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CEM - Human Swine Influenza
Revised and updated 3rd November 2009.
Recent Updates
Since 28th October 2009:
· Added new DH clinical management guidelines for adults and children (link 4)
· Added new DH and RCOG clinical guidelines for pregnancy (link 5)
Since 22nd October 2009:
· Added new DH advice on prophylaxis (link 10)
· Updated revised UK planning assumptions (link 12)
· Added pandemic flu vaccination programme and Green Book chapter (link 13)
As we enter the winter season the number of cases of Human Swine Influenza (H1N1v) is rising steadily week on week. Although it remains difficult to predict when this wave will peak or how large it will be, different parts of the country will be affected to different degrees at different times. The general trend appears to be a steady increase in the number of relatively well patients attending the ED, and a smaller number of more seriously ill patients requiring hospital admission, some into critical care beds.
It is possible that a significant expansion of critical care services will be required, particularly for children, and preparations have been made accordingly (see resource 3 below). Less consideration has been given to the need to expand emergency department resuscitation facilities as the initial area for reception and treatment of this patient group, and to care for those waiting to be admitted into critical care facilities. In some cases difficult triage decisions may be required, and this will need to be carefully considered in local plans.
This resource has been prepared by the College of Emergency Medicine to assist Emergency Departments in dealing with the swine flu pandemic, and its effects on emergency services. It is divided into three sections: principles, links and resources. This page will be reviewed, and if necessary updated, on a regular basis. If you have any questions or comments these should be sent to Phil McMillan at the College: Philip.McMillan@collemergencymed.ac.uk
Principles (PDF download of Principles)
1. Every Emergency Department should have a nominated lead to coordinate the ongoing response whilst remaining up to date with official guidance.
2. It is essential to work with Primary Care Trusts and healthcare partners to ensure a co-ordinated response. The ED must be strongly represented on local pandemic flu working groups and committees.
3. The current situation varies substantially across the UK, in terms of the number of patients infected, the configuration and availability of local services and therefore the response required. Each Emergency Department will need to agree a local plan, constantly updated, to address their unique situation.
4. Routine swabbing and prophylaxis of contacts is no longer recommended. Patients being admitted to hospital and those where there is significant diagnostic doubt should still be swabbed in order to establish a diagnosis. Advice regarding prophylaxis is given in link 10 below.
5. The College of Emergency Medicine continues to recommend that Emergency Departments do NOT prescribe or dispense antiviral drugs to patients who do not require hospital admission. The role of Emergency Departments, and acute hospitals in general, is to continue to provide the core emergency service whilst also treating the small proportion of flu patients who require hospital admission. This preserves vital emergency capacity for those patients who need it most. EDs cannot function effectively if they are overwhelmed by relatively well patients seeking antivirals, and the prescription and dispensing of antiviral medication must therefore occur in the community. The pandemic flu service allows patients to access advice and antivirals either on-line or by telephone (see link 2 below). This approach is supported by official advice from the Department of Health: please contact the College if you are experiencing local problems in this regard.
6. Antiviral stocks within hospitals should be reserved for patients requiring admission, and possibly NHS staff who develop symptoms whilst at work (local arrangements apply).
7. The College of Emergency Medicine recommends that all patients attending the ED should be seen and assessed by an appropriate clinician to ensure that they are suitable for discharge, and that a full differential diagnosis is considered. The College has become aware of a number of patients who have been erroneously assumed to have swine flu when they are in fact suffering from an alternative, and potentially life-threatening, disease. Patients diagnosed with likely swine flu who are fit for discharge from the ED should be directed to community-based services (e.g. the patient’s usual GP, NHS Direct or the Pandemic Flu Service in England) for consideration of antiviral therapy.
8. Notwithstanding the above, individual EDs may agree to prescribe and/or dispense antivirals to small numbers of patients within specified groups. Such groups may include:
- Those referred by a GP for assessment, but deemed fit for discharge
- Those at particularly high risk of serious complications
- Those judged unable to access community-based services
However the over-arching principle in point 5 applies: EDs must not become the default service supplying antiviral drugs to the community as a whole, and local PCTs should have well established antiviral collection points (ACPs) in the community.
9. The DH “swine flu clinical package” was updated on 6th October 2009 (see link 3 below). It is important to emphasise that “these tools and pathways are for use only when high healthcare demand leads to the need for strict hospital admission triage in affected areas”. In other words, the clinical package should only be applied, by agreement across a healthcare community, in a severe and exceptional situation.
10. It remains uncertain as to which patients are at high risk of developing complications. However, current guidance would suggest that the following groups are likely to be at significant risk:
- Pregnant women
- Children under 5 years, and particularly those under 1 year
- Children with neurodevelopmental delay
- Immunocompromised patients
- Patients with significant obesity or asthma
Antiviral therapy is most effective within 48 hours of symptom onset, and probably has limited value after this time.
11. The most successful approach to managing increasing numbers of patients appears to be the creation of an “influenza stream” in a clinical area that is separated from the ED. This allows dedicated staff to assess patients in order to identify those who need to be admitted and those who can be safely discharged. As patient numbers increase the establishment of this separate stream will have significant resource implications.
12. Staff morale is essential to maintaining a service (see link 11 and resource 1 below). The College recommends that all staff are regularly briefed and reassured regarding the generally benign nature of the disease. A vaccination programme is currently being rolled out across the UK, however the implications of running an effective service when staff may themselves be off sick needs to be considered and explained. It is also essential to ensure that all ED staff and patients attending the ED are as protected as possible, for example by ensuring suitable measures for physical separation and enforcing strict infection control procedures.
13. Current advice would suggest that staff should still come to work if they have had contact with a probable or confirmed case of swine flu but have no symptoms. On the other hand, staff should not come to work if they have flu-like symptoms. As a general guide, staff who are known to be pregnant or immunocompromised should not be exposed to potentially infected patients. Guidance on incidents where patients have been treated by a healthcare worker who is suspected to be infected with pandemic influenza has recently been issued by the HPA (see link 8 below).
14. Consideration should be given to compiling a list of reserve staff who can be called upon at times of increased demand. Those recently retired have the advantage that they often do not require a CRB check, and can rapidly return to work following completion of a skills matrix and induction programme.
15. Swine flu should be considered in all adults and children being admitted to hospital with any respiratory illness, in order to avoid overlooking cases that will then lead to widespread transmission on the wards.
16. The use of nebulisers, non-invasive ventilatory support (BiPAP or CPAP) and invasive ventilation (tracheal intubation) in swine flu patients all pose a significant risk of infection to healthcare staff due to aerosolisation of the virus. Maximal infection control procedures should be implemented where these treatments are required.
Links
1. A single section of the Department of Health’s website now hosts all information and guidance for NHS professionals on pandemic flu. This is available at:
http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/InformationandGuidance/index.htm
Information is also available regarding swine flu vaccination and prophylaxis.
2. In England, the National Pandemic Flu Service is a self-care service with online and phone access that allows patients to assess their symptoms and access antivirals if required. This service is only intended for people who are ill with swine flu. Persons with serious underlying illness, who are pregnant or whose condition suddenly worsens should consult their GP, as should the parents or carers of children under the age of one year.
To access the new service, people should first visit the National Pandemic Flu Service website at www.direct.gov.uk/pandemicflu. This website is available 24 hours a day and is designed to identify the symptoms of swine flu and to provide authorisation to access antivirals. Two telephone lines are also available, and are open from 8am – midnight. People should call:
0800 1 513 513 for information
0800 1 513 100 for treatment
A textphone number is available on 0800 1 513 200.
3. The swine flu clinical package for use only in a severe and exceptional situation (see point 9 above) can be accessed at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_106495
4. Clinical management guidelines for adults and children were released by the Department of Health on 30th October 2009. These are available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_
5. Department of Heath clinical guidelines for pregnancy (prepared with the Royal College of Obstetricians and Gynaecologists) were also released on 30th October 2009, and are available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107770
6. Additional DH advice in relation to pregnancy and breast feeding can be accessed at:
http://www.dh.gov.uk/en/Healthcare/Children/Maternity/Maternalandinfantnutrition/DH_099965
7. The Health Protection Agency (HPA) website includes diagnostic criteria and advice regarding testing and treatment, personal protective equipment and prescribing anti-viral drugs at:
http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1240812234677?p=1240812234677
8. The Health Protection Agency has also issued guidance on incidents where patients have been treated by a healthcare worker who is suspected to be infected with pandemic influenza at:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1247816545177
9. Advice on managing demand and capacity in healthcare organisations can be found at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098769
10. Current DH advice regarding prophylaxis can be found at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107133
11. The Intensive Care Society has recently produced a document for the Support of NHS Staff working in Exceptional Circumstances, which is available at:
http://www.ics.ac.uk/downloads/2009102632_Support%20for%20NHS%20Staff%20working%20in%20Exceptional%20Circumstances%20Revised%20011009.doc.
The intention of this document is to raise awareness of the potential implications for staff, and to provide suggestions to their employers and supporting professional organisations on how to minimise the implications which may have potentially adverse effects for staff faced with a range of difficulties.
12. Current UK planning assumptions, providing reasonable worst case scenarios for planning purposes, and based on the latest scientific evidence and updated on October 22nd can be found at:
http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/InformationandGuidance/DH_107424
13. The new Green Book chapter on the pandemic flu vaccine can be found at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_107408.pdf
14. A range of useful documents and links can be found on the website of the Royal College of General Practitioners:
http://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspx
15. Fellows and Members in the Republic of Ireland are advised to use their local guidelines, to be found at:
http://www.ndsc.ie/hpsc/A-Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/
16. The World Health Organisation provides further useful advice at:
http://www.who.int/csr/disease/swineflu/en/index.html
Resources
1. Specific advice from the College of Emergency Medicine on the preparation of Emergency Departments for pandemic flu can be downloaded here.
2. An article entitled “ten things your emergency department should consider to prepare for pandemic influenza” has been published in the Emergency Medicine Journal, and provides useful information regarding ED preparation: http://emj.bmj.com/misc/em61499flupandemic.pdf
3. A critical care strategy document, focussing on critical care services and strategy in the event of escalating demand can be downloaded here.
4. A clinical practice guideline for the management of critically ill adult swine flu patients (developed by the HPA for the Royal College of Anaesthetists) can be found here.
5. An algorithm developed by the Royal College of General Practitioners and designed for use by GPs working in the community (published 16th July), is available here.
6. A pathway for patients with suspected swine influenza, developed at the Leicester Royal Infirmary and updated in October 2009, can be found here (with thanks to Martin Wiese).
7. An anti-viral prescribing guide, also developed at the Leicester Royal Infirmary and updated in October 2009, can be found here (with thanks again to Martin Wiese).
8. An example patient information sheet from the Luton and Dunstable Hospital (including contact details for the National Pandemic Flu Service in England) can be found here (with thanks to David Kirby, Clare Taylor and Tony Bleetman). This sheet has also been translated into Hindi, Tamil and Danish.
9. Video clips demonstrating procedures for handwashing and mask fitting have been provided by Addenbrooke's Hospital (with thanks to Sue Robinson).
(The .avi files may require you to download a codec to view in Windows Media Player, click on 'Web Help' if prompted. The .rv files can be viewed with RealPlayer).
Individual departments may wish to adapt resources 6, 7, 8, and 9 for local use. Translations of resource 8 into other languages may be submitted to Phil McMillan (e-mail above) and will also be posted here.
Professor Jonathan Benger.
Chair, Clinical Effectiveness Committee.
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