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Prevention and Control of Influenza during a Pandemic for All Healthcare Settings

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VI. Planning for an Influenza Pandemic – Using the Organizational Risk Assessment to develop the Pandemic Influenza Infection Prevention and Control and Occupational Health Plan

2. Establishing a Pandemic Influenza IPC/OH Plan for the Management of Pandemic Influenza in All Healthcare Organizations

2.1. Developing the Pandemic Influenza IPC/OH Plan

Based on the inter-pandemic ORA, healthcare organizations should develop a pandemic influenza IPC/OH plan which incorporates IPC and Occupational Hygiene principles and is integrated with the existing IPC and OH programs.

All organizations responsible for existing and temporary prehospital, acute, non-acute, long-term, ambulatory (including physicians’ offices), home care, healthcare clinics and other community healthcare settings should have a pandemic influenza IPC/OH plan.

The organization should establish a multi-disciplinary team to lead the development and implementation of the pandemic influenza IPC/OH plan.

  • The pandemic influenza IPC/OH planning team should liaise closely with the organization’s pandemic influenza planning team.
  • The pandemic influenza IPC/OH plan should be integrated with existing IPC and OH programs.

The planning team should ensure that the pandemic influenza IPC/OH plan:

  1. Is reviewed annually, potentially during the seasonal influenza campaign, and updated according to emerging knowledge, regulations and legislation.
  2. Includes measures to identify and manage respiratory illness affecting HCWs.
  3. Includes plans for evaluating and counselling HCWs at risk of severe complications should they acquire influenzaFootnote 17.
  4. Includes recommendations for how patient accommodation will be handled to reduce transmission.
  5. Includes policies to deal with patient visitation during the pandemic waves.
  6. Provides a clear screening method to identify patients and visitors with ILI symptoms upon entry into the healthcare setting.
    • Consider developing policies to limit visitation (see Section VII.1.7.).
    • Consider developing multi-lingual signage for entrances to healthcare settings, that should provide patients, HCWs, visitors, contractors, etc., with:
      • Directions to influenza assessment and admission areas;
      • Instructions regarding respiratory hygiene;
      • Instructions regarding hand hygiene.
  7. Includes specific pandemic influenza education and skills training for HCWs, including how to do Point of Care Risk Assessments (see Section VI.4.).
  8. Includes recommendations for the delivery of a pandemic influenza vaccine (when it becomes available) according to the Canadian Pandemic Influenza Plan for the Health Sector (CPIP)Footnote 5 (see Annex E of the CPIP The Canadian Pandemic Influenza Plan for the Health Sector - Annex E) and provincial/territorial/regional or local pandemic influenza vaccine distribution initiatives.
  9. Includes recommendations for the use and distribution of antiviral medications according to the CPIP Annex on antiviralsFootnote 5 Footnote 19 (see Annex D of the CPIP The Canadian Pandemic Influenza Plan for the Health Sector - Annex D) and provincial/territorial/regional or local pandemic influenza antiviral medication distribution initiatives.

2.2. Planning for the Accommodation and Cohorting of Patients/Residents/Clients

Single rooms are preferred for patients/residents admitted with influenza to acute care facilities, LTC facilities or other healthcare settingsFootnote 2 Footnote 3. However, during an influenza pandemic wave, healthcare organizations may not have sufficient numbers of single rooms to accommodate all inpatients with ILI symptoms. The use of temporary healthcare settings and the use of influenza cohorts may provide options when caring for large numbers of patients with ILI symptoms.

  1. The IPC/OH plan should provide for appropriate spatial separation between patients/residents/clients with ILI symptoms or infected with the pandemic influenza virus (infected sources) and patients/residents without influenza (susceptible hosts)Footnote 46-54 Footnote 115-117 by predetermining:
    • The need for physical barriers (e.g., glass/acrylic partitions in entrances to assessment centres) to separate infectious agents/infected sources from susceptible hosts (other patients, HCWs, visitors, contractors, etc.).
    • The location of influenza care/isolation areas and non-influenza care areas (i.e., these areas should be identified in acute care, long-term care, and community infirmary settings).
    • The location of influenza care areas within specialty units (e.g., Trauma Intensive Care Units, Coronary Care Units, Maternity Units, Neonatal units).
    • The location of separate assessment areas for patients/residents with ILI symptoms and those without influenza symptoms.
    • The location of separate admission holding areas for patients and LTC residents with ILI symptoms and those without influenza symptoms.
    • A process for alternative methods of ambulatory care and home care delivery to decrease the numbers of vulnerable people potentially exposed to influenza through time spent waiting for service in the healthcare setting.
  2. Provision should be made to establish inpatient units to cohort patients/residents with ILI symptoms separately from non-influenza patients/residents during a pandemic wave. Criteria should also be developed for closing inpatient units at the end of the wave. Opening and closing patient/resident units should be based on the needs and requirements that emerge during the pandemic.
    • An active screening process should be established to separate patients/residents with ILI symptoms from non-influenza patients/residents as soon as influenza symptoms are identified.
    • LTC facilities should identify areas to hold newly admitted residents for one incubation period.
    • LTC facilities should identify a separate area to isolate residents that develop ILI symptoms.
    • Cohorting of non-influenza patients/residents who are at high risk of severe complications if they were to be infected with influenza should be consideredFootnote 17.
    • Any patient/resident admitted from the community to a non-influenza cohort should be assumed to have been exposed to influenza in the community (i.e., maintain a high index of suspicion during the incubation period).
      • Patients/residents should be closely monitored (i.e., every four to six hours) for influenza symptoms for the duration of the incubation period.
    • Non-influenza patients/residents without high risk of severe influenza complications should be accommodated as per the organization's routine patient or residential accommodation system (e.g., medical, surgical).
      • Assume that all acute care patients and newly admitted LTC residents admitted to a non-influenza cohort have been exposed to influenza in the community.
      • Processes should be established to monitor for symptoms of influenza upon admission and every four to six hours for the duration of the incubation period.
      • Processes should be developed to separate patients/residents with ILI symptoms from non-influenza patients as soon as symptoms are noted.
    • Plans should be developed to cohort confirmed influenza patients/residents and patients/residents with ILI symptoms including those who also require specialty care or assessment for other conditions (e.g., Trauma Intensive Care Units, Coronary Care Units, Maternity Units, Neonatal units).
      • A plan to establish and maintain spatial separation of two metres between influenza and non-influenza patients should be developed.
      • Wherever possible plan to use physical barriers to minimize exposure to other patients, HCWs, visitors, contractors, etc., from patients/residents with ILI symptoms.
    • Patients/residents who are immune to the pandemic influenza strain (i.e., those who were immunized at least two weeks previously or who have recovered from the pandemic strain of influenza) may be accommodated in the area most appropriate to their care needs.
      • The influenza vaccine may not be fully efficacious in providing immunity. Immunized patients/residents should continue to be assessed for signs of influenza.
2.2.1. Use of Patient Rooms During the Pandemic Period

Single rooms are preferred for patients with ILI symptoms (seasonal and pandemic influenza).

Note: Ambulatory care settings including physicians’ offices and other outpatient settings. Processes should be established for waiting areas to enable the spatial separation of infected sources and susceptible hosts (e.g., two metres, partitions, immediate placement of patients with ILI symptoms into an examination room).

2.2.2. Planning Airborne Infection Isolation Rooms During a Pandemic Period

Patients/residents with influenza caused by the pandemic strain do not require airborne infection isolation.

  1. AGMPs (see Section V.4.4.4. and Section VII.1.5.4.) on patients with influenza caused by the pandemic strain should be performed in a designated airborne infection isolation room or other rooms with enhanced air exchanges and air exhausted to the outside, if feasibleFootnote 2 Footnote 3 Footnote 35.
  2. As the number of airborne infection isolation rooms is limited in most healthcare settings, these rooms should be prioritized for patients with known or suspected airborne infections (e.g., tuberculosis, measles, varicella and disseminated zoster) or those undergoing sputum induction or bronchoscopyFootnote 60-70 over patients with ILI symptoms.
  3. Moving influenza patients/residents to an airborne infection isolation room for treatment should not be considered if it compromises the delivery of care.
2.2.3. Temporary Healthcare Settings
  • To limit confusion, whenever possible, the temporary setting's pandemic influenza IPC/OH plan should be integrated with the parent organization's pandemic influenza IPC/OH plan.
  • The temporary setting's pandemic influenza IPC/OH plan should be based on published IPC recommendationsFootnote 2 Footnote 3 Footnote 10 Footnote 11.
  • The temporary setting's pandemic influenza IPC/OH plan should be integrated with federal/provincial/territorial/regional pandemic influenza contingency plans.
  • Pandemic influenza planning should ensure that all HCWs working in temporary healthcare settings (e.g., housekeeping and laundry workers and workers handling waste) are offered appropriate immunizations.
  • Reprocessing of reusable medical instruments should not be undertaken in temporary settings.

2.3. Planning for Transfer/Transport of Patients with ILI symptoms Within and Between Healthcare Settings

Prior determination of an organization's patient transportation/transfer policies during a pandemic period should enable the application of consistent care policies. Planners should consider the organization’s patient population, the possibility of HCWs and other staff shortages, and the impact of transportation/transfer policies and capacities on the medical care and recovery of patients.

In preparation for an influenza pandemic, the organization should:

  1. Plan to limit the movement of patients with ILI symptoms to moves that are medically necessary.
    • For patients that must be moved between departments, units or organizations, formal communication processes should be established to ensure that the transporting agency, and the receiving department, unit or facility is made aware of the patient's ILI symptoms, diagnosis and laboratory results (i.e., direct communication with the staff of the receiving department, unit or facility).
    • Ensure transfer/transport personnel perform a PCRA (see Appendix D) and put on appropriate PPE (see Section V.6.2.6.2.) for the transport.
  2. When transfer/transport is necessary plans should be in place to teach patients with ILI symptoms (if able) the following functions:
    • Perform hand hygiene prior to transfer/transport.
    • Wear a mask (NOT a respirator) for the duration of transfer/transport (if tolerated).
    • Practice respiratory hygiene during transport.

2.4. Planning for Visitors: Responsibilities and Restrictions

Prior determination of an organization's visitor policies during the pandemic period should enable the application of consistent restrictions. Planners should consider their patient population, the possibility of HCWs and other personnel shortages, and the impact of restrictions on care and recovery of patients.

  1. In preparation for an influenza pandemic, the organization should plan that asymptomatic visitors may visit asymptomatic patients/residents in accordance with the organization’s visitation policies.
  2. Organizations should identify processes for visitors who wish to visit a patient with ILI symptoms. Visitors should:
    • Consider NOT visiting if they are at high risk of complications should they contract influenza (e.g., immunosuppressed, pregnant).
    • Perform hand hygiene on entry to and exit from the patient's room.
    • Consider wearing the same PPE that HCWs are using/wearing if they will be within two metres of the patient they are visiting.
    • Restrict the visit to one patient only to prevent inadvertent influenza transmission to multiple patients.
  3. The organization should identify processes to enable the identification of visitors with ILI symptoms upon entry into a healthcare setting.
    • Symptomatic visitors should be prevented from visiting except under exceptional circumstances (see Section VI.2.4.).
    • Consideration should be given to identifying prominent areas at the entrances of the healthcare setting for all visitors to perform an influenza self-assessment under the direction of organizational personnel to monitor for any ILI symptoms (see Appendix A).
  4. Organizations should identify areas where visitors can perform hand hygiene upon entering a healthcare setting and on entrance to and exit from a patient's room.
  5. Organizations should identify methods to ensure that all visitors receive respiratory hygiene instructions prior to or immediately upon entry into the healthcare setting.
  6. Organizations should plan for further visitor restrictions if an outbreak or active transmission of pandemic influenza is occurring in the facility. During a facility influenza outbreak, consideration should be given to:
    • Restricting visitors who have not yet had the pandemic strain of influenza.
    • Restricting visitors who have not been immunized against the pandemic strain in the prior two weeks.
  7. The organization should plan for special exemptions for a visitor with ILI symptoms (e.g., if the visitor is a close relative of a terminally ill patient or a parent of a sick/admitted child).
    • The organization should ensure that symptomatic visitors do not have opportunity to expose other patients, HCWs, visitors, contractors, etc., to influenza while in the healthcare setting.
    • The organization should plan to provide resources (i.e., equipment and direction) to enable the ill visitor to receive instruction on proper mask wearing and removal, hand hygiene and respiratory hygiene including:
      • Putting on a mask upon entering and wearing the mask for the duration of the time in the healthcare setting.
      • Performing hand hygiene upon entering the healthcare setting and prior to entering and leaving a patient's room.
      • Observing respiratory hygiene throughout the time in the healthcare setting.
    • Ill visitors should restrict their visit to a single patient (terminally ill adult or sick child). Under no condition should they visit anyone other then the designated patient/resident.
    • Children with ILI symptoms, who are relatives of a terminally ill patient, may visit if the parents or guardians provide strict supervision of the child.
      • Parents or guardians should ensure that the sick child/visitor wear a mask and practice strict hand and respiratory hygiene.
      • Under no condition should visiting children with ILI symptoms visit any other area/room/patient in the facility (e.g., cafeterias, common areas, play areas, etc.).
      • Patients who have received ill visitors should be monitored for one incubation period after the last visit by an ill visitor.

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