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Policy And Procedure: Pandemic Influenza 9110006



It is the policy of Mahaska Health Partnership to assist in prompt and effective response in the event of a pandemic influenza outbreak, to provide the best care possible and to prevent further spread of disease.  This plan will focus on identifying a pandemic, planning and close collaboration with community partners, physicians, public health, EMS and other healthcare facilities.

The World Health Organization had described 6 phases of pandemic influenza.  They include: 

Inter-pandemic Period 
Phase 1:  No new influenza virus subtypes in humans; subtype that has caused
      human infection may be present in animals.

Phase 2:  As above, but circulation of animal subtype poses substantial risk of 
         human disease.

Pandemic Alert Period
Phase 3:  Human infection with new subtype, no human to human spread, or rare
     spread to close contact.

Phase 4:  Small clusters with limited human to human transmission, highly 
localized spread, suggesting virus not well adapted to humans.

Phase 5:  Larger clusters, but human to human spread still localized, virus 
    increasingly better adapted to humans, but not yet fully transmissible.

Pandemic Period:
Phase 6:  Increased and sustained transmission to general population.
a. Pandemic virus has not reached U.S.
b. Outbreak in the U.S. but not in Iowa
c. Pandemic influenza virus identified in Iowa

I. SURVEILLANCE:
Symptoms include fever, headache, myalgia, prostration, coryza, sore throat and cough.  
Nausea and vomiting are also commonly reported among children.  Typical influenza 
Symptoms such as fever may not always be present in elderly patients, young children, 
Residents in long term care facilities or persons with underlying chronic illness.
A. During Phases 1-5, Mahaska Health Partnership (MHP) will be alert for  suspected cases of infection with novel strains of influenza.  The Infection 
Control Coordinator (ICC) will conduct routine surveillance.  The Emergency Department (ED) will notify Public health and will monitor any alerts from Iowa Department of Public Health (IDPH), World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC).
B. During Phase 6, increased syndromic surveillance will be initiated.  The ICC will  make surveillance rounds to the ED and the lab.  The ICC will be notified if positive influenza tests are received.  Employee absences will be tracked.  Suspected or known cases of influenza will be reported to Community Health Services.

II. HOSPITAL COMMUNICATION:  See Disaster Plan.




III.       PATIENT TRIAGE AND ADMISSION PROCEDURES:
A. Triage:
All patients with possible influenza should put on a surgical (procedure) mask upon arrival.  These masks will be made available at the entrances.
1. During Phase 6A, signage will be placed at the main front entrance, clinic and ED directing patients with possible influenza to report to their physician or local clinic.
2. During Phase 6B, Mahaska Health Partnership (MHP) will depend on  instructions from local and state public health departments regarding local  treatment clinics and advice for quarantine.
B. Hospitalization of pandemic influenza patients:
1. Patient placement
a. Limit admission of influenza patients to those with severe complications of influenza who cannot be cared for outside the hospital setting.
b. Admit patients to single-patient rooms or in an area designated for patients with pandemic influenza.  Negative air flow rooms should be used whenever possible.
2. Cohorting of patients
a. Designated areas should be used for cohorting patients with pandemic influenza.  During a pandemic other respiratory viruses, i.e., respiratory syncytial virus (RSV), non-pandemic influenza, parainfluenza, may be circulating concurrently in the community.  Therefore, to prevent cross-contamination of respiratory viruses, whenever possible, assign only patients with confirmed pandemic influenza to the same room.
b. If possible, clinical and non-clinical personnel assigned to cohorted patient care areas should not float or be assigned to other patient care areas.  The number of personnel entering the cohorted area should be limited to those necessary for patient care and support.
   c. Personnel assigned to cohorted patient areas should be aware that patients with pandemic influenza may also be infected with other pathogenic organisms, i.e., staph aureus, Clostridium difficile, and should follow all infection control practices required for all infections the patient may have.
d. Cohorting should occur early in a local outbreak.

IV.       Infection Control Practices
Precautions for early stages of a pandemic should be consistent with all possible etiologies should be implemented, as it may not be clear that patient with severe respiratory illness has pandemic influenza.  This may involve the combined use of airborne and contact precautions in addition to Standard Precautions until a diagnosis is established.  

CDC will update these recommendations if changes occur in the anticipated pattern of transmission (www.cdc.gov/flu).
A. Standard Precautions are to be used for all patients.
      B. N-95 respirators or PAPRs should be used while caring for patients with 
known or suspected pandemic influenza.  
1. If pandemic flu patients are cohorted in a common area and multiple patients may be visited over a short time, it may be practical to wear one mask N-95 respirator for the duration of the activity. 
2. Perform hand hygiene upon touching or discarding a used mask or  respirator. 
C. If the pandemic virus is associated with diarrhea, Contact Precautions
   should also be used.
D. Gloves should be worn for contact with blood and body fluids, including
     contact with respiratory secretions, i.e., providing oral care, handling soiled tissues. 
    1. If gloves are in short supply, priorities for glove use may need to be    established.  In this circumstance, reserve gloves for situations where there is a likelihood of extensive patient or environmental contact with blood or body fluids include suctioning.  
2.  Use other barriers such as disposable paper towels, paper napkins, where there is only limited contact with a patientís respiratory section, i.e., to handle used tissues.  
E. Hand Hygiene should be strongly enforced.
F. Gowns should be worn if soiling of personal clothes with a patientís blood or body fluids, including respiratory secretions, is anticipated.  
1. Most patient interactions do not necessitate the use of gowns.  However,
procedures that involve holding the patient close or intubation are examples of when a gown may be needed.  
2.  A disposable gown made of synthetic fiber or a washable cloth gown may       be used.  Gowns should fully cover the area to be protected.  
3. A gown should be worn once and then placed in a waste or laundry   receptacle and hand hygiene performed. 
4.   If gowns are in short supply, priorities for their use may need to be   established.  In this circumstance, reinforcing the situations in which they are needed can reduce the volume used.  
G. Goggles or face shields are not necessary for routine contact.  If sprays or   splatter of infectious material is likely, goggles or a face shield should be worn as recommended for Standard Precautions.
      1. Aerosol-generating procedures which may generate increased small-
particle aerosols of respiratory secretions such as endotracheal intubation, nebulizer treatments, bronchoscopy, or suctioning require the use of gloves, gowns, face/eye protection and an N95 respirator or PAPR.  
      2. Respirators should be used within the context of a Respiratory Protection     Program that includes medical clearance, fit-testing and training.  
      3. If possible and when practical, use of an airborne isolation room (room     1309 room set up with Mintie unit) may be considered when conducting       aerosol-generating procedures.
H. Hand Hygiene
1. Healthcare personnel should be particularly vigilant to avoid touching their    eyes, nose or mouth or contaminated environmental surfaces that are not directly related to patient care such as door knobs or light switches with       contaminated hands, gloved or ungloved.
2.  Hand hygiene should be performed between patient contact and after   removing PPE.
a. Hands visibly soiled or contaminated should be washed with soap  and water.
   b.  Hands not visibly soiled or contaminated should be decontaminated with an alcohol product.
I. Disposal of solid waste should be performed using standard precautions.

J. Linen and laundry that may be contaminated with respiratory secretions should be handled using standard precautions.
1.  Wear gown and gloves when directly handling linen contaminated with   respiratory secretions.
2. Place soiled linen directly in a laundry bag in the patientís room.
3. Perform hand hygiene after removing gloves.
4.   Wash and dry linen according to routine procedures.
K.   Dishes and eating utensils should be handled using standard precautions.
1.    Wash reusable dishes and utensils in a dishwasher with recommended    water temperatures.
2. Disposable dishes and utensils such as those used for an alternative care   site should be discarded with other general waste.
L. Patient care equipment should be handled and reprocessed using standard practices.
1. Wear gloves when handling and transporting used patient care equipment.
2. Wipe external surfaces of equipment with an approved disinfectant before removing from the patientís room.
M. Environmental cleaning and disinfection should be performed using standard procedures using an EPA-approved hospital disinfectant.
1.  Wear gloves for environmental cleaning per Standard Precautions.
2.  Use an N-95 respirator or a PAPR.
3. Gowns generally are not needed for routine cleaning of a room.
4.  Pay special attention to frequently touched areas such as light switches,    bed rails, TV controls, call buttons, etc.
5.  Clean spills of blood or body fluids in accordance with current policy.
6.  Upon dismissal of the patient, follow standard cleaning procedures.  No   special treatment is necessary for window curtains, ceilings, walls unless there is visible soiling. 
N.  Laboratory specimens should be collected, handled and processed using standard facility and laboratory practices.
O. Postmortem care should be performed using standard facility practices.
   P.         Isolation/Quarantine: In collaboration with Mahaska County Department of Health and the Iowa Department of Public Health, MHP will cooperate with any order of the potential impact orders may have on the flow of patients to/from MHP and on the ability of MHP staff members  to ingress and egress their work assignments at/with MHP.
           Q.         Social Distancing:  It is recognized that the spread of biological pathogens can be significantly reduced through careful and deliberate efforts to limit close physical contact (> 3 feet).  As may be necessary, MHP will curtail all non-essential meetings and external activities that might be inconsistent with the effort to promote social distancing.  With respect to MHP operations, efforts will be made to install temporary physical barriers, as may be necessary, to promote the social distancing effort (e.g. registration and information desk venues).  In addition, MHP will explore its processes and activities to determine if opportunities exist to conduct some functions in a remote fashion via telephone and/or Internet/Intranet connections.

  
V.    Occupational Health Issues
 A.   Screen all personnel for influenza-type symptoms before they come on duty.
1. Symptomatic personnel should be sent home by occupational health or  their manager until they are physically ready to return to duty.
       2.  Healthcare personnel who have recovered from pandemic influenza should develop protective antibody against future infection with the same virus, and therefore should be prioritized for the care of patients with active pandemic influenza and its complications. These workers would also be well-suited care for patients who are at risk for serious complications from influenza, such as neonates.
B.   Personnel who are at high risk for complications of pandemic influenza, i.e.,  pregnant women, immunocompromised persons, should be informed about their medical risk and offered an alternative work assignment, away from influenza-patient care, or considered for administrative leave until pandemic influenza has abated in the community.
C.  If vaccine is available, pharmacy will prioritize the administration to staff 

VI. Visitors
A. Visitors will not be allowed unless involved in direct care of the patient. 
   1. Visitors should enter the facility at the main entrance  
2. Visitors should be screened for signs and symptoms of influenza by on-duty staff and sent home if they exhibit signs of influenza. 
3. Family members who accompany patients with influenza-like illness to the hospital are assumed to have been exposed to influenza and should wear a surgical mask.
4. Instruct visitors to wear an N-95 mask while in the patientís room.
5.  Instruct visitors on hand hygiene.

VII.   Patients without symptoms of influenza.  
A. Patients and others without symptoms of influenza but who are at high risk for influenza or its complications should be instructed to avoid unnecessary contact with healthcare facilities caring for pandemic influenza patients, i.e., do not visit patients, postpone nonessential medical care.
B. If appointments are necessary, patients entering the clinic will be instructed on infection control measures.

VIII.   MHP reserves the right to lock down in order to conserve resources to care for the most seriously    ill.

IX. Credentialing of volunteer professional staff ;
See Disaster Plan.   

X. Education and Training
A.  Staff will be provided with education on the prevention and control of influenza.
This will include the benefits of annual vaccination and infection control       principles in the control of influenza
B.  Just in Time training for staff will be provided during a pandemic influenza      outbreak with emphasis on intake/triage staff.
C.  Patient, family and visitor education materials will be developed as needed by    infection control and by the Public Information Officer and staff.  They will utilize information from the Iowa Department of Public Health and the Health Alert Network.    

















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