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Monday, February 06, 2012

WHO Documents on H5N1 Pandemic : How to protect yourself from Kawaoka's Weaponized H5N1 Virus Created at Kobe-Tokyo Universities


The 5th Estate has just purchased a library on H5N1 "Novel" virus pandemics, there are dozens of PDF and Exel documents we feel will assist you in saving lives following intentional releases of the H5N1 and now MERS viruses; we will begin by printing those that appear to be extremely relevant here:  H5N1 Kobe-Kawaoka-Ernala series continues soon with more "Smoking Gun" e-mails from Teridah Ernala to The 5th Estate

The 5th Estate
02/06/2012

The first is a propaganda document, however it contains not only the intentions of WHO and the government - which will assst you in countering the threat of forced vaccination and quarantine - there are also bits and pieces of information to assist readers in countering the weaponised H5N1, H1N1 and now MERS viruses.


H5N1 creators Kawaoka and Teridah Ernala of Kobe University

 DRAFT
 Pandemic Influenza
Medical Response Model

Includes:
Triage and Treatment Guidelines

Revision 1



DRAFT


 
  
May 24, 2007


Table of Contents

Executive Summary                                                                                            

Introduction                                                                                                           

            Assumptions                                                                                      

            Estimates of Impact of Pandemic Influenza                                     

            Pandemic Severity Index                                                                               

            WHO Global Pandemic Phases/ Federal Government  Stages

            Triggers to Activate    

Medical Coordination

Triage and Treatment Guidelines


A.      Pre-Tier 1 – EMS Respose and Phone Triage

B.     Tier 1 – Triage and Outpatient Treatment, and Referral (NEHC)

C.     Tier 2 – Alternate Care Facilities (Acute Care Centers)

            D.  Tier 3 – Hospital Care


Supplement 1:                 Straw Person
                                    Pre-Tier: Straw Person EMS & Phone Triage
                                    NEHC Straw Person: Tier 1 – Neighborhood Emergency Help Center
                                    ACC Straw Person: Tier 2 – Alternate Acute Care Centers

Supplement 2:                      Forms
                                    Pandemic Influenza Screening & Triage Form
                                    History and Physical Exam
                                    Admission Orders
                                    Pediatric History and Physical Exam
                                    Pediatric Admission Orders
                                    Central Pierce Fire & Rescue, Release of Responsibility Form

Supplement 2a:       Checklists

Supplement 3:                      Education & Information for Home Care       Infection Control Guidelines
                                    Infection Control Practices in the Home
                                    Pandemic Influenza: Tier 1: Infection Prevention Guidelines
                                    Pandemic Influenza: Tier 2: Infection Prevention Guidelines
                                    Pandemic Influenza: Tier 3: Infection Control
                                    Infection Control Guidelines: Residential Group Settings



A community based group, organized through Tacoma-Pierce County Health Department and Washington State Department of Health, including hospital representatives, doctors, military (Madigan), fire and Emergency Medical Services (EMS), Pierce County Medical Society, Puyallup Tribe, Community Health Clinics, City of Tacoma, and Pierce County Department of Emergency Management (DEM), met to develop a model for medical response in a pandemic influenza scenario. Assumptions include a World Health Organization (WHO) estimated contraction rate of 25%, a very high hospitalization rate, and the local outpatient healthcare systems being overwhelmed.

A four-tiered disaster medical care delivery system is being proposed as follows:

Pre-Tier 1:       EMS Response and Health Information Care and Nurse Triage Lines
Tier 1:              Neighborhood Emergency Help Centers (NEHC): Triage and Referral function
Tier 2:              Alternate Care Facilities (Acute Care Centers)
Tier 3:              Hospital care reserved for most critically ill with likely favorable outcomes

Triggers have been defined to activate incremental mobilization, based on need. Specific patient medical symptoms and condition criteria are developed for each evaluative decision resulting in categorization of patients, and referral to appropriate level of care.  A Tier 3 (Hospital) Response Matrix has been developed that outlines the Category of the pandemic, the Triggers, the Admission and Triage Guidelines and Actions.  The Category and the Triggers refer to the transition from Normal Standards of Care to Altered Standards of Care as the pandemic moves through the stages of impact and severity and activate certain Admission and Triage Guidelines and Actions.

A Medical Reserve Corps (MRC) is being developed.  MRC is a group of community based volunteers called upon during an emergency to supplement existing medical response systems by providing surge capacity and working in alternate triage and treatment facilities. MRC can be practicing or retired doctors, nurses, dentists, EMT, pharmacists, mental health practitioners, medical assistants, and non-medical volunteers to help with management, communication and non-medical clinic roles.

All public health activities and medical response in Pierce County will be founded on accepted ethical values.  Ethicists from the University of Washington have been consulted and reviewed the guidelines for the Alternate Care Facilities and have provided feedback.  Legal consultants have also participated at all levels of planning for triage and treatment during a pandemic. 

We have built our treatment guidelines primarily on the principal of medical utility, i.e. maximizing the amount of medical benefit we can provide to the most number of people.  This includes protecting our medical infrastructure so as to maintain a robust medical capacity, and treating all patients based solely on the amount of benefit they are likely to receive from our treatment of them.

Pre-Tier 1: EMS Response and Health Information Care Lines

To decrease burden on health care facilities and to lessen exposure of the “worried well” to persons with influenza, telephone hotlines will be established to provide advice on whether to stay home, be referred to a triage site, send EMS or a home care or hospice provider. These calls could come directly into 911 and 211 or the nurse advice lines.

Criteria are developed to identify “stable patient” and the “urgent sick” patient. The “stable patient” will be advised to remain at home and will be provided educational materials on home care with access to antibiotics and antiviral medications (AVM), if available.

The “urgent sick patent” will be referred to EMS or the nurse and/or general advice line. The nurse line will evaluate whether patient needs an in-person evaluation. If so, EMS may be sent or the patient will be referred to a Tier 1 NEHC. If EMS is sent, there are different outcomes including “no transport” and “transport” based upon condition criteria. The patient can be transported to Tiers 2 or 3, depending upon condition.
Late phase in the pandemic: when limited EMS available, limited resources, limited or no hospital beds, equipment or supplies available, the criteria for defining “urgent sick” remains the same, however, as resources become scarce, a new category of patient is assigned, the “too sick” patient. Chances of survival are assessed to be minimal, based upon established medical criteria. Morbidity scale to be followed. EMS transport determined by services available. Home health nurse or hospice sent, as appropriate and available. Place on list for follow up when Tier 2 or 3 open up. Provide family with home health care educational materials.

TIER 1: Alternate Care Facilities: Triage  and Outpatient Treatment Centers/Neighborhood Emergency Help Centers (NEHC)

Tier 1 sites are located in approximately 36 urgent care and medical clinics located away from, but many in proximity to, hospitals and are geographically distributed throughout the county. Staffing may include MDs, RNs, ARNPs, PAs, LPNs, behavioral health, security staff, health educators, and pharmacy technicians. The Tier 1 sites will provide physical assessments of the patient, treatment per standing protocols for antibioticis and AVM, if eligible and available, and either advise the patient to return home or arrange for transport to Tier 2 (ACC) or to Tier 3 (Hospitals), depending upon patient’s condition. Standard patient screening forms, history and physical exam forms, and admission and treatment orders forms have been developed.  A patient tracking system is being developed. 


TIER 2: Alternate Care Facilities - Acute Care Centers

Acute Care Centers are 14 proposed locations throughout the county, predominantly high schools, designed to function as alternate inpatient care facilities to augment hospital capacity to admit pandemic influenza patients. Local hospitals may be linked to the alternate triage and treatment centers to coordinate and direct patient care, medical logistics and information flow. Tier 2 facilities are designed to care for patients who are too sick to be cared for at home and might need a few hours to a few days of medical care. Examples of types of services available include supplemental oxygen requirement, oral hydration therapy, IV bolus, O2/NC, as appropriate, antiviral medication, IV antibiotic treatment of pneumonia, vital signs monitoring including pulse oximetry, antipyretics and analgesics, limited airway management (but no ventilators available), lab work, palliative care, and fatality management. No X-ray; no aerosolized procedures.   Standard forms will accompany patient from Tier 1.


TIER 3: Hospital Care

A Response matrix has been developed to provide guidelines for hospital personnel in determining admission of patients to critical care units. 



A major biological incident, such as Pandemic Influenza, has the potential to significantly overwhelm the health and medical capabilities of a region.  A major obstacle facing public health and emergency managers is that most communities have limited ability to expand health and medical capacity on a daily basis within existing infrastructure. Pierce County medical care infrastructure is a patchwork of primarily private and public medical provider offices, hospitals, tribal, military, and mental health practitioners and makes emergency planning for response to medical disasters extremely difficult.

A Pandemic Influenza will most likely present in waves, with the Pandemic lasting as long as 9 months to well over a year. Upwards of one-third of the workforce will be affected with healthcare workers overwhelmingly impacted. Antiviral medications and vaccines may be of limited availability. Hospitalization rates for Pierce County alone is estimated to be close to 25,000 and over 113,000 outpatient medical care visits. Although social distancing and other methods will be instituted, they will only, at best, mitigate the expected demands on the medical system.

Pandemic Influenza planning assumptions include planning for NO or MINIMAL FEDERAL response capacity. This is very different from other types of emergency response planning, where preparation plans recommend 3 to 7 days of supplies and capabilities to be self-sufficient until help arrives. In the case of a Pandemic Influenza, communities may stand alone throughout the pandemic period.

According to the Pierce County Comprehensive Emergency Management Plan (CEMP) that outlines response authorities, and primary and support agency responsibilities, Tacoma-Pierce County Health Department is the primary agency responsible for health and medical response, coordination and management. For this reason, TPCHD along with many other community partners, has been engaged in a lengthy and challenging process of planning for the county’s medical response to pandemic influenza.

A critical and essential function during a pandemic will be to divert the “worried well,” “stable sick,” and “urgent sick” patients away from the existing hospital medical systems by using alternate care facilities to ensure medical resources are used for maximum benefit.  These alternate care facilities  will be available for the public to be triaged, receive information, and obtain medical services. A review of existing medical disaster models resulted in the proposal of creating a four-tiered disaster medical care delivery system, using existing infrastructure as much as possible.

Objectives include:

·                     Develop processes to recruit, educate, and activate community medical providers and ancillary personnel to deliver medical care during prolonged medical emergencies.
·                     Develop standardized triage and treatment protocols for pandemic influenza and clinical standards that include consideration of ethical and legal issues regarding allocation of limited resources.
·                     Identify and develop a Concept of Operations document for the Pierce County integrated medical disaster care delivery system in response to a pandemic influenza.

We understand that difficult decisions may need to be made in implementing a pandemic influenza medical response model, and that regardless of how these decisions are made, some people will be dissatisfied with the outcome.  As a community, we must strive to make the best choices possible and remain transparent.  To guide our planning, we rely on the following principles:

1.      To the greatest extent possible, everyone in Pierce County who becomes ill should be given the best care we can provide at that time, regardless of that person’s social worth.
2.      To maximize our ability to implement this model, caregivers who work directly with patients and essential healtcare support workers should be considered a priority group for all preventive healthcare resources that become available (e.g. vaccine, prophylactic antiviral drugs).
3.      If resources become so scarce that we cannot provide all patients with the care they need, care should be given to the patients likely to receive the most benefit from those resources.
4.      If it should become necessary to restrict individual liberties for the sake of the public health, the least restrictive interventions likely to be effective should be employed.

Promoting pre-registration of all healthcare providers in the Pierce County’s Medical Reserve Corps is essential. Pre-registering provides consistent baseline training on Alternate Care Facilities, Command and Control, and introduction of the medical disaster system.  A clinical management group will be established to coordinate evolving standards of care  issues consistently across the health care delivery model. 

Declared emergencies and emergency declarations permit relaxation of standards of care through waiver of laws and regulations, closure of business, and staff reassignments. Pierce County medical professionals and their offices will be impacted. In an environment of social distancing, limited resource procurement, equipment and supply shortages, and high absenteeism due to fear and illness, coordination of the medical care delivery system is absolutely necessary.

As stated above, a pandemic influenza will expose healthcare systems to difficult ethical choices that will arise rapidly.  All public health activities and medical response in Pierce County will be founded on accepted ethical values.  These include the basic belief that every individual should receive the best care that can be provided as long as this is possible, and that individual liberty should be respected to the greatest extent possible while still protecting the health of the public.

Abiding by these principles can lead to some decisions that are not pleasing.  For example, at the height of the pandemic, patients who have little chance of survival may have care denied or be moved to palliative care to free up resources for someone who has a better chance of recovery.  Such life and death decisions are not easy to make, so it is crucial that we understand them well and discuss them in detail before such an event occurs.  This will help us in making the right decisions when the pressure is on, and it will ease the burden on those who are responsible for making such decisions.

A team of community members has organized to develop a model of medical care delivery during a pandemic influenza.  Members include TPCHD personnel, representatives from the hospital systems, Infection Control Practitioners, community medical provider practice representatives, Emergency Response Planners, First Responders such as EMS personnel, PC Department of Emergency Management, Madigan Army Medical Center, Fort Lewis, The Red Cross, and legal and ethics representatives, and the EIS officer from the DOH/CDC.

The medical model formulated is based on a four-tiered response to people who will be seeking medical care during a pandemic influenza.

·                     Pre-Tier I – EMS Response and Health Information Care and Nurse Triage Lines
·                     Tier 1 – Neighborhood Emergency Help Centers (NEHC): Triage, Outpatient Care, and Referral Function
·                     Tier 2 – Alternate Care Facilities (Acute Care Centers)
·                     Tier 3 – Hospital care – reserved for most critically ill with favorable outcomes

·                     Due to the high degree of infectiousness of pandemic influenza, the number of persons affected will be high. The CDC has estimated a “contraction” rate of 30% of the population for the flu strain that may develop from the current avian flu threat.
·                     Due to the severity of the avian flu strain, experts believe that it would result in a very high hospitalization rate. The number of ill people requiring outpatient medical care and hospitalization will overwhelm the local healthcare systems.
·                     Health care workers and other first responders will be at higher risk of exposure and illness than the general population, further straining the health care system.
·                     Effective therapeutic measures, such as vaccines and antiviral medications will be delayed and in short supply.

   Estimates of the Impact of a Pandemic Influenza:
Number of Episodes of Illness, Healthcare Utilization, and Deaths in Pierce County Associated with Moderate and Severe Pandemic Influenza Scenarios*

Characteristic
Moderate (1958/68-like)
Severe (1918-like)
Illness
226,500
226,500
Outpatient medical care
113,250
113,250
Hospitalization
2,176
24,915
ICU Care
324
3,737
Mechanical ventilation
163
1,876
Deaths
525
4,789

1. Estimates based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20th century pandemics.
2. Projected impact over 2 waves; majority will occur in one wave; difficult to predict which wave will be worse.
3. The clinical attack rate estimated to be 30% in the overall population.   (Ref: CDC, WHO, HHS)


The CDC has recently created a Pandemic Severity Index for categorizing the severity of a pandemic (Feb 2007).  The index is designed to enable estimation of the severity of a pandemic on a population to allow better forecasting of the impact and to enable recommendations to be made on the use of mitigation interventions that are matched to the severity.

Pandemic Severity Index Table

Case Fatality Ratio
Pandemic Severity Index
Projected Number of Deaths*U.S. Population, 2006
Projected Number of Deaths in Pierce County**
> 2.0%
Category 5
> 1,800,000
>4,500
1.0 - < 2.0%
Category 4
900,000 - < 1,800,000
2,250 - < 4,500
0.5 - < 1%
Category 3
450,000 - < 900,000
1,125 - < 2,250
0.1 - < 0.5%
Category 2
90,000 - < 450,000
233 - < 1,125
< 0.1 %
Category 1
< 90,000
< 233

*Assumes 30% Illness Rate and Unmitigated Pandemic without Interventions. ** Pierce County population estimate of 775,000.   Ref: Interim Pre-Pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States, February 2007 adapted Figure 4.


An essential function for managing the provision of medical care during a pandemic influenza will be the development of Alternate Care Facilities (Tiers 1 and 2) that will provide triage and treatment in the community, following standardized protocols, and the development of a Response Matrix for hospitals (Tier 3) to guide admissions and triage guidelines for acutely ill patients.  Appropriate management of influenza cases will reduce the progression to severe disease and thereby reduce the demand for inpatient care.

The recognition of pandemic flu in Pierce County will be accomplished through surveillance, both active and passive, community providers reporting to Tacoma-Pierce County Health Department (TPCHD) and by reports from the Washington Department of Health (DOH), State Labs, and the Center for Disease Control (CDC). TPCHD, with the clinical management group, will assess the evolution of the pandemic, identify age and risk factors of individuals, and the severity index as it evolves.

Assumptions:

  • There will be increased demands for Critical Care beds and care.
  • Available resources will affect all health and medical response.
  • Criteria used for making decisions about the allocation of resources will be guided by Admission and Triage Guidelines, as outlined in this document.
  • Standards of Care  will be altered as a pandemic progresses and an emergency is declared.
  • A legal opinion and ethical criteria will assist in deciding the distribution of scarce resources.
  • The U.S. Government Pandemic Severity Index and Government Stages will be the triggers guiding Pierce County response.
  • Medical and health coordination will occur via conferencing through policy level participation in the EOC.
  • Planning focuses on keeping the health care system functioning to deliver optimum care.
  • Community Planning efforts are activated to coordinate regional response across multiple agencies and disciplines.
Activation Criteria for implementing the Alternate Care Facilities (Tiers 1 and 2) and triggering the Tier 3 (Hospitals) Response Matrix Guidelines will be based on a phased approach. Triggers have been identified that will define Standards of Cares (Categories), admission and triage guidelines and actions.

The CDC has developed corresponding stages to the WHO Phases that characterize the stages of an outbreak in terms of the immediate and specific threat a pandemic virus would pose to the U.S. population.  This model assumes the outbreak will start overseas.  The following stages provide a framework for Federal Government actions.  

WHO GLOBAL PANDEMIC PHASES AND THE
STAGES FOR FEDERAL GOVERNMENT RESPONSE
WHO Phases
Federal Government Response Stages

INTERPANDEMIC PERIOD


0 - New domestic animal outbreak in at-risk country

PANDEMIC ALERT PERIOD



0 - New domestic animal outbreak in at risk country
1 - Suspected human outbreak overseas


2 - Confirmed human outbreak overseas
PANDEMIC ALERT

 


3 - Widespread human outbreaks in   multiple locations overseas
4 - First human case in North America
5 - Spread throughout United States
6 - Recover and preparation for subsequent waves
    Ref: Interim Pre-Pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation
    I in the United States, February 2007, adapted Appendix 3.


Triggers to activate Health Care Delivery Model in a Pandemic Flu:

Category I – Federal Government Response Stage 4: First human case in N. America

·         Usual Standards of Care
·         One to five ICU cases have been identified in Pierce County
·         Full resources are still available
·         Action: 
q       Alert and Standby Pre-Tier 1, Tier 1 and 2 Alternate Care Facilities
q       Conduct Just-inTime Training (JIT)
q       Activate Hospital Facility Emergency Plans
q       Activate and Standby Hospital surge capacity

Category II – Federal Government Response Stage 5: Spread throughout U.S.

·         Altered Standards of Care
·         UP to 50 ICU cases in Pierce County; increased ventilator demand
·         Emergency Declaration
·         Hospital capacity and resources diminishing
·         Action:
q       Activate Pre-Tier 1 Altered triage protocols
q       Activate Tier 1 and 2 Alternate Care Facilities
q       Activate hospital surge capacity
q       Implement Hospitals’ emergency response plans

Category III – Federal Government Stage 5+: Community Spread

·         Altered Standards of Care
·         Greater than 50 ICU cases in County
·         Action:
q       Activate Critical Care inclusion/exclusion criteria
q       Asses function of Tier 1 and 2 Alternate Care Facilities
q       Cancel all elective procedures

Demobilization Criteria

Demobilization will be phased and determined by policy group in the Emergency Operating Center (EOC). Alternate care sites will be shut down gradually, minimizing patient movement and disruption of clinical services. A challenge will be transitioning back from the proposed federal government as the last payer to the fee for service system.

·         Beds become available at established hospitals

·         ICU beds become available

·         Staffing ratios return to acceptable levels

Medical Coordination

A pandemic influenza will put great pressures on the health care systems in our community. Faced with a very serious disease for which there may be no absolute protection or cure, health care workers will find themselves facing overwhelming demands. They will be forced to weigh their duty to provide care against competing obligations, such as their duty to protect their own health and that of families and friends. Health care workers will also face significant challenges related to resource allocation, scope of practice, professional liability and workplace conditions.  The employers of medical providers should recognize these pressures and take what actions they can to mitigate the stress placed on these individuals.

Development of a Medical Reserve Corps (MRC) in advance of a pandemic or other mass casualty event will be essential. A MRC is a group of community-based volunteers called upon for any large-scale emergency, natural disaster, or public health incident in Pierce County. A function of the MRC will be to supplement existing community medical response systems by providing surge capacity and capability. It will also be important to communicate to the medical providers that there are legal provisions to “impress” personnel into service during a declared emergency.

The MRC would consist of medical and non-medical volunteers. Volunteers may be practicing or retired medical professionals such as doctors, nurses, dentists, EMT, pharmacists, mental health practitioners, nurse and medical assistants, etc. Non-medical volunteers provide support services such as, communication and non-medical clinic roles regarding flow, supply and maintenance.

Existing medical and hospital staff will also be registered as emergency workers.  Emergency worker registration provides liability coverage to anyone, professional or non-professional, responding to pandemic influenza.  When an emergency is declared, altered standards of care become the standard during an emergency. 

Staffing Recruitment and Training

a.      Recruitment - Recruit and pre-register volunteers and staff to be involved in a emergency medical disaster. Provide contact information, exercise and training opportunities, forms, and direction to those who will respond and who are interested.

b.      Training – All volunteers and registered emergency workers – whether medical or non-medical – will have appropriate training to comply with minimum requirements, such as:

§         Orientation to MRC
§         CPR
§         Basic First Aid
§         Blood Borne Pathogens
§         Incident Command Systems
§         Additional training “Just in Time Training” – based on job assignment

c.      Tracking – Development, implementation, and maintenance of database to track all volunteers.



In a medical disaster, responding medical personnel must be trained to understand that it will not be possible to allow their natural instinct to deliver as much care as needed for each patient and that prioritization of resources will be essential. Predefined guidelines for the delivery of care, such as standard admission orders and treatment protocols are developed and available.

In this section, triage and treatment guidelines will be identified.

Four-Tiered response for medical care during a pandemic influenza:

·                     Pre-Tier I – EMS Response and Telephone Health Information Care and Nurse Triage Lines
·                     Tier 1 – Neighborhood Emergency Help Centers (NEHC): Triage and outpatient care, and Referral Function
·                     Tier 2 – Alternate Care Facilities (Acute Care Centers)
·                     Tier 3 – Hospital care – reserved for most critically ill with favorable outcomes

·                     See Pre-Tier 1 Straw Person Algorithm (Appendix 1)

To decrease the burden on health care facilities and to lessen exposure of the “worried well” to persons with influenza, telephone health information care and Nurse Triage lines will be established to provide advice on whether to stay home or to be referred to a Tier 1 Triage site, or to send EMS or a homecare or hospice provider. (Refer to Puget Sound Call Center Coordination Project – Conceptual Model.)

Criteria is developed to assist 911 and 211 Dispatchers and Phone Triage and nurse advise lines to determine appropriate EMS response. Criteria will identify the Stablepatient and the Urgent sick,” patient. The “stable” patient will be advised to remain at home and will be given education for home care. The “urgent sick” patient will either be referred to a Tier 1 – Triage site, or EMS will respond. The EMS response will be driven by certain assumptions based on the pandemic influenza phase in the community.

1.      Triggers:  Category I – Federal Government Response Stage 4: First human case in N. America

·         Usual Standards of Care
·         One to five ICU cases have been identified in Pierce County
·         Full resources are still available
·         Calls coming into phone triage lines either directly from patients or diverted from 911 dispatch
·         Action: 
o        Alert and Standby Pre-Tier 1, Tier 1 and 2 Alternate Care Facilities
o        Activate Hospital Facility Emergency Plans
o        Activate and Standby Hospital surge capacity

2.      Criteria to identify the “Stable” patient
·         No fever or low grade (less than 102.5 for older than 3 months of age), with usual mobility
·         Slight complaint of or lack of sore throat, muscle aches, or cough
·         No labored breathing

     3.  Response to the “Stable” patient
·         Advise to remain at home.
·         Provide education on Home care of stable patient. See “Home Care” (Supplement #3)
·         Education and Information will also be available on the TPCHD Website.

    4.  Criteria to identify “Urgent Sick” patient (driven by chief complaint flu-type symptoms)

a.                              Single criteria - Only one criteria required to send EMS at this Phase:
q       Difficulty breathing with fever > 102.5; difficulty breathing is assessed as rapid breathing, needing to sit up to breathe, blue color around the lips, and being unable to talk in more than 3-4 words: or:
q       Altered mental status, which suggests hypoxia or sepsis

b.                             Two or more of the following criteria required to send EMS
q       Symptoms of dehydration (check for dry mucous membranes, lack of tears in children, decreased urination in past 12 hours)

q       Cool, clammy, sweaty skin
q       Extremes of age: under 2 or over 64 years of age
q       Comorbidities, such as pneumonia in the last year, COPD, etc.

          5. Response to the “Urgent Sick” patient

The response to the identified “Urgent Sick” patient will involve either EMS being dispatched or a referral to the Nurse Advice Line/Phone Triage. (Refer to Puget Sound Call Center Coordination Project, attached). If EMS is sent, there are different possible outcomes.

a.      EMS Response: (Per Altered Standards of Care)

(1)               No transport - Transport to a Tier 2 (ACC) or Tier 3 (Hospital) not warranted.

q       Patient advised to remain at home
q       Provide flu pack
q       Provide education on home care (Supplement # 3) and on TPCHD website
q       Provide information about location of Triage centers, if illness worsens.

(2)               Requires transport: (Per Altered Standards of Care)

q       Transport to Tier 2 (ACC) if SP02 is greater than 90%
q       Transport to Tier 3 (Hospital) if SP02 is less than 90%

b.         Referral to Health Information Care Line or Nurse Triage Line:

q       May determine that EMS needs to be sent, or they may refer the patient to a Tier 1 -Triage Center

         6.  Criteria for Health Information Care Line/Nurse Triage Line or EMS to refer to Tier 1 –Triage:  

This may be determined by EMS personnel at patient’s home or by the Nurse Triage Line.

q       Fever greater than 102.5; or does not reduce with anti-pyretics
q       Fever greater than 100.5 in infants and children under 2 years of age
q       Fever greater than 101.0 for 5 days and not improving
q       Symptoms for dehydration
q       Candidate for Anti-viral medication

       7.  EMS Treatment Protocols

If EMS dispatches to the home, the following treatment protocols have been identified.

q       Hydration
q       Fever Reduction
q       Pain medication, as needed
q       Oxygen, once transport is decided
q       No aerosol generating procedures will be done in the field, including intubation and nebulized treatments

 8.  Triggers: Category II /III– Federal Government Response Stage 5: Spread throughout  U.S. and in community

·         Altered Standards of Care
·         50 + ICU cases in Pierce County; increased ventilator demand
·         Emergency Declaration
·         Hospital capacity and resources diminishing
·         Action:

q       Activate Pre-Tier 1 Altered triage protocols
q       Activate Tier 1 and 2 Alternate Care Facilities
q       Activate hospital surge capacity

In evaluating triage guidelines for Pre-Tier 1, Tiers 1 and 2, the criteria to identify the “Urgent Sick” patient during Categories II and III of the Pandemic will be the same as noted above in the Category I. EMS and Health care Telephone Information/Triage Lines’ response to the “Urgent Sick” will also be the same, but only if resources and services continue to be available. As resources become scarce, a new category of sick patient will be assigned. This category is the “Too Sick” patient. Chances for survival for this patient are assessed to be minimal. A “morbidity scale” will be followed to determine if the patient fits this category.

 9.  Criteria to identify the “Too Sick” patient (under discussion due to ethics consult)

·         Documented DNR (Do not resuscitate)
·         Unresponsive
·         Agonal or gasping breathing
·         Fever greater than 102.5 (along with any of the other criteria)
·         Cyanotic
·         Age greater than 75 years (Age factor may decrease to 70, 65, 60, etc., as needed, per direction of Health Officer, as resources become more limited.)
·         Also, consider patients who may not have the flu, but are still “too sick” due to other conditions

10.  Response to the “Too Sick” patient:

·         EMS transport will be determined by services available
·         Send Home Health Nurse or Hospice nurse, as appropriate
·         Place on list to be contacted for follow-up when Tier 2 or Tier 3 open up
·         Refer to mortuary service, if patient deceased
·         Advise family re no resources in the community to provide care
·         Provide education on home comfort care:
    • Hydration
    • Fever reduction
    • Pain medication, as needed
B.      Tier 1Neighborhood Emergency Help Centers (NEHC): Triage and Outpatient care, and Referral function

·                     See Tier 1 (NEHC) Straw person logarithm.

Several sites (primarily urgent care and medical clinics that are located away from hospitals and geographically distributed throughout the county) have been identified as Tier 1 – Triage and Outpatient Treatment Centers and NEHC (Neighborhood Emergency Help Centers) to be used in the event of a pandemic influenza. A patient may arrive at this site on their own, having received information about the Triage Sites through education efforts by TPCHD via media announcements (radio, TV, newspapers) or the TPCHD website. Or a patient may arrive as the result of a referral from the Health Care/Nurse Advice Phone Line.

The Triage Centers staffing may include: MDS, RNS, ARNPS, PA, LPNS, Behavioral health, security staff, health educators, and pharmacy technicians. See the Operations portion of this plan for further description of positions and job task sheets.

1.  Tier 1 – Triage and Outpatient Treatment Centers Capabilities

a.      Provide physical assessments of the patient,
b.      Provide treatment per standing protocols (i.e. antibiotic and anti-viral medications)
c.      Advise the patient to return home or arrange for transport to Tier 2 (ACC) or to Tier 3 (hospital), depending on patient assessment.

2.  Assumptions

a.      Pregnant women will not be treated in the Alternate Triage or Care Facilities
b.      It is recommended that certain hospitals or birthing centers be designated for delivery; and that high-risk pregnancies are referred to NICU hospitals.
c.      Tier 2 (ACC) will receive children 3 years old and older. Children younger than three years old will be transported to Tier 3 (Hospitals), preferably hospitals with pediatric specialties.

3.  Forms: (See Supplements: Forms)

a.      Patient Screening Form
b.      History and Physical Exam Form
c.      Admission and Treatment Orders Forms

4.Treatment Guidelines for Tier 1 – Triage Center

a.      Assist patient with filling out Patient Screening Form.
b.      Separate worried well, minor/major sick.
c.      Evaluate symptoms and co-morbidities
d.      Use Standardized History and Physical Exam Form
e.      Determine if patient is Hypoxic or Hypotensive.

q       If hypotensive

§         Administer IV bolus
§         If resolves with bolus: Transport to Tier 2 (Acute Care Center)
§         If does not resolve with bolus – Transport to tier 3 (Hospital)

q       If hypoxic:

§         Administer 02
§         If resolves with 02: Transport to Tier 2 (Acute Care Center)
§         If does not resolve with 02 – Transport to tier 3 (Hospital)

q       If not hypotensive or hypoxic:

§         Dispense AVM or antibiotics, if eligible and available or necessary
§         Dispense “Flu Pack” and instructions for Home Care

f.        Determine treatment, using Standarized Admission and Treatment Orders Forms.

g.      Patient Tracking (Development of “IRIS” system)
It is recommended that the Forms used in Tier 1 and Tier 2 (Screening, History and Physical Exam, and the Admissions Orders) travel with the patient if transported to another Tier.

C.  Tier 2 – Alternate Care Facilities (Acute Care Centers) – Triage And Treatment Protocols

  • See Tier 2 (ACC) Straw Person logarithm
Tier 2 – Alternate Care Faciltities (Acute Care Centers) are designed to function as alternate inpatient care facilities to augment the hospital capacity to admit pandemic influenza patients. A network of these pre-planned centers will enhance the community’s capability to care for large numbers of sick patients. Local hospitals and emergency management will be linked to the Alternate Care Facilities (Tiers 1 and 2) to coordinate and direct patient care, medical logistics, and information flow.

The Tier 2 facilities are designed to care for patients that are too sick to be at home and might need a few hours to a few days of medical care. The Tier 3 Level (Hospitals) will be providing medical care to only the “sickest of the sickest” patients.

1.      Admission Criteria to Tier 2

·         Oxygen requirement that can be met with supplemental oxygen
·         Assumption: No ventilators at the ACC
·         Dehydration requiring IV hydration
·         Secondary Pneumonia requiring IV antibiotics

2.  Tier 2 Capabilities

·         Staffing directed by hospital systems
·         Physical assessment, vital signs
·         Pulse oximetry
·         Point of care testing (Chem 7, Blood glucose)
·         No Xray – treat with antibiotics based on clinical diagnosis
·         IV and oral rehydration
·         Pharmacist technician
·         Capability to prescribe and dispense antibiotics and antivirals
·         Other medications, such as antipyretics, analgesics
·         Limited airway management: ability to intubate and transfer
·         Children 3 years and older – transport children less than 3 years old to Tier 3 Hospitals that normally treat children
·         Palliative care, if not available at patient’s home

3.         Forms: (See Supplement: Forms)

·         History and Physical Exam Form for adults and children over 3 years
·         Admission -Treatment Orders – Adult and Pediatric

4.  Treatment Protocols for Tier 2 – ACCs

a.                  Arrives at Tier 2
b.                  Assign to Nursing subunit
c.                  Obtain History and perform Physical Exam
q       Form:  History and Physical Exam
q       Table 1:  Clinical Criterial for classifying Dehydradion
d.                  Evaluate symptoms (MD/NP/PA/RN
e.                  Follow Standardized Admission and Treatment orders
q       Form: Admission – Treatment Orders
q       Tables 2 & 3: Oral Rehydration Therapy
q       Provide IV bolus, as appropriate per standardized treatment orders
q       Provide O2/NC, as appropriate per standardized treatment orders
q       Determine Antiviral Medication (AVM) eligibility
q       Dispense AVM and antibiotics as appropriate per standardized treatment orders
q       If diagnosis of pneumonia – prescribe antibiotic as appropriate per standardized treatment orders
f.                    Patient Sorting: Determine - Short Stay, Longer Stay, Palliative Care
g.                  Continue treatment and observation until discharge

5.  Disposition – Tier 2

a.    Arrange for transport to home, hospital or morgue
b.      Develop criteria for Discharge
c.      Develop system for Fatality management

C.  Tier 3 – Hospitals  (See Tier 3 Response Matrix)

1.  Patient Types

A matrix has been developed that outlines and defines patient types.  Four types of patients have been identified: Red, Yellow, Green, and Blue.

Red (Type 1 Patient) is a patient that is considered to have a very poor prognosis and is expected to die within 2-3 days, possibly within hours, of the onset of symptoms.  If a severe pandemic occurs, such as the 1918 flu, the cause of death in many patients will be massive respiratory failure from the overwhelming entry of inflammatory cells and fluid into the lungs, called a cytokine storm.  Clinical signs include rapid onset of shortness of breath, cyanosis, tachypnea and bleeding from different sites. In the 1918 pandemic flu this type of response was found mainly to occur in the younger, healthier portions of society, i.e. those aged 15-40 years old. If treated in the ICU with access to ventilators, survival rate is estimated to be 50%.  A mortality rate of 95% is estimated if the patient is left at home.
 (ref: Grattan Woodson, M.D. 2/13/07).

Yellow (Type 2 Patient) is a patient that presents as very ill, survives past 3 days and may have pulmonary and/or cardiovascular complications.  These patients will tend to be elderly or very young, or adults with chronic medical conditions.  They often improve then relapse with malaise, aches, pains and fever.  They may have significant co-morbidities such as emphysema, chronic bronchitis, diabetes, coronary heart disease, hypertension, and children with asthma. Pregnant women are considered to be at highest risk.  Survival rate of 85% is expected if the patient is treated with IV antibiotics, ICU and ventilator when needed.  A 50% mortality rate is estimated if the patient is left at home.
(ref: Grattan Woodson, M.D. 2/13/07).

Green (Type 3 Patient) is the type of patient with the greatest chance of survival.  This will comprise the majority of those ill with the pandemic flu, and they will be dependent upon others (i.e. household members and family) to care for them.  Clinical signs include fever, cough, malaise, no cyanosis, hypoxia or hemorrhage.  If co-morbidities exist, they will be controlled.  The survival rate is expected to be as high as 99% if admitted to the hospital when needed; and 95% if treated at home.  Death is primarily due to dehydration.
(ref: Grattan Woodson, M.D.2/13/07).

Blue (Patient in extremis) is the patient that is near death, may be unconscious and will receive palliative care.
2. Tier 3 Response Guidelines (See Response Matrix)
Category I: Usual Standards of Care are still in effect.
a.Triggers to implement the Tier 3 Response Matrix during a pandemic influenza:

·         Federal Government Stage 4 (First human cases in N. America)
·         Pierce County hospitals reporting 1 to 5 ICU cases total in the county. 

b.  Resources: Full hospital resources are still available. 

c.  Admission and Triage Guidelines in Category I include

·         Admitting all patient types (RED, YELLOW, and GREEN) as needed. 
·         GREEN patients may be referred for home health monitoring which will include assessing the home environment to identify household members that can provide care. 
·         Critical Care admission will involve normal pre-pandemic triage
·         Elective procedures will continue.

d.  Actions in Category I include:

·         Increasing surveillance for pandemic flu patients
·         Alerting and standing-by the ACFS
·         Activating hospital facility emergency plans
·         Activating EOC and ESF 8
·         Alerting hospitals to be prepared to activate their surge capacity plans. 
·         Home health, hospice, and long-term care facilities will be alerted to activate their emergency plans.

Category II:  Altered Standards of Care come into effect

a.Triggers:

·         Federal Government Response Stage 5 (spread throughout the U.S.)
·         pandemic flu in Western Washington
·         Emergency Declaration in effect. 
·         Up to 50 ICU cases and increased demand for ventilators are reported by hospitals in the county. 

b.  Resources: Hospital capacities are diminishing. 

c.  Admission and Triage Guidelines in Category II include

·         Triage Emergency Department patients to Tier 1 Triage and Treatment sites, as appropriate. 
·         GREEN patients will be referred to Tier 1.
·         RED and YELLOW patients will be admitted to the hospital. 
·         Criteria guidelines for admission to Critical Care will be the assessed need for ventilator and hemodynamic support. 
·         When ICU beds are still available, both YELLOW and RED patients will be admitted.  Once all ICU beds are filled, YELLOW patients will receive priority (i.e. if both a YELLOW and a RED patient arrive at the same time, the YELLOW patient will be admitted first.)

d. Actions in Category II include:

·         Lifting of EMTALA by decree of a Declaration of Emergency. 
·         Hospitals will activate their surge capacity and their emergency response plans.  ACFS will be operational and the hospitals’ Command Centers will communicate on patient triage and movement. 
·         Resources will be conserved to maximize capacity;
·         Elective procedures will gradually decrease, and staff beds will gradually be converted to critical care. 

Category III  Altered Standards of Care are in effect.

a.  Triggers:
·         Community spread of pandemic flu
·         ICU cases greater than 50 in the county. 

b.  Resources:  Hospital resources are nearing or completely diminished. 

c.  Admission and Triage Guidelines in Category III

·         Outline criteria for inclusion/exclusion to Critical Care (See Matrix).
·         YELLOW patients identified as having greater chances of survivability are admitted. 
·         Inclusion criteria include patient requiring ventilator and hemodynamic support.
·         Depending on hospital resources, exclusion criteria might include severe trauma, severe burns, cardiac arrest, severe cognitive impairment, advanced untreatable neuromuscular disease, metastatic malignant disease, advanced immunocompromise, advanced neurologic condition, end-stage organ failure, and age 85 years and older. 
·         Elective surgeries will also be excluded. 
·         RED patients will be assessed case by case.  If an ICU bed is available and no YELLOW patient is waiting, the RED patient will be admitted.  When ICU beds are not available, RED patients will be referred to hospice, home-health, or Tier 2 palliative care.  Emergency surgeries and non-flu procedures such as traumas, appendectomies, and stent replacements will be continued.

d.  Actions in Category III will include:

·         Activation of resource conservation and conversion, such as converting surgical suites, day surgery and recovery suites into critical care units, along with shifting human resources from the operating room and recovery to critical care. 
·         All elective procedures will be canceled
·         Implementation of withdrawing critical care from patients with non-survivability conditions will be considered. 
·         The hospitals’ command centers will coordinate movement of patients between hospitals based on bed availability.

Reference #1:  CMAJ article: November 21, 2006.  Research: Development of a triage protocol for critical care during an influenza pandemic Box 2 p. 1379.


TIER 3 (HOSPITAL): PATIENT TRIAGE DURING PANDEMIC INFLUENZA

Tier 3 Patient Typing Definitions

RED (Type 1 Patient)


Prognosis:  Poor: die within 2-3 days of onset of symptoms


Age:   15-40 year -olds due to cytokine storm


Clinical signs: rapid onset SOB, cyanosis, tachypnea, bleeding from sites

 

 

 

 

 

 

Survival: 50% survival rate w/ access to ICU/Vents; 95% mortality if left at home

YELLOW (Type 2 Patient)

Prognosis:  Very ill, survival past 3 days; pulmonary and/or cardiovascular complications.

Age:  All elderly, very young, or adults with chronic medical disorders

Clinical Signs:  Often improve then relapse with malaise, aches, pains and then fever.
Significant co-morbidities: Emphysema, chronic bronchitis, children with asthma, diabetes, Coronary heart disease, high BP, Pregnant women are at high risk

Survival: 85% survival rate with IV antibiotics, diagnostic testing, ICU, vent when needed.
50% mortality rate if left at home

GREEN (Type 3 Patient)

Prognosis:  Greatest chance of survival;
majority of those ill with flu; dependent on others for care.



Clinical Signs: Fever, cough, malaise, no cyanosis, hypoxia or hemorrhage. None or controlled co-morbidities. 





Survival: 99% survival rate if admitted to hospital when needed; 95 % survival rate if treated at home. *Death is primarily due to dehydration.

BLUE (Patients in extremis)

Near death
Unconscious
Supportive care only




 



Tier 3 Response Matrix

Category

Triggers

Available Resources

Admission & Triage Guidelines

Action


I


Usual
Standards
Of Care
Fed Govt Stage 4: First human cases in N. America
                

1-5 ICU cases in Pierce County
Full Resources
Admit all Patient types: RED, YELLOW, & GREEN, if able.

GREEN patients: assess home environment; identify family members that can provide care; assess ability to take oral fluids; refer to home health monitoring as appropriate (guidelines to be developed)

Critical Care Admission: Normal triage
Continue Elective procedures


Increase surveillance (tool to be developed)

Alert and Standby Tier 1 & 2 Sites
Conduct Just-in-time Training of staff for Tier 1, 2
Acquire anticipated resources (pre-planning needs identified)

Activate Facility Emergency Plans
Activate EOC & ESF 8

Alert Home Health/Hospice/LTCF to activate Emergency Plans

Alert status: activation of hospitals’ surge capacity

Category

Triggers
Available Resources
Admission & Triage Guidelines
Action

 

II


Altered
Standards
Of Care
Fed Govt. Stage 5: Spread throughout U.S.
Pan Flu in Western WA

Up to 50 ICU cases in County
Increased Vent demand

Emergency Declaration
Hospital capacity diminishing
(develop incremental measurements)
ED Criteria: Triage to Community Tier 1 sites, as appropriate.

Refer GREEN patients to Tier 1.

Admit RED & YELLOW patients.

Critical Care Admissions:
- Require ventilator support
- Require hemodynamic support

Transition between Category II & III – admit both Yellow and Red until all ICU beds filled; once filled, Yellow patients receive priority (i.e. if both a Yellow and Red patient arrive at the same time: admit Yellow patient.)
Lift EMTALA by decree of Declaration of Emergency

Activate hospitals’ surge capacity matrix
Implement Hospitals’ Emergency Response plans; HICS initiated

Activate Tier 1 & 2 sites

Hospitals’ EOC communications between hospitals on patient triage and movement

Conserve resources, maximize capacity: limit elective procedures – decrease by 25% increments; convert staff and beds to CC

Implement Early Discharge protocols 

Implement Social Distancing Strategies

Request additional supplies (SNS/Vendors)

Advise LTCF No transport to Hospitals
Standby Home Health/Hospice/LTCF re Early Discharges from Tier 3











Category

Triggers

Available Resources

Admission and Triage Guidelines

Action

 

III


Altered
Standards of Care
Fed Govt. Stage 5:
Community spread

Greater than 50 ICU cases in County

Note: gradual transition from Category II to II.
Hospitals maxed out
Limited equipment, supplies, staff
Admit YELLOW patients – those identified as having greater survivability.

Critical Care Inclusion: (ref: 1)
- Require ventilator support
- Require hemodynamic support

Critical Care Exlusion: (ref 1)
- Severe trauma
- Severe burns
- Cardiac arrest
- Severe baseline cognitive impairment
- Advanced untreatable neuromuscular disease
- Metastatic malignant disease
- Advanced/irreversible immunocompromised
- Advanced/irreversible neurologic event or condition
- End-stage organ failure
 -Age > 85
- Elective palliative surgery

RED Patients: assess case by case – if bed available, and no Yellow patient is waiting, admit to ICU; when ICU beds not available, refer RED patients to hospice, home-health, Tier 2 Palliative Care

Continue emergent surgical, non-flu procedures (traumas, appendectomies, stent replacement)
Activate Critical Care Inclusion/Exclusion Criteria.

Assess function and effectiveness of Community Tier 1 & 2 sites (develop assessment tool).

Activate resource conservation/conversion: surgical suites, day surgery, recovery suites into CC units.
Shift of human resources, i.e. from OR, Recovery to CC.

Cancel all elective procedures

Implement established withdrawal of Critical Care guidelines for patients with non-survivability conditions.  (Clarify ??)

Hospitals’ ECO coordinate between hospitals transfers of yellow patients where beds available.





Tier 3 Planning:

“Parking Lot”

Criteria for moving patients out of Tier 3 and into community based services

Criteria for withdrawal of support (i.e. vent support or ICU care)

Criteria for stopping, or phasing out/prioritizing elective surgeries

Criteria for “most viable” for admission to ICU; priority list for YELLOW patients – those identified with greater survivability

Develop Early Discharge criteria

Create tool: to Activate Tier 1 & 2 sites – phased approach, number and locations

Develop assessment tool to assess function and effectiveness of Community Tier 1 & 2 sites

Mechanism to integrate Home Health/Hospice/LTCF into plan; agreements on criteria on types of patients they can receive

Pediatric care

Pregnancy care

Stockpile ventilators

Train staff to administer ventilators

Reimbursements to hospitals

Tier 1 & 2 Revisions

Patient Education forms: Home Care and “When to seek medical care”
Home Health Criteria
Hospital Surge Capacity estimates
Legal Opinion
Education of hospital medical staff re “development of plan”



Supplement 1 – Straw Person























Supplement 2 - Forms


Pandemic Influenza Screening and Triage Form

Name: _______________________________________   Birth Date: ______________  Age: _____________
                     Last                              First                     MI  

Address: _______________________________________________________ Zip Code: ________________

Telephone: ___________________   Sponsor SSN: ____________________   Unit: ____________________

Date: ______________________   Time:  _____________________

Instructions:       Please complete the form and review it with the care provider.
Answer all the questions to the best of your ability.

MEDICAL HISTORY

YES

NO
Are you taking any medications?
If yes, please list them:




Are you allergic to any medications?
If yes, please list:




Have you been sick for more than 24 hours?




Have you been around someone that is sick with the ‘flu”? 




Is someone in your house sick with a fever, shortness of breath, sore throat, and cough?




Have you been traveling in an area where severe flu or pandemic influenza is known to be present?




Are you pregnant?




Do you have any of the following symptoms?




Fever




Shortness of breath




Cough




Sore Throat




Vomiting and/or diarrhea




In the past 6 months, have you had?




Cancer




Heart Failure




Immune disorder/disease




COPD [chronic obstructive pulmonary disease]




Asthma




Diabetes




Other serious diseases: 






Person completing form if other than patient: ____________________________ Relationship____________



This page is blank



Text Box: History and Physical ExamText Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________


Chief Complaint:         cough         fever
sore throat    myalgias     pain (1-10)____

Onset:____________________________

Review of Symptoms:
dyspnea:  mild  moderate  severe
sputum:  color  _____________  blood
wheezing         chest pain ____________
nausea            vomiting  x___________
abd pain          diarrhea x____________
myalgias          headache         joint pain
chills                fever ________________
syncope          urine output ___________
rash _____________________________
other ____________________________

PMH:  asthma             COPD
diabetes: insulin/oral   HTN
pneumonia _______   CAD __________
cancer ___________  HIV: CD4 ______
PE                               DVT
Tobacco__________  ETOH _________
Other:

FMH:
Medications:


Allergies: NKDA


Temp_______  HR________  RR________
BP ______/______   RA O2 sat________%
Primary physician____________________


General appearance:  well            ill        toxic
Eyes:   nml                  sunken                injected
Ears:   nml                          _______TM red/dull
Nose:   nml                      drainage___________
Throat: mnl            red       exudate
Mucous membranes:  nml            tacky     dry
Neck:   supple      LAD           stiff            JVD
Heart:  rate:           brady         nml         tachy
      murmur________ gallop________     rub
Resp:  rate:     nml            incr            incr/deep
      distress:  none            mild     mod severe
      lungs: clear    quiet      cough________
      wheezing: none       mild   mod     severe
      stridor        rales          rhonchi
      retractions       accessory muscle use
Abd:     soft                  tender______________
      guarding          rebound    
      bowel sounds: nml            incr           decr
      organomegaly     __________________
Extrem:     pink      pallor         cyanosis
      warm   cool     cold
      diaphoresis     edema       rash________
      pulses:      nml            decreased                         poor
      turgor:  instant delayed            prolonged
Neuro: awake  alert     oriented     confused
      sleepy        lethargic    obtunded
      focal deficit      ____________________
Assessment Plan:








Provider Name: _____________________

Date: ______________________________


Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________


Table 1. Clinical Criteria Commonly used for Classifying Dehydration Severity

Mild
(3-5%)
Moderate
(6-9%)
Severe
(> 10%)
General Appearance/
Level of consciousness*
Well-appearing
Ill-appearing, non-toxic
Lethargic, toxic
Heart Rate
Normal to increased
Tachycardic
Marked tachycardia
Breathing
pattern*
Normal
Increased
Increased, deep
Pulses
Normal quality
Normal to decr quality
Poor quality
Capillary refill*
Normal (< 2sec)
Normal to sl prolonged (2-4sec)
Markedly prolonged
Perfusion
Warm
Cool
Cold, mottled
Blood pressure
Normal
Normal
Hypotensive
Eyes
Normal
Slightly sunken
Very sunken
Tears
Normal
Decreased
Absent
Mucous membranes
Moist
Tacky
Very Dry
Skin turgor/recoil*
Instant recoil
Delayed (2 sec)
Very prolonged (> 2sec)
Urine output
Normal to slightly decreased
Decreased
Minimal
Adapted as a composite from WHO 1995, Gorelick 1997, Friedman 2004
* 4 items with the highest predictive value for dehydration: general appearance, breathing pattern, capillary refill, and skin turgor/recoil.



Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________
There are several commercially available products but an inexpensive home-made solution consists of 8 level teaspoons of sugar and 1 level teaspoon of table salt mixed in 1 liter of water. A half cup of orange juice or half of a mashed banana can be added to each liter both to add potassium and to improve taste. If commercial solutions are used, true rehydration solutions should be used and sports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough electrolytes.

Table 2. Constituent components and Recommendations for Oral Rehydration Therapy (ORT)


Osmolality
(mOsm/kg)
Glucose
(mmol/L)
Sodium
(mmol/L)
Potassium
(mmol/L)
Recommendation
as an ORS
WHO
331
111
90
20
Recommended for All ages
Low Osmlarity WHO
245
75
75
20
Recommended for All ages
Commercial ORS
(i.e., Pedialyte®)
250
139
45
20
Recommended for All ages
Sports Drink
(i.e., Gatorade®)
330
255
20
3
Not recommended for children less than 2 yrs
Cola
500
700
2
0.1
Not recommended
Seven-up
388
500
4
0
Not recommended
Orange juice
687
680
1
486
Not recommended
Apple juice
694
690
0
27
Not recommended
Adapted from Sandhu 2001 pg S37



Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________
Vomiting itself does not mean that oral rehydration cannot be given. As long as more fluid enters than exits, rehydration will be accomplished. It is only when the volume of fluid and electrolyte loss in vomit and stool exceeds what is taken in that dehydration will continue. When vomiting occurs, rest the stomach for ten minutes and then offer small amounts of ORS solution. Start with a teaspoonful every five minutes in children and a tablespoonful every five minutes in older children and adults.

Table 3. Age and Weight-based ORT Dosing Guidelines


Age


Weight

Initial Dosing

Volume/hr

First Advance

Next Advance
0-6mo
8kg
5cc every 5min
60cc
(10cc/kg)
15cc every 15min
30cc every 1/2hr
6-12mo
10kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
12-18mo
12kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
18-24mo
13kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
2-3yrs
15kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
3-5yrs
20kg
15cc every 5min
180cc
(10cc/kg)
45cc every 15min
90cc every 1/2hr
5-8yrs
25kg
15cc every 5min
180cc
(10cc/kg)
60cc every 15min
90cc every 1/2hr
8-10yrs
35kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr
10-12yrs
40kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr
12-15yrs
50kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr




Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________Text Box: Admission Orders
1.         Admitting Team: ________________________________________________

2.         Admitting Facility: _________________________ Area _________________

3.         Primary Diagnoses: Influenza __________________________________________

            Secondary Diagnoses:  _________________________________________________
□ diabetes  □ heart disease  □ stroke  □ asthma  □ COPD  □ cancer  □ renal disease

4.         Condition:  □ good    □ fair    □ poor    □ critical

5.         Vital Signs:  □ Every 8 hours with oximeter check     □ Weight: ___________ kg

6.         Allergies: ____________________________________________________________

7.         Supplemental Oxygen:           □ O2 to keep saturations > 94%     □ Mask __________
            □ Nasal cannula _____________       □ other ___________________________

8.         Diet:    □ regular            □   diabetic    □ other___________________________________

9.         Activity:   □ bedrest      □ bedrest/bathroom privileges           □ other_________________

10.       Antiviral Treatment:  If onset of illness is less than 72 hours consider one of the following (based upon protocol and availability).
           
            □ Tamiflu         75mg PO twice daily for 5 days

            □ Relenza       10 mg inhaled twice daily for 5 days
                                               
11.       Fluids:             □  Oral/nasogastric rehydration (use weight based protocol)
           
                                    □  Intravenous (IV)      
□ NS:               20cc/kg bolus      1Liter bolus        2Liter  bolus 
Follow by __________cc/hour
                                   
□ Other ______________________________________
12.       Antipyretics:
                        Acetaminophen           □ 650mg          □ 975mg          PO Q6hrs PRN fever or pain

                        Ibuprofen      □  400mg    □ 800mg     PO every  □ 6hrs  □ 8hrs PRN fever or pain


Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________
13.       Analgesics: (do not double dose acetaminophen)
                        □ Acetaminophen 300mg/codeine 30mg                   1 – 2 PO Q4 - 6° PRN pain
                        □ Acetaminophen 500mg/hydrocodone 5mg             1 – 2 PO Q4 - 6° PRN pain
                        □ Acetaminophen 325mg/oxycodone 5mg                 1 – 2 PO Q4 - 6° PRN pain
                        □ Morphine   □ 1-4mg      □ 2-8mg                  IV / SC / IM         Q2 - 4° PRN pain

14.       Antibiotics:
           
                        □ Ciprofloxacin            500mg PO every12 hours
           
                        □ Azithromycin            500mg IV/PO every 24 hours

            □ Rocephin                 1 gram IV every 24 hours

15.       Bronchodilators (use only in restricted area; MDIs with spacers):

                        □ Albuterol       1-2 puffs                                              Q4 - 6° PRN wheezing
                           MDI

                        □ Ipratropium   < 2yr                250mcg/dose              Q6 - 8° PRN wheezing
                           SVN              ≥ 2yr                250 - 500mcg/dose     Q6 - 8° PRN wheezing

                        □ Ipratropium   < 12yr              1-2 puffs                      Q6 - 8° PRN wheezing
                           MDI               ≥ 12yr              1-2 puffs                      Q6 - 8° PRN wheezing

16.       Antiemetic:                  □ Phenergan 12.5 – 25mg IV every 6 hours PRN nausea

17.       Antihistamine:             □ Benadryl 25 – 50mg PO/IV every 6 hours PRN itching

18.       Other








Provider Name______________________________________ Date________________



Text Box: Pediatric History and Physical ExamText Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________


Chief Complaint:         cough         fever
wheezing                     other ____________

Onset:____________________________

Review of Symptoms:
dyspnea:  mild  moderate  severe
Poor feeding _____________________
wheezing         chest pain ____________
nausea            vomiting  x___________
abd pain          diarrhea x___________
myalgias          headache         joint pain
chills                fever ________________
syncope          urine output ___________
rash _____________________________
other ____________________________

PMH:  asthma             prematurity
diabetes:                     Immunodeficiency
pneumonia                  congen heart dz
cancer                         HIV: CD4


Other:

FMH:
Medications:


Allergies: NKDA


Temp_______  HR________  RR________
BP ______/______   RA O2 sat________%
Wt ________(%)   Ht ________(%)


Primary Physician: ___________________

General appearance:  well            ill        toxic
Eyes:   nml                  sunken                injected
Ears:   nml                          _______TM red/dull
Nose:   nml                      drainage___________
Throat: mnl            red       exudate
Mucous membranes:  nml            tacky     dry
Neck:   supple      LAD           stiff
Heart:  rate:           brady         nml         tachy
      murmur________ gallop________     rub
Resp:  rate:     nml            incr            incr/deep
      distress:  none            mild     mod severe
      Grunting
      lungs: clear    quiet      cough________
      wheezing: none       mild   mod     severe
      stridor        rales          rhonchi
      retractions       accessory muscle use
Abd:     soft                  tender______________
      guarding          rebound
      bowel sounds:       nml            incr                        decr
      organomegaly     __________________
Extrem:     pink      pallor         cyanosis
      warm   cool     cold
      diaphoresis     edema       rash________
      pulses:      nml            decreased                         poor
      turgor:  instant delayed            prolonged
Neuro: awake  alert     oriented     confused
      sleepy        lethargic    obtunded
      focal deficit      ____________________
Assessment Plan:






Provider Name: _____________________

Date: ______________________________



Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________

Table 1. Clinical Criteria Commonly used for Classifying Dehydration Severity

Mild
(3-5%)
Moderate
(6-9%)
Severe
(> 10%)
General Appearance/
Level of consciousness*
Well-appearing
Ill-appearing, non-toxic
Lethargic, toxic
Heart Rate
Normal to increased
Tachycardic
Marked tachycardia
Breathing
pattern*
Normal
Increased
Increased, deep
Pulses
Normal quality
Normal to decr quality
Poor quality
Capillary refill*
Normal (< 2sec)
Normal to sl prolonged (2-4sec)
Markedly prolonged
Perfusion
Warm
Cool
Cold, mottled
Blood pressure
Normal
Normal
Hypotensive
Eyes
Normal
Slightly sunken
Very sunken
Tears
Normal
Decreased
Absent
Mucous membranes
Moist
Tacky
Very Dry
Skin turgor/recoil*
Instant recoil
Delayed (2 sec)
Very prolonged (> 2sec)
Urine output
Normal to slightly decreased
Decreased
Minimal
Adapted as a composite from WHO 1995, Gorelick 1997, Friedman 2004
* 4 items with the highest predictive value for dehydration: general appearance, breathing pattern, capillary refill, and skin turgor/recoil.




Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________

There are several commercially available products but an inexpensive home-made solution consists of 8 level teaspoons of sugar and 1 level teaspoon of table salt mixed in 1 liter of water. A half cup of orange juice or half of a mashed banana can be added to each liter both to add potassium and to improve taste. If commercial solutions are used, true rehydration solutions should be used and sports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough electrolytes.

Table 2. Constituent components and Recommendations for Oral Rehydration Therapy (ORT)


Osmolality
(mOsm/kg)
Glucose
(mmol/L)
Sodium
(mmol/L)
Potassium
(mmol/L)
Recommendation
as an ORS
WHO
331
111
90
20
Recommended for All ages
Low Osmolarity WHO
245
75
75
20
Recommended for All ages
Commercial ORS
(i.e., Pedialyte®)
250
139
45
20
Recommended for All ages
Sports Drink
(i.e., Gatorade®)
330
255
20
3
Not recommended for children less than 2 yrs
Cola
500
700
2
0.1
Not recommended
Seven-up
388
500
4
0
Not recommended
Orange juice
687
680
1
486
Not recommended
Apple juice
694
690
0
27
Not recommended
Adapted from Sandhu 2001 pg S37




Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________
Vomiting itself does not mean that oral rehydration cannot be given. As long as more fluid enters than exits, rehydration will be accomplished. It is only when the volume of fluid and electrolyte loss in vomit and stool exceeds what is taken in that dehydration will continue. When vomiting occurs, rest the stomach for ten minutes and then offer small amounts of ORS solution. Start with a teaspoonful every five minutes in children and a tablespoonful every five minutes in older children and adults.

Table 3. Age and Weight-based ORT Dosing Guidelines


Age


Weight

Initial Dosing

Volume/hr

First Advance

Next Advance
0-6mo
8kg
5cc every 5min
60cc
(10cc/kg)
15cc every 15min
30cc every 1/2hr
6-12mo
10kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
12-18mo
12kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
18-24mo
13kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
2-3yrs
15kg
10cc every 5min
120cc
(10cc/kg)
30cc every 15min
60cc every 1/2hr
3-5yrs
20kg
15cc every 5min
180cc
(10cc/kg)
45cc every 15min
90cc every 1/2hr
5-8yrs
25kg
15cc every 5min
180cc
(10cc/kg)
60cc every 15min
90cc every 1/2hr
8-10yrs
35kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr
10-12yrs
40kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr
12-15yrs
50kg
15cc every 2min
450cc
(10cc/kg)
90cc every 15min
120cc every 1/2hr





Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________
Text Box: Pediatric Admission Orders



1.         Admitting Team: ________________________________

2.         Admitting Facility: _______________________________

3.         Primary Diagnoses:  Influenza  ___________________________________________

Secondary Diagnoses:  _________________________________________________
□ prematurity     □ congenital heart disease     □ diabetes     □ asthma 
□  immunodeficiency     □ cancer     □ renal disease

4.         Condition:        □ good     □ fair     □ poor     □ critical

5.         Vital Signs:  □ Every 8 hours with oximeter check     □ Weight ___________kg

6.         Allergies: ____________________________________________________________

7.         □ O2 to keep saturations > 94%                     □ Respiratory and droplet precautions

8.         Diet:     □ regular for age   □ diabetic               □ other___________________________

9.         Activity:   □ bedrest      □ bedrest/bathroom privileges           □ other _______________

10.       Antiviral Treatment:
Onset of illness:          □  < 72 hours              □  > 72 hours
                        If onset < 72 hrs consider (based upon protocol and availability)
           
                        Tamiflu            □          Children ≤ 15kg  –  30mg twice daily
                                                            NOT approved < 12months of age
                                                □          >15kg to 23kg – 45mg twice daily
                                                □          >23kg to 40kg – 60mg twice daily
                                                □          >40kg to Adult – 75mg twice daily

                        Relenza           □          10 mg inhaled twice daily for 5 days
                                                            age 7 years and older

11.       Fluids:
                        □  Oral rehydration (see weight based protocol)
           
                        □ Intravenous (IV)       
NS       □ 20cc/kg bolus   then __________cc/hour D5 1/2NS
                                                □ add 20 KCL/L when urinating

                        1/4NS with 20KCL/L       □  _____cc/hour




Text Box: Influenza Pandemic Patient Name _________________________
Acute Care Center
Pierce County Date _________________________

12.       Antipyretics:
                        Acetaminophen           □ 15mg/kg                   PO Q6° PRN fever or pain
                                                            □ 15mg/kg                   PR Q6° PRN fever or pain

            Ibuprofen         □ 10mg/kg                   PO   □ Q6° □ Q8° PRN fever or pain
                                   
13.       Analgesics:  (do not double dose acetaminophen)
                        □ Acetaminophen120mg /codeine12mg elixir 0.5 – 1 mg/kg/dose CODEINE
                                    component  Q4 – 6 hours PRN pain
                        □ Morphine  0.1 – 0.2mg.kg.dose       IV / SC / IM     Q2 - 4° PRN pain

14.       Antibiotics:
                        □   Ceftriaxone 50mg/kg IV once daily
                        □   Ceftriaxone 100mg/kg/ IV once daily
                        □   Azithromycin 10mg/kg first dose, then 5mg/kg daily PO on days 2 - 5

15.       Bronchodilators:

                        □ Albuterol       Infant               0.05-0.15 mg/kg/dose   Q4 - 6° PRN wheezing
                           SVN              1yr. – 5yr.        1.25 – 2.5 mg/dose       Q4 - 6° PRN wheezing
                                                5yr. – 12yr.      2.5mg-5mg/dose          Q4 - 6° PRN wheezing
           
□ Albuterol       1 – 2 puffs                                             Q4 - 6° PRN wheezing
                           MDI with or without face mask spacer

            □ Ipratropium      < 2yr.            250mcg/dose                            Q6 - 8° PRN wheezing
               SVN     ≥ 2yr.            250 - 500mcg/dose                   Q6 - 8° PRN wheezing

            □ Ipratropium   < 12yr.            1 – 2 puffs                                Q6 - 8° PRN wheezing
                                       ≥ 12yr.          2-4puffs (max 12/day)               Q6 - 8° PRN wheezing
               MDI with or without face mask/spacer

16.       Other







Provider Name: _____________________________________ Date: ____________________



SampleCentral Pierce Fire & Rescue

Release of Responsibility Form
                                                                                                        
Your current medical condition is such that emergency transport is not necessary

¨    18 years old or emancipated minor
¨    Conscious and alert, communicates their choices.
¨    Oriented (GCS 15) – understands situation and consequences; and able to weigh risk/benefit options; and rationally processes information before making a decision.
¨    Vital signs are normal as per Pierce County protocol
¨    Metabolically normal (i.e. blood glucose > 80 mg/dl).
¨    Not impaired or under influence of alcohol/drug(s).
¨    Not suspected of brain trauma or hypoxia (pulse oximetry > 85%).
¨    No dementia, mental illness, or other medical disease that affects the patient’s ability to make decision.
I, the undersigned, do hereby release and hold harmless, Central Pierce Fire & Rescue and its personnel from further responsibility.

Print name of patient or guardian
Signature of patient, legal guardian or witness

Signature of EMS personnel
Date & Time
Against Medical Advice Form

1.                Your condition may not seem as bad to you as it actually is.  Without treatment your condition or problem could become worse.  If you are planning to get medical treatment, a decision to refuse treatment or transport by EMS may result in a delay which could make your condition or problem worse.
2.                The evaluation and/or treatment offered to you by EMS cannot replace treatment by a doctor.  You should obtain medical evaluation and/or treatment by going to any hospital Emergency Department in this area, or by calling your doctor if you have one.
3.                If you change your mind or your condition becomes worse, do not hesitate to call 9-1-1.  Don’t wait.  When medical treatment is needed, call 9-1-1, it is better to get help immediately.
Risks explained:

Options offered:

Plan:


I, the undersigned having been advised of the need to accept medical treatment and/or transport to a medical facility, do hereby release and hold harmless, Central Pierce Fire & Rescue and its personnel from further responsibility arising from my refusal of treatment and/or transport.  I acknowledge the emergency medical personnel have fully explained the risks and benefits of treatment and transportation and decline the services described.

Print name of patient or guardian

Signature of patient, legal guardian or witness
Relationship

Hospital contacted  
Date & time
Base station physician

Signature of EMS Personnel
MIR Number






This page is blank



Supplement 2a - Checklists

Pre-Tier 1
911 Dispatchers/Phone Triage Operators/Nurse Advice Lines
Checklist

Criteria to Identify the “Stable Patient”

 No fever or low grade (less than 102.5 for older than 3 months of age), with usual mobility

 Slight complaint of or lack of sore throat, muscle aches, or cough

 No labored breathing

Response to the “Stable Patient”

 Advise to remain at home.

 Provide education on Home care of stable patient.

 Home Care Education/Information Sheet.(Appendix:_____)


Criteria to Identify the “Urgent Sick Patient”

Single criteria - Only one criteria required to send EMS :

 Difficulty breathing with fever > 102.5; difficulty breathing is assessed as rapid breathing, needing to sit up to breathe, blue color around the lips, and being unable to talk in more than 3-4 words.

 Altered mental status, which suggests hypoxia or sepsis

Two or more of the following criteria – two or more of the following required to send EMS

 Symptoms of dehydration (check for dry mucous membranes, lack of tears in children, decreased urination in past 12 hours)

 Cool, clammy, sweaty skin

 Extremes of age: under 2 or over 64 years of age

 Comorbidities, such as pneumonia in the last year, COPD, etc.


Response to the “Urgent Sick Patient”

 EMS Response:

 No transport Transport to a Tier 2 (ACC) or Tier 3 (Hospital) not warranted.
 Patient advised to remain at home
 Provide flu pack
 Provide education on home care (See Appendix # _____)
 Provide information about location of Triage centers, if illness worsens.

 Requires transport:
 Transport to Tier 2 (ACC) if SP02 is greater than 90%
 Transport to Tier 3 (Hospital) if SP02 is less than 90%

 Referral to Nurse Advice Line (Phone Triage)


Criteria for Advise Line or EMS to Refer Patient to a Tier 1 Triage Center”

 Fever greater than 102.5; or does not reduce with anti-pyretics

 Fever greater than 100.5 in infants and children under 2 years of age

 Fever greater than 101.0 for 5 days and not improving

 Symptoms for dehydration

 Candidate for Anti-viral medication

Dispatched EMS Treatment Protocols
           
 Hydration

 Fever Reduction

 Pain medication, as needed

 Oxygen, once transport is decided

No aerosol generating procedures will be done in the field




Critera to Identify the “Too Sick” Patient – Morbidity Scale


In later phases of the Pandemic, there may not be resources and services available. As resources become scarce, a new category of sick patient – “The Too Sick Patient” will be assigned. Chances for survival for this patient are assessed to be minimal. A morbidity scale will be followed to determine if the patient fits this category.

 Documented DNR (Do not resuscitate)

 Unresponsive

 Agonal or gasping breathing

 Fever greater than 102.5 (along with any of the other criteria)

 Cyanotic

 Age greater than 75 years (Age factor may decrease to 70, 65, 60, etc., as needed, per direction of Health Officer, as resources become more limited.)

 Also, consider patients who may not have the flu, but are still “too sick” due to other conditions

Response to the “Too Sick” Patient

 EMS transport will be determined by services available

 Send Home Health Nurse or Hospice nurse, as appropriate

 Place on list to be contacted for follow-up when Tier 2 or Tier 3 open up

 Refer to mortuary service, if patient deceased

 Advise family re no resources in the community to provide care

 Provide education on home comfort care




Supplement 3 – Education & Information for Home Care




Education And Information For Home Care
For Individuals with Influenza-like symptoms


q                   Drink plenty of clear fluids: hot drinks, soup, sour and spicy foods may help relieve congestion

q                   Use salt water to wash mucus out of nasal passages (plain water will sting)

q                   Using a bulb syringe, gently squirt 1-2 ounces of salt water solution into your nose, one nostril at a time.

q                   Blow nose gently; repeat 2-4 times a day.

q                   To make salt water drops: dissolve ¼ teaspoon salt in 1 cup hot water; let cool.

q                   May be stored in refrigerator for up to one week.

q                   Breathe moist, warm air from a hot shower or a room humidifier.

q                   Wear light clothing, avoid heavy covers or bundling.

q                   Rest

q                   Treat fever with Tylenol or Ibuprofen (or may use aspirin, if over age 20)

q                   Place warm washcloth over sinuses, if sinus plain




Supplement 5 – Infection Control Guidelines



Infection Control Practices in the Home


·                     Designate only one person in the household to provide care to the person sick with the flu.
·                     Desingate one area of the home for the care of the ill person.
·                     Caregiver to wash hands frequently with soap and water or waterless hand santizer.
·                     Caregiver keeps hands away from your eyes, nose and mouth.  It is possible to pick up the flu virus from door knobs, telephones, and other common objects.
·                     Ill person should wear a mask around other family members.
·                     Wash dishes, utensils, ets., in a dishwasher or along in hot water.
·                     Practice cough etiquette, including the use of disposable tittues (no handkerchiefs); use tissues once, and dispose of perperly; wash hands after use of tissue; coughing, sneezing, or blowing the nose.



Pandemic Influenza
TIER 1
Infection Prevention Guidelines

Summary Of Infection Control Recommendations For Care Of Patients With Pandemic Influenza Or Suspected Influenza

Tier 1 Definition:
The use of standardized infection control precautions used in the Ambulatory Care, Emergency Department, and triage settings to prevent and contain respiratory disease exposure and transmission.
Supply and Equipment List:
·                     Tissues
·                     Masks for patients- adult and pediatric (prevents droplet transmission)
·                     Masks with eye protection for staff (prevents mucous membrane exposure to droplets)
·                     N-95 respirators with eye protection for staff providing direct patient care
·                     Gloves (nitrile, vinyl to prevent unknown latex exposure to latex sensitive individuals)
·                     Disinfectant Wipes or spray (any quaternary ammonium with or without alcohol)
·                     Hand sanitizers/wipes/gel
·                     Gowns (disposable or reusable (for anticipated exposure to body substances)
·                     Accessible bathroom facilities with running water and soap
·                     Cover Your Cough signage
·                     Kiosks for patients with signage, tissues, masks, hand sanitizers at entry points
·                     Trash receptacles and biomedical waste containers

Process:
1.                  Entry to building will be limited to key locations.
2.                  Designate receiving and holding areas for patients with respiratory illness.
3.                  May need to initiate Command and Control Center.
4.                  Security guard placement at key entry points may be necessary to control flow and direct patients and staff.
5.                  Upon facility or triage entry initiate Standard and Droplet Precautions:
Patients:
·                     Patients with a respiratory infection symptoms or cough will be provided masks, tissue, and asked to clean their hands with antiseptic wipe or gel.
·                     Spatially separate patients with respiratory illness from those without respiratory illness, if physically possible, in a designated area.Patients with a respiratory infection symptoms or cough unable to wear mask or cover their mouth and noses will be contained or cohorted in a designated area or placed in exam rooms.
·                     Exam room doors may be shut or left ajar during patient occupation.



Employees:
·                     Will wear mask with eye protection when:
o                    Within 3 feet of an unmasked patient with respiratory illness or cough
o                    When performing respiratory exams, nasopharyngeal or throat culturing (patient is unmasked)
o                    Aerosolizing procedures:
§                     during procedures that may generate small particles of respiratory secretions (e.g., endotracheal intubation, bronchoscopy, nebulizer, treatment, suctioning), healthcare personnel will wear gloves, gown, face/eye protection, and a fit-tested n95 respirator or other appropriate particulate respirator.
·                     Will use Standard precautions for all other care necessary:
COMPONENT
RECOMMENDATIONS
STANDARD PRECAUTIONS

Hand Hygiene
·          Perform hand hygiene between patient contacts, before and after gloving, after touching blood, body fluids, secretions, excretions, and contaminated items.
·          Hand hygiene includes both handwashing with either plain or antimicrobial soap and water or use of alcohol-based products (gels, rinses, foams) that contain an emollient and do not require the use of water.
·          If hands are visibly soiled or contaminated with respiratory secretions, they should be washed with soap (either non-antimicrobial or antimicrobial) and water.
·          In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience.
Personal Protective Equipment
(PPE)

Gloves
For touching blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes and non-intact skin
Gown
During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
Face/eye protection (e.g., surgical or procedure mask and goggles or a face shield)
Wear mask with eye protection during procedures and patient care activities likely to generate splash

Safe Work Practices
Avoid touching eyes, nose, mouth, or exposed skin with contaminated hands (gloved or ungloved); avoid touching surfaces with contaminated gloves and other PPE that are not directly related to patient care (e.g., door knobs, keys, light switches).
Patient Resuscitation
Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation bag, or other ventilation devices to prevent contact with mouth and oral secretions.


COMPONENT
RECOMMENDATIONS
STANDARD PRECAUTIONS

Patient Care Equipment
Handle in a manner that prevents transfer of microorganisms to oneself, others, and environmental surfaces; wear gloves if visibly contaminated; perform hand hygiene after handling equipment.
·          Wear gloves when handling and transporting used patient-care equipment.
·          Wipe heavily soiled equipment with an EPA-approved hospital disinfectant before removing it from the patient’s room. Follow current recommendations for cleaning and disinfection or sterilization of reusable patient-care equipment.
·          Wipe external surfaces of portable equipment for performing x-rays and other procedures in the patient’s room with an EPA-approved hospital disinfectant upon removal from the patient’s room.
Soiled linen and laundry
Handle in a manner that prevents transfer of microorganisms to oneself, others, and to environmental surfaces; wear gloves (gown if necessary) when handling and transporting soiled linen and laundry; and perform hand hygiene. Wash and dry linen according to routine standards and procedures
Needles and other sharps
Use devices with safety features when available; do not recap, bend, break or hand-manipulate used needles; if recapping is necessary, use a one handed scoop technique; place used sharps in a puncture-resistant container.
Environmental Cleaning And Disinfection
·          Use any facility EPA-registered hospital detergent-disinfectant.
·          Wear gloves when disinfecting equipment and surfaces
·          Clean whatever has been touched by the patient or staff during the exam.
·          Waiting rooms may be cleaned at least daily or more often by EVS staff or designated staff according to facility procedure.
·          Emphasize cleaning/disinfection of frequently touched surfaces (e.g., exam tables, chair arm rests, counters, elevator buttons, light switches, doorknobs, medical equipment used during the care of the patient (thermometer, stethoscope)
·           No special treatment is necessary for window curtains, ceilings, and walls, floors, carpets unless there is evidence of visible soiling.
·          Do not spray (i.e., fog) occupied or unoccupied rooms with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit.
Disposal Of Solid Waste
·          Regular trash/waste including respiratory secretions may go into regular trash.
·          Biomedical waste such as gross bloody or body fluid saturated items will be disposed of in biomedical waste container.
·          Sharps will be disposed of in a sharps container.
·          Wear gloves when handling waste.
·          Wear gloves when handling waste containers;
·          Perform hand hygiene after removing gloves
Respiratory Hygiene/Cough Etiquette
·          Cover the mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacles
·          Perform hand hygiene after contact with respiratory secretions; wear a mask (procedure or surgical) if tolerated; sit or stand as far away as possible (more than 3 feet) from persons who are not ill.
Postmortem Care
·          Follow standard facility practices for care of the deceased.
·          Practices should include standard precautions for contact with blood and body fluids.


COMPONENT
RECOMMENDATIONS
STANDARD PRECAUTIONS

Laboratory Specimens And Practices
·          Follow standard facility and laboratory practices for the collection, handling, and processing of laboratory specimens.
·          Will wear clean gloves when performing culture procedure and when handling the culturette to prevent cross contamination.
Patient Transport
·          Limit patient movement outside of room to medically necessary purposes; have patient wear a procedure or surgical mask when outside the room.
·          The patient’s nurse or designee is responsible for proper transport of the patient. He/she will notify the department receiving the patient of the droplet/standard precautions and anyone assisting with the transport.
·          Nursing personnel or designee will travel with the patient to ensure isolation precautions are maintained. Mask with eye protection will be worn by staff and in addition wear other PPE as recommended for standard precautions. The patient will wear a surgical mask at all times when out of the room. The patient will perform hand hygiene.
·          Transport routes should be determined to avoid as much contact as possible with other persons (security may need to assist with this).
·          The requisition for medically necessary tests must be marked to indicate the droplet/standard precautions and the Special Precautions Sign will go with the patient.
·          The patient should be the last case of the day in OR and/or procedure rooms, if possible.
·          The patient will not be held in a waiting room or a hallway unless masked
Transfer/Discharge to another facility or to home care
Notify health department of discharge or transfer.
If the patient is transferred to another health care facility or home health care agency, it is the responsibility of the patient’s provider, case coordinator and/or nurse to notify the appropriate person at the receiving institution/agency/service of the patient’s PD status. 
Precaution use of PPE’s outlined below must be maintained during the patient’s transfer or discharge. 
The patient must:
·          Wear surgical mask during the transfer/discharge
·          Perform hand hygiene before transfer/discharge






Pandemic Influenza
TIER 2
Infection Prevention Guidelines

Summary Of Infection Control Recommendations For Care Of Patients With Pandemic Influenza Or Suspected Influenza

Tier 2 Infection Control:

The use of standardized infection control precautions for facilities identified throughout the community where surge capacity medical care will be delivered to patients seen at both the first and third tiered facilities [and assigned to Tier 2] to prevent and contain respiratory disease exposure and transmission. 

Supply and Equipment List:
·                     Tissues
·                     Masks for patients- adult and pediatric (prevents droplet transmission)
·                     Masks with eye protection for staff (prevents mucous membrane exposure to droplets)
·                     N-95 respirators with eye protection for staff who perform direct patient care
·                     Gloves (nitrile, vinyl to prevent unknown latex exposure to latex sensitive individuals)
·                     Disinfectant Wipes or spray (any quaternary ammonium with or without alcohol)
·                     Hand sanitizers/wipes/gel
·                     Gowns (disposable or reusable (for anticipated exposure to body substances)
·                     Accessible bathroom facilities with running water and soap
·                     Cover Your Cough signage
·                     Kiosks for patients with signage, tissues, masks, hand sanitizers at entry points
·                     Soap available [plain or antimicrobial] at sinks; signage over sink with instructions on performing hand hygiene
·                     Trash receptacles and biomedical waste containers

Process:

1.                  Security guard placement at key entry points may be necessary to control flow and direct patients and staff.
2.                  Upon facility entry initiate Standard and Droplet Precautions:

Patients:

·                     Patients with a respiratory infection symptoms or cough will be provided masks, tissue, and asked to clean their hands with antiseptic wipe or gel.
·                     Patients with a respiratory infection symptoms or cough unable to wear mask or cover their mouth and noses will be contained or cohorted in a designated area.


Employees:
·                     Will wear mask with eye protection when:
o                    Within 3 feet of an unmasked patient with respiratory illness or cough
o                    When performing respiratory exams, nasopharyngeal or throat culturing (patient is unmasked)
·                     Will wear gloves, gown, face/eye protection, and a fit-tested n95 respirator or other appropriate particulate respirator when performing aerosolizing procedures [may generate small particles of respiratory secretions (e.g., endotracheal intubation, bronchoscopy, nebulizer, treatment, suctioning).

When to Use Standard Precautions-Detailed
COMPONENT
RECOMMENDATIONS
STANDARD PRECAUTIONS

Hand Hygiene
Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items; after removing gloves; and between patient contacts. Hand hygiene includes both handwashing with either plain or antimicrobial soap and water or use of alcohol-based products (gels, rinses, foams) that contain an emollient and do not require the use of water.

If hands are visibly soiled or contaminated with respiratory secretions, they should be washed with soap (either non-antimicrobial or antimicrobial) and water. In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience.
Personal Protective Equipment
(PPE)

Gloves
For touching blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes and non-intact skin
Gown
During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
Face/eye protection (e.g., surgical or procedure mask and goggles or a face shield)
Wear mask with eye protection during procedures and patient care activities likely to generate splash

Safe Work Practices
Avoid touching eyes, nose, mouth, or exposed skin with contaminated hands (gloved or ungloved); avoid touching surfaces with contaminated gloves and other PPE that are not directly related to patient care (e.g., door knobs, keys, light switches).
Patient Resuscitation
Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation bag, or other ventilation devices to prevent contact with mouth and oral secretions.


COMPONENT
RECOMMENDATIONS
STANDARD PRECAUTIONS

Needles and other sharps
Use devices with safety features when available; do not recap, bend, break or hand-manipulate used needles; if recapping is necessary, use a one handed scoop technique; place used sharps in a puncture-resistant container.
Environmental Cleaning And Disinfection
Use EPA-registered hospital detergent-disinfectant; follow procedures for cleaning and disinfection of environmental surfaces; emphasize cleaning/disinfection of frequently touched surfaces
(e.g., bed rails, phones, TV Control, call buttons, overbed table, door knobs, lavatory surfaces).

Cleaning and disinfection after patient discharge or transfer
·          Follow standard procedures for post-discharge cleaning of a patient room/area.
·          Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care. No special treatment is necessary for window curtains, ceilings, and walls unless there is evidence of visible soiling.
·          Do not spray (i.e., fog) occupied or unoccupied rooms with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit.
Dishes and Eating Utensils
·          Wash reusable dishes and utensils in a dishwasher with recommended water temperature (www.cdc.gov/ncidod/hip/enviro/guide.htm).
·           Disposable dishes and utensils (e.g., used in an alternative care site set-up for large numbers of patients) should be discarded with other general waste.
·          Wear gloves when handling patient trays, dishes, and utensils.
Disposal Of Solid Waste
Contain and dispose of solid waste (medical and non-medical) in accordance with facility procedures and/or local or state regulations; wear gloves when handling waste; wear gloves when handling waste
containers; perform hand hygiene.
Respiratory Hygiene/Cough Etiquette
Cover the mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacles; perform hand hygiene after contact with respiratory secretions; wear a mask (procedure or surgical) if tolerated; sit or stand as far away as possible (more than 3 feet) from persons who are not ill.
Postmortem Care
Follow standard facility practices for care of the deceased. Practices should include standard precautions for contact with blood and body fluids.
Laboratory Specimens And Practices
Follow standard facility and laboratory practices for the collection, handling, and processing of laboratory specimens.




When to Use Droplet Precautions-Detailed

DROPLET PRECAUTIONS

Patient Placement
Place patients with influenza in a private room or cohort with other patients with influenza.  Keep door closed or slightly ajar; and apply droplet precautions to all persons in the room.
Personal Protective Equipment
Wear a surgical or procedure mask with eye protection for entry into patient room or when within 3 feet of the ill patient; wear other PPE as recommended for standard precautions.
Patient Transport
·          Limit patient movement outside of room to medically necessary purposes; have patient wear a procedure or surgical mask when outside the room.
·          The patient’s nurse is responsible for proper transport of the patient. He/she will notify the department receiving the patient of the droplet/standard precautions and anyone assisting with the transport.
·          Nursing personnel will travel with the patient to ensure isolation precautions are maintained. Mask with eye protection will be worn by staff and in addition wear other PPE as recommended for standard precautions. The patient will wear a surgical mask at all times when out of the room and a clean gown or sheet covering them. The patient will perform hand hygiene.
·          Transport routes should be determined to avoid as much contact as possible with other persons (security may need to assist with this).
·          The requisition for medically necessary tests must be marked to indicate the droplet/standard precautions and the Special Precautions Sign will go with the patient.
·          The patient will not be held in a waiting room or a hallway.
Transfer/Discharge to another facility or to home care
Notify health department of discharge or transfer.
If the patient is transferred to another health care facility or home health care agency, it is the responsibility of the patient’s provider, case coordinator and/or nurse to notify the appropriate person at the receiving institution/agency/service of the patient’s PD status. 
Contact and airborne precautions and use of PPE’s outlined below must be maintained during the patient’s transfer or discharge. 
The patient must:
·          Wear surgical mask during the transfer/discharge
·          Perform hand hygiene before transfer/discharge
Aerosol-Generating Procedures
During procedures that may generate small particles of respiratory secretions (e.g., endotracheal intubation, bronchoscopy, nebulizer, treatment, suctioning), healthcare personnel will wear gloves, gown, face/eye protection, and a fit-tested N95 respirator or other appropriate particulate respirator.



 Pandemic Influenza: Tier 3 Infection Control

·                     Standard & droplet precautions for all patients with acute febrile respiratory illness.
·                     Airborn precautions with aerosol-generating procedures. [Discussion item: always if know or suspected avian influenza?]
o                    If >12 years of age, maintain for 7 days after fever resolves.
o                    If £12 years of age, maintain for 21 days after onset of illness.
·                     Cohort patients with influenza.
·                     Assign staff who have recovered from influenza to care for patients with influenza (if have serological evidence of past infection).
·                     Screen susceptible healthcare workers who cared for avian influenza (AI) patients for symptoms each time they report for duty.
·                     Triage centers outside of ER.
·                     Signs directing patients (and staff), with security to enforce.
·                     Treatment of staff with anti-viral medications, if available, as per guidelines.
·                     Any intermediate-level disinfectant (e.g., tuberculocidal) will inactivate AI virus.




Infection Control Guidelines
Residential Group Settings such as School or College
Residence Halls/Dormitories

Care of pandemic influenza patients in residence halls/dorms

In some cases, students with pandemic influenza will be directed to remain at home during the course of their illness but may not be able to travel to their out-of-state or out-of-country residence due to their illness or travel restrictions.  In this case, they will need to remain in their residence hall and be cared for by school staff or others who live in the dorm.
Anyone residing in the dormitory with an influenza patient during the incubation period and illness is at risk for developing influenza. A key objective in this setting is to limit transmission of pandemic influenza within and outside the residential dorm. Infection control within the dormitory should be focused on promoting respiratory hygiene/cough etiquette and hand hygiene to decrease exposure and segregating ill students from others. Infection within the dorm may be minimized if a primary caregiver is designated, ideally someone who does not have an underlying condition that places them at increased risk of severe influenza disease. Although no studies have assessed the use of masks in a residential group setting to decrease the spread of infection, use of surgical or procedure masks by the patient and/or caregiver during interactions may be of benefit.
1.                  Management of influenza patients in the dorm
·                     Physically separate the patient with influenza from non-ill persons living in the dorm as much as possible.
·                     If possible, designate a specific dorm for ill individuals by consolidating residence halls.
·                     Patients should not leave the dorm during the period when they are most likely to be infectious to others (i.e., 5 days after onset of symptoms). When movement outside the dorm is necessary (e.g., for medical care), the patient should follow cough etiquette (i.e., cover the mouth and nose when coughing and sneezing) and wear procedure or surgical masks if available.
2.                  Management of other persons in the dorm
·                     Persons who have not been exposed to pandemic influenza and who are not essential for patient care or support should not enter the dorm while persons are actively ill with pandemic influenza.
·                     If unexposed persons must enter the dorm, they should avoid close contact with ill patients (>3 feet away in distance).
·                     Persons living in the dorm with a pandemic influenza patient should limit contact with the patient to the extent possible; consider designating one person as the primary caregiver.
o                    Dorm members should monitor closely for the development of influenza symptoms and contact a telephone hotline or medical care provider if symptoms occur
o                    Post signs that promote respiratory hygiene/cough etiquette in common areas (e.g., elevators, waiting areas, cafeterias, lavatories) where they can serve as reminders to all persons in the residential dorm. Signs should instruct persons to:
o                    Cover the nose/mouth when coughing or sneezing.
o                    Use tissues to contain respiratory secretions.
o                    Dispose of tissues in the nearest waste receptacle after use.
o                    Perform hand hygiene after contact with respiratory secretions.
·                     Infection control measures in the dorm
·                     All persons in the dorm should carefully follow recommendations for hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand sanitizer) after contact with an influenza patient or shared environmental surfaces.
·                     Although no studies have assessed the use of masks in a residential group setting to decrease the spread of infection, use of surgical or procedure masks by the patient and/or caregiver during interactions may be of benefit. The wearing of gloves and gowns is not recommended for individuals providing care in the dorm.
·                     Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary.
·                     Laundry can be washed in a standard washing machine with warm or cold water and detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other laundry. Care should be used when handling soiled laundry (i.e., avoid “hugging” the laundry) to avoid contamination. Hand hygiene should be performed after handling soiled laundry.
·                     Tissues used by the ill patient should be placed in a bag and disposed with other dormitory waste. Consider placing a bag for this purpose at the bedside.
·                     Normal cleaning of environmental surfaces in the dorm should be followed and periodically wipe down surfaces that are frequently touched with any over the counter disinfectant.
3.                  Respiratory Hygiene/Cough Etiquette

To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should be instructed to:

·                     Cover the nose/mouth when coughing or sneezing.
·                     Use tissues to contain respiratory secretions.
·                     Dispose of tissues in the nearest waste receptacle after use.
·                     Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials.

Residential facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette in congregate areas for ill-students:

·                     Provide tissues and no-touch receptacles (e.g., waste containers with pedal-operated lid or uncovered waste container) for used tissue disposal.
·                     Provide conveniently located dispensers of alcohol-based hand sanitizer.
·                     Provide soap and disposable towels for hand washing where sinks are available.
·                     Post visual alerts (in appropriate languages) at every entrance to the residential dormitory to promote:
o                    Respiratory hygiene/cough etiquette
o                    Frequent hand hygiene





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