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Influenza - pandemic strains: PICU management

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PICU patient management guidelines for pandemic influenza (PI) and highly pathogenic avian influenza (HPAI): May 2009

As with any emerging disease, information and guidelines pertaining to pandemic influenza and highly pathogenic avian influenza (HPAI) are in constant evolution. The latest information available will be on the ADHB Intranet under Infection Control.

Refer to Northern & Auckland Regional Clinical Management Guidelines for Highly Pathogenic Avian Influenza and Pandemic Influenza for possible, probable and confirmed case definitions, investigations and notification required. The following infection control guidelines should be used for all patients with confirmed, probable or suspected case of influenza. Patients should be considered infectious from 1 day prior to the onset of symptoms until symptoms have resolved or for at least 7 days.

Seasonal Influenza - Contact and Droplet Precautions are recommended for the care of patients with 'seasonal' influenza because large droplets and indirect and direct contact are the major modes of transmission for influenza.

Pandemic Influenza - It is assumed that pandemic influenza will have similar transmission and communicability as 'seasonal influenza'. Contact and Droplet Precautions are therefore recommended for the care of patients with pandemic influenza because large droplets, and indirect and direct contact are the major modes of transmission. Airborne Precautions should be followed for aerosol generating procedures.

Highly Pathogenic Avian Influenza - Standard, Contact and Airborne Precautions are recommended for HPAI. There is minimal evidence that HPAI is transmitted between humans and to date nosocomial transmission of HPAI has not occurred. However, the high mortality rate of the disease, and the possibility that the virus could mutate or reassort into a strain capable of human-to-human transmission, warrants the use of these enhanced infection control precautions for patients with suspected or confirmed HPAI. (WHO, 9 Feb 2006).

  HPAI Seasonal Influenza and Pandemic Influenza
    Entering the patient  area/close contact Aerosol Generating  procedures*
Hand hygiene ✔  
Gloves ✔  
Gown ✔  
Surgical Mask x  x
N95 ✔   x
Eye protection ✔  

*Aerosol generating procedures include intubation, nebuliser therapy, nasopharyngeal aspirate or swab, suctioning and non-invasive ventilation.

Hand hygiene is the single most important practice for preventing the spread of infection. Gloves are not a substitute for hand hygiene. Hand hygiene includes washing with soap and water and thorough drying, or the use of alcohol hand gel. Practice hand hygiene before and after contact with the patient or their immediate environment, after removing your gloves and protective clothing, and after cleaning equipment.

Respiratory Hygiene/Cough Etiquette refers to containing respiratory secretions by the use of disposable tissues when coughing, sneezing, wiping and blowing noses, prompt disposal of tissues in nearest waste bin and hand washing after coughing, sneezing and use of tissues. Keep hands away from the nose, eyes and mouth to avoid self-inoculation.

The following PICU guidelines explain more fully the requirements for Pandemic Influenza and Highly Pathogenic Avian Influenza and are split into 4 areas: Environment, Staff, Patient and Caregiver.

Pandemic Influenza

Potential patient transports should be screened and precautions instituted as required.

Environment

  • Patients will be nursed in the single rooms in PICU (not room 6 which is positive pressure). The doors are to remain closed and opened only for access.
  • If single rooms are not available, patients with confirmed pandemic influenza can be cohorted together in a four bedded room. The doors must be kept closed.
  • For aerosol generating procedures (e.g. bronchoscopy, elective intubation, suctioning, administering nebulised medications) patients should be within a negative pressure room (room 9) if possible.
  • Ensure 4% Chlorhexidine is used for washing hands
  • Alcohol handrub, masks, eye protection, gowns and gloves are provided outside the room.
  • A laminated "STOP" isolation sign is to be placed onto the door of the room.
  • Supplies and equipment within the room are to be kept to a minimum.
  • Single use items are preferred.
  • There will be a designated stethoscope within the room.
  • Regular environmental cleaning is important. The virus is inactivated by using approved cleaning products (e.g. Nature Clean, Sodium Hypochlorite or Viraclean).
  • The isolation room/area should be cleaned daily as per standard isolation room specifications.
  • The room(s) must be cleaned last of all the rooms on the ward.
  • White linen bags are routinely used in the room, however heavy soiled items should be put in a yellow topped bag.
  • White rubbish bags are routinely used in the room, however heavy soiled items should be placed in a yellow rubbish bags (biohazard waste).
  • Patient notes should remain outside the room as far as possible.

Staff

It is important all health care workers are aware of the reasons for and correct procedure for using personal protective equipment (PPE). The bedside nurse is responsible for ensuring all other staff and caregivers comply with guidelines.

  • Prior to entering the room all staff must remove items of jewellery and personal stethoscopes. (Valuables may be stored in the locked drug cupboard).
  • When in the patient area do not touch your nose, mouth or eyes
  • It is vital all staff entering the patient area maintain strict hand hygiene.
  • Mask: all staff are to wear a mask.
    • Surgical mask is to be worn by all staff entering the room.
    • N95 mask: is to be worn for aerosolising procedures such as suction, intubation and NIV. These masks should be correctly fitted with a good seal. Once an aerosolising procedure has been carried out using an N95 mask, there should be a 20 minute period before reverting to using a surgical mask when entering that room. Minimise traffic into and out of the room during this time.
  • Gown: all staff entering the patient room are to wear a disposable gown
  • Gloves: all staff entering the patient room are to wear gloves, which are worn over the wristbands of the gown.
  • Eye protection: all staff entering the patient room are to wear eye protection
    • "Safeview" visor eye protection may be worn. The head band is cleaned between use and the visor is disposed.
    • Mask with Visor: may be worn for close personal contact or may be worn over N95 mask for respiratory procedures.
    • Goggles: may be worn with either mask. Each staff member is responsible for cleaning goggles after use.
  • Apart from reusable eye protection, PPE is single use. New gowns, gloves and masks must be put on for every individual patient contact.
  • On leaving the isolation room/area, staff should remove gown and gloves then perform hand hygiene before removing mask and eye protection. Handle masks and eyewear by strings, straps or arms to avoid contaminating the hands.
  • Place disposable items into a waste bin and immediately wash hands or use alcohol gel.
  • Wash reusable eye protection in warm water and detergent, dry well and store for reuse.
  • In a cohort room, gloves must be changed and hand hygiene practiced between individual patients, however the same mask, gown and eye protection may be worn for multiple patient contacts provided it is not visibly soiled.
  • A log is to be kept of staff who have cared for the child.
  • Surveillance of staff to be carried out as per ADHB guidelines.

Patient

  • Non-intubated patients are to wear a surgical mask. Provide patients with ample supplies of disposable tissues and teach them to cover their mouth and nose when coughing or sneezing as able.
  • Non invasive ventilation may be required.
  • Ventilated: Patients will be ventilated with the addition of a viral filter in line. Filters can get water logged as evidenced by an increase in pressure.
  • The ventilator tubing, ambu bag, T piece and laryngoscope blade are all disposable. The laryngoscope handle is not disposable and should be removed prior to disposing of the blade and cleaned with alcohol wipe.
  • Hand ventilation equipment should be used with an in line viral filter.
  • The current practice is to change the ventilator tubing at 7 days, in these cases the tubing may be used for longer and is not to be routinely changed.
  • The PEEP valves are also disposable and used on the disposable re-breathing bag.
  • These function the same as the orange and green valves.
  • The patient's movement around other departments will be minimal. Ensure a filter is on the exhalation circuit of the transport ventilator.
  • CXR will be performed as per normal, machine cleaned as per isolation protocol with domestos.
  • All patients will be discharged to 25B.

Caregivers

  • One person is to be nominated as the caregiver to minimise visitors and potential contacts.
  • The caregiver is to be isolated with the patient.
  • Caregivers are to have priority for accommodation in self contained flat and encouraged when leaving the room to go directly to the flat.
  • The caregiver is to wear personal protective equipment in the room. This is to both protect them from the child's virus and to protect healthcare staff from potential virus from them. Nursing staff are to demonstrate and supervise correct use and removal of the protective attire and thorough hand washing technique.
  • When leaving the patient room, the caregiver is to remove all protective attire, wash their hands thoroughly, and wear a new surgical mask before accessing a shared ward facility e.g. toilet.
  • If the patient has a procedure likely to result in exposure to respiratory secretions e.g. intubation, or suction the caregiver should leave the room for the procedure plus twenty minutes or wear an N95 mask.
  • The caregiver is to be monitored daily for signs of elevated temperature and/or respiratory symptoms; should these occur in the hospital the caregiver is to be directed to seek medical attention.
    • The caregiver is to be asked to notify the hospital by phone if he or she becomes symptomatic in the community so that appropriate follow up and an alternative caregiver can be discussed.

Highly Pathogenic Avian Influenza

Environment

  • Ideally patients will be nursed in the negative pressure single room in PICU (room 9). If this is not possible, room 7 and 8 may be used. The doors are to remain closed and opened only for access.
  • Room 6 is not to be used (positive pressure room).
  • 4% chlorhexidine is to be used for hand washing.
  • Alcohol handrub, masks, eye protection, gowns and gloves are provided outside the room.
  • A laminated "STOP" isolation sign is to be placed onto the door of the room.
  • Supplies and equipment within the room are to be kept to a minimum.
  • Single use items are preferred.
  • There will be a designated stethoscope within the room.
  • Regular environmental cleaning is important. The virus is inactivated by using approved cleaning products (e.g. Nature Clean, Sodium Hypochlorite or Viraclean).
  • The isolation room/area should be cleaned daily as per standard isolation room specifications.
  • The room(s) must be cleaned last of all the rooms on the ward.
  • White linen bags are to be used in the room.
  • Rubbish generated in the room is to be disposed of in a standard white rubbish bag.
  • Patient notes should remain outside the room.

Staff

It is important all health care workers are aware of the reasons for use and correct procedure for using personal protective equipment (PPE). The bedside nurse is responsible for ensuring all other staff and caregivers comply with the guidelines.

  • Prior to entering the room all staff must remove items of jewellery and personal stethoscopes. (Valuables may be stored in the locked drug cupboard).
  • When feasible limit the number of staff having direct contact with the patient.
  • Staff caring for these patients are considered exposed to HPAI and if possible should not care for other patients in the unit.
  • When in the patient area do not touch your nose, mouth or eyes
  • It is vital all staff entering the patient area maintain strict hand hygiene using 4% chlorhexidine or alcohol hand rub.
  • Mask: all staff entering the patient room are to wear a N95 mask. Masks are a single use item and a new mask must be worn for each entry.
  • Gown: all staff are to wear a disposable gown
  • Gloves: all staff are to wear gloves, which are worn over the wrist bands of the gown.
  • Eye protection: all staff are to wear eye protection
    • "Safeview" visor eye protection may be worn. The head band is cleaned between use and the visor is disposed.
    • Mask with visor: may be worn over N95 mask.
    • Goggles: may be worn. Each staff member is responsible for cleaning goggles after use.
  • Apart from reusable eye protection, PPE is single use. New gowns, gloves and masks must be put on for every individual patient contact.
  • On leaving the isolation room/area, staff should remove gown and gloves then perform hand hygiene before removing mask and eye protection. Handle masks and eyewear by strings, straps or arms to avoid contaminating the hands.
  • Place disposable items into a waste bin and immediately wash hands or use alcohol gel.
  • Wash reusable eye protection in warm water and detergent, dry well and store for reuse.
  • Staff caring for an infected patient should monitor temperature twice daily and report any febrile event.
  • The need for pre-exposure prophylaxis should be considered for staff involved in aerosol generating procedures.
  • A log is to be kept of staff who have cared for the child.

Patient

  • Non-intubated patients are to wear a surgical mask.
  • Ventilated: Patients will be ventilated using the addition of a viral filter and gas scavenging on the expiratory limb (refer to SARS folder). NB. Remain vigilant for waterlogging of filters as evidenced by an increase in ventilator pressures.
  • The ventilator tubing, ambu bag, T piece and laryngoscope blade are all disposable. The laryngoscope handle is not disposable and should be removed prior to disposing of the blade and cleaned with alcohol wipe.
  • Hand ventilation equipment should be used with an in line viral filter.
  • The current practice is to change the ventilator tubing at 7 days, in these cases the tubing may be used for longer and is not to be routinely changed.
  • Use in-line suction equipment.
  • Use a disposable PEEP valve on disposable ambu bag if required.
  • The patient's movement around other departments will be minimised.
  • CXR will be performed as per normal, machine cleaned as per isolation protocol with domestos.

Caregivers

  • One person is to be nominated as the caregiver to minimise visitors and potential contacts.
  • The caregiver is to be isolated with the patient.
  • Caregivers are to have priority for accommodation in self contained flat and encouraged when leaving the room to go directly to the flat.
  • HPAI is a notifiable disease and Public Health is to be notified within 24 hours.
  • The caregiver is to wear protective attire (surgical mask, gown, gloves) in the room. This is to both protect them from the child's virus and to protect healthcare staff from potential virus from them. Nursing staff are to demonstrate and supervise correct use and removal of the protective attire and thorough hand washing technique.
  • When leaving the patient room, the caregiver is to remove all protective attire, wash their hands thoroughly, and wear a new surgical mask before accessing a shared ward facility e.g. toilet.
  • If the patient has a procedure likely to result in exposure to aerosolised respiratory secretions e.g. intubation or suction, the caregiver should leave the room or wear a N95 mask.
  • The caregiver is to be monitored daily for signs of elevated temperature and/or respiratory symptoms; should these occur in the hospital the caregiver is to be directed to seek medical attention.
  • The caregiver is to be asked to notify the hospital by phone if he or she becomes symptomatic in the community so that appropriate follow up and an alternative caregiver can be discussed.

For further information refer to:

ADHB website Emergency Management Pandemic Management1
MOH website Pandemic influenza

References

  1. Beigel, J.H. et al. (2005). Avian influenza A (H5N1) infection in humans. New England Journal of Medicine, 353(13): 1374-85
  2. NZ Ministry of Health, www.moh.govt.nz/pandemicinfluenza
  3. World Health Organisation, Clarification: Use of masks by health-care workers in pandemic settings, Mask%20Clarification10_11.pdf
  4. Infection Control Guidance for the Prevention and Control of Influenza in Acute-care facilities, CDC 2008. www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm
  5. Guidance for Infection Prevention and Control during Influenza pandemic: Ministry of Health New Zealand 2006.
  6. Centers for Disease Control and Prevention (CDC) Interim Guidance for Infection
  7. Control for care of patients with confirmed or suspected novel influenza A (H1N1) virus infection in a healthcare setting. 13th May 2009.
  8. Infection prevention and control in healthcare in providing care for confirmed or suspected A (H1N1) swine influenza patients. WHO 29th April 2009

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Document Control

  • Date last published: 19 June 2009
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Editor: John Beca
  • Review frequency: 2 years