Background

This edition of MICKS is the second part on the important subject of pandemic flu; the first of which was published in April 2008. The first article considered the clinical features of pandemic flu, the risks, Governmental planning and infection control guidance for hospital practitioners. This article, however, concentrates on infection control guidance for community care settings.

Experts at the World Health Organisation (WHO) and elsewhere believe that the world is now closer to another influenza pandemic than any time since 1968, when the last of the previous century’s three pandemics occurred. WHO uses a series of six phases of pandemic alert (discussed in Part 1) as a system for informing the world of the seriousness of the threat and of the need to launch progressively more intense preparedness activities.

The world is presently in phase 3: a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently and sustainably among humans. A ‘pandemic’ would not be declared by the WHO until phase 6 is reached.

The main objectives of a national health response to an influenza pandemic will be to:

• Limit illness and death arising from infection.
• Provide treatment and care for those who become ill.
• Minimise disruption to health and other essential services.
• Maintain business activity as far as possible.
• Reduce as far as possible disruption to society

Within the community and society this translates to a number of important functions:

• To identify the emergence of pandemic flu in a locality
• To reduce its spread initially by providing timely, authoritative and up-to-date information for the public, professionals and media
• To reduce morbidity and mortality from influenza-related illness among the local residents through rapid diagnosis and appropriate treatment
• To cope with large numbers of people becoming seriously ill, with many dying, both at home and in hospital, and to deal with issues of bereavement
• To ensure that essential services are maintained for the local residents

The key challenge faced by all organisations planning against an influenza pandemic is that the nature and impact of the virus cannot be known until it emerges. Governments will need to provide advice on the full range of response policies that should be adopted by local communities to achieve the objectives set out above, are based on its understanding of the nature of the pandemic virus and its likely impact.

As there is a wide variety of settings in the community where healthcare is delivered, planning for pandemic flu is essential. This article discusses guidance for infection control practices for community care settings such as community clinics, dental practices, ambulances, schools and the wider public.

General Infection Control strategies for Community Care Services

• Wherever possible patients with influenza should be managed at home
• Patients with symptoms of pandemic influenza who are not seriously ill should be encouraged to seek telephone advice
• Where possible create a separate waiting area for influenza and non-influenza patients and display clear signs at surgery/clinic entrance
• Where possible, part of the surgery/clinic (at a minimum a consulting room) should be designated for the duration of the pandemic
• Where possible, in common waiting areas or during transport coughing and sneezing patients should wear a surgical mask
• Assign staff to see either influenza patients or non-influenza patients on a daily basis
• Aerosol generating procedures such as nebulisation, chest physiotherapy and dental procedures requiring the use of a dental hand piece should be undertaken in a dedicated room with suitable ventilation and personal protective equipment
• If aerosol generating procedures are likely to be undertaken during the pandemic
• ensure community practitioners are fully trained and fit-tested to use FFP3 respirator masks
• Ensure supplies of hand decontamination products, personal protective equipment, tissues, waste bags and waste bins and cleaning equipment
• Ensure the provision of enhanced cleaning programme throughout all clinical areas, at least daily or after a session when an influenza patient has been seen and before the next non-influenza patient
• Ensure that all community practitioners have been trained in cleaning and decontamination procedures and are aware of pandemic influenza policy
• If a patient requires hospital admission, liaise with admitting hospital to ensure patient is admitted directly to the area designated in the hospital for Pandemic Influenza
• All non-influenza visits/appointments/clinics should continue as long as possible. However, it may be necessary to cancel routine appointments and clinics.

Infection control practice in community care areas

The standard infection control practices that are adopted in hospitals should be applied by community practitioners. Fundamentally these are Standard and Droplet Infection Control Precautions, which are noted in the first article. Hand hygiene: is critical to the effective management of pandemic flu in the community. Community practitioners, patients and the public should be encouraged to wash their hands and practitioners use alcohol hand rub at the point of care.

Patient placement, segregation and cohorting

Key points　:

・in all community healthcare settings, patients with flu should be kept separate from non-flu patients; and

・this requires careful consideration and flexibility in accommodation and staffing arrangements.

A designated self-contained area within each premise should be used for the treatment and care of patients with flu whenever possible. Ideally this area should:

• be fully self-contained;
• include reception and waiting areas separated from non-flu patients;
• have a separate entrance/exit door; and
• not be used as a thoroughfare by other patients, visitors or staff. This includes patient transfers, and staff and visitors entering and exiting the building.

To control entry, signage should be displayed warning of the segregated pandemic area.

While such arrangements may not be possible in some community heath premises, innovative solutions should be sought which incorporate the above principles, e.g. no ‘mixed’ (flu and non-flu patients) surgeries to be carried out.

Infection control practice for Community Health practices/clinics

Once a pandemic is established, segregation principles should be applied from the outset to address the dual aims of handling a large number of patients with flu whilst minimising transmission to others.

GP surgeries/ community outpatient settings: where possible, part of the should be designated for the duration of the pandemic.
Temporary care settings: pandemic flu arrangements should plan for high numbers of patients being discharged from hospital into the community. It is recommended that plans should be in place to provide accommodation for segregated intermediate care (e.g. in a designated nursing home). As the incidence of pandemic flu increases locally, there may be a need to establish temporary care facilities. These are likely to be situated in establishments that are not designed or optimised for the delivery of clinical care (e.g. sports halls, schools, town halls).
Telephone Advice: patients with flu symptoms who are not seriously ill should be encouraged to telephone community health, medical services or the GP practice for advice and consultation to minimize crowding in reception areas and thus the potential for cross infection.
Entry procedures: if possible, designate a segregated area of the GP premises for flu patients. Practice staff should be limited to those necessary for patient care and support. Records should be kept of staff working in the designated area. Place a sign (not breaching patient confidentiality) at the entrance alerting staff to the precautions to be adopted.
Infection control precautions: Standard and Droplet Infection Control Precautions should be maintained both in the surgery and during home visits.
Patient equipment: clean and disinfect re-usable equipment (e.g. ECG machine, stethoscope) between patients.
Cleaning: the consulting, treatment and waiting areas should be cleaned daily as a minimum and after being used for a flu session.

Dentists
Standard and Droplet Infection Control Precautions should be maintained both in the dental practice by the dental practitioners.

Patient visits: it may be prudent to cancel routine dental visits during the pandemic. At a minimum, practices should implement active screening of all patients prior to entering the clinical area. Patients with flu symptoms should not be seen at all unless an emergency is suspected.
Performance of procedures on patients with flu: emergency patients should be treated at the end of a surgery session when other patients have left. Staff in attendance should be kept to a minimum and all should wear PPE in accordance with an aerosol generating procedure.

Ambulance services

Key points　:

・where practical, designate an ambulance(s) for flu patients for the duration of each shift;

・Standard and Droplet Infection Control Precautions are applicable in most circumstances;

・crew members should wear FFP3 respirators if critically ill patients require aerosol-generating procedures (e.g. intubation, nasopharyngeal aspiration); and

・equipment carried should be kept to a minimum.

The immediate environment i.e. trolley and patient equipment must be decontaminated between patients. On completion of transfer of patients with flu (e.g. at the end of a shift) the vehicle must be thoroughly cleaned and decontaminated using detergent and hot water before further use. All disposable materials must be disposed of as clinical waste. Waste bags must be sealed, labelled and sent for incineration.

Coughing and sneezing patients should be transported singularly where possible but, if pressure upon the service occurs, two patients with flu symptoms may be transported together. Symptomatic patients should be encouraged to wear a surgical mask to assist in the containment of respiratory secretions and reduce environmental contamination of the ambulance.

Guidance for Schools

Guidance is available from most governments and expert organisations to help schools and other educational institutions plan for a human flu pandemic. This is part of Government's coordinated efforts to encourage prudent planning across all community sectors, in preparing and planning for a possible flu pandemic.

The guidance supports planning for schools, as well as childcare settings and other children's services. There is guidance available for further education colleges and higher education institutions, as well as brief information for parents.

The key message in all these guidance papers is that in a human flu pandemic, in order to reduce the spread of infection among children and young people, the Government may advise schools, colleges, universities and childcare providers to close for part or all of the pandemic. The closure of these services would have an impact on parents working in all sectors, and thus on their employers. It is therefore relevant to contingency planning by all organisations.

Advice & Information for the Public

Most Governments have published a range of information and policies to inform the public and healthcare practitioners about the risk of a human flu pandemic. Information is generally also available from professional organisations, and international bodies such as the World Health Organisation and the Centres for Disease Control. The key message relates to advice for people with flu and ways of prevention.

General public health messages

The key public health messages in a pandemic will be:

If you do catch flu:

• Stay at home and rest
• Take medicines such as aspirin, ibuprofen or paracetamol to relieve the symptoms (following the instructions with the medicines). Children under 16 must not be given aspirin or ready-made flu remedies containing aspirin
• Drink plenty of fluids.

You can reduce, but not eliminate the risk of catching or spreading influenza during a pandemic by:

• Covering your nose and mouth when coughing or sneezing, using a tissue when possible
• Disposing of dirty tissues promptly and carefully – bag and bin them
• Avoiding non-essential travel and large crowds wherever possible
• Maintaining good basic hygiene, for example washing your hands frequently with soap and water to reduce the spread of the virus from your hands to your face, or to other people
• Cleaning hard surfaces (eg kitchen worktops, door handles) frequently, using a normal cleaning product
• Making sure children follow this advice.

Further Information and Guidance:

To assist practitioners, health authorities and the public in developing their local plans most governments provide a range of further guidance e.g.

• Pandemic Flu – A national framework for responding to an influenza pandemic. UK Deaprtment of Health 2007 .
• Pandemic Influenza Guidance for Primary care trusts and primary care professionals on the provision of healthcare in a community setting in England. UK Department of Health 2007
• CDC Pandemic Influenza Operational Plan (OPLAN) 2008

Summary Checklist for pandemic flu infection control - community care

Layout/configuration of the practice

• Create separate waiting areas for influenza and non-influenza patients
• Designate clinical rooms/doctors’ offices for influenza and non-flu patients
• Remove extraneous items (e.g., toys, soft furnishings, magazines) from waiting areas
• Display clear signage at surgery entrances and clinical rooms/doctors’ indicating influenza/non-influenza areas

Staff assignments

• Assign doctors, Practice Nurses, and other Primary Care staff to see either flu patients or non-flu patients on a daily basis

Infection control issues

• ensure that hand hygiene facilities (e.g. sinks, soap, alcohol hand gel, paper towels) are available for staff and patient use;
• consider use of hand carried alcohol rub for GPs and practice staff when making community/home visits;
• ensure that tissues and waste receptacles are available for patients and staff;
• monitor adherence to hand hygiene and other infection control measures;

PPE

• ensure that supplies of gloves, surgical masks, aprons and any other items that may be needed;
• ensure that eye protection is available if needed;
• perform local risk-assessment to review potential for performing aerosol-generating procedures; order FFP3 disposable respirators and fluid repellent gowns if this is likely;

Environmental cleaning

• ensure that an environmental cleaning rota is in place and domestic staff have been trained in cleaning and decontamination procedures;
• ensure that there are adequate supplies of cleaning materials;

Education and training

• provide all staff with training in flu infection control procedures;
• ensure that any potential users of FFP 3 disposable respirators have been fit tested and trained in their proper use and care;

Record keeping

• track and document staff sickness and absence;
• track and document staff assignments;

Patient and Public information

• provide information sheets, pamphlets for patients.

Jg/2008