitoring of staff illness

� Requirements for detection Requirements for detection Requirements for detection Requirements for detection ---- ActionsActionsActionsActions◦ Recognition� Case definition of influenza like illness� Definition of influenza like illness outbreak◦ Reporting◦ Guidelines

OutbreaksOutbreaksOutbreaksOutbreaks

• 111 acute respiratory outbreaks reported to HPSC, 91 associated with Influenza

• Majority of outbreaks in residential care facilities/community hospital for those aged >65years

• 31 outbreaks in South

• 11 confirmed in acute hospitals

Morbidity & MortalityMorbidity & MortalityMorbidity & MortalityMorbidity & Mortality

• 1394- confirmed influenza hospitalised cases – highest age specific rate in those 65yrs and older

• 50 critical care admissions – 28 over 65 and 13 under 14

• 92 deaths – median age 80 yrs

Influenza Surveillance in Ireland – Weekly Report Influenza Week 18.19 & 20 2017 (1st – 22nd May 2017)

• Written policies on immunisation, IPC and Outbreak Management related to influenza

• Education for staff at induction and on going to include influenza

• Staff should• receive education re Influenza (signs & symptoms) and the essential role of vaccination

• have a high index of suspicion for influenza during flu season• be able to recognise and report potential cases and clusters• be familiar with and have access to recommended PPE• have access to details for their local Infection Prevention & Control staff (where available) and local Public Health department

• Nominate a senior manager to co-ordinate all actions and communication in the event of a suspected or actual outbreak to Public Health

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� Resident Vaccination◦ Has flu vaccine been offered to all residents throughout the flu season i.e. from September to the end of April?

◦ Ideal time for flu vaccination is Sept/Oct.

◦ If residents are not vaccinated at this time, the vaccine can be given until the end of April.

� In Disability Services vaccination is strongly recommended for children with any condition that can compromise respiratory function especially those attending special schools and day centres.

Resident Vaccination Resident Vaccination Resident Vaccination Resident Vaccination –––– RespitesRespitesRespitesRespites & Admissions& Admissions& Admissions& Admissions

� Is advice re flu vaccination provided to respite admissions from September to the end of April?

� Ideally flu vaccination should be given 2 weeks prior to admission

� Are all new /respite residents vaccinated, ideally 2 weeks prior to admission?

� If not vaccinated, is vaccine offered as soon as possible after admission?

� To protect long term residents, the patient has been informed to:

� Rationale: Rationale: Rationale: Rationale: To assist in appropriate placement on admission in order to prevent an outbreak within the facility.

2. 2. 2. 2. Rationale: Rationale: Rationale: Rationale: The “Checklist for Residential Care Facilities on the Prevention, Detection and Control of Influenza-like illness and Influenza Outbreaks 2014/2015” advises that all respite admissions should ideally have the seasonal influenza vaccine, ideally 2 weeks prior to admission. (HPSC, 2014).

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• Used in St Finbarrs Hospital, Cork

• Letter sent in Sept • Requesting not to visit units if they

have flu like illness in the preceding 2 days

• Asking cooperation with visiting restrictions where a unit is experiencing symptoms of flu

• Encourage to use the hand hygiene facilities

• Advised re respiratory hygiene & cough etiquette

Staff Vaccination• Was flu vaccination promoted amongst staff at the start of the flu season?

Records• Is a record of staff vaccination available?• Is a record of resident seasonal flu vaccination available?

• Is a record of resident pneumococcal vaccination available?• Where?

SuppliesSuppliesSuppliesSupplies

• Is there a supply of 2 viral swabs available to take a throat swab in the event of an outbreak on the advice of a Consultant in Public Health? • List of sites where swabs are is held by DPH , if used will be replaced by post

• Discard pack from 2016/2017 Season

• Is there access to antiviral medication (Tamiflu) within 24 hours in place with the facility pharmacy if needed in the event of an outbreak?

• Are supplies of surgical face masks and eye protection available?• Are they the correct standard?

MASK FACE TYPE II DISPOSABLE MASK FACE TYPE II DISPOSABLE MASK FACE TYPE II DISPOSABLE MASK FACE TYPE II DISPOSABLE FACE MASK TIE ON FACE MASK TIE ON FACE MASK TIE ON FACE MASK TIE ON

MASK SURGICAL TYPE IIR MASK SURGICAL TYPE IIR MASK SURGICAL TYPE IIR MASK SURGICAL TYPE IIR DISPOSABLE DISPOSABLE DISPOSABLE DISPOSABLE FLUID RESISTANT/ANTIFLUID RESISTANT/ANTIFLUID RESISTANT/ANTIFLUID RESISTANT/ANTI----FOG FOG FOG FOG WITH VISOR WITH VISOR WITH VISOR WITH VISOR

Surveillance Surveillance Surveillance Surveillance ––––Monitoring Monitoring Monitoring Monitoring

� Is staff absenteeism monitored for influenza like illness (ILI) and for unusual patterns i.e. ◦ more than expected staff absent

◦ 3 or more cases of ILI in a 72 hr period?

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Patricia Coughlan, Cork & Kerry Disability Services

Sudden onset of symptoms

AndAndAndAndAt least one of the following four systemic symptoms:At least one of the following four systemic symptoms:At least one of the following four systemic symptoms:At least one of the following four systemic symptoms:

� Fever or feverishness

� Malaise

� Headache

� Myalgia (muscle pains)

AndAndAndAndAt least one of the following three respiratory symptoms:At least one of the following three respiratory symptoms:At least one of the following three respiratory symptoms:At least one of the following three respiratory symptoms:

� Cough

� Sore throat

� Shortness of breath

� In older adults, symptoms may initially be very subtle and difficult to recognise. Elderly residents may present only with

◦ cough, fatigue and confusion.

◦ fever response may be more blunted.

◦ Influenza may present in the elderly patient as an exacerbation of an underlying condition

� If an increased number of residents become unwell over a short period of time with respiratory illness, influenza should be suspected.

Three or more cases (amongst residents and/or staff)

of influenza like illness (ILI) or influenza or respiratory

illness

• within the same 72 hour period in the RCF,

• which meet the same clinical case definition

and

• where an epidemiological link can be

established.

Definition of Influenza/Influenza like

illness (ILI) Outbreak� Inform the local medical team/attending GP for an appropriate diagnosis to be made

� If cases are confirmed the GP confirming the suspected outbreak notifies the Department of Public Health at 021-49 27601 / 066 7184542

• Department of Public Health will

• undertake a risk assessment and • establish an outbreak control team if deemed appropriate

• advise on • appropriate clinical specimens to be taken

• Decide re antiviral treatment and chemoprophylaxis

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• Pre-addressed postage box to the “National Virus Reference Lab”

• 2 Viral swabs • Instructions for Throat Swab to test for Influenza

• NVRL Request form with “Respiratory Viral Suite”

• Results sent to Dept Public Health

� Clean hands, clean gloves

� Rub the swab over the tonsillar fossa or any area with visible exudate

� Avoid touching the tongue or mouth with the swab

� Carefully place the swab into the bottle and snap off the excess stick , secure the green cap on the bottle

� Remove gloves, clean hands

� Complete the form and add details to swab bottle – name, DOB, clinical details, date & time swab was taken.

� If postage is delayed store in a cool dry place, ideally in a fridge at 4°C

� Inform your Infection Prevention & Control Nurse where available

� Agree a communication strategy◦ Nominate a person to act as liaison with the Dept of Public Health and the Infection Prevention & Control Nurse

� In addition to Standard Precautions, implement Droplet Precautions as advised –See Section 3 and Section 6 of the Infection Prevention and Control Guidelines, HSE South, 2017

� www.hse.ie/infectioncontrol

� Refer to “Checklist for Residential Care Facilities on the Prevention, Detection and Control of Influenza-like Illness and Influenza Outbreaks, 2017/2018”

• Make a list of residents and staff with symptoms (use a template):• Name/DOB• Date of first symptoms (onset)• Symptoms - fever, cough, fatigue • Vaccination status

• Consider• Layout of the facility (location of cases) and possible links between affected residents

• Timeline – 3 affected within 72 hours

• If there is more than one GP attending the facility, ensure all are aware of other potential affected residents/staff.

Accurate information is essential as this will guide

Public Health response

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• In addition to Standard Precautions, implement Droplet Precautions immediately for symptomatic cases in healthcare settings• do not wait for laboratory results

• Patient Placement in RCF• Place patient in a single room or cohort with similar patients

• Maintain a distance ≥ 1 metre between infectious patient and others

• Wear surgical masks within 1 metre of care• Limit patient movement Standard Precautions

• Hand Hygiene• Respiratory Hygiene and Cough

Etiquette• Patient Placement • Protective Clothing• Cleaning of the Environment• Care of Client Care Equipment• Care with Laundry• Dealing with spills of body fluids

safely• Care and disposal of sharps• Dealing with needle stick injury or

blood or body fluid exposures• Staff Health, hygiene and staff

immunisations• Healthcare risk waste

PLUS - Droplet Precautions

• Additional Protective ClothingAdditional Protective ClothingAdditional Protective ClothingAdditional Protective Clothing• Patient Placement Patient Placement Patient Placement Patient Placement • Cleaning of the EnvironmentCleaning of the EnvironmentCleaning of the EnvironmentCleaning of the Environment• Care of Client Care EquipmentCare of Client Care EquipmentCare of Client Care EquipmentCare of Client Care Equipment

PPE for routine care for suspected or PPE for routine care for suspected or PPE for routine care for suspected or PPE for routine care for suspected or confirmed influenza case.confirmed influenza case.confirmed influenza case.confirmed influenza case.

1. Surgical mask.

2. Wear gloves/apron/gown/goggles

if risk of contact with blood, body

fluids, mucous membranes or

non-intact skin anticipated as per

Standard Precautions

PPE for an aerosol generating PPE for an aerosol generating PPE for an aerosol generating PPE for an aerosol generating procedure (AGP) and if remaining in procedure (AGP) and if remaining in procedure (AGP) and if remaining in procedure (AGP) and if remaining in or entering the patient’s room within or entering the patient’s room within or entering the patient’s room within or entering the patient’s room within one hour after cessation of the AGP:one hour after cessation of the AGP:one hour after cessation of the AGP:one hour after cessation of the AGP:

1. FFP2 or FFP3 respirator (correctly fitted), goggles, long sleeved

disposable gown, gloves.

2. AGP – intubation, tracheostomyinsertion, ventilation

1. Gown / Apron first

2. Mask

3. Goggles or face shield (if required)

4. Gloves

****Combination of PPE will affect sequence Combination of PPE will affect sequence Combination of PPE will affect sequence Combination of PPE will affect sequence –––– be practicalbe practicalbe practicalbe practical

� Place over nose, mouth and chin

� Fit flexible nose piece over nose bridge

� Secure on head with ties or elastic

� Adjust to fit

� Remove Gloves first – and perform hand hygiene

� Face shield or goggles (if required)

� Gown

� Mask

Remember the outside aspect of PPE is considered Remember the outside aspect of PPE is considered Remember the outside aspect of PPE is considered Remember the outside aspect of PPE is considered contaminatedcontaminatedcontaminatedcontaminated

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� Untie the bottom, then top, tie

� Remove from face

� Discard

� Hand Hygiene

Management of admissions/transfers during an outbreak

� Transfers ◦ to acute facility - inform the admitting facility/infection control team in advance of the outbreak

◦ admission of new residents to RCF not recommended

◦ Non –urgent transfers to another facility generally not recommended.

Additional measures within the facility

• Restrict movement between affected and unaffected areas

• Consider rescheduling non urgent appointments

• Limit visitors as much as possible

• Excluded symptomatic visitors & all children

• Essential Visitors –• Instruct to use hand hygiene facilities

• Visit one resident only and exit immediately after visiting

• Appropriate signage

Link with Section 18 Admissions, Transfers &

Discharges www.hse.ie/infectioncontrol

� Should be in place at all time

� Emphasise during influenza season

� Signage, provide facilities

� Consider visitors, residents

What is it ?• Element of Standard Precautions (2007)

Advising • Control of respiratory secretions

• Hand hygiene after contact with respiratory secretions

• Spatial separation >3 ft of persons with respiratory infection

• Visual cue to remind people

� Environmental cleaning and disinfection◦ Clean with detergent and water◦ Disinfect with 1,000ppm available chlorine� Or Combined cleaner & disinfectant

◦ Rinse and dry

� Emphasis on frequently touched surfaces and surfaces in close proximity to the affected residents

� Dedicate care equipment or clean and disinfect between affected residents

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� Staff◦ Vaccinated staff to care for the ill

◦ Exclude ill staff – until 5 days post onset of symptoms

◦ Limit staff movement

◦ Asymptomatic unvaccinated staff should wait one incubation period (3 days) prior to working in a non-outbreak facility.

◦ Asymptomatic vaccinated staff have no restrictions working at other facilities

� Ongoing surveillance of ill pts/staff & maintain line list

� Ongoing communication with DPH, IPCN

� Appropriate signage for visitors

� Duration of precautions – 7 days following symptom onset or longer as advised◦ Precautions required whilst people are symptomatic

◦ Advise should be sought regarding those who residents with risk factors

� An influenza outbreak is declared ‘over’ eight days after the onset of symptoms in the last new case

� Vaccination of healthcare staff, patients, residents and visitors remains the cornerstone of flu prevention strategies

� Be prepared

� Record of staff and resident flu vaccination

� Record of pneumococcal vaccine

� Supplies available – PPE, swabs,

� Know who to contact – Dept. Public Health

� Know how to access antiviral drugs

� Continuous surveillance for ILI

� PREPARATION IS KEY – BE WINTER READY!

Cork Kerry Community Healthcare Influenza Preparedness 2017-2016

Cork Kerry Community Healthcare Influenza Preparedness 2017-2016